A 77-year-old Japanese man with a 1-month history of low back pain and 2 days of fever was referred to the department of infectious diseases at our hospital because his urine smear was positive for acid-fast bacilli (AFB). Ten months prior to this referral, the patient had experienced dysuria, which was easily relieved by the administration of tamsulosin. The patient was otherwise healthy and was independent in his activities of daily life. A physical examination showed that the patient was 156 cm tall and weighed 47.6 kg, thin but with a good general appearance, and had a body temperature of 37.2C and stable vital signs. A lower back examination revealed knocking pain on the left costovertebral angle. The laboratory test results showed him to have leucopenia (white blood cell count 2,500 /muL), mild anemia (hemoglobin 11.4 g/dL), renal dysfunction (serum creatinine 1.54 mg/dL), and mild inflammatory response (C reactive protein 5.02 mg/dL and erythrocyte sedimentation rate 31 mm/hr). A urinalysis revealed sterile pyuria, and a polymerase chain reaction (PCR) test for Mycobacterium tuberculosis showed positive findings in the urine as well as gastric aspirate samples. A sputum smear was negative for AFB. Drug-sensitive M. tuberculosis was isolated from both the urine and sputum samples. Chest X-rays showed multiple nodular lesions on the left lung field (Fig. 1). Chest computed tomography (CT) showed multiple centrilobular nodules (Fig. 2a), and abdominal CT showed bilateral hydronephrosis: dilatation of both ureters; severe cortical thinning of the right kidney, indicating a complete loss of function; and calcification of the bladder wall (Fig. 2b-d).
The patient was diagnosed with both urinary and pulmonary tuberculosis. Anti-tuberculosis treatment with isoniazid 300 mg/day, rifampicin 450 mg/day, ethambutol 750 mg/day, and pyrazinamide 1.2 g/day was initiated from the day following admission. On the 6th hospital day, the patient developed anuria with a fever of 39C, and his serum creatinine levels rose to 4.21 mg/dL (Fig. 3a). We attempted to insert a double J stent into the left ureter, but were unsuccessful. A smaller-bore catheter was therefore placed to relieve the obstruction, but it could not reach the pelvis of the left kidney (Fig. 3b).
Since no signs of improvement in the ureteral stricture were noted during the 3 weeks of anti-tuberculosis treatment, we started the patient on 60 mg/day oral prednisolone on the 27th hospital day. Two days later, urine began leaking from both the catheter in the left ureter as well as in the bladder. This indicated improvement in the ureteral stricture (Fig. 3c). Subsequently, we removed the ureteral catheter 8 days after the initiation of prednisolone. Prednisolone was continued for a further 2 weeks before being tapered to 10 mg/week. Although the patient complained of frequent urination, probably due to a shrunk bladder, there was no sign of re-occlusion thereafter (Fig. 3d). Anti-tuberculosis treatment was continued for nine months in total.
Chest and abdominal CT on admission day. Chest CT (a) showed multiple centrilobular nodules.