Renal tuberculosis

Introduction to kidney tuberculosis Tuberculosis of kidney occupies an important position in genitourinary tuberculosis. Tuberculosis of other organs of the genitourinary system is mostly secondary to tuberculosis. Therefore, it is necessary to treat genitourinary tuberculosis as part of systemic tuberculosis, as well as tuberculosis in one part of the genitourinary system as part of the overall systemic tuberculosis. Mycobacterium tuberculosis invades the kidneys, first forming lesions in the renal capillary plexus, but does not produce clinical symptoms. Most of the lesions are cured due to increased body resistance. This is called pathological renal tuberculosis. If the number of M. tuberculosis invading the kidney is large, the toxicity is strong, and the body's resistance is low, it can invade the renal medulla and the kidney nipple, and produce clinical symptoms. This is called clinical renal tuberculosis. basic knowledge The proportion of illness: 0.006% Susceptible people: no specific population Mode of infection: non-infectious Complications: cystitis edema hydronephrosis tuberculous bladder spontaneous rupture

Cause of kidney tuberculosis

Reduced immunity (30%):

Humans are easily infected by tuberculosis, but the body's response to infection depends on the number of bacteria and the size of the virulence. On the other hand, it depends largely on the strength of the immunity. Therefore, after the patient is infected with tuberculosis, The response is related to whether there has been any infection or immune response caused by infection in the past. The first infection is called primary infection or primary infection. The infection that occurs after the immune response or delayed allergic reaction has been established in the body is called the primary infection. Infection (post-primary infection) or reinfection, the two reactions in the body are not the same, usually after the first tuberculosis infection for 3 to 4 weeks, with the establishment of cellular immune or delayed allergic reactions in the body, early non-special The heterosexual inflammatory response is replaced by granulomatous tuberculous nodules. The nodules are mainly composed of lymphocytes and macrophages. The center often has caseous necrosis. At this time, 90% of the patients are infected and the dissemination is contained. Although it is infected by tuberculosis, it is not developed into tuberculosis because of its strong immunity. It has no clinical manifestations. Only a small number of children and adults with low immunity can directly develop from primary infection. Tuberculosis.

Tuberculosis metastasis (40%):

Kidney tuberculosis is almost always secondary to tuberculosis infection, and occasionally secondary to bones and joints, lymphatic and intestinal tuberculosis, there are four ways for tuberculosis to reach the kidney, that is, through blood, urinary tract, lymphatic vessels and direct spread, the latter two The infection of the path is relatively rare, only occurs under special circumstances. Transurethral infection is only a spread of tuberculosis in the urinary system. It is not the way in which the tuberculosis initially causes infection in the urinary system. The tuberculosis reaches the kidney through the blood. It is recognized as the most important and most common route of infection, and the bloodstream infection of renal tuberculosis has more chances of simultaneous infection on both sides. However, during the development of the disease, one side of the lesion may be severe, while the contralateral lesion develops slowly if the patient resists The force is reduced and the condition develops rapidly. It may be characterized by severe bilateral renal lesions. Pathological examination proves that more than 80% of the cases are bilateral infections, but in fact, most patients have self-healing of the contralateral mild lesions, so it is clinically seen. Most of the renal tuberculosis is unilateral, accounting for more than 85%, and bilateral renal tuberculosis accounts for about 10% in clinical.

Kidney tuberculosis prevention

In 1989, the US Center for Disease Prevention and Prevention proposed a strategic plan to eliminate tuberculosis within 20 years, using new prevention, diagnosis and treatment methods to eliminate tuberculosis, including:

1. Prevent infection from developing into clinical disease. Use isoniazid 300mg/d or intermittent medication (3 times a week) for 10 to 30 treatments. Close contact with new patients with tuberculosis and other people who may develop tuberculosis Preventive treatment can reduce the incidence of tuberculosis and reduce the spread of disease.

2. Using new techniques to study the species of tuberculosis, specificity, surface antigens, manufacture of monoclonal antibodies, and production of tuberculosis-specific DNA probes for early diagnosis of tuberculosis.

3. Produce a vaccine that is more effective than BCG to enhance immunity and resistance to tuberculosis.

4. To study more effective anti-tuberculosis drugs, and to effectively control tuberculosis through the above new methods, the incidence of kidney tuberculosis will also be reduced or even eliminated.

Renal tuberculosis complications Complications cystitis edema hydronephrosis tuberculous bladder spontaneous rupture

(a) bladder contracture

1. Causes and pathological changes of bladder contracture: Mycobacterium tuberculosis from kidney tuberculosis often invades the bladder repeatedly, causing severe tuberculous cystitis, causing congestion and edema in the bladder muscle layer of the bladder, tuberculous nodules, tuberculosis ulcers, Tuberculous granulation, a large number of lymphocytic infiltration and fibrous tissue formation, and finally cause bladder contracture, after the bladder contracture, the bladder wall loses normal elasticity, the capacity is significantly reduced, it is generally believed that the capacity of the contracture bladder is below 50ml, and in severe cases, the bladder can be shrunk to A few milliliters of volume, because the bladder is repeatedly infected by Mycobacterium tuberculosis, the pathological changes in the bladder are acute and chronic, the coexistence of inflammation and fibrosis, the incidence of bladder contracture according to 837 cases of renal tuberculosis in Shanghai Zhongshan Hospital The statistics are 9, 67%.

2, the symptoms of bladder contracture: bladder contracture caused by the bladder capacity significantly reduced, the patient appears urinary frequency phenomenon, because the process of contracture is gradually occurring, so the frequency of urination is gradually increased, the number of urination can be from more than ten to dozens of times a day, or even One minute of urination, the patient feels extremely painful, because the contracture bladder is often mixed with acute tuberculous inflammation, and even combined with non-specific bacterial infections, so in patients with frequent urination, non-specific infections and acute tuberculous inflammation should be resistant. The control of inflammation and anti-tuberculosis drugs is the true bladder volume and urinary symptoms. In addition, bladder contracture can often affect the ureter of the interstitial segment by the change of tuberculosis around the ureteral orifice, causing the sphincter function of the ureteral orifice to be destroyed, resulting in "closed incomplete" phenomenon. Causes ureteral reflux during urination, resulting in ureteral dilatation, hydronephrosis, urinating during this period of patients, urine in the bladder can be emptied, urine in the ureter, urinary urinary bladder immediately fills the bladder and urinate again, so there is a urine Severe discharge or intermittent urination should also be considered as a contracture of bladder contracture , Must be checked further clarify, bladder contracture other ureteral orifice may be generated and / or induced intramural ureteral obstruction ipsilateral ureter and hydronephrosis.

3, the diagnosis of bladder contracture: in addition to the above symptoms, must rely on X-ray examination, cystography can show that the appearance of the bladder is significantly reduced, especially delayed urography can also observe the ureteral orifice reflux and contralateral ureter and The expansion of the renal pelvis, at the time of examination should pay attention to the presence of acute inflammation of the bladder, when the bladder has acute inflammation, on the one hand is not suitable for cystography, on the other hand can be stimulated by contrast agent to contract the bladder, causing bladder contracture The illusion should be taken seriously so as not to be misdiagnosed.

(two) contralateral hydronephrosis

Contralateral hydronephrosis is a late complication of renal tuberculosis caused by bladder tuberculosis. According to the report, the incidence rate is 13%. In 1963, 4748 cases of renal tuberculosis, secondary contralateral hydronephrosis accounted for 13. 4%.

Symptoms of contralateral hydronephrosis contralateral hydronephrosis is a late complication of renal tuberculosis, so patients report the clinical symptoms of general renal tuberculosis, and the symptoms of contralateral hydronephrosis depend on the degree of hydronephrosis, lighter The stagnant water can be asymptomatic, physical signs, water can be obvious and severe, abdominal fullness and pain, or waist pain, and a lump in the abdomen or waist.

(C) spontaneous rupture of tuberculous bladder

Spontaneous rupture of the bladder is rare, but tuberculosis is the most common in ruptured cases. There are 10 cases (12, 5%) in 80 cases reported in foreign literature. 15 cases out of 23 cases reported spontaneous rupture of tuberculous bladder, so Clinical attention should be paid.

1. Causes and pathology of spontaneous rupture of tuberculous bladder: The cause of spontaneous rupture of bladder tuberculosis is mainly due to the extensive and serious tuberculosis in the bladder. Tuberculous inflammatory ulcers penetrate deep into the muscular layer and involve the entire lining of the bladder wall. Obstruction, bladder contraction or sudden increase in intra-abdominal pressure can cause spontaneous rupture. The ruptures are mostly in the top or posterior wall, almost all of which are intraperitoneal.

2. Symptoms of spontaneous rupture of tuberculous bladder: spontaneous rupture of the bladder is often an acute onset process. The patient suddenly develops lower abdominal pain without trauma. After the attack, there is no urination or a small amount of hematuria. The abdomen has peritoneal irritation, but because Patients with tuberculous bladder, so before the rupture, there is a history of tuberculosis, symptoms of urinary tuberculosis, and diagnosis of urinary tuberculosis.

3, the diagnosis of tuberculous bladder spontaneous rupture: urinary tuberculosis patients with sudden acute abdomen symptoms, and the following abdomen is obvious, because the bladder rupture, urine continuously into the abdominal cavity, so often have ascites, diagnostic abdominal puncture can be extracted More yellow liquid, catheterization often has no urine outflow, or only a small amount of bloody urine. If the bladder perfusion test is performed in the catheter, the amount of fluid injected may be significantly different from the amount of fluid pumped back, or Reduce (liquid into the abdominal cavity), or significantly increased (abdominal urine is extracted), if the catheter enters the abdominal cavity from the rupture of the mouth, there may be a large amount of urine to be exported, if necessary, X-ray cystography can be diagnosed.

Kidney tuberculosis symptoms Common symptoms Bladder irritation urgency Urinary frequency Urinary pain Hematuria Low back pain Pus hypothermia Night sweats Bladder tuberculosis

There are no obvious symptoms in the early stage, and there is no abnormality in urography. The only important positive finding is that there are a small amount of red blood cells and pus cells in the urine. At this time, M. tuberculosis can be found in the urine. With the development of the disease, the following symptoms may occur. :

1, bladder irritation

This is a typical symptom of renal tuberculosis. About 80% of patients have frequent urination, which gradually increases from 3 to 5 times/d to 10 to 20 times/d. This is because pyuria containing M. tuberculosis stimulates bladder mucosa or mucosal ulcer. Late bladder contracture, the capacity is very small, the number of urination can reach dozens of times per day, and even urinary incontinence, urinary urgency and dysuria in the case of urinary incontinence.

2, hematuria

This is another important symptom of kidney tuberculosis. The incidence rate is about 70%. It usually occurs with frequent urination, urgency, and dysuria. Most of them are terminal hematuria. In severe cases, there is a blood clot. It is due to tuberculous inflammation of the bladder. Bleeding caused by bladder contraction during urination, such as tuberculosis of the kidney before bladder disease, is characterized by painless total hematuria.

3, pyuria

The incidence rate is about 20%. There are a lot of pus cells in the urine. It can also be mixed with cheese-like substances. In severe cases, it is rice soup or pus hematuria.

4, low back pain

The incidence rate is about 10%. There is generally no back pain in the early stage, but late tuberculous pus and kidney may cause low back pain. If the contralateral hydronephrosis occurs, there may be contralateral low back pain. A small number of patients may cause renal stenosis due to blockage of the ureter due to blood clot or pus. pain.

5, systemic symptoms

Anemia, low fever, night sweats, loss of appetite, weight loss, etc., bilateral renal tuberculosis or one side of kidney tuberculosis, contralateral hydronephrosis, uremia may occur in the advanced stage, some patients with renal tuberculosis may have hypertension, and may be associated with renal arteriolar stenosis Lead to increased renin secretion.

It is generally believed that the possibility of kidney tuberculosis should be thought of in the following situations: 1 There are symptoms of chronic bladder irritation such as frequent urination, urgency, dysuria, and protein and red in the urine, and white blood cells. 2 Young male patients showed chronic bladder irritation. 3 gradually increased urinary frequency, urgency, dysuria or accompanied by hematuria, anti-infective treatment is invalid. 4 urine is acidic, there are pus cells and ordinary culture without bacteria growth. 5 There are tuberculosis or other extra-renal tuberculosis lesions, a small amount of protein in the urine, and red blood cells in the microscopic examination. 6 physical examination found that the prostate shrinks, hardens, the surface is uneven, epididymis, seminal vesicle hard or vas deferens thickening, scrotum with chronic sinus.

The above is a common manifestation of renal tuberculosis, but a considerable number of atypical cases may not have the above-mentioned performance. For example, in the recently reported group of 349 patients with renal tuberculosis, about 25% of patients have no symptoms or only 1 or 2 of the above. Very mild manifestations, such atypical cases are often difficult to diagnose from clinical manifestations and general laboratory tests, but have the following characteristic characteristics: 1 young and middle-aged patients repeatedly have asymptomatic hematuria. 2 only mild low back pain without bladder irritation, intravenous pyelography (IVU) showed one side of the lower ureter obstruction for unknown reasons. 3 Asymptomatic and accidental physical examination IVU showed that one side of the kidney was not developed. 4 There are only intractable urinary frequency and no other clear reasons. The above performance is very helpful for the diagnosis of renal tuberculosis. However, further comprehensive systematic examination is needed to confirm the diagnosis.

Kidney tuberculosis examination

Laboratory inspection

1, urine routine

About 90% of patients can find abnormal urine, urine is generally acidic, microscopic pyuria and hematuria are the most common, with a small amount of urine protein, urine routine examination is an important clue to early screening of renal tuberculosis.

2, urine smear to find tuberculosis

To take 24h urine or direct smear of the first urine sediment in the morning, for acid-fast staining to find tuberculosis, even 3 times, 50% to 70% of patients can be found tuberculosis, but need to pay attention, if smear Positive, can not be completely determined, because the smear bacteria or other acid-fast bacilli can contaminate the urine, it is morphologically difficult to distinguish from Mycobacterium tuberculosis, leading to false positives, especially can not rely on 1 positive result to diagnose, so collect urine specimens The vulva and urethral opening should be washed to avoid contamination. All anti-tuberculosis drugs should be stopped 1 week before the test to increase the positive rate of urine test.

3, urinary tuberculosis culture

It is an important basis for the diagnosis of renal tuberculosis, and can be monitored for bacterial resistance. It is generally considered that morning urine specimens are better than 24h urine. Because morning urine is easy to collect and there are fewer chances of pollution, it is intermittent because tuberculosis is excreted into the urine. Therefore, before the application of anti-tuberculosis treatment, at least 3 days of morning urine for tuberculosis culture, the positive rate can reach 80% to 90%, some scholars have proposed to collect 6 morning urine culture better.

4, immunology method immunology

The diagnosis is based on the principle of specific reaction between antigen and antibody, to detect antigen, antibody, antigen-antibody complex in serum and urine, which is helpful for the diagnosis of tuberculosis. Commonly used detection methods include radioimmunoassay (RIA) and enzyme-linked immunosorbent assay. (ELISA), Hubei Medical College used ELISA to measure tuberculosis antibody to diagnose renal tuberculosis, the coincidence rate with pathological diagnosis was 82%. If the simultaneous determination of antigen and antibody positive rate reached 96, 5%, it was close to tuberculosis culture.

Since the 1980s, molecular biology techniques have been applied to isolate specific DNA plasmids from tuberculosis, and DNA-DNA hybridization directly with specimens has shown that DNA probes are superior to tuberculosis in diagnosing tuberculosis. Accurate and rapid, recently researched successful multi-slurry enzyme chain reaction (PCR) technology, which can amplify specific DNA or RNA in vitro, greatly improving the sensitivity of the test. This method is especially suitable for difficult diagnosis and eager for an early date. Patients undergoing treatment have gradually been promoted and applied in the clinic.

Film degree exam:

Although the diagnosis of tuberculosis can be confirmed in the urine, the location of the lesion, the size of the lesion, the unilateral or bilateral, and the choice of treatment plan depend on further imaging examination.

1, flat film

Urinary plain film can observe the outline, size, position, image of the psoas muscle, kidney, ureter, bladder with or without stones, calcification or foreign body, renal tuberculosis calcification, irregular density, uneven cheese, common tuberculosis Calcification around the cavity wall, round or semi-circular, mostly located in the renal parenchyma, unless extensive renal calcification, tuberculous ureteral calcification is very rare, should be distinguished from schistosomiasis in Egypt, the former is ureteral calcification, ureteral increase Thick and not dilated, and schistosomiasis in Egypt is ureteral calcification, usually with ureteral dilatation and distortion. Sometimes lumbosacral calcification can be confused with renal calcification, and intravenous urography can be performed to further confirm the diagnosis.

In addition, chest and spine films should be taken to rule out old or active lung and spinal lesions.

2, intravenous urography (IVU)

It can not only show the damage of kidney and ureteral tuberculosis, but also understand the contralateral renal function. The early stage of renal tuberculosis is not like worm-like edge. The renal pelvis loses the shape of the cup. In severe cases, the nephron-like necrosis of the renal parenchyma forms a cavity. The department can be narrowed due to tuberculous fibrosis, and even the complete obstruction of the renal pelvis neck is not developed. The localized tuberculous abscess can force the deformation of the renal pelvis to appear. If the kidney is completely destroyed or the ureter is completely obstructed due to the lesion, the kidney may not be developed. The performance of the kidney is "non-functional", but it can not show the degree of renal damage. The ureteral tuberculosis shows ureteral dilatation above the ureteral bladder junction. If the lesion is severe, it shows ureteral stiffness and multiple segmental stenosis. You can understand the bladder condition, whether you have a contracted bladder or bladder spasm.

High-dose contrast-enhanced intravenous urography is an important advance in the study of urinary tract disorders, which can greatly reduce the use of retrograde pyelography in the diagnosis of urinary tuberculosis. If the urography is supplemented by a tomography technique, the diagnosis can be made more Accurate, in addition, the ureter can be dynamically observed under the TV, to understand the ureteral peristalsis and the location and length of the stenosis, to observe the ureteral bladder junction and ureteropelvic junction at the junction with or without obstruction.

3, retrograde pyelography

If intravenous urography cannot be diagnosed, retrograde pyelography can be considered. In early stage of renal tuberculosis, pale yellow miliary tuberculous nodules can be seen in cystoscopy, scattered in the vicinity of the ureteral opening and in the triangle area. Mucosal edema and congestion can be seen in heavier cases. Ulcers, sometimes feasible bladder biopsy, such as the diagnosis of bladder tuberculosis can also indicate the diagnosis of renal tuberculosis, if the bladder is found to be acute tuberculous cystitis changes, bladder biopsy is contraindicated.

In addition, if you want to understand the length of the ureteral stenosis, the degree of obstruction and ureteral dilatation, as well as the need to collect collateral pyelone tuberculosis smear or culture, retrograde pyelography can be performed.

Retrograde pyelography can show tuberculosis of the kidney and ureter as described above. If it is observed dynamically on TV, it is more helpful to make a clear diagnosis and develop a surgical plan.

When the bladder volume is less than 100ml or the bladder disease is severe, the intubation is difficult to be successful, and it is easy to cause bladder perforation or massive bleeding. It is a contraindication for cystoscopy and retrograde angiography.

4, percutaneous nephrolithotomy

Recently, percutaneous nephrolithoscopic angiography is considered to be an important diagnostic method, especially for non-functional kidneys that are not developed by intravenous urography. It is more appropriate to understand the urinary tract above the obstruction site. In cases of enlarged kidney, percutaneous kidney Puncture angiography has the tendency to replace retrograde pyelography. It can be inserted into the enlarged renal pelvis and injected with contrast agent to show the renal pelvis and ureter. It can also extract urine, routinely check and smear to find tuberculosis, and can measure chemotherapy drugs in tuberculosis cavity. Concentration, and can be directly injected into the anti-tuberculosis chemotherapy drug by this technology, but there are bleeding, retroperitoneal infection, tuberculous fistula and other complications.

5, B-ultrasound

It is of little significance for the diagnosis of early renal tuberculosis, but it is very helpful for the diagnosis of existing cavity formation and hydronephrosis. In addition, B-ultrasound is of great significance for monitoring renal lesions and changes in bladder volume during anti-tuberculosis drug treatment. After tuberculosis nephrectomy, regular ultrasound monitoring of the contralateral kidney to develop hydronephrosis, compared with intravenous urography and CT examination, is economical and safe.

6, CT examination

CT examination of early renal tuberculosis has certain difficulties, but the observation of advanced lesions is better than intravenous urography. The late stage of severely damaged non-functional kidneys is not shown in intravenous urography, and no direct signs of any tuberculosis are known. However, CT can clearly show enlarged renal pelvis, renal pelvis, cavities and calcification, and can also show thickened pelvis and ureter of fibrotic wall. The latter is one of the pathological features of renal tuberculosis but difficult to be tested by other existing methods. It was found that CT can also observe the thickness of renal parenchyma, reflecting the degree of destruction of tuberculosis, and provide a reference for determining the surgical approach. In addition, it is difficult to distinguish renal tuberculosis from intrarenal lesions, and CT examination has a great advantage in renal tuberculosis with renal tumor. Therefore, although most cases of renal tuberculosis can be clearly diagnosed without CT examination, CT scan can still be considered for patients with difficult diagnosis.

Diagnosis and identification of renal tuberculosis

diagnosis

Diagnosis can be based on medical history, clinical symptoms, and laboratory findings.

Differential diagnosis

Kidney tuberculosis is the main cause or primary disease of chronic cystitis. Therefore, the disease that needs to be identified by kidney tuberculosis is a common disease that can cause symptoms of bladder inflammation.

1, chronic non-specific infection of the urinary system: non-specific cystitis caused by chronic pyelonephritis has longer-term bladder irritation symptoms, no progressive aggravation, may have fever, low back pain and other acute pyelonephritis episodes, chronic cystitis can be repeated, When it is light and heavy, hematuria often coincides with bladder irritation, and cystitis caused by kidney tuberculosis starts with urinary frequency, gradually worsens, no seizures, and hematuria occurs after a period of bladder irritation. Tuberculous cystitis merges with non-special Heterosexual infection accounts for about 20%, mostly Escherichia coli infection, and pathogenic bacteria can be found in urine culture. Chronic cystitis is generally not an independent disease, and there are often incentives. Comprehensive examination should be performed to exclude tumors, stones, congenital malformations, etc. .

2, urethral syndrome: women often sudden onset of frequent urination, urgency, dysuria and other symptoms, when the time is good, the urine routine examination is negative, so women with bladder irritation should be routinely checked for urine This disease, genital examination can often be found in the hymen or urethral opening and the vaginal opening are close, and there is no vaginal discharge or vaginitis.

3, urinary calculi: hematuria is more than the whole process of hematuria after exercise, blood volume is not much, there are few blood clots, kidney stones are only when the kidney is still pain, seizure can cause renal colic, bladder stones can also cause long-term, chronic bladder Stimulating symptoms, urine routine red, white blood cells, but often interrupted by urinary flow, increased pain in the lower abdomen after urination, etc., mostly in male children or elderly patients, combined with B-ultrasound, X-ray examination can make a differential diagnosis.

4, urinary tumors: often with painless, intermittent gross hematuria as the main symptoms, bladder tumors with infection or advanced can have frequent urination and dysuria and similar to renal tuberculosis, but the age of onset of the tumor is more than 40 years old, hematuria Larger and more blood clots, feasible B-ultrasound, CT and cystoscopy to confirm the diagnosis.

5, chronic nephritis: sometimes kidney tuberculosis was misdiagnosed as nephritis, the latter actually has no bladder irritation, more high blood pressure, urine has a lot of protein and only a small amount of red, white blood cells, granules or white blood cell cast.

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