? Peak incidence in 20-40 age group worldwide
? Male-female ratio 2:1
? Virulence of mycobacterium strain
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? Cord factor - inhibits granuloma formation
? Sulphatides - impairs macrophage phagocytosis
? Lipoarabinomannan ? inhibits macrophage killing
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? Host factors - immunocompromiseMicrobiology
Mycobacteria
? 2.4 um long x 0.5um wide
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? Non-motile, non-flagel ated? Strict aerobes
? Thick cel wal containing 4 complex layers of approx 50%
lipids
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? Very difficult to stain (hot carbolfuschin)
? Stain is `fast' to acid or alcohol
? Very slow growing ? doubling time 16-20 hrs
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4 mycobacteria strains cause human tuberculous disease? M. tuberculosis
? M. bovis
? M. leprae
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? M. africanumMycobacteria tuberculosis accounts for most of the
disease
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Humans are the only reservoir of the disease
Pathogenesis
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Clinical presentation
? Frequent painless micturition
? LUTS
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? Sterile pyuria, 20% without pyuria? Gross hematuria 10%, microscopic hematuria 50%
? Renal or suprapubic pain
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Renal TB? Renal TB is caused by the activation of a prior blood
borne renal infection
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? Healing process results in fibrous tissue and calcium
salts being deposited
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? Papillary necrosis and strictures in the calyceal stemKUB radiographic view in a patient with left renal tuberculosis with associated calcifications
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Ureter TB? Tuberculous ureteritis is always an extension of the
disease from the kidney
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? Leads to fibrosis and stricture formation
? Site most commonly affected is the ureterovesical
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junction (UVJ)Stricture at the distal left ureter
Bladder TB
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? Earliest forms of infection start around one oranother ureteral orifice
? Healed mucosal lesions have a stellate appearance
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Diagnosis
Urine Examination
? Urine culture (3-5 specimen)
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? Tuberculin Test
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? Radiography
? Plain Radiographs
? Intravenous Urography
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? Computed Tomography (gold standard tool )? Cystoscopy and Biopsy (rarely indicated )
? Retrograde Pyelography
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? stricture at the lower end of the ureter? ureteral catheterization
? Percutaneous Antegrade Pyelography
? Arteriography, Radioisotope Investigation and MRI
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CT after oral contrast medium with bilateral tuberculosis
Management
Antitubercular drugs:
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? Multidrug treatment? 6 to 9 months ( Iseman, 2000 )
? Rifampicin, INH, pyrazinamide, and ethambutol
Surgery
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? Current focus is on organ preservation andreconstruction
? Delayed until medical therapy has been administered
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for at least 4 to 6 weeks
Nephrectomy
? Indications
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? nonfunctioning kidney with or without calcification? extensive disease involving the whole kidney, together
with hypertension and UPJ obstruction
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? coexisting renal carcinoma
Partial Nephrectomy
? Localized polar lesion containing calcification that
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has failed to respond after 6 weeks of intensive
chemotherapy
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? Area of calcification slowly increasing in size and maygradually destroy the whole kidney
Reconstructive Surgery
? Ureteral Strictures: entire stricture should be excised
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? Augmentation Cystoplasty? Urinary Conduit Diversion
? Orthotopic Neobladder