International Journal of Urology
Blackwell Publishing AsiaMelbourne, AustraliaIJUInternational Journal of Urology0919-81722005 Blackwell Publishing Asia Pty LtdJanuary 20061316768Case Report
Renal tuberculosis with hepatic involvement
Correspondence: Hemendra Shah MCh DNB, Department of
Urology, J.J. Hospital and Grant Medical College, Byculla,
Mumbai, Maharashtra, India. Email:
Received 15 September 2004; accepted 15 March 2005.
Renal tuberculosis simulating xanthogranulomatous
pyelonephritis with contagious hepatic involvement
HEMENDRA N SHAH, PRITESH JAIN AND PERCY J CHIBBER
J.J. Hospital and Grant Medical College, Urology, Mumbai, Maharashtra, India
a non-functioning kidney. Renal tuberculosis is a major cause of morbidity in developing countries. Despite recent advances in
diagnosis, it is sometimes difficult to differentiate renal tuberculosis preoperatively from XGPN. We present herewith a case report
of a patient who was preoperatively diagnosed with a right non-functioning kidney due to renal calculus with stage 3 XGPN and
adjacent liver abscess on computed tomography. Subsequent histopathological examination of the nephrectomised specimen
revealed renal tuberculosis. To our knowledge this is the first case of renal tuberculosis spreading to the liver and causing liver
abscess formation which was misdiagnosed as XGPN preoperatively.
Xanthogranulomatous pyelonephritis (XGPN) is a chronic renal infection typically associated with nephrolithiasis and
hepatic abscess, renal tuberculosis, xanthogranulomatous pyelonephritis.
Despite recent advances in diagnosis and treatment of
tuberculosis, it remains a major cause of morbidity in
developing countries. Developed countries are also facing
a resurgence of tuberculosis due to the increasing preva-
lence of HIV infection. We present herewith a case report
of a 28-year-old male patient with right renal calculus and
non-functioning kidney. His computed tomography (CT)
scan revealed findings suggestive of stage 3 xanthogranu-
lomatous pyelonephritis (XGPN) and adjacent liver
abscess. Renal tuberculosis was found on histopathological
examination of the nephrectomised specimen.
A 28-year-old man presented with dull aching right flank
pain of 2-years duration. He denied the presence of any
associated urological or constitutional symptoms. There
was no past history of any medical or surgical illness
including tuberculosis. He was immunized at birth with the
bacillus Calmette-Guérin (BCG) vaccination for tubercu-
losis. His physical examination was unremarkable. Urine
examination revealed 8–10 pus cells/high power field.
Urine culture was sterile. Routine hematological and bio-
chemical investigations were within normal limits. There
was no polymorphonuclear leukocytosis. Abdominal
sonography was suggestive of a 1.5 cm calculus in the right
kidney with altered echo texture of renal parenchyma. The
liver showed a 5.5 cm
8.5 cm ill-defined hypoechoic
lesion that was inseparable from the upper pole of the right
kidney. The right kidney was not visualized on intravenous
pyelography (Fig. 1). A CT scan (Fig. 2) to define the liver
lesion revealed findings suggestive of Malek Stage 3
XGPN. The right kidney was contributing 4% of the total
renal function on diethylene triamine pentacetic acid renal
scan. The patient underwent right nephrectomy with drain-
age of the liver abscess through a transperitoneal flank
approach. Intraoperatively there were dense perirenal adhe-
sions, and the liver abscess was in continuity with the
upper pole of the kidney. Postoperatively the patient had
persistent sterile purulent discharge of approximately 50–
100 mL/day from the drain. The histopathological exami-
nation of the nephrectomised specimen revealed tubercu-
lous pyelonephritis with acid-fast positive bacilli (Fig. 3).
The patient was started on standard four drug antitubercu-
lar therapy that included four drugs for the initial 2 months
followed by two for the remaining 4 months. The initial
drugs were 5 mg/kg isoniazid orally once daily, 10 mg/kg
rifampicin orally once daily, 25 mg/kg pyrazinamide orally
in two divided doses daily and 15 mg/kg ethambutol orally
once daily. For the remaining 4 months isoniazid and
rifampicin were administered daily in the described doses.
The discharge gradually decreased and stopped after
10 days of antitubercular treatment. The patient is now
asymptomatic at 2 years follow up.
Xanthogranulomatous pyelonephritis is a rare, severe,
chronic renal infection typically resulting in diffuse renal
destruction. Most cases are unilateral and result in a non-
functioning, enlarged kidney associated with obstructive
uropathy secondary to nephrolithiasis. It is also referred to
as replacement lipomatosis.
Malek and Elder divided it into three extents of retro-
peritoneal involvement: (i) kidney alone; (ii) kidney and
perinephric fat; and (iii) kidney, perinephric fat and
adjacent retroperitoneal structures.
standard of care in management of this condition.
Renal tuberculosis is known to have varying presenta-
tion with its symptoms and signs varying in both intensity
and duration. Most tubercular non-functioning kidneys
Both renal tuberculosis and XGPN may show thicken-
ing of the perirenal fasciae and spread of inflammation into
Nephrectomy is the
the adjacent organs. Hence in some cases it becomes
difficult to differentiate XGPN from renal tuberculosis.
. reported the ultrasonography, CT and
magnetic resonance imaging findings of a case of renal
tuberculosis mimicking XGPN.
of XGPN mimicking renal tuberculosis
XGPN associated with renal tuberculosis.
Xanthogranulomatous pyelonephritis was suspected in
our patient clinically due to the typical findings of renal
stone with non-functioning kidney on intravenous pyelog-
raphy. The diagnosis was supported by the findings of a CT
scan. However, to our surprise, postoperative histopatho-
logical findings were suggestive of renal tuberculosis. It
was due to tuberculous infection that the patient had post-
operative sterile purulent discharge from the drain site for
approximately 3 weeks and subsided only after the initia-
tion of specific antitubercular treatment. To our knowledge
this is the first case of renal tuberculosis spreading to the
liver and causing liver abscess formation which was mis-
diagnosed as XGPN preoperatively.
There is a report of a case
and a localized
1 Malek RS, Elder JS. Xanthogranulomatous pyelonephritis:
a critical analysis of 26 cases and of the literature.
Izbudak-Oznur I, Sozen S, Isik S. Renal tuberculosis mim-
icking xanthogranulomatous pyelonephritis: ultrasono-
graphy, computed tomography and magnetic resonance
Turk. J. Pediatr.
Gol’fel’d IL, Drobner VL, Khenkin SKh, Kuraeva LI,
Min’kovich LD. Xanthogranulomatous pyelonephritis sim-
Urol. Nefrol. (Mosk)
Saissy JM, Abounidane A, Benomar S. Localized xan-
thogranulomatous pyelonephritis associated with renal
: 2194–5. (In French.)
with a non-visualized kidney and normally functioning left
Intravenous urography showing right renal calculus
Kidney is surrounded by low attenuation collection (10 HU)
with perinephric stranding and adjoining liver abscess.
Computed tomography showing right renal calculus.
tuberculous granulomas with Langhans giant cells. Haema-
A histopathological section from kidney showing the