A 38-year-old Mexican man presented with progressive nausea and vomiting, explaining that he had had dry mouth, nausea, and nonbloody emesis for several weeks. He had noticed a 10-pound weight loss, but he was not anorectic. Urinary hesitancy without dysuria had been an increasing problem for several months. He denied fever, chills, cough, dizziness, syncope, chest pain, shortness of breath, swelling, rash, or leg weakness; he was not taking any medications and had no allergies; and he denied use of tobacco, alcohol, or street drugs. He had undergone a left-sided orchiectomy for a nonhealing abscess in Mexico over 20 years earlier. He was born in Mexico and moved to Houston as a young adult, living there 13 years before moving to Dallas several years ago. He worked in construction and described no recent travel, known sick contacts, or prior exposure to tuberculosis.
His initial vital signs were normal (temperature, 98.2°F; blood pressure, 124/87 mm Hg; heart rate, 105 beats per minute; respirations, 16 breaths per minute with 97% oxygen saturation), and his lung auscultation was clear. His abdomen was diffusely tender to palpation with no guarding or rigidity. The left testicle was missing with a well-healed scrotal scar and round soft right testicle. There was no skin rash or edema.
His pertinent laboratory results were as follows: white blood cell count, 14.4 K/uL, with 90% neutrophils, 2% lymphocytes, and no bands; hemoglobin, 11.4 g/dL; hematocrit, 34.1%; sodium, 125 mEq/L; potassium, 5.0 mEq/L; chloride, 80 mEq/L; bicarbonate, 19 mEq/L; anion gap, 26 mEq/L; blood urea nitrogen, 190 mg/dL; creatinine, 19.7 mg/dL; glucose, 151 mg/dL; total protein, 9.7 g/dL; albumin, 4.5 g/dL; and lactate, 1.3 mEq/L. Urinalysis results revealed a specific gravity of 1.015, pH of 6, 2+ protein, 2+ blood, 4 red blood cells per high-power field, 50 to 100 white blood cells per high-power field, and positive dipstick for leukocyte esterase and nitrite. In spot urine chemistries, the fractional excretion of sodium was 12.5%. Timed urine collection revealed a urinary volume of 2250 mL/day, a creatinine clearance of 6 mL/min, a urea clearance of 4 mL/min, and urine protein of 1.5 g/day.
Several imaging studies were completed. Renal sonography revealed a 13.0 × 7.0 cm right kidney with a 2.9 × 3.7 cm anechoic lesion in the superior pole and mild hydronephrosis, and a 13.4 × 8.5 cm left kidney with numerous echogenic lesions in the posterior pole up to 1.3 cm and severe hydronephrosis (Figure ). No ureteral jets were visualized. Computed tomography (CT) of the abdomen and pelvis without contrast revealed multilocular renal cysts, 7.6 cm in the left kidney and 3.7 cm in the right kidney, multiple calcified retroperitoneal lymph nodes up to 13 mm in size, and calcific deposits in the prostate and both seminal vesicles. CT of the chest (Figure ) revealed innumerable 1 to 2 mm nodules in both lungs, predominantly in the upper lobes. A chest radiograph revealed increased density in the medial left lung apex.
Renal sonogram of the left kidney, which was 13.4 cm in length, showing severe hydronephrosis and posterior acoustic shadowing compatible with debris.
Chest CT showing innumerable diffuse small nodules throughout the lungs and a 6 mm nodule in the right upper lobe.
On Day 2, the patient's renal function was unchanged. Because of difficulties placing the Foley catheter, urology was consulted. The catheter was placed with difficulty during cystoscopy because of a rigid “leadpipe” urethra. The bladder contained a large amount of white debris, which was adherent to the bladder mucosa but easily irrigated off the mucosa. The bladder debris was sent for bacterial, fungal, and mycobacterial culture. Retrograde pyelography revealed an irregular beaded appearance of both ureters consistent with ureteritis cystica (Figure ). Bilateral ureteral stents were placed, and the Foley catheter was left in place. Renal biopsy was performed, which showed several areas of granulomatous interstitial nephritis with multiple areas of caseous necrosis (Figure ). There was evidence of extensive tubular atrophy. Visualized glomeruli were normal with no glomerulosclerosis. Fungal and mycobacterial stains were negative. All initial tuberculosis tests were negative, including a purified protein derivative skin test, two sputum acid-fast bacilli tests, and three urine stains for acid-fast bacilli. In addition, a QuantiFERON TB Gold test was indeterminate.
A pyelogram showing an irregular beaded appearance of the right ureter consistent with ureteritis cystica.
Renal biopsy with hematoxylin-eosin stain. (a) A low-power view (10×) showing granulomatous interstitial nephritis. (b) A high-power view (100×) showing a classic granuloma.
The patient's renal function improved throughout his hospital stay with volume expansion and continued urinary drainage. Repeat timed urine collection revealed urinary volume of 2800 mL/day, creatinine clearance of 10 mL/min, urea clearance of 7 mL/min, and urinary protein of 1.5 g/day. No hemodialysis was needed. Lung nodules and retroperitoneal lymph nodes were felt to be too small for successful biopsy.
A fifth urine test for acid-fast bacilli on day 11 yielded a positive result. Culture of the bladder debris ultimately returned positive for Mycobacterium tuberculosis after a 7-week incubation. It was concluded that the patient had disseminated M. tuberculosis with both pulmonary involvement and extrapulmonary spread. The patient was started on rifampin, isoniazid, pyrazinamide, and ethambutol, with plans for 9 months of directly observed therapy.
At discharge, renal chemistries had stabilized with a blood urea nitrogen of 134 mg/dL and creatinine of 9.9 mg/dL. It was felt that the patient would likely need hemodialysis within the next several weeks or months. An arteriovenous fistula was placed in preparation for hemodialysis. His volume status was stable, with urine output matching oral fluid intake. He had no uremic symptoms.