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Kidney Tuberculosis - Symptoms and Diagnosis
Last reviewed: 20.11.2021
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Symptoms of kidney tuberculosis
Symptoms of kidney tuberculosis, unfortunately, are few and not very specific. In the parenchymal stage, when inflammatory foci are only present in the tissue of the organ, clinical manifestations can be minimal, meager: mild malaise, rarely subfebrile temperature. In 30-40% of patients, clinical manifestations may be absent. As the process progresses, pain in the lumbar region, macrogematuria, and dysuria may occur.
Pain on the side of the lesion is observed in 7% of patients in the initial stage and in 95% in the case of a neglected process; can be a dull aching on the background of the progression of infiltrative inflammation and gradually developing processes that disrupt the outflow of urine from the kidney. In the event of destruction, rejection of necrotic caseous masses, especially with changes in the ureteropelvic and ureteral segments, the pain may resemble renal colic with all its clinical features, accompanied by chills, fever, signs of intoxication. However, bright symptoms of an acute inflammatory process in the kidney may be absent.
Bezbolevaya macrohematuria is observed in 17% of patients. Arterial hypertension as a sign of specific kidney damage occurs in 1% of observations in the initial stages and in 20% - with advanced tuberculosis. Macroscopic hematuria, according to summary statistics, occurs only in 8-10% of cases, it is not massive and is rarely accompanied by urinary excrement of blood clots.
The most common symptoms of kidney tuberculosis are: dysuria, frequent painful urination (2% in the initial stages and 59% in the subtotal and total destruction). Dysuria occurs due to early damage to the bladder. Considerable information is given by the anamnesis: to make suspect the possible tuberculosis of the kidney should be the transferred tuberculosis of the lungs, lymph nodes, exudative pleurisy, tuberculosis of bones and joints, etc. Long-term contact with tuberculosis patients in the family and in everyday life, in work collectives, in places of deprivation of liberty and others.
Diagnosis of kidney tuberculosis
Tuberculosis of the lungs or other organs in the anamnesis; extrapulmonary tuberculosis coexisting with renal tuberculosis; tuberculosis in close relatives; contact with tuberculosis patients; characteristic for the transferred tuberculosis changes, revealed at the X-ray examination of the lungs, all this allows to suspect the specific nature of the kidney disease. In the majority of patients with kidney tuberculosis, in a comprehensive examination, one can detect a lesion by a specific process of other organs and systems. The diagnosis and therapy of urogenital tuberculosis is of particular importance today, when in our country there is a pronounced tendency to increase the incidence of pulmonary tuberculosis.
Unfortunately, the diagnosis is not always timely, which deprives the patient of the possibility of full-fledged conservative treatment and often makes the outcome of the disease favorable. Many patients with newly diagnosed tuberculosis of the kidney suffer from severe, neglected forms of the disease and need nephrectomy. The late diagnosis of kidney tuberculosis is caused not so much by the atypical or hidden course of the painful process, as by the insufficient information of practical doctors about this serious and common disease.
[1], [2], [3], [4], [5], [6], [7], [8]
Laboratory diagnosis of kidney tuberculosis
Laboratory diagnosis of kidney tuberculosis plays an important role. Clinical blood tests are largely non-specific. Immunoenzyme analysis allows to detect antibodies to mycobacteria of human and bovine types, it is highly specific for detecting the tuberculosis process, but it is useless in clarifying its localization.
Important and reliable information that allows to suspect a tuberculosis lesion, gives an overall analysis of urine. It shows a stable, sharply acid reaction, proteinuria (92% of patients), which is false, does not exceed 0.001 g and is not accompanied by the formation of cylinders; significant leukocyturia (70-96% of patients), less pronounced microhematuria (30-95%) in the absence of a banal microflora. The usual sowing of urine in this case, in spite of reliable signs of inflammation of the kidneys and urinary tract, is usually sterile (aseptic pyuria). It should be emphasized that the totality of the described laboratory signs must certainly alarm any doctor in terms of specific tuberculosis of the kidneys.
In a quantitative study of urine (Nechiporenko's test), more reliable data can be obtained if urine is obtained directly from the affected kidney by catheterization. In doubtful cases, a comparative analysis of leukocyturia before and against provocation by subcutaneous injection of tuberculin (a prototype of the Koch test) is possible, increasing its intensity in the presence of a specific process. No less valuable are the results of inoculation and bacteriological examination of urine obtained directly from the affected kidney.
Tuberculosis of the kidney can be combined with nonspecific pyelonephritis, especially in patients who underwent instrumental diagnostic examinations and massive antimicrobial therapy. This combination in many respects makes it difficult to recognize the tuberculosis process, since secondary non-specific flora (up to 70% of observations) is attached, the urine reaction changes to neutral or alkaline. The lack of proper effect against banal antibacterial and anti-inflammatory therapy in patients with pyelonephritis, even in the presence of non-specific flora, should be an indication for polymerase chain reaction, urine culture and bacteriological tests for the diagnosis of tuberculosis.
One of the leading methods of diagnosing this disease can rightfully be considered bacteriological. For this purpose, in the aseptic conditions under the supervision of medical personnel, a morning portion of urine is collected in sterile dishes for seeding on special elective media. This allows us to detect the initial growth of mycobacteria in 2-3 weeks by fluorescence microscopy and give an approximate response, and within 2-3 months to obtain their growth with the determination of sensitivity to the drugs. Biological tests by intraperitoneal administration of the urine of a guinea pig patient and observation for 2-4 weeks, despite the sensitivity (can be positive even with an extremely low titer of the pathogen up to single mycobacteria), today do not find wide application due to significant financial costs.
By its sensitivity (more than 1 mycobacteria in 1 ml) with a bioassay, only the polymerase chain reaction of urine can be compared. After 5 hours with a sensitivity of 94% and specificity of 100%, renal tuberculosis can be confirmed. Thus, in modern conditions, a reliable diagnosis of tuberculosis can be made only with the help of diagnostic methods: polymerase chain reaction of urine, bacteriological (growth of mycobacterium tuberculosis in urine culture) and morphological, when histological examination of the tissue of the kidney, urinary tract, bladder wall biopsy reveal the characteristic signs of tubercular inflammation with the presence of giant cells Pirogov-Langgans.
Tuberculodiagnostics
Among the other diagnostic methods, especially in doubtful cases, are the so-called provocative tests using tuberculin. Its dose for these purposes is usually 20 TE, if necessary, it can be increased to 100 TE. After its subcutaneous injection, the focal reaction is assessed by urine testing. This confirms the specific nature of the inflammation increase in the titer of the elemental elements in the sediment, especially in the study of renal urine. Sometimes it is possible to achieve the growth of mycobacteria tuberculosis. Since the tuberculous process in the kidney is more often unilateral, and in the urinary bladder the urine is diluted due to the unaffected kidney, the cell titre, especially mycobacteria, drops sharply and the results of provocation in the study of only pancreatic urine may be negative. Therefore, if necessary, it is advisable to combine provocative tuberculin tests with catheterization of the corresponding ureter to obtain urine directly from the kidney, and retrograde ureteropyelography, thereby increasing the informative value of the studies.
Ultrasonic diagnosis of kidney tuberculosis
Unfortunately, this method does not allow to diagnose early manifestations of kidney tuberculosis, but is effective only in destructive, cavernous forms of the process. With cavernous lesions of the kidney, it is possible to reveal rounded echo-negative formations that are surrounded by a dense echopositive membrane, since the border of the cavity, in contrast to the cyst, is dense. Sometimes in the center of the cavern in the liquid contents are seen separate ehopozitivnye inclusions due to the heterogeneous content. Ultrasound diagnosis does not allow to reliably diagnose a specific process in the kidney, but it helps a lot in establishing the severity and exact localization of destructive changes. The results of the ultrasound study make it possible to clarify the indications for other radiation studies, and also give an opportunity to judge the regression or progression of a specific process against the background of therapy.
Radiographic diagnosis of kidney tuberculosis
In the review image and native nephrotomograms, one can notice an increase in the contours of the kidney, areas of calcification, more often with the mistletoe of the site or the entire kidney. The excretory urography and retrograde ureteropyelography are traditionally assigned to the importance of obtaining information about the nature, localization and prevalence of tubercular lesion.
Computer and magnetic resonance imaging of kidney tuberculosis
The use of multispiral CT and MRI, especially with contrast, in patients with kidney tuberculosis allows you to clearly identify the foci of destruction located in the parenchyma. These methods make it possible to visually assess the relationship between destructive foci with the pelvic-pelvic system, the elements of the renal sinus and the main vessels, and also to clarify the involvement of regional lymph nodes in the inflammatory process.
Radionuclide Diagnosis of Kidney Tuberculosis
Radionuclide studies (dynamic nephroscintigraphy) make it possible to obtain an idea of the functional capacity of the kidney as a whole and segmentedly, assessing the dynamics of the intake, the accumulation of the radiopharmaceutical in the parenchyma and its excretion along the urinary tract. It is possible to use isotope drugs, tropic to a greater extent to the vascular, glomerular and tubular system of the kidney. Combinations of such studies with provocation of tuberculin are successfully used. Impairment of the kidney function after the introduction of tuberculin when compared with the original indirectly indicates the possibility of a specific lesion.
Morphological diagnosis of kidney tuberculosis
Due to the focal nature of the pathological process, a kidney biopsy with subsequent histological examination in case of tuberculosis lesion is ineffective and dangerous by disseminating the infection in surrounding tissues. With dysuria, endoscopic studies with biopsies of altered areas of the mucous membrane can diagnose tuberculosis lesions. However, in more than 50% of patients with kidney tuberculosis, even in the absence of visible changes in the mucous membrane of the bladder, with a thorough histological examination of her biopsies obtained endoscopically, giant cells of Pirogov-Langgans can be detected in the submucosal layer, indicating a specific lesion.
Differential diagnosis of kidney tuberculosis
Differential diagnosis of kidney tuberculosis should be performed with hydronephrosis, ureterohydronephrosis, pyelonephritis, especially with the outcome of pionephrosis and the presence of festering fistulas in the lumbar region. X-ray signs of the process must be distinguished from medullary necrosis complicating the course of purulent pyelonephritis, anomalies of medullary matter (spongy kidney, calyx diverticula, megacalix, megakalysis). Disconnected destructive foci in tuberculosis can be similar to cystic and dense tumor-like formations in the parenchyma, deforming the contours of the kidney and the bowl-and-pelvis system. The leading criterion should be a combination of clinical, laboratory, ultrasound, radiographic and other data. Persistent dysuria and pyuria should be an indication for the exclusion of banal chronic inflammation by laboratory tests of urine in two (in men in three, with the study of secretion of the prostate) portions and bacteriological studies, as well as urethrocystoscopy and endovezical biopsy.
[12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22]