Urinary tract tuberculosis misdiagnosed and treated as renal carcinoma in the presence of diffuse interstitial nephritis: a case report

(2022) 16:276 Swed et al. Journal of Medical Case Reports https://doi.org/10.1186/s13256-022-03491-8 Open Access CASE REPORT Urinary tract tuberculosis misdiagnosed and treated as renal carcinoma in the presence of diffuse interstitial nephritis: a case report Sarya Swed1* , Mais Barazi2, Yamane Chawa3, Mahmoud Alhamadeh Alswij2, Leena Abdelwahab Alshareef4, Sami Bitar2, Hazem S. Ghaith5 and Karam R. Motawea6 Abstract Background: Urinary tract tuberculosis (UTTB) is a common form of extrapulmonary tuberculosis (TB) which can infrequently present as renal carcinoma, leading to serious errors in the diagnosis and treatment of UTTB. Case presentation: A 76-year-old Syrian man presented with gross hematuria as the main symptom. A urinary endoscopic examination and pelvic multi-slice computed tomography imaging increased the suspicion of a speared renal mass in the right urinary tract. The patient was treated for renal cancer. After nephrectomy and ureterctomy, the histopathology of the resected mass confirmed the diagnosis of UTTB and interstitial nephritis. Conclusion: This case should serve to increase the attention of clinicians to perform an accurate diagnosis step by step. This is especially important if they have a patient similar to the case described here who presents with a renal mass, to avoid serious results such as the loss of an essential organ system. Keywords: Urinary tract tuberculosis, Pseudotumoral renal tuberculosis, Renal carcinoma Background The bacillus Mycobacterium tuberculosis causes tuberculosis (TB). About one quarter of the world’s population is infected with this bacillus, and it is the leading cause of death due to a single infectious agent and among the top ten causes of death worldwide [1]. There are two types of TB: pulmonary TB, which typically affects the lung, and extrapulmonary TB, which might affect any other organ in the body. Urogenital TB is the third most common form of extrapulmonary TB after lymph node involvement and tuberculous pleural effusion [2]. Urogenital TB usually remains undiagnosed for years because it is a clinically silent disorder. It occurs with a peak incidence *Correspondence: 1 Faculty of Medicine, University of Aleppo, Aleppo, Syria Full list of author information is available at the end of the article in the 20- to 40-year age group and has male:female ratio of 2:1. The typical classical presentation of urinary tract TB (UTTB) involves the whole urinary collecting system (including renal pelvis, calyces, ureters, and bladder). However, kidney parenchymal lesions are less common, including interstitial nephritis and glomerulonephritis [3]. An atypical manifestation is a pseudotumor, which in extremely rare cases is diagnosed and managed as renal cell carcinoma (RCC). The clinical manifestations of a pseudotumor are often nonspecific symptoms, such as pyuria and microscopic hematuria, as well as symptoms related to the bladder, including dysuria, urgency, nocturia, gross hematuria, low back pain, fever, and weight loss. Patients with advanced disease may have end-stage kidney disease and, rarely, refractory hypertension [4]. The diagnosis of urogenital TB depends on the results of urine examination, radiographic imaging studies, tuberculin skin test, interferon-gamma release assay, © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Swed et al. Journal of Medical Case Reports (2022) 16:276 and histopathology. Depending on the findings of these diagnostic measures, management with anti-TB drugs is usually the treatment choice, but surgery may be the preferred choice in some cases. Here we present an extremely rare case reported in the literature that revealed a significant medical mistake in the diagnosis of urogenital TB as RCC. Analysis of the case shows a combination of diffuse and interstitial TB in the same patient. Case report A 76-year-old Syrian man was admitted to the emergency room with a complaint of frequency dysuria and gross hematuria lasting for 6 h. The medical history included hypertension and diabetes mellitus type 2 with no abnormalities. Other medical, family and psychosocial histories were clear. At presentation, the vital signs were stable, and clinical examination revealed that the other organs were normal. Initial hematology tests revealed elevated white blood cell counts (WBCs) (20,000/μL), hemoglobin (HGB) (11 g/dL), mean corpuscular volume (MCV; 82 fl), and platelet counts (254,000/μL), as well as moderate renal insufficiency (creatinine: 1.9 mg/dL; urea: 130 mg/dL). Abdominal echography revealed severe and mild hydronephrosis in the right and left kidney, respectively, with no renal stones or calculus. However, there was a significant thickness in the bladder wall (diameter: 1.5 cm). A cystoscopy was then performed to obtain a biopsy. The histopathology report showed pathological changes, possibly suggesting denuded cystitis, low-grade dysplasia, and severe interstitial cystitis. No invasive tumor was found in the specimen examined. Abdominal and pelvic contrast-enhancing multi-slice computed tomography (CT) revealed the presence of hydronephrosis in the right kidney with a filling defect in the pelvis; this was described as a non-enhancing hypodense area in the pelvis and inferior calyces (Fig. 1). Thoracic CT revealed band-like opacities in the right upper lobe. A primary diagnosis of RCC was made based on the clinical presentation, the laboratory test results, and the imaging investigations. As a result, the patient underwent an open radical right nephrectomy and ureterectomy. The histopathology examination of specimens showed the existence of granulomatous pyelonephritis and necrotizing and caseous centers, which confirmed the correct diagnosis of urinary tract TB (UTTB). The granulomatous inflammation was extended to most of the ureter, pelvis, and calyces. In addition, patchy infiltrations were present in the renal parenchyma accompanied by focal segmen (...truncated)