A 13-year-old girl from a remote village of Bandung presented with urology emergency to our hospital with gross hematuria and difficult and painful micturition since 2 years before admission. She had flank pain as well since a year ago. There was no history of cough, night sweats, malaise, or swelling of abdomen or extremities. The patient had lost her weight for about 2 kg in a month. There was no history of TB disease previously, but her grandmother was diagnosed as having pulmonary TB and was on TB treatment.
Physical examination showed undernourishment, body weight 27 kg (-2 to -3SD), and height 137 cm (-2 to -3SD). On examination, her general appearance was moderately ill and blood pressure was within the normal limit and had no fever. There was pain on the left flank. Urine microscopy showed leukocyturia, hematuria, and positive acid-fast bacilli, and M. tuberculosis was detected in rapid-test molecular test (gene Xpert). Laboratory findings showed serum creatinine 0.80 mg/dL, serum urea 12.0 mg/dL, serum sodium 142 mEq/L, serum potassium 4.5 mEq/L, serum calcium 5.61 mg/dL, Hb 10.6 g/dL, hematocrit 33.9%, WBC 11,800/mm3, platelet count 663,000/mm3, differential count 0/2/0/73/19/6, and quantitative CRP 1.2 mg/dL, and anti-HIV, anti-HCV, and HbsAg were negative. Ultrasound of kidney-ureter-bladder showed bilateral kidney pelvocaliectasis, and diuretic renogram revealed an important difference in renal function, i.e., the uncorrected glomerular filtration rate (GFR) of the right kidney and the left kidney was 32.5 mL/min/1.73 m2 and 5 mL/min/1.73 m2, respectively. Chest radiograph showed active pulmonary tuberculosis; Mantoux test showed positive result (an induration of 17 mm). Based on those findings, we diagnosed complicated urinary tract infection, left ureteral stenosis, bilateral hydronephrosis, and stage 3 chronic kidney disease (CKD). Left kidney nephrectomy and bladder augmentation were performed by a pediatric urologist, and then the anatomopathological result was pyelonephritis tuberculosis (tuberculoma).
The patient was treated with four antituberculous drugs in the intensive phase which she had completed and then continued with two antituberculous drugs in the continuation phase. She experienced antituberculous drug-induced hepatotoxicity (ADIH) after two months of antitubercular treatment (ATT). We diagnosed the patient as complicated urinary tract TB, stage 3 chronic kidney disease (CKD), and ADIH. The patient was given ethambutol and streptomycin with an adjusting dose according to GFR and was given calcium carbonate, folic acid, and vitamin D orally. The child gained 2.5 kilograms during this time period, and her condition improved significantly (Figure 1).