CASE 16823 Published on 29.06.2020

A rare case of disseminated tuberculosis with putty kidney, ileal stricture and symphysis pubis involvement

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Dr. Nirmal Prasad Neupane1, Dr. Kapil Dawadi2, Dr. Keshika Koirala2, Dr. Ongden Yonjen Tamang3

1Radiologist, Grande International Hospital, Kathmandu, Nepal

2Radiologist, Grande International Hospital, Kathmandu, Nepal

2Resident, Nepal Medical College Teaching Hospital, Kathmandu, Nepal

3Radiologist, Grande International Hospital, Kathmandu, Nepal

Patient

80 years, female

Categories
Area of Interest Abdomen, Gastrointestinal tract, Kidney ; Imaging Technique CT, CT-Enterography
Clinical History

An 80-year-old female presented to the emergency department with a chief complaint of abdominal distension associated with a few episodes of vomiting. No history of abdominal pain or fever was noted. The patient was cachexic and had lost significant weight in the last 6 months. The patient was never operated before for any surgical conditions. No past history of tuberculosis was noted in the patient or in the family members.

Imaging Findings

Contrast-enhanced CT of abdomen and pelvis was done with the suspicion of acute intestinal obstruction. It showed diffuse symmetrical thickening of the terminal ileum with heterogeneous enhancement in the post-contrast study. The thickened segment of the ileum measured approximately 7.2 cm in length and showed maximal wall thickness of approximately 5.2 mm. Narrowing of the bowel lumen was noted in the region. Proximally the ileal and the jejunal loops were dilated suggestive of intestinal obstruction. There was approximately 36.2 cc of collection noted in the mesentery abutting the thickened segment of the ileal loop. Few enlarged enhancing lymph nodes were also noted in the mesentery. The left kidney was relatively small in size and showed diffuse peripheral and cortical calcification. No enhancement of the renal parenchyma was noted in the post-contrast study. The kidney was non-functioning and showed no excretion of contrast. Ill-defined lytic lesions were noted in the pubic bone on either side of the pubic symphysis. Minimal soft tissue component was noted in the region. No associated abscess formation or sinus tract formation was noted. Since the patient had stricture with bowel obstruction and collection in the adjacent mesentery, laparotomy was done. Resected bowel segment was sent for histopathology and it was suggestive of gastrointestinal tuberculosis. For pubis symphysis lesion,  FNAC was done separately and it showed granulomatous inflammation consistent with tuberculosis.

Discussion

Tuberculosis is a multisystem disease and is caused by mycobacterial species. It is one of the major causes of mortality worldwide. Because of the resurgence of TB among the immunocompromised patients and with the development of multidrug-resistant tuberculosis, it is still a disease with global concern [1]. It has a spectrum of presentations and manifestations. TB primarily affects the respiratory system but is known to have a propensity for other systems like genitourinary, musculoskeletal, gastrointestinal and central nervous system [2]. Tuberculous manifestations can range from simple infections to severe life-threatening complications. Here, we present a case of an elderly patient with concomitant genitourinary, gastrointestinal and musculoskeletal tuberculosis. Genitourinary tuberculosis can involve the kidneys (parenchymal granulomas, papillary necrosis, infundibular and calyceal strictures), ureters (multifocal ureteric strictures, granulomas), urinary bladder (bladder calcification, thimble bladder) and the male and female genital organs. End-stage renal manifestations can present as a small kidney with dystrophic calcification hat is commonly referred to as putty kidney [3]. Ileocaecal tuberculosis is the most common form of intestinal tuberculosis. There is thickening of terminal ileum and caecum with pulled up caecum and associated necrotic lymph nodes [4]. Mesenteric abscesses and intestinal fistulas can occur as complications of tuberculosis. The symphysis pubis is a relatively uncommon site of musculoskeletal tuberculosis and only a few cases have been reported before [5]. It can present as lucent bony lesion with erosions and associated abscess or sinus tract formations [6]. A high index of suspicion and meticulous evaluation can help us in making an early diagnosis in cases of multi-system involvement of tuberculosis. This can not only lead to prevention of the complications but can also guide us in the early start of anti-tubercular therapy preventing the morbidity and mortality associated with dissemination of tuberculosis.

Take home message: Concomitant multisystem involvement of tuberculosis can pose a diagnostic challenge if not meticulously evaluated. High index of suspicion and proper imaging can help in early diagnosis and proper treatment of patients with disseminated tuberculosis. Significant reduction in morbidity and mortality can occur with proper diagnosis and early start of anti-tubercular therapy.

Written informed patient consent for publication has been obtained.

Differential Diagnosis List
Disseminated tuberculosis with multisystem involvement
Crohn’s disease
Xanthogranulomatous pyelonephritis
Osteitis pubis
Final Diagnosis
Disseminated tuberculosis with multisystem involvement
Case information
URL: https://www.eurorad.org/case/16823
ISSN: 1563-4086