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.

Poncet's disease (tuberculous rheumatism): two case reports and review of the literature

We report two human leukocyte antigen (HLA) B27-positive cases of urogenital tuberculosis (TB) with asymmetric polyarthritis. Stained smears with Ehrlich Ziehl-Neelsen and polymerase chain reaction (PCR) tests for Mycobacterium tuberculosis complex (MTC) of the ejaculate were positive in both cases, despite negative cultures. Stained smear, culture and PCR results of the synovial fluid for mycobacteria were negative. The patients were diagnosed with Poncet's disease. Polyarthritis was resolved rapidly with anti-tuberculosis treatment. We suggest that in cases with unexplained arthritis and non-articular TB, Poncet's disease should be considered. PCR can be used in the routine diagnostic algorithm when conventional methods fail to identify MTC.

[Disability in patients with urogenital tuberculosis]

The timely diagnosis of urogenital tuberculosis and the early initiation of specific therapy are an essential prerequisite to the maximum maintenance of function of an affected organ and to a good prognosis of the disease. Analysis of 205 history cases in patients with new-onset urogenital tuberculosis who were examined and treated at our hospital in 1999-2003 has revealed advanced destructive urogenital tuberculosis in 56.1% of cases. The able-bodied patients were 58.05%. Medical examination determined disability group II in 27.8%. The able-bodied patients who were recognized to be disabled were 57.89%. Since the highest disability rates (34.15%) among the patients with new-onset urogenital tuberculosis were observed in the group of the most able-bodied age (41-50 years), this condition inflicts a great economic loss. The true disability rates are higher than those observed by us since some patients undergo medical examination in their local tuberculosis dispensaries and fail to be statistically registered at our hospital.

[Active detection of patients with tuberculosis of urinary organs from increased risk groups at the polyclinics of the general therapeutic-and-prophylactic network]

To timely detect tuberculosis of urinary organs (TUO), the authors have proposed a procedure for detecting the disease in increased risk groups. By analyzing 272 cases with TUO and 12 control persons, they established the most important risk factors. The authors have developed a procedure for stratification of contingents and differential measures in accordance with the risk (three degrees). The procedure has shown to be effective.

[Combined clinical forms of pulmonary and extrapulmonary tuberculosis]

60 medical reports of patients with combination of pulmonary and urogenital organs tuberculosis were analyzed. Our study has shown that with heightening sickness rate of all forms of tuberculosis including pulmonary tuberculosis one can notice a slight rise of extrapulmonary tuberculosis. It can be explained first of all by difficulty in diagnosing extrapulmonary tuberculosis and absence of professional watchfulness to a possibility of combination of pulmonary and extrapulmonary tuberculosis. For example, in 45.3% of all cases with no positive effect of antibiotic therapy wasn't taken into account additional diagnostic methods for finding etiologic agent of the pathological process (Mantu test with 2 TU, Koh test with 50-100 TU, biological test, plan X-ray film of lungs, ultrasonic diagnostics of visceras, urine inoculation for MBT before treatment) and patients often were found with advanced tubercular process as in lungs so in urogenital organs.

[The epidemiological and clinical aspects of extrapulmonary tuberculosis in children and adolescents in Primorsk Region]

The incidence of extrapulmonary tuberculosis has been studied in children and adolescents in the Primorye Territory in 1996 to 2001. There is a decrease in the incidence and prevalence of extrapulmonary tuberculosis in both children and adolescents, which does not reflect the true situation as the process is more frequently diagnosed on their referral in the period of late clinical manifestations. Young age children have fallen ill more frequently (54.7%); 76% of the patients were identified on their referral. Most children are permanent residents and live in the high- and middle-class families. In the clinical pattern, there were predominant ostcoarticular forms of tuberculosis running with a complication of the underlying disease in 80%. The study suggests that there are great gaps in the detection of extrapulmonary tuberculosis in children.

Tuberculosis in Egyptian kidney transplant recipients: study of clinical course and outcome

BACKGROUND

Tuberculosis (TB) is an important infection encountered post-transplantation especially in developing countries, with high incidences of morbidity and mortality. In this report, we study the risk factors and impact of TB on the outcome of kidney transplantation.

METHODS

Of 1200 live-donor Egyptian kidney transplantations, 45 (3.8%) patients developed post-transplant TB. Of these, five had had TB pre-transplantation and 40 were male. The mean age was 32.6 +/- 10.5 years. Primary immunosuppression treatment for 39 (86.7%) patients was cyclosporine (CsA).

RESULTS

The mean time interval between transplantation and TB diagnosis was 49.8 +/- 41.5 (range 2-180) months. In 86.7% of patients, TB was diagnosed one year post-transplantation. Urinary TB was the most common form (53%), while pleuropulmonary TB accounted for 38%. All post-transplant TB patients received a triple anti-tuberculous therapy (rifampicin, ethambutol and INH) with a favorable response in all but two patients who needed another 24-month course. Hepatotoxicity was seen in 11 patients, eight were mild with normalization after temporary withdrawal of rifampicin, and three cases were severe, but mortality was not attributable to hepatocellular failure. Twelve patients died, 11 of them due to unrelated causes. Chronic rejection occurred in more than half of the patients (55.6%), of whom 24 (96%) were CsA-treated, which can be attributed to rifampicin/CsA interaction. More than 35% of TB patients lost their graft as a result. Pre-transplant tuberculosis patients had a comparable post-transplant course.

CONCLUSIONS

TB is a common infection in renal transplant recipients with a peak incidence occurring one year post-transplant. Chronic rejection is a serious complication that had a negative impact on the graft survival, especially in CsA-treated recipients. INH prophylaxis is safe in pre-transplant TB. The post-transplantation outcome in the pre-transplant tuberculosis patients is no different from non-TB patients.

Genitourinary tuberculosis: a review of 174 cases

In 174 cases of genitourinary tuberculosis diagnosed and treated in our clinic we evaluated, retrospectively, age and sex distributions, symptoms, physical and laboratory findings, primary focus, surgical and medical treatments. Flank pain and non-specific urinary complaints, e.g. dysuria, were the major symptoms. Although some authors prefer short-term medical therapy for the treatment of genitourinary tuberculosis, the relapse rate in our series after 12 months of therapy was 19% and we therefore suggest that therapy should be continued for at least 12 months. The poor nutritional status and social conditions characteristic of subjects from our region may, however, have influenced this high relapse rate.

[Extrathoracic forms of tuberculosis in Mahajanga hospitals (Madagascar)]

Pathological samples issued from patients suspected of extrapulmonary tuberculosis were examined in Laboratories of Mycobacteria and of Histopathology at the Androva Hospital in the University Hospital Centre of Mahajanga. A retrospective study was carried out from 1989 to 1993. During this period, 64 cases of extrapulmonary tuberculosis were recorded. Samples came from Androva Hospital, from Lutherian Hospital of Antanimalandy and from the Medical Centre of Mahabibo. The sex-ratio was of 1.28/1, mean age was 28 years old (extreme ages: 1-78 years old). The diagnosis was confirmed by bacteriological and/or histopathological examinations. Ganglial tuberculosis were the most frequent (53.1%), then digestive tract tuberculosis (20.2%) and anal fistula tuberculosis (14%). In front of chronic lesions, biopsies must be performed to obtain confirmation of diagnosis.

Non-pulmonary tuberculosis

Tuberculosis (TB) is a serious disease of global importance, with a rising incidence in the developed world in recent years. Tuberculous lymphadenitis, tuberculous meningitis, osteoarticular tuberculosis and miliary tuberculosis are some of the more well-recognised manifestations of non-pulmonary TB in childhood. The diagnosis of non-pulmonary TB poses a particular challenge for clinicians because of the protean ways in which the disease presents. The omission of tuberculosis from the differential diagnosis of patients with obscure illnesses and the relatively insensitive bacteriological methods for detecting Mycobacterium tuberculosis add to the complexity of the problem. A high index of suspicion is required in order to avoid delays in diagnosis which may influence treatment outcome. The advent of DNA amplification techniques such as the polymerase chain reaction may herald a promising new era in the prompt and accurate management of extrapulmonary tuberculosis.

[Extrapulmonary tuberculosis in children in Russia (epidemiology, clinical forms and their study)]

The paper provides the data of comprehensive epidemiological and clinical studies made at the Clinic of Tuberculosis in Children and Adolescents. Research Institute of Phthisiopulmonology, I. M. Sechenov Moscow Medical Academy, Ministry of Health of the Russian Federation, in the past 15 years and dedicated to extrapulmonary tuberculosis in children and adolescents with tuberculosis. Due to the specific features of manifestations of extrapulmonary tuberculosis in childhood and adolescence and to the existing system of prevention and early detection of the disease in children and teenagers in the Russian Federation, the number of children with severe generalized extrapulmonary tuberculosis is not on the rise despite that the epidemiological situation has aggravated in the past 15 years. The clinical features of most common forms of extrapulmonary tuberculosis are shown and measures for their monitoring proposed.

Does tuberculosis after kidney transplantation follow the trend of tuberculosis in general population?

Despite improvement in graft survival, infection continues to be an important cause of morbidity and mortality after kidney transplantation. We analyzed the clinical courses and outcomes of 16 transplanted patients with positive cultures for mycobacterium tuberculosis. In the course of a 20 year period, there were 13 cases of tuberculosis registered that developed in 456 patients who underwent kidney transplantation in our department, and in three refugees transplanted in other centers (a prevalence of 3.13%). Five of them developed tuberculous infections during 1997. Five patients had residual tuberculosis in preoperative chest X-ray, and specific pyelonephritis as an underlying kidney disease in two of them. All patients with treated with triple immunosuppressives. Before tuberculosis onset, 14 patients experienced one or more episodes of acute rejection and were treated with steroid pulses, ALG or OKT3. Tuberculosis was diagnosed after a period of 1.5 months to 10 years after transplantation. At the time of an infection, the graft function was normal in eight patients and chronic graft failure was evident in eight patients (sCr 210-700 micromol/L). The infection was pulmonary in 12 patients; urinary in two; disseminated in two; pulmonary and urinary, pulmonary and intestinal, and pancytopenia in one patient. All patients were treated with rifampicin and isoniazid in addition to ethambutol for the first two-month period. Treatment lasted from 1-22 months. With 14 patients favorable microbiological responses were registered. Two patients died within the first six months (both with disseminated disease), and the mortality rate was 14.3%. Throughout the followup period, the graft function remained stable and normal in eight patients who had normal graft function at the time of infection onset. Although six patients recovered, progressive graft failure developed and hemodialysis was restarted in one patient two months after antituberculous therapy introduction, and in two patients three years later. Four patients died 2-14 months after AT therapy withdrawal. The causes of death were severe liver failure, cerebrovascular insult and CMV.

[Epidemiological analysis of extrapulmonary tuberculosis in Shanghai]

OBJECTIVES

To find out the epidemiological characteristics of extrapulmonary tuberculosis (TB) in Shanghai, and to explore value of this surveillance.

METHODS

Distribution of extrapulmonary TB for sex, age and suffering site 1996-1999 were analyzed. In addition, its incidence trend and mortality were also investigated. All registered cases from ten urban districts of Shanghai were included.

RESULTS

The new registration rates of extrapulmonary TB 1996-1999 were 4.65-5.78/100,000. The proportion of extrapulmonary TB to all TB was 9.7%-11.8%. The extrapulmonary TB accounted for 14.1%-17.6% of all death due to TB. The rankings of extrapulmonary TB were as follows: lymph node TB (38.3%), bone and joint TB (19.9%), urinary and genital TB (16.7%), intestine and peritoneum TB (9.1%), cerebral and nervous TB (6.4%). The sex ratio of male to female was 1 to 1.35. The new registration rates of extrapulmonary TB increased with age except that of cerebral and nervous TB was the highest in middle and young age group.

CONCLUSIONS

Surveillance on extrapulmonary TB is an important part of TB surveillance, with significant value for TB control.

[Urinary bladder cancer in patients with tuberculous and post-tuberculous cystitis]

125 patients with tuberculous and posttuberculous cystitis were examined using cytological test of the aspirate from the bladder for atypical cells and histological investigation of the biopsy. Cancer of the bladder has developed in long-term chronic tuberculous or posttuberculous cystitis in 4% of the cases. The best objective method of the diagnosis was histological examination of the biopsy obtained from cancer-suspected sites of the bladder mucosa.

[Urogenital tuberculosis in the Ukraine population]

The prevalence and incidence rates of urogenital tuberculosis in the Ukraine in the past 10 years were studied. They tended to decrease in the first period (1988-1992) and to become stable in the second period (1993-1997), being equal to 10.71 and 1.0 per 100,000. In the past 5 years, the incidence of urogenital tuberculosis tended to increase among urban residents as compared to rural ones. These changes show a total trend in the population living in the radioactively polluted area.

[Epididymal manifestations of urogenital tuberculosis]

The morbidity of tuberculous epididymitis is due to the risk of male infertility secondary to vasal or epididymal obstruction or testicular necrosis. The aim of this study was to emphasize the epidemiological, clinical and therapeutical aspects of tuberculous epididymitis in adult. About eleven cases of epididymal localisation of urogenital tuberculosis, it appears that the diagnosis of the condition is rather difficult and often necessitate pathological exam of a specimen of epididymectomy. In other aspects, if antituberculous drugs are always effective in initial stages, surgery is usually radical, and rarely conservative. The latter procedures are vasovasostomy or vasoepididymostomy whose results are very hazardous.

[Comparison of cases of isolated pulmonary tuberculosis with cases of other localizations of tuberculosis in the course of an active surveillance (Gironde, 1995-1996)]

PURPOSE

Data collected during the years 1995 and 1996 in the course of an epidemiological survey of tuberculosis in Gironde allowed comparison of pulmonary tuberculosis with extrapulmonary localizations, evaluation of the importance of each localization and highlighting of potential risk factors.

METHODS

Patients living in Gironde who had evidence of either clinical, radiological or bacteriological expression of tuberculosis were included in the survey. Statistical comparisons were done using either Pearson's Chi 2 or Fisher's exact test.

RESULTS

The survey included 292 cases subdivided into 183 cases of pulmonary tuberculosis (63%) and 109 cases in which another localization had been diagnosed (37%). Extrapulmonary localizations that were the most often encountered either alone or in association with pulmonary localization were the following: lymphadenopathy (32%), pleural (28%), genito-urinary (12%) and osteo-articular localizations (7%). The survey showed that patients in whom tuberculosis localization was extra-pulmonary were more frequently under 20 years of age or over 60 years of age (P < 0.04). These patients also presented more often with HIV-infection (P < 0.02).

CONCLUSION

Extrapulmonary localizations of tuberculosis should be systematically investigated in young and elderly patients as well as in HIV-infected patients.

[Clinical study on 17 cases of genitourinary tuberculosis]

Between 1987 and 1995, 17 patients with genitourinary tuberculosis were treated at Iwate Prefectural Central Hospital. The incidence of newly diagnosed genitourinary tuberculosis was 17 out of 16,363 outpatients (0.1%) during the 9-year period. Twelve patients had urinary tuberculosis and genital as well as urinary organs were affected in 5. Six (35%) patients presented in their fifties and 5 (29%) each in their forties and sixties. Nine (53%) patients had irritative voiding symptoms as the chief complaint. Only 29% had a known history of extra-genitourinaty tuberculosis. In addition to the standard multidrug chemotherapy, nephrectomy was performed in 5 patients and orchiectomy in 2 with epididymal tuberculosis. The incidence of tuberculosis has recently increased in many parts of our country and more attention should be paid to genitourinary tuberculosis.

[Characteristics of nephrotuberculosis in children, adolescents and young persons]

According to the author, urogenital tuberculosis in children and young subjects occurs in 10% of all the cases with this disease. Antituberculosis service registers 71.2% of cases in preschool children, whereas in schoolchildren 70.4% of diagnoses are made by general practitioners. 90% of nephrotuberculosis cases are detected early, in 85% bacteriological examination.

Factors determining ethnic differences in the incidence of bacteriologically confirmed genitourinary tuberculosis in south east England

In South East England, genitourinary (GU) tuberculosis is a much less common manifestation of non-respiratory tuberculosis in patients of Indian subcontinent (ISC) ethnic origin than in those of European ethnic origin. When considered in relation to all bacteriologically confirmed cases of tuberculosis, both respiratory and non-respiratory, the ethnic difference in the occurrence of GU tuberculosis is much less evident, while there is a highly significant excess of other forms of non-respiratory tuberculosis among the ethnic ISC patients. Unlike other forms of non-respiratory tuberculosis, GU disease tends to occur in an older age range in the ethnic ISC population and, when stratified for age, the ethnic difference in the occurrence of this form of tuberculosis is not significant while that of lymph node tuberculosis remains significantly high. Thus, after elimination of the confounding factor of age, the occurrence of GU tuberculosis is very similar in the two ethnic groups while other forms of non-respiratory tuberculosis differ considerably.

Genitourinary tuberculosis: the importance of early diagnosis and management. Case presentation

Genitourinary tuberculosis is the second most common form of extrathoracic tuberculosis. The most common signs are persistent sterile pyuria in up to 90% of patients, irritative voiding symptoms and painless hematuria in up to 80% of the patients. In Puerto Rico the incidence of tuberculosis is rising, being 9.2 per 100000 population in 1992. A.I.D.S. has had a steady rise since 1983. With the rise in the incidence of both diseases and with the influx immigrants from countries were tuberculosis is endemic we should expect a rise in the number of cases of genitourinary tuberculosis. Chemotherapy is the mainstay of treatment. Surgery is performed less often. Early recognition and management is important to avoid irreversible damage to the genitourinary tract. The cases of a 43 y/o man and a 30 y/o male with A.I.D.S. are discussed.

Extra-pulmonary tuberculosis in Lothian 1980-1989: ethnic status and delay from onset of symptoms to diagnosis

We have retrospectively determined the incidence and delay in diagnosing extrapulmonary tuberculosis (ETB) by ethnic group in Lothian, Scotland, from 1980-1989. One hundred and sixteen (13.3%) of 874 TB notifications were for ETB. Eighty-seven records were available for analysis: 59 with a mean age of 57.9 years (range 10-90) were Caucasian (C) and 28 with a mean age of 30.3 years (range 10-86) were non-Caucasian (NC). There were 42 cases of lymphatic TB; 23 (7M,16F) with a mean age of 62 years (range 10-82) were C and 19 (14M,5F) with a mean age of 29 years (range 10-60) were NC. Lymphatic TB was a significantly commoner ETB site in NC (67.9%) cf C (39%) (P < 0.01). Of 24 cases of genito-urinary TB, 23 (14M,9F) with a mean age of 54 years (range 24-82) were C compared to one NC male aged 29 years. Genito-urinary TB was a significantly commoner ETB site in C (39%) cf NC (3.6%) (P < 0.001). Bone and joint TB was found in 11 (5M,6F) C with a mean age of 55 years (range 28-86) compared to five (3M,2F) NC with a mean age of 36 years (4-47). Five cases of abdominal TB (2C,3NC) were also identified. Delay from onset of symptoms to diagnosis for lymphatic TB was significantly longer for NC (mean 26 weeks, range 0-156) than for C (mean 9 weeks, range 2-28) (P < 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)