Introduction: Renal tuberculosis (TB) is a rare extrapulmonary manifestation that can mimic obstructive pyelonephritis. Diagnosis is especially challenging in immunocompromised patients with overlapping infections and non-specific symptoms. Description: A 78-year-old woman from Bangladesh with myelodysplastic syndrome (MDS), chronic kidney disease (CKD), and recurrent urinary tract infections (UTI) presented with fever, hematuria, and right flank pain. She had recently undergone ureteral stenting for presumed ESBL E. coli pyelonephritis but returned with worsening hydronephrosis and sepsis. She underwent nephrostomy with drainage of purulent material and was treated empirically with meropenem, vancomycin, and fluconazole. Despite this, she remained febrile, encephalopathic, and hypoxic. Her hospital course was complicated by pulmonary edema requiring BIPAP, thrombocytopenia, and hyperbilirubinemia. Although transferred from the ICU, she continued to have fevers of unknown origin (FUO). CT revealed persistent right hydroureteronephrosis with urothelial enhancement. Urine AFB smear returned positive, prompting initiation of RIPE therapy. Despite negative sputum AFB, renal TB was strongly suspected. She became oliguric and was started on CRRT. Worsening respiratory failure required intubation. Bronchoscopy revealed black airway plaques. Urine Histoplasma antigen returned positive, prompting amphotericin B therapy. MTB PCR from urine and sputum confirmed disseminated TB. CNS involvement was suspected due to encephalopathy and MTB PCR positivity, though LP was deferred. Empiric steroids were started. Despite aggressive management, her condition deteriorated and she was transitioned to comfort care. Discussion: This case illustrates the importance of considering renal TB in persistent pyelonephritis with FUO, especially in immunocompromised patients from endemic regions. Negative cultures and antibiotic failure should prompt evaluation for atypical infections. Co-infections and multi-organ involvement complicate treatment and worsen prognosis. Renal TB should be suspected in immunocompromised patients with FUO and persistent urinary symptoms despite broad-spectrum antimicrobials. Early recognition is critical, though outcomes remain poor in disseminated disease.
Mundluru et al. (Sun,) studied this question.