Disseminated tuberculosis after extracorporeal shock-wave lithotripsy in an AIDS patient presenting with urosepsis

Introduction

Tuberculosis (TB) and HIV co-infection place an immense burden on health care systems and pose particular diagnostic and therapeutic challenges. Infection with HIV is the most powerful predisposing factor for Mycobacterium tuberculosis infection and progression to active disease by increasing the risk of latent TB reactivation twenty-fold; simultaneously, TB exacerbates HIV infection and is the most common cause of AIDS-related death. ¹

Dissemination of urinary TB after performing lithotripsy is a rare entity and to the best of our knowledge only three cases have been reported previously.^2,3 Herein, the authors report a case of undiagnosed HIV in a patient with urinary TB who presented with disseminated TB after performing extracorporeal shock wave lithotripsy (ESWL).

Case presentation

A 41-year-old man presented with fever, chills, urinary retention, dysuria, urge incontinence and lethargy to the emergency room. On physical examination, the patient had an ill appearance, pallor, sweaty skin, a 39.9℃ oral temperature, 90/60 mmHg blood pressure and a respiratory rate elevated to 25/min. A tattoo on his left arm and left-side costovertebral angle tenderness were present on physical examination. He mentioned a two-month history of night sweats, fever and chills; however, no visits to the clinic were made. He had undergone ESWL three weeks prior to admission due to left renal colic caused by renal calculi, which was diagnosed during work-ups for left lower limb oedema. On intravenous pyelography (IVP), 2–3 hyperdense lesions of about 5 mm were observed on the shadow of both kidneys. Additionally, mild irregularity of the bladder wall was seen. Ultrasonography revealed an 8 mm stone in middle calyx of the left kidney and 7−8 stones of 4 mm diameter disseminated throughout other calyces. The upper calyx of the left kidney was dilated. A 4 mm renal stone was also observed in the lower calyx of the right kidney accompanied by three stones in other calyces, and ESWL was performed. Fever and chills remained consistent after lithotripsy and the patient’s general status deteriorated. He had been an injecting drug user (IDU) for five years and had quit for about a year. A six-year history of imprisonment was reported. A positive family history of prostate cancer in his father was noted. On the abdominopelvic ultrasonography performed in the ER, the right kidney showed normal size with no sign of hydronephrosis; however, mild hydronephrosis in the left middle calyx was noted; prostate showed a heterogenous pattern (mostly hypoechoic) with enlarged diameters (4.5 × 5.5 × 6 cm), which was suggestive of prostatitis. CRP was elevated to 36 mg/L (nL = 0−10 mg/L) and ESR level was 88 mm/h (nL = 0−15); anaemia (serum haemoglobin = 9.8), mild leukocytosis (WBC = 12,300) and mild hyponatraemia (130 mEq/L) were observed on blood tests. On urine analysis, a 2+ proteinuria, moderate bacteriuria, pyuria (WBC = many HPF) haematuria (3+, RBC = 15−20 HPF) and glucosuria (3+) were present.

Retention resolved following catheterization and the patient received IV-antibiotic administration. However, the patient remained feverish, therefore the patient was admitted to the infectious ward. The patient was conscious at that time and was able to obey, however aphasia developed after a few days, followed by diminished active movements in his right upper limb and lethargy. Chest X-ray (CXR) lesions were suggestive of miliary TB; chest CT scan was performed and miliary TB was diagnosed (Figure 1(a)). As suggested by the miliary pattern on CXR and to investigate for the aetiology of hypotension and lethargy, brain CT was performed in which two hypodense lesions around the left ventricle were reported and necessitated a brain MRI that showed several hypointense lesions throughout the brain (Figures 1(b) and (c)). As the patient was an IDU, systemic emboli secondary to endocarditis was suspected; consequently echocardiography was performed in which no abnormal finding was detected and all valves revealed normal function. Finally, the diagnosis of disseminated TB with pulmonary, urinary and CNS involvement was established. The patient received four-drug anti-TB therapy accompanied by vitamin B₆. Lethargy remained unchanged and the patient went into a coma with a Glasgow coma scale (GCS) score between 6/15 and 11/15 for five days. Immediate admission to the ICU was made, and his condition improved after a week. During the treatment course, morning urinary and gastric bacillus Koch (BK) tests were performed. Urinary BK was positive for three times. HIV and hepatitis C seropositivity were detected; however, results were negative for hepatitis B surface antigen. Absolute CD₄ cell count was 76 cells/µL (CD₄ %: 11.2%; CD₄ /CD₈ ratio: 0.23). Rheumatoid factor (RF) was positive (+1). PSA result was 1.4 ng/mL (normal range: 0–2.5 ng/mL). Finally, the patient was discharged on a combination of anti-retroviral and anti-TB therapy and monthly visits to the clinic were scheduled. OPEN IN VIEWER

Discussion

To the best of our knowledge, only three reports on disseminated TB after performing ESWL have been published;^2–4 however, none of them occurred in an HIV⁺ patient. Remarkably, the present case is the first report in an AIDS patient. In this case study, a 41-year-old patient presenting with disseminated TB after undergoing ESWL was reported in whom HIV coinfection was diagnosed.

Due to the tear and shear forces of lithotripsy with ESWL combined with cavitation activity, vessels can be damaged, with venules being affected initially followed by rupture of cortical arterioles. ⁵ Urinary TB usually manifests as renal parenchymal scarring on CT; additionally, calcification may be observed in the ureterorenal system. ⁶ However, there was no renal calcification suggestive of renal TB (Figures 2 and 3). In the setting of urinary TB, disruption of vessels leads to consequent haematogenous dissemination. ⁴ In our patient, urosepsis and septicaemia occurred shortly after undergoing ESWL and disseminated TB was diagnosed during evaluation, conferring to the dissemination of a latent urinary TB through blood circulation. In the present case, abdominopelvic sonography revealed a heterogenous pattern with enlarged diameters in the prostate, suggestive of prostatitis. TB of the prostate due to local spread from the urinary tract was proposed, following the diagnosis of urinary TB. Miliary TB, an entity usually seen in immunosuppressed patients, is a consequence of vascular dissemination and can remain undiagnosed until late in the course. In the present case, CXR revealed findings suggestive of miliary TB, which was confirmed by CT scan. OPEN IN VIEWER

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Figure 3.

Kidney, ureter, bladder (KUB) study of the patient with no signs of calcification.

Observation of a pattern indicative of CNS TB on brain MRI raised the question of HIV coinfection and was confirmed by blood tests. Prognosis of tuberculous meningitis (TBM) is strongly correlated to its stage at presentation and varies from a good outcome in Stage I to only 50% survival rate in stage III. Other less important determinants of a poor prognosis include malnutrition, presence of miliary disease, an associated debilitating comorbidity, old age, hydrocephalus and focal neural deficit. As our case was diagnosed with stage III TBM (GCS of 10 or less, with or without focal neurological deficits) ⁷ and due to the presence of HIV-coinfection with a very low CD₄ count (76 cells/µL), miliary TB and malnutrition, a poor prognosis was anticipated. As a result, this case highlights the importance of performing CXR, preoperative screening tests considering the possibility of urinary TB and a blood test investigating for viral markers in high-risk patients before the patient undergoes ESWL, in order to efficiently avoid the risk of TB dissemination and the subsequent morbidity and mortality. Moreover, disseminated TB should be taken into consideration when urosepsis or septicaemia in the setting of prior ESWL in an HIV⁺ patient is manifested and evaluations should be carried out immediately.

In conclusion, obtaining a thorough history and giving attention to predisposing factors of HIV infection and the following reduction in complications and increase in life quality in an HIV⁺ patient is of great value. In a patient diagnosed with ureterolithiasis, a thorough history and physical examination with specific attention to HIV predisposing factors, including a history positive for IDU or imprisonment and observation of a body tattoo on physical examination, should be carried out; serum viral markers should be checked and preoperative screening tests considering urinary TB should be performed.

Finally, if urinary TB is detected, ESWL must be postponed and the patient should receive anti-TB therapy prior to intervention.