RAPID DIAGNOSIS OF GENITOURINARY TUBERCULOSIS BY POLYMERASE CHAIN REACTION AND NON-RADIOACTIVE DNA HYBRIDIZATION

Uncommon Haemorrhagic Cystitis of Infectious Origin: A Narrative Review for Urologists

Purpose

Haemorrhagic cystitis may be due to different etiologies with infectious diseases representing an insidious cause to diagnose. The aim of this narrative review is to provide a comprehensive overview of less common but difficult-to-diagnose causes of infectious haemorrhagic cystitis of bacterial, mycobacterial, and parasitic origin, Moreover, we highlight possible diagnostic tools and currently available treatment options in order to give an updated tool for urologists to use in daily practice.

Patients and Methods

The search engine PubMed was used to select peer-reviewed articles published from 1/Jan/2010 to 31/Aug/2022.

Results

Bacteria, fungal, TB and schistosomiasis are uncommon causes of haemorrhagic cystitis burdened by high morbidity, especially if not promptly diagnosed.

Conclusion

Because haemorrhagic cystitis ranges in severity from mild dysuria associated with pelvic discomfort to severe life-threatening haemorrhage, punctual diagnosis, and immediate treatment are essential to avoid further complications.

Spatial bacterial subpopulations of a human lung lobe and their potential impact on the progression of pulmonary tuberculosis

Better understanding the spatial variation in resident pulmonary bacteria can help to link the disease severity of pulmonary tuberculosis (TB) with lung bacteriomes. This study aimed to investigate bacterial compositions in subniches of a lung lobe from pulmonary TB patient with two separate visible lesions. There were no significant differences between the bacterial compositions in normal tissue and TB lesions, but the bacterial compositions of the two TB lesions differed significantly (P = 0.009). Interestingly, 52 OTUs (relative abundance >1%) that specifically inhabiting certain lung niches were observed and they were affiliated with five phyla. Specific OTUs affiliated with Firmicutes mainly inhabited normal tissues. The dominant phylum in the lung subniches was Proteobacteria, with a relative abundance between 67.03% and 99.99%. Ralstonia, Achromobacter, and Pseudomonas were the most abundant genera, collectively accounting for 34.02% of total bacterial species. A total of 667 of the 700 bacterial connections in a co-correlation network of 145 OTUs (Operational Taxonomic Unit) were positive, indicating a cooperative relationship between bacterial members. Using PICRUSt tool, we do predict bacterial MetaCyc functions responsible for lipid synthesis and heme biosynthesis across the lung lobe that are essential for generation of caseous necrosis and TB disease pathology. MetaCyc pathways responsible for the degradation of aromatic biogenic amines, sulfur oxidation, and denitrification were all related to M.tb growth status, and they were significantly enriched in the lesion with necrosis than that with inflammation. These results open a new insight for us to comprehend the spatial profile of bacteriomes in a pulmonary TB human lung lobe, and shed light on the design of future diagnosis and treatment for pulmonary TB disease.

Urethral Tuberculosis: A Forgotten Cause of Urethral Stricture

We describe the clinical features of a 75-year-old man who presented to our hospital with frequent urination for 3 months. Retrograde urethrography showed extended and continuous narrowing of the stricture in the anterior urethra. Cystourethroscopy showed extended narrowing of the urethral lumen without normal membrane. Urine acid-fast bacillus culture and polymerase chain reaction assays indicated a diagnosis of urethral tuberculosis. Anti-tuberculosis therapy was initiated. Urethral tuberculosis is a very rare cause of urethral stricture in developed countries that can be diagnosed by cystourethroscopy. Urethral tuberculosis should be considered in the differential diagnosis of urethral stricture.

All in one, a rare case presentation of genitourinary tuberculosis

Background

The kidneys are the most common site of urogenital tuberculosis. Tuberculosis of the urethra and bladder is caused by a descending infection through the urinary collecting system. Urogenital tuberculosis affects 2% to 10% of pulmonary tuberculosis cases in developed countries, but 15% to 20% in developing countries.

Case presentation

A 55-year-old male referred to us with bilateral percutaneous nephrostomy, which was done for obstructive uropathy with raised creatinine of 4.5 mg/dl. He was diagnosed with pulmonary tuberculosis two years back and took antitubercular therapy for one year. His routine blood parameters were within normal limits. On evaluation with bilateral nephrostograms, he was found to have right-sided pelvic ureteric junction stricture and left-sided vesicoureteric junction stricture. On retrograde urethrography, there was evidence of 4-cm stricture at proximal bulbar urethra. On contrast-enhanced CT whole abdomen, he was found to have small-sized right kidney and findings in par with nephrostogram with thickened, small capacity bladder (thimble bladder). Patient underwent urethroscopy and urethral dilatation followed by augmentation ileocystoplasty with left ureteric reimplantation and right nephrectomy done at 3 months of follow-up.

Conclusion

Only 1.9 percent to 4.5 percent of all cases of urogenital tuberculosis are urethral tuberculosis, and it never happens alone. For urogenital tuberculosis diagnosis, imaging techniques are up to 91.4 percent sensitive, with intravenous urography and abdominal computerised tomography being the most widely used. Diagnosis relies on a range of signs such as “caliceal irregularities; infundibular stenosis; pseudotumor or renal scarring; nonfunctioning kidney; renal cavitation; urinary tract calcification (present in 7% to 19% of cases); collecting system thickening, stenosis, or dilatation; contracted bladder”.

Urological infections in the developing world: an increasing problem in developed countries

PURPOSE

Infectious diseases that often follow geographical distribution patterns are increasingly crossing such boundaries, aided by human travel and commerce. These pose a new challenge to physicians who are required to diagnose previously unseen conditions and address drug-resistant organisms. We review some such common infections.

METHODS

A literature review was performed for six common urological infections and a narrative review based on recent publications on these infections was compiled.

RESULTS

In Urology, some infections that are now crossing geographical boundaries include Brucellosis, Schistosomiasis, Tuberculosis, Filariasis, Hydatidosis and emphysematous pyelonephritis. Brucellosis, a zoonotic infection, is common in the Mediterranean areas, Asia, South America and Africa. Infection can involve all parts of the genitourinary tract. Schistosomiasis, a parasitic disease, is particularly common in Sub-Saharan Africa and may have bacterial superinfection. Voiding symptoms are common and bladder carcinoma may develop. Tuberculosis affects almost every organ in the body and in the male genital system, often presents with abscesses, nodules, ulcers and infertility that is difficult to manage. Filariasis is caused by two species of worms and is transmitted through a bite from a mosquito carrying larvae of the worm. It causes lymphatic obstruction leading to scrotal edema, hydrocoele to elephantiasis of scrotum. Emphysematous pyelonephritis is a life-threatening suppurative necrotizing infection of the renal parenchyma. While not being geographically limited, it is more common in developing areas with poor health care access. Genitourinary hydatidosis is a rare disease that is associated mainly with renal involvement in the genitourinary tract. Large cysts with destruction of renal parenchyma may be found.

CONCLUSIONS

Although uncommon, these urological infections are associated with significant morbidity and mortality and awareness in all healthcare settings is now an essential requirement.

Utility of GeneXpert in the diagnosis, reliance on urine microscopy and clinical characteristics of genitourinary tuberculosis at a tertiary care hospital

Background

One-third of the world's population is infected with tuberculosis (TB) with new infection occurring every second. In humans, TB is primarily caused by Mycobacterium tuberculosis(MTB). Genitourinary TB (GUTB) is still a major health problem in many developing countries including India and had been declared by the World Health Organisation as 'public health emergency' in 1993.

Materials and Methods

This is a prospective study conducted at a tertiary care hospital involving 46 patients who presented with clinical feature suggestive of GUTB - urine specimens of these 46 patients were analysed for acid-fast bacilli (AFB), AFB culture, GeneXpert, and other relevant investigations were done to reach the diagnosis. Majority of patients were female (65.25%). This is especially relevant to rural and low socioeconomic areas in developing countries where women's health is worse than men's (in terms of nutrition); women's risk of disease may be increased. Most of our patients were above 30 years of age and exhibited nonspecific symptoms such as dysuria, haematuria and frequency. All patients were put on antitubercular drugs and followed as per the guidelines.

Conclusion

The sample size in the present study is small to arrive at a brisk inference, but it may safely be postulated that yield of detection for GeneXpert may be improved using multiple sampling, especially the early morning ones. It is also pertinent to mention here that GeneXpert may not be able to pick up mutant genomes.

Evaluation of a Urine-Based Rapid Molecular Diagnostic Test with Potential to Be Used at Point-of-Care for Pulmonary Tuberculosis: Cape Town Cohort

Tuberculosis (TB) diagnosis among sputum-scarce patients is time consuming. Thus, a nonsputum diagnostic alternative is urgently needed. The Mycobacterium tuberculosis-specific transrenal (Tr) DNA from urine is a potential target for TB diagnostics. In this study, a new urine-based Tr-DNA molecular assay was evaluated for diagnosis of pulmonary tuberculosis among 428 adults suspected of having pulmonary TB (164 HIV positive, 263 HIV negative) from Cape Town, South Africa. Tr-DNA was isolated from 4 mL of EDTA urine, and a rapid, double-stranded, primer-based PCR method was performed targeting the Mycobacterium tuberculosis-specific direct repeat region. Each Tr-DNA eluate was tested in triplicate using an automated molecular analyzer with controls included in each test. With liquid culture used as the gold standard, the Tr-DNA assay showed sensitivity of 42.9% (n = 75/175; 95% CI, 35.4%-50.5%) and specificity of 88.6% (n = 210/237; 95% CI, 83.9%-92.4%). Among HIV-infected patients with TB, sensitivity and specificity were 45.2% and 89.0%, respectively. The combination of smear microscopy and Tr-DNA increased the sensitivity to 83.8% (smear microscopy alone, 75.1%), with 96.6% specificity. This study indicates that Tr-DNA has a moderate specificity with low sensitivity for diagnosis of pulmonary TB. Despite low sensitivity, this diagnostic test may have potential in combination with smear microscopy to support TB diagnosis in HIV-endemic regions, where sputum-scarce patients are common.

GeneXpert MTB/RIF assay in the diagnosis of urinary tuberculosis from urine specimens

Conventional bacteriological methods are not generally helpful in diagnosing urinary tuberculosis (UTB). GeneXpert is endorsed for the detection of pulmonary tuberculosis, whereas the data on its utility for urine specimens is limited. In this study, we aimed to evaluate its performance on urine specimens in a country with high TB incidence. A total of 163 suspected UTB patients were consecutively enrolled in the analysis, including 37 (22.7%) culture-positive and 44 (27.0%) clinically diagnosed UTB cases. Compared with conventional culture, the sensitivity of GeneXpert (94.6%) was significantly higher than that of smear microscopy (40.5%, P < 0.001). When setting clinical diagnosis as gold standard, 51 out of 81 clinically diagnosed UTB cases were detected by GeneXpert, demonstrating a sensitivity of 63.0%, which was significantly higher than that of smear microscopy (18.5%, P < 0.001) and culture (45.7%, P = 0.027), respectively. In addition, the proportion of UTB cases in the migrant population was significantly higher than that in the resident population (P = 0.019). To conclude, our data demonstrate that GeneXpert outperforms AFB smear and culture for the detection of MTB in urine samples, which provides an alternative for the diagnosis of UTB. The migrant population and previously diagnosed TB cases are high risk factors for developing UTB cases.

Urogenital Tuberculosis

Urogenital tuberculosis is the second most frequent form of extrapulmonary tuberculosis. Starting with a pulmonary focus, 2 to 20% of patients develop urogenital tuberculosis through hematogenous spread to the kidneys, prostate, and epididymis; through the descending collecting system to the ureters, bladder, and urethra; and through the ejaculatory ducts to the genital organs. Urogenital tuberculosis occurs at all age ranges, but it is predominant in males in their fourth and fifth decades. It is a serious, insidious disease, generally developing symptoms only at a late stage, which leads to a diagnostic delay with consequent urogenital organ destruction; there are reports of patients with renal failure as their initial clinical presentation. Although the condition has been long recognized by nephrologists, urologists, and infectious disease specialists, urogenital tuberculosis is still largely unknown. Even when suggestive findings such as hematuria, sterile pyuria, and recurrent urinary infections are present, we rarely remember this diagnostic possibility. Greater knowledge of the features of urogenital tuberculosis then becomes relevant and should emphasize the importance of an early diagnosis.

Diagnostic accuracy of nucleic acid amplification tests (NAATs) in urine for genitourinary tuberculosis: a systematic review and meta-analysis

BACKGROUND

Genitourinary tuberculosis is the third most common form of extrapulmonary tuberculosis. Diagnosis is difficult because of unspecific clinical manifestations and low accuracy of conventional tests. Unfortunately, the delayed diagnosis impacts the urinary tract severely. Nucleic acid amplification tests yield fast results, and among these, new technologies can also detect drug resistance. There is lack of consensus regarding the use of these tests in genitourinary tuberculosis; we therefore aimed to assess the accuracy of nucleic acid amplification tests in the diagnosis of genitourinary tuberculosis and to evaluate the heterogeneity between studies.

METHODS

We did a systematic review and meta-analysis of research articles comparing the accuracy of a reference standard and a nucleic acid amplification test for diagnosis of urinary tract tuberculosis. We searched Medline, EMBASE, Web of Science, LILACS, Cochrane Library, and Scopus for articles published between Jan 1, 1990, and Apr 14, 2016. Two investigators identified eligible articles and extracted data for individual study sites. We analyzed data in groups with the same index test. Then, we generated pooled summary estimates (95% CIs) for sensitivity and specificity by use of random-effects meta-analysis when studies were not heterogeneous.

RESULTS

We identified eleven relevant studies from ten articles, giving information on PCR, LCR and Xpert MTB/RIF tests. All PCR studies were "in-house" tests, with different gene targets and had several quality concerns therefore we did not proceed with a pooled analysis. Only one study used LCR. Xpert studies were of good quality and not heterogeneous, pooled sensitivity was 0·87 (0·66-0·96) and specificity was 0·91 (0·84-0·95).

CONCLUSION

PCR studies were highly heterogeneous. Among Xpert MTB/RIF studies, specificity was favorable with an acceptable confidence interval, however new studies can update meta-analysis and get more precise estimates. Further high-quality studies are urgently needed to improve diagnosis of genitourinary tuberculosis.

PROTOCOL REGISTRATION

PROSPERO CRD42016039020.

Role of anti-tubercular treatment for positive endometrial aspirate DNA-PCR reproductive outcome in infertile patients in Indian setting - A randomized trial

AIMS

The aim of the study was to determine the effect of anti-tubercular therapy (ATT) versus no ATT on reproductive outcome in patients with positive endometrial aspirate DNA-PCR for tuberculosis.

SETTINGS AND DESIGN

Department of Obstetrics and Gynecology in collaboration with the Department of Microbiology at the All India Institute of Medical Sciences, New Delhi, India.

METHODS AND MATERIALS

This prospective randomized study was conducted on 100 women in the reproductive age group with primary or secondary infertility, attending the Gynecology OPD at AIIMS. Women with positive endometrial DNA-PCR, patent tubes on laparoscopy, and all other tests being negative for genital TB were randomized into two groups. In Group 1, patients received ATT for 6 months while in Group 2, patients were not given ATT. In patients who did not conceive a repeat endometrial sampling for DNA-PCR was performed at 6 months and 12 months post-laparoscopy.

STATISTICAL ANALYSIS

It was carried out using Stata 11.0 (College Station, TX, USA).

RESULTS

In Group 1 (ATT), 25 women achieved pregnancy with a pregnancy rate of 50% while in Group 2 (no ATT), 21 women achieved pregnancy with a pregnancy rate of 42% and the difference (95% CI) was 8.0% (-11.5%, 27.5%) which was not statistically significant (p=0.422). Difference (95% CI) in the rate of repeat EA DNA-PCR being positive between the two groups at 6 months was 3.1% (-2.9%, 9.1%), p=0.299, while at the end of 12 months, repeat DNA-PCR remained positive in 23 patients in Group 1 and in 26 patients in Group 2. Difference (95% CI) in the rate of repeat EA DNA-PCR being positive between the two groups at 12 months was 2.3% (-13.0%, 17.7%), p=0.767.

CONCLUSION

The present study does not validate ATT for positive DNA-PCR; however, it does provide an evidence to stop over-treating patients on the basis of positive EA DNA-PCR even after they have received a 6 months course of ATT. Repeating PCR at 6 months and at 12 months has no role and ATT should not be repeatedly given to the patient on the basis of repeat DNA-PCR alone.

CLINICAL TRIAL REGISTRATION NUMBER

CTRI/2015/10/006235, www.ctri.nic.in.

Urinary tuberculosis: a cohort of 79 adult cases

We aimed to investigate the demographic, clinical, diagnostic, treatment and outcome features of patients with urinary tuberculosis (UTB). Patients with UTB admitted to seven separate centers across Turkey between 1995 and 2013 were retrospectively evaluated. The diagnosis of UTB was made by the presence of any clinical finding plus positivity of one of the following: (1) acid-fast bacilli (AFB) in urine, (2) isolation of Mycobacterium tuberculosis, (3) polymerase chain reaction (PCR) for M. tuberculosis, (4) histopathological evidence for TB. Seventy-nine patients (49.36% male, mean age 50.1 ± 17.4 years) were included. Mean time between onset of symptoms and clinical diagnosis was 9.7 ± 8.9 months. The most common signs and symptoms were hematuria (79.7%), sterile pyuria (67.1%), dysuria (51.9%), weakness (51.9%), fever (43%) and costovertebral tenderness (38%). Cystoscopy was performed in 59 (74.6%), bladder biopsy in 18 (22.8%), kidney biopsy in 1 (1.26%) and nephrectomy in 12 (15.2%) patients. Histopathological verification of UTB was achieved in 12 (63.1%) patients who undergone biopsy and in 100% of those undergone nephrectomy. Mycobacterium tuberculosis was isolated in the urine of 50 (63.3%) cases. Four-drug standard anti-TB treatment was the preferred regimen for 87.3% of the patients. Mean treatment duration was 10.5 ± 2.7 months. Deterioration of renal function occurred in 15 (18.9%) patients two of whom progressed to end-stage renal disease and received hemodialysis. Only one patient died after 74-day medical treatment period. Cases with UTB may present with non-specific clinical features. All diagnostic studies including radiology, cyctoscopy and histopathology are of great importance to exclude UTB and prevent renal failure.

Synchronously detected secondary signet ring cell urinary bladder malignancy from the stomach masquerading as genitourinary tuberculosis

Secondary bladder neoplasms are very rare and represent 1% of all malignant bladder tumours. Among secondary bladder tumours, metastasis from the stomach accounts for about 4% of cases. These secondary tumours are generally detected during follow-up of patients already treated for gastric cancer. We report a case of metastatic adenocarcinoma of the urinary bladder from an occult primary poorly differentiated signet ring cell type gastric carcinoma masquerading clinically as genitourinary tuberculosis. Our case illustrates the importance of obtaining a bladder biopsy in suspected chronic inflammatory conditions such as urinary tract tuberculosis before starting medical management to avoid the serious consequences of missing a bladder malignancy.

Tuberculosis of testis and prostate that mimicked testicular cancer in young male soccer player

Staphylococcus infection was the most common organism found in infection of athletics, and tuberculosis (TB) was rare. Although genitourinary tuberculosis (GUTB) was the most common subtype of extrapulmonary tuberculosis (EPTB) in the past, it was recently reported to account for less than 0.5% of all patients with EPTB and 1.5% of all patients with pulmonary tuberculosis (TB). And, there are few cases reported about concomitant tuberculous infection of testis and prostate. Pubic pain is a common symptom in soccer player and its cause can be difficult to determine. A 25-yr-old male soccer player presented with persistent pubic pain of unknown origin. Incidentally, right testicular mass was detected on physical examination. Computed tomography revealed a multiple enlarged retroperitoneal lymph nodes. Under the clinical diagnosis of a right testicular tumor, right radical inguinal orchiectomy was performed. And prostate biopsy was performed due to elevated serum prostate specific antigen (PSA). Pathologic examination confirmed concomitant TB of testis and prostate.

Renal tuberculosis in the modern era

Tuberculosis (TB) is a disease caused by Mycobacterium tuberculosis. The disease remains as an important public health problem in developing countries. Extrapulmonary TB became more common with the advent of infection with human immunodeficiency virus and by the increase in the number of organ transplantation, which also leads to immunosuppression of thousand of persons. Urogenital TB represents 27% of extrapulmonary cases. Renal involvement in TB can be part of a disseminated infection or a localized genitourinary disease. Renal involvement by TB infection is underdiagnosed in most health care centers. Most patients with renal TB have sterile pyuria, which can be accompanied by microscopic hematuria. The diagnosis of urinary tract TB is based on the finding of pyuria in the absence of common bacterial infection. The first choice drugs include isoniazide, rifampicin, pirazinamide, ethambutol, and streptomycin. Awareness of renal TB is urgently needed by physicians for suspecting this disease in patients with unexplained urinary tract abnormalities, mainly in those with any immunosuppression and those coming from TB-endemic areas.

Diagnostic value of PCR in genitourinary tuberculosis

Genitourinary tuberculosis is a disease of the genitourinary system which includes the entire urinary tract and reproductive system. Genital tuberculosis is an important cause of female infertility, especially in developing nations like India. In the present study, a total of 257 clinical specimens comprising of endometrial biopsy (109), endometrial curetting (42), menstrual blood (8), semen (17), placenta (11) and urine (70) were collected from patients and subjected for PCR, Culture and AFB detection. The endometrial biopsy, endometrial curetting, menstrual blood, semen, placenta, urine showed 30.2, 45.2,12.5, 5.8, 27.2, 31.4 %, positivity rate for tuberculosis by PCR, 7.3, 9.5, 25.0, 0, 9, 8.5 % by culture and 1.8, 2.3, 0, 0, 0, 2.8 % respectively by AFB smear. Being a novel, rapid technique, PCR is the method of choice for rapid diagnosis and management of genitourinary tuberculosis shared with the other concerned tests. This study reveals that genital tuberculosis can occur in any age group, however, the majority of patients were from reproductive age (nearly 75 % of them were from 20-45 years of age) group.

Testicular tuberculosis in multidrug-resistant pulmonary tuberculosis

We report a rare case of multidrug-resistant pulmonary and testicular tuberculosis (TB) in a 25-year-old immunocompetent patient. The patient was suspected to have a testicular cancer. He underwent radical orchiectomy, and surgical pathology revealed a granuloma containing acid-fast bacilli in the testis. Bronchial washing fluid culture grew Mycobacterium tuberculosis resistant to isoniazid, rifampin, and ethambutol. To our knowledge, this patient represents the first case of testicular TB in multidrug-resistant pulmonary TB.

Diagnosis of extrapulmonary tuberculosis by PCR

During the last two decades, the resurgence of tuberculosis (TB) has been documented in both developed and developing nations, and much of this increase in TB burden coincided with human immunodeficiency virus (HIV) epidemics. Since then, the disease pattern has changed with a higher incidence of extrapulmonary tuberculosis (EPTB) as well as disseminated TB. EPTB cases include TB lymphadenitis, pleural TB, TB meningitis, osteoarticular TB, genitourinary TB, abdominal TB, cutaneous TB, ocular TB, TB pericarditis and breast TB, although any organ can be involved. Diagnosis of EPTB can be baffling, compelling a high index of suspicion owing to paucibacillary load in the biological specimens. A negative smear for acid-fast bacilli, lack of granulomas on histopathology and failure to culture Mycobacterium tuberculosis do not exclude the diagnosis of EPTB. Novel diagnostic modalities such as nucleic acid amplification (NAA) can be useful in varied forms of EPTB. This review is primarily focused on the diagnosis of several clinical forms of EPTB by polymerase chain reaction (PCR) using different gene targets.

[Genitourinary tuberculosis in Germany: diagnosis and treatment]

Genitourinary tuberculosis (GUTB) usually results from the reactivation of old, dormant tuberculous diseases by pathogens of the Mycobacterium tuberculosis complex. The diagnosis of tuberculosis of the urinary tract is based on the case history, the finding of pyuria in the absence of infection as judged by culture on routine media and by radiological imaging. A positive yellow egg culture and/or histological analysis of biopsy specimens possibly combined with the polymerase chain reaction (PCR) is still required in most patients to establish a definitive diagnosis of GUTB. Antituberculous drug treatment is based on an initial 2 month intensive phase with three or four drugs daily followed by a 4 month continuation phase with only two drugs. Surgery as a treatment option in GUTB might be indicated in complicated urinary tuberculosis. After antituberculous treatment of GUTB a follow-up surveillance over 5 years is recommended. Although the incidence of GUTB in Germany is relatively low, it is still necessary to impart and deepen scientific knowledge of the diagnosis and therapy of GUTB.

Can tissue PCR augment the diagnostic accuracy in genitourinary tract tuberculosis?

PURPOSE

Conventional methods like smear and culture for Mycobacterium tuberculosis are of limited sensitivity and specificity. Histopathological examination (HPE) for the tissues obtained gives inconclusive diagnosis in the absence of caseous necrosis or stained acid-fast bacilli. This study was conducted to determine the utility of tissue PCR for diagnosing tuberculosis of the genitourinary tract (GUTB) and its comparative evaluation with HPE.

PATIENTS AND METHODS

A prospective study was conducted from January 2006 to August 2009 with 78 tissue specimens (renal, prostate, epididymis, penile and soft tissue) from patients with clinically suspected GUTB. All the samples were processed for both PCR and histopathology.

RESULTS

In 68 (87.1%) samples, results for both PCR and HPE were coinciding. False positivity and false negativity was observed in 5.1% (4/78) and 7.6% (6/78) samples, respectively. With HPE as the gold standard, PCR has shown sensitivity of 87.5% (95% CI 80.1; 91.9) and specificity of 86.7% (95% CI 74.9; 93.8) and positive agreement between two tests was observed as significant (0.7). PCR results were obtained within a mean period of 3.4 days while those of HPE were obtained in 7.2 days.

CONCLUSIONS

Tissue PCR is a sensitive and specific method for obtaining early and timely diagnosis of GUTB. Application of tissue PCR results can augment the diagnostic accuracy in histopathologically labelled granulomatous inflammations.

Rapidly progressive renal failure-a rare presentation of granulomatous interstitial nephritis due to tuberculosis-case report and review of literature

Granulomatous interstitial nephritis (GIN) is a rare manifestation of renal tuberculosis (TB). We report a case of rapidly progressive renal failure (RPRF), granulomatous inflammation of cervical lymph node and GIN as presenting manifestations of TB. Aspiration cytology of cervical lymph node showed granulomatous necrotizing inflammation with acid-fast bacilli (AFB). The renal biopsy and urine specimen did not show AFB. Urine polymerase chain reaction (PCR) for Mycobacterium tuberculosis was positive. We observe that GIN due to TB can present as RPRF and emphasize the value of PCR-based techniques in making a correct diagnosis.

Urogenital tuberculosis: patient classification in seven different groups according to clinical and radiological presentation

PURPOSE

To describe and classify 80 cases of urogenital tuberculosis in seven groups of similar clinical and radiological presentation.

MATERIALS AND METHODS

80 patients (56 males, 70%; median age 34 years; age range 12 to 75) with urogenital tuberculosis were retrospectively reviewed. The patients were divided in seven groups: 1) Bilateral parenchymatous renal lesions; 2) No or minimal changes on radiographic examination; 3) Unilateral renal tuberculosis; 4) Contracted bladder; 5) Contracted bladder with renal failure; 6) Tuberculosis on a transplanted kidney; 7) Isolated genital tuberculosis.

RESULTS

1) Seven (8.8%) patients had multiple bilateral parenchymatous renal lesions with fever and malaise, characteristic of miliary tuberculosis. Three of these patients had AIDS. 2) Six (7.5%) cases had an early diagnosis, with minimal or no radiographic lesions. Two did not have any urologic symptoms. 3) Twelve (15%) patients had unilateral renal tuberculosis with partial (1 case) or total non-function kidney. 4) Thirty-seven (46.3%) patients had contracted bladder associated with unilateral partial (1 case) or total non-function kidney. 5) Ten (12.5%) patients had end stage renal disease due to tuberculosis with contracted bladder. 6) Four (5.0%) patients had tuberculosis on a transplanted kidney, with graft loss in half the cases. 7) Four (5.0%) patients had prostate or epididymis tuberculosis without associated renal lesion.

CONCLUSIONS

Urogenital tuberculosis is a destructive disease of the urogenital tract with variable clinical and radiographic presentation. A classification according to similar patterns correlating with disease stage is feasible although early diagnosis is the only prevention of the most severe forms.

Late diagnosis of extra-pulmonary tuberculosis leads to irreversible kidney failure in a non-immunocompromised patient

We report a case of extra pulmonary tuberculosis with multiple localizations including bone and kidney in a 21-year-old Pakistani immigrant living in Belgium. Late diagnosis of tuberculosis may lead to end stage renal disease and dialysis. Countries with low prevalence of tuberculosis should be vigilant towards high risk groups for tuberculosis because this preventable and curable disease may lead to devastating complications when diagnosed late.

TB or not TB?: a case of isolated testicular TB with scrotal involvement

Despite the genitourinary tract being the most common site affected by extrapulmonary TB, isolated testicular TB remains a rare clinical entity. In patients with co-morbidities such as hepatic impairment, treatment proves a challenge, as first-line hepatotoxic pharmaceuticals are contraindicated. Here, we report a case of isolated testicular TB with scrotal involvement, on a background of hepatic dysfunction.

Current survey of urinary tuberculosis in Hokkaido, Japan

Urinary tuberculosis has been rare in recent years and its diagnosis is difficult because there are no disease-specific symptoms. We tried to clarify the occurrence of urinary tuberculosis in recent years in our area. During the past 5 years, there were 12 patients with urinary tuberculosis in the clinics that participated in this study. Their chief complaints were frequent voiding in 7 patients and gross hematuria in 3 patients. They were diagnosed by nucleic acid amplification tests and imaging modalities such as excretory urography, computed tomography, and/or cystoscopy. Most of the patients received multidrug treatment and had relatively favorable treatment outcomes. There has been a small but neglected number of patients with urinary tuberculosis in recent years. We should keep this rare and difficult-to-diagnose disease in mind and suspect it when patients complain of longstanding urinary symptoms with no obvious cause.

Clinical relevance of nucleic acid amplification test for patients with urinary tuberculosis during antituberculosis treatment

The nucleic acid amplification test (NAAT) has been valuable in the diagnosis of urinary tuberculosis; however, no studies have attempted to determine the significance of NAAT post treatment. We encountered three patients with urinary tuberculosis who underwent sequential NAAT during antituberculosis chemotherapy and post treatment. All patients were diagnosed as having urinary tuberculosis by positive NAAT and specific renal deformity revealed by imaging. In two of the three patients, positive culture results were obtained and one was negative in standard culture. During antituberculosis chemotherapy, a negative NAAT was obtained from 3 to 5 months after the start of treatment and no positive culture results were obtained during the same period. At the end of chemotherapy, 6 months or more after the start of medication, all patients had negative NAAT results. These results suggest that NAAT for Mycobacterium tuberculosis provides an effective and rapid detection method for urinary tuberculosis both pre- and post-treatment.

Molecular diagnostics in tuberculosis

Molecular diagnostics in tuberculosis has enabled rapid detection of Mycobacterium tuberculosis complex in clinical specimens, identification of mycobacterial species, detection of drug resistance, and typing for epidemiological investigation. In the laboratory diagnosis of tuberculosis, the nucleic acid amplification (NAA) test is rapid and specific but not as sensitive as culture of mycobacteria. The primary determinant of successful NAA testing for tuberculosis depends on the shedding of mycobacterial DNA in secretions from caseating granulomas and its dissemination into sterile body fluids or tissue biopsies. In multibacillary diseases with a high mycobacterial load, a positive Ziehl-Neelsen smear with a positive NAA test is diagnostic of active tuberculosis, whereas a positive Ziehl-Neelsen smear with a negative NAA test in the absence of inhibitors would indicate nontuberculous mycobacterial disease. The role of the NAA test is more important in paucibacillary diseases with low mycobacterial loads. The presence of polymerase chain reaction (PCR) inhibitors, however, especially in extrapulmonary specimens, may produce false-negative results. Although this problem can be overcome to some extent by extra extraction steps, the additional processing invariably leads to the loss of mycobacterial DNA. To circumvent this problem, a brief culture augmentation step is carried out before the NAA test is performed, which can enhance the mycobacterial load while concomitantly diluting inhibitors, thereby maintaining the sensitivity of the test without excessively increasing turnaround time.

EAU Guidelines for the Management of Genitourinary Tuberculosis

Nearly one third of the world's population is estimated to be infected with Mycobacterium tuberculosis. Moreover, tuberculosis is the most common opportunistic infection in AIDS patients. Genitourinary tuberculosis is not very common but it is considered as a severe form of extra-pulmonary tuberculosis The diagnosis of genitourinary tuberculosis is made based on culture studies by isolation of the causative organism; however, biopsy material on conventional solid media may occasionally be required. Drug treatment is the first line therapy in genitourinary tuberculosis. Treatment regimens of 6 months are effective in most of the patients. Although chemotherapy is the mainstay of treatment, surgery in the form of ablation or reconstruction may be unavoidable. Both radical and reconstructive surgery should be carried out in the first 2 months of intensive chemotherapy.

Epididymal tuberculosis: Case report and review of the literature

The incidence of tuberculosis (TB) is increasing worldwide, with more than 20% of cases exhibiting extrapulmonary manifestations. The genitourinary tract is the most common site of extrapulmonary TB. Epididymal TB, although rare, may be the initial location of infection and may cause infertility. The diagnosis depends on culture of the organism but has been facilitated by the development of urine polymerase chain reaction analysis. Treatment for TB remains the combination of three or four anti-TB drugs for 6 to 9 months. Genitourinary TB remains relatively rare in the United States and requires a high index of suspicion to make the diagnosis.

Evaluation and selection of potential live kidney donors

PURPOSE

Renal transplantation is an optimal therapy for patients with end stage kidney disease. A thorough evaluation of potential donors is necessary to provide the best functional outcome for recipients and ensure no or minimal morbidity for donors.

MATERIALS AND METHODS

Between 1992 and 2001, 1661 ABO compatible potential living donors were evaluated clinically as well as by laboratory and imaging studies.

RESULTS

Of 1661 potential donors 814 (49%) were excluded. The reasons for elimination were general medical reasons in 34.4% of cases, nephrological disorders in 25.6%, urological diseases in 11.7% and immunological causes in 16.2%. Exclusion on an ethical basis accounted for 12.2% of cases.

CONCLUSIONS

Although kidneys from living donors provide the best functional outcome, 50% of potential candidates must be excluded.