Case Presentation:

A 63–year–old male with a history of prostate cancer status post open prostatectomy in 2000 presented in July 2010 to the emergency department with fevers. He reported 6 months of terminal dysuria and brownish urine for which he had previously received Bactrim, without resolution of his symptoms. He denied chills, night sweats, weight loss or pulmonary symptoms. He was originally from the Philippines and received BCG vaccination as a child. He had a positive tuberculin skin test as an adult but never took isoniazid (INH) prophylaxis and had reportedly normal chest x–rays. He was exposed to a cousin who died of active tuberculosis. Urinalysis showed large leukocyte esterase, grade 2 proteinuria, moderate hemoglobin, 100 white blood cells and 89 red blood cells with a negative urine culture. Bladder cytology revealed acute and chronic inflammation without malignant cells and cytoscopy revealed multiple small nodules and a caseating granulomatous type reaction at the bladder base. Bladder biopsies showed multiple necrotizing and nonnecrotizing granulomata with positive acid fast stains consistent with genitourinary tuberculosis. CT Urogram and retrograde urography showed no calyceal narrowing or ureteral strictures. Chest imaging revealed a 6mm stellate shaped lesion in the left upper lobe consistent with a scar from old pneumonia, tuberculosis or neoplasm but no active tuberculosis. Three smears for sputum acid fast bacilli were negative. HIV, blood and urine cultures were negative. He was started on RIPE therapy (rifampin, INH, pyrazinamide, ethambutol) and pyridoxine but was lost to follow up.

Discussion:

Tuberculosis (TB) infects one–third of the world’s population and is the eighth leading cause of death in the world. Extrapulmonary TB comprises 15% of tuberculosis cases in immunocompetent hosts and 50–70% of cases in HIV infected populations. It can occur in any organ system, with the genitourinary system being one of the most common sites of extrapulmonary infection. Genitourinary TB includes infection in the kidneys, bladder, ureters and male/female reproductive tracts. It usually presents with local symptoms including gross hematuria, frequency, nocturia, dysuria, suprapubic pain, flank pain and less commonly, systemic symptoms such as fever. Imaging (including CT scan and ultrasound) provide only indirect evidence for infection. Diagnostic studies typically reveal a sterile pyuria and diagnosis requires urine culture/smear and biopsy/culture of tissue. HIV status should be checked. Treatment consists of 6–9 months of INH/rifampin containing regimens and symptoms can take up to 3 months to resolve.

Conclusions:

UTIs are a common reason for hospital admission. Although relatively rare in developed nations, genitourinary TB is an important diagnosis to exclude when studies reveal a sterile pyuria and symptoms do not respond to classic UTI treatment. This is increasingly important in today’s world of global travel and in immunocompromised hosts.

Figure 1Bladder biopsy: necrotizing granuloma.

Figure 2Bladder biopsy: positive acid fast stain.