Unusual presentations of urogenital tuberculosis
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The patient is a 44-year-old woman with no medical nor familiar nor surgical history. She was referred by family physician for an isolated right back pain during 5 months with no fever nor haematuria nor deterioration of his general condition. Physical examination revealed no abnormalities. The cytobacteriological examination of the urine (CBEU) showed leukocyturia 200/ml with a negative culture test and no biological inflammatory syndrome.

An abdominal CT-Scan (Fig. 1A) revealed two cystic lesions in the upper part of the right kidney, each one of them measures 2 cm, which becomes heterogeneous and intensely enhanced after injection of a contrast agent.

To better characterize these lesions, a magnetic resonance imaging (MRI) (Fig. 1B) was performed and revealed the presence of 2 masses in the upper pole of the right kidney enhanced only at the periphery after Gadolinium injection associated with dilation of the ureter, renal pelvis and calyces with no obstacle detected.

According to the above suspected radiologic criteria, the absence of genetic diseases and family history of renal cancer, the multifocal lesions and the little age of the patient, the malignancy of the 2 renal lesions was suggested.

A radical laparoscopic trans-peritoneal nephrectomy was performed, the intervention was well tolerated. No complication was noticed and the post-operative procedures were simple.

Histologic investigation of the excised tissues revealed a BCG-induced granulomatous and necrosis inflammation of the renal parenchyma.

No contraindications were established in the pre-treatment assessment and the patient received the anti-Tuberculosis therapy, a quadruple therapy consisting of 4 tablets of HRZE : Isoniazide (H) (75 mg) + Rifampicine (R) (150mg) + Pyrasinamide (Z) (400mg)+ Ethambutol (E) (275mg) for 2 months, followed by a dual therapy based on 4 tablets of HR: Isoniazide (H) (75mg) + Rifampicine (R) (150mg) for 6 months. The dose was adjusted according to the patient's weight. The tablets were taken once a day at a fixed time and in the morning with an empty stomach. The outcome was satisfying with a good tolerability and with no side effects.

The patient showed clinical, biological improvement and the radiological control CT scan showed no further tuberculosis associated lesions.