泌尿生殖系統結核併呼吸衰竭之病例報告

彭致凱、何承儒、王紹全、陳文榮、謝佐宜、楊旻鑫、宋文瑋、陳順郎

中山醫學大學附設醫院 泌尿科

A case report of urogenital tuberculosis with associated respiratory failure

Chih-kai Peng, Cheng-Ju Ho, Shao-Chuan Wang, Wen-Jung Chen, Tuzo-Yi Hsieh, Ming-Hsin Yang, Wen‑Wei Sung, Sung-Lang Chen

Department of Urology, chung shan medical university hospital, Taichung, Taiwan

Urogenital tuberculosis is responsible for 30% to 40% all extra-pulmonary TB and complicated 4% of patients with pulmonary TB. With kidneys being the most commonly involved site, ureteral and bladder tuberculosis is secondary to descending infection through the urinary collecting system. Urogenital tuberculosis patients usually present with nonspecific symptoms such as pyuria, dysuria, and fever. The current literature is going to present an asymptomatic urogenital tuberculosis case which initially mimicked as occult malignancy and later developed into disseminated tuberculosis after urological intervention.

A 63-year-old male was referred to our department due to abnormal findings on abdominal computed tomography (CT) examination. He had rheumatoid arthritis and chronic hepatitis C virus infection history, but without regular follow up and medication. His physical examination was unremarkable. Laboratory investigation including renal function and liver function test were normal. Urinalysis demonstrated urinary pH 5.5, leukocytes >=100, protein 1+, erythrocytes 3-5, and negative culture of the urine for pyogenic agents. Abdominal CT for his chronic hepatitis incidentally found relative atrophy of left kidney with hydroureteronephrosis, and diffuse thickened enhancing ureteral wall with periureteral fat stranding was noted. Chronic inflammation or occult lesion including urothelial carcinoma cannot be ruled out. Percutaneous nephrostomy drainage for hydroureteronephrosis was performed prior to diagnostic ureteroscopy.

After operation, intermittent fever with tachycardia developed, and progressed dyspnea emerged. Empirical antibiotic was implied, but persistent fever was noted. On post operation day 6, it progressed to respiratory failure. Chest CT revealed consolidation over bilateral lung combined with ground glass opacities distribution, and endotracheal tube was then intubated. Urine culture and blood culture on operation day all showed no pathogen growth. Mycobacterium tuberculosis - polymerase chain reaction (TB-PCR) on post operation day 6 showed positive in urine but negative in sputum sample. In contrast, acid fast stain later showed both positive results of tuberculosis in urine and sputum culture. Pathologic report of ureteroscopic biopsy demonstrated chronic granulomatous inflammation with mixed inflammatory cells and multinucleated giant cells infiltration, compatible with tuberculosis histopathological pattern. Treatment with anti-tuberculosis drug was started and continued, and he discharged on day 57.