"TB - Mindedness"-the only way to beat "the great mimicker": A case series with atypical presentation of female genital tuberculosis.

BACKGROUND: Incidence of Tuberculosis (TB) cases in India reported in 2019 is 193 per 1 lakh population [National Tuberculosis Elimination Plan (NTEP)]. In India, annual extra pulmonary TB burden is 20-25%, of which 4% of cases are of urogenital origin (Revised National TB Control Programme, 2019; World Health Organization, 2019). The Ministry of Health and Family Welfare has made a target of eliminating tuberculosis by 2025 under the NTEP by the process of identification, notification and treatment of cases. Tuberculosis being a leading cause of infertility in developing countries, employing best clinical practices and being "TB-minded" will also save the patient of enormous anxiety and uncertainity and also decrease the time gap between clinical presentation and diagnosis to optimize fertility outcome. METHODOLOGY: A prospective cohort study of cases presenting with unusual findings and ultimately being diagnosed as genital tuberculosis was conducted in the gynaecology OPD, AIIMS, New Delhi, from November 2020 to November 2021 (1 year). Patients were investigated judiciously, diagnosis made and followed up for their response to anti tuberculosis therapy (ATT). RESULTS: This data comprises of conglomerate of ten cases with unconventional exhibition of genital tuberculosis. 70% of the cases presented with pain lower abdomen not specifically related to menstrual cycle and often confused with IBD. Tubo ovarian mass (70%) mimicking as simple ovarian cyst, ovarian carcinoma or endometriosis was the most common clinical finding we came across.

Diagnosis of genitourinary tuberculosis: detection of mycobacterial lipoarabinomannan and MPT-64 biomarkers within urine extracellular vesicles by nano-based immuno-PCR assay.

We detected a cocktail of Mycobacterium tuberculosis lipoarabinomannan (LAM) and MPT-64 biomarkers within urine extracellular vesicles (EVs) of genitourinary TB (GUTB) patients by nano-based immuno-PCR (I-PCR) assay, i.e., magnetic bead-coupled gold nanoparticle-based I-PCR (MB-AuNP-I-PCR) and compared the results with I-PCR and Magneto-ELISA. The size (s) of urine EVs ranged between 52.6 and 220.4 nm as analyzed by transmission electron microscopy (TEM) and nanoparticle tracking analysis. Functionalized AuNPs (coupled with detection antibodies/oligonucleotides) were characterized by UV-vis spectroscopy, TEM, ELISA, PCR, Atomic Force Microscopy and Fourier Transform Infrared spectroscopy, while conjugation of capture antibodies with MBs was validated by UV-vis spectroscopy and Magneto-ELISA. Our MB-AuNP-I-PCR exhibited sensitivities of 85% and 87.2% in clinically suspected (n = 40) and total (n = 47) GUTB cases, respectively, with 97.1% specificity in non-TB controls (n = 35). These results were further authenticated by the quantitative SYBR Green MB-AuNP-real-time I-PCR (MB-AuNP-RT-I-PCR). Concurrently, I-PCR and Magneto-ELISA showed sensitivities of 68.1% and 61.7%, respectively in total GUTB cases, which were significantly lower (p < 0.05-0.01) than MB-AuNP-I-PCR. Markedly, a wide range (400 fg/mL-11 ng/mL) of LAM+MPT-64 was quantified within urine EVs of GUTB cases by SYBR Green MB-AuNP-RT-I-PCR, which can assess the disease dynamics. This study will certainly improve the current algorithms used in GUTB diagnostics.

Utility of laboratory diagnostic tests in women suspected of genital tuberculosis attending a tertiary care teaching hospital.

Background: Genital Tuberculosis is a form of extrapulmonary tuberculosis, which if not diagnosed early can lead to complications. The objective of this study was to determine the sensitivity and specificity of Xpert Mycobacterium tuberculosis/rifampin (MTB/RIF) assay in genital tuberculosis (TB) in comparison with culture as a gold standard. Methods: The results of the Xpert MTB/RIF assay performed from January 2020 to August 2021 were compared with the results of culture by Mycobacterium Growth Indicator Tube (MGIT) 960. Results: Out of 75 specimens, fluorescent microscopy and liquid culture using MGIT and Xpert assay were positive in 3 (4%), 21 (28%), and 14 (18%), respectively. The sensitivity and specificity of the Xpert MTB/RIF assay were 66.67% and 100%. All smear-positive specimens were positive by culture and Xpert assay. Three specimens were positive by all the tests, i.e., microscopy, culture, and Xpert assay. Fifty-four specimens were negative by microscopy, culture, and Xpert assay. Discordance between the results of culture and Xpert assay was observed in seven specimens which were culture positive and Xpert assay negative. Three (21.42%) out of 21 culture-positive specimens showed monoresistance to rifampicin by Xpert MTB/RIF assay and culture drug susceptibility testing. Conclusion: Xpert MTB/RIF assay showed good sensitivity and specificity compared to liquid culture in genital TB. This test is easy to perform, provides results in 2 h, and can also detect rifampicin resistance, which is a surrogate marker for multidrug-resistant TB. Hence, the Xpert assay can be used under the National TB Elimination Program for early and rapid diagnosis of TB in endometrial specimens to prevent complications like infertility.

Correlation of past tuberculosis with current screening for female genital tuberculosis in infertile women in a tertiary care hospital.

OBJECTIVES: To analyse correlation of past history of tuberculosis with present state of infertility with respect to HSG and diagnostic findings, with a view to assess the frequency of genital tuberculosis in infertile women, its clinical presentation and association with infertility. MATERIALS AND METHODS: The study is an ongoing study conducted in the Department of Obstetrics and Gynaecology, Kasturba Hospital, Delhi and included 174 infertile women enrolled as OPD patients in our hospital. A detailed history with special emphasis on past history of tuberculosis, thorough clinical examination, all routine investigations for Infertility & special investigations for genital tuberculosis was done. Diagnostic tests and laparoscopy was further performed as per the protocol. RESULTS: Female genital tuberculosis has been described as a disease of the younger population. The present study shows that 87.9% patients diagnosed for genital tuberculosis were between 20 and 35 yrs of age. It was observed that amongst 174 infertile patients who attended our OPD, 40 patients had a positive history of present or previous incidence of Koch's, pulmonary or extra pulmonary, namely 22.9% (Group I) and the remaining patient comprising 77.1%, who had no record of any previous tuberculosis (Group II). Active Tuberculosis was seen in 5 patients out of a total of 40 females. Out of the total of 174 infertile patients suffering from tubal disorder 52.5% of Group I patients had evidences of tubal disease as compared to only 27.6% in Group II thus suggesting a strong correlation of tubal destruction and subsequent infertility to a positive history of tuberculosis. Out of the 56 laparoscopies performed, it was seen that 75% of Group I patients with past history of TB had abnormal laparoscopic findings (18 out of 24 patients), as compared to Group II which had only 9 out of 32 patients (28%) showing positive pelvic pathology. This seems to be very significant. CONCLUSION: In conclusion the results of the present study validate arguments in favour of incorporating screening for genital tuberculosis as a part of the baseline investigation for all patients of infertility, in countries like ours and especially in such patients who have suffered from Tuberculosis sometimes earlier in their lives.

A case of concurrent gastrointestinal, peritoneal and urinary bladder tuberculosis.

Tuberculosis is a top 10 leading cause of death worldwide. Lungs are primarily involved organs in tuberculosis. The rest of cases are extrapulmonary tuberculosis (14% reported in 2017). Extrapulmonary tuberculosis always presents with non-specific symptoms, thus at risk of delay diagnosis and management. In genitourinary tuberculosis, kidney alone and kidney with urinary bladder or ureter is affected in more than 70% of cases. The ureter and urinary bladder infections are almost always secondary to tuberculous involvement of the kidney. Bacilli haematogenic spreading is a known transmission pathway to the kidney. In this case, we diagnosed isolated urinary bladder tuberculosis caused by direct gastrointestinal tuberculosis infiltration, a rare occurrence of extrapulmonary tuberculosis. We illustrate the multiorgan involvement in tuberculosis infection including pulmonary, gastrointestinal, peritoneal and urinary bladder.

Urological problems in elderly patients of tuberculosis.

Development of tuberculosis is closely linked to poor socioeconomic condition, poor immune functioning and mental health including depression and anxiety. Elderly population becomes an important target group for the disease and deserves special attention. Unique problem with genito urinary tuberculosis (GUTB) in elderly population is the diagnosis. One of the earliest symptoms of GUTB is increased urinary frequency which a large majority in elderly population may already have, owing to their enlarged prostates or an overactive bladder/detrusor over activity mediated centrally or peripherally, which are not uncommon in this group. When left undiagnosed and thereby untreated, GUTB usually leads to irreversible tissue damage and consequences range from abscesses, small capacity urinary bladder to renal failure.

Diagnosis of urogenital tuberculosis by multiplex-nested PCR targeting mpt64 (Rv1980c) and IS6110: comparison with multiplex PCR and GeneXpert® MTB/RIF.

A multiplex-nested PCR (M-nested PCR) targeting mpt64 (Rv1980c) + IS6110 was designed to detect Mycobacterium tuberculosis (Mtb) DNA within urine (n = 35), endometrial biopsies (n = 22) and menstrual blood (n = 3) of male/female UGTB patients, and results were compared with M-PCR using the same targets. Detection limit of the purified Mtb DNA was found to be 1 fg by M-nested PCR, which was 106 -fold lower than M-PCR. Moreover, sensitivities of 100% and 81·8% were obtained in confirmed (n = 5) and clinically suspected UGTB (n = 55) cases, respectively, by M-nested PCR, with a specificity of 97·1% (n = 70). Sensitivities attained by M-nested PCR were significantly higher (p < 0·05) than M-PCR in both clinically suspected and total UGTB (n = 60) cases. To confirm the true PCR-negative results, an internal amplification control, that is, human ß-globin gene (hbb) was incorporated in the M-nested PCR/M-PCR assays, wherein all the clinical specimens (positive/negative for mpt64/IS6110) were found to be positive for hbb. Some UGTB specimens (n = 35) were also subjected to GeneXpert® MTB/RIF assay that revealed a significantly lower (p < 0·001) sensitivity (17·1 vs 88·6%) than M-nested PCR, although high specificity (100%) was attained with GeneXpert. After validating the results in a higher number of UGTB specimens, our M-nested PCR may be translated into an attractive diagnostic kit.

Identification of mycobacterial MPT-64 and ESAT-6 proteins in urogenital tuberculosis patients by real-time immuno-PCR.

Aim: Diagnosis of urogenital tuberculosis (UGTB) is difficult and there is an immediate need to develop a reliable diagnostic test. Methods: A real-time immuno-PCR (RT-I-PCR) was developed to identify a cocktail of MPT-64 + ESAT-6 in both male/female UGTB patients comprising five confirmed cases, 40 clinically suspected cases and 37 non-TB controls, from whom mid-stream urine specimens were collected, while endometrial biopsies of female patients were obtained on day 1 of their menstrual cycle. Results obtained by RT-I-PCR were compared with I-PCR/ELISA and GeneXpert. Results: A wide range (500 fg/ml-10 ng/ml) of MPT-64 + ESAT-6 was detected in UGTB specimens by RT-I-PCR, although ELISA showed a narrow range (2.5-11 ng/ml). Sensitivities of 80% and 82.2% were obtained by RT-I-PCR in clinically suspected and total UGTB cases, respectively, whereas 94.6% specificity was obtained. Concurrently, RT-I-PCR revealed significantly higher (p < 0.05-0.001) sensitivity than I-PCR/ELISA and GeneXpert. Conclusion: After improving the specificity, the authors may develop RT-I-PCR into a diagnostic kit.

Urogenital tuberculosis (UGTB) involves infection of the urinary tract and genital organs of male/female patients by Mycobacterium tuberculosis bacteria. Delayed diagnosis and therapy of UGTB lead to infertility and kidney failure. The routine tests used to detect the bacteria are not very sensitive due to low levels of bacteria present in UGTB specimens. Moreover, most nucleic acid amplification tests, such as PCR tests, give false-positive and false-negative results. The authors designed a real-time immuno-PCR test for detecting a cocktail of M. tuberculosis proteins in UGTB patients that revealed quite promising results, which were superior to immuno-PCR/ELISA and GeneXpert tests. After further improvement in the specificity and reduction of the price, this real-time immuno-PCR test could be used in routine diagnosis.

[Dynamics of the structure of renal tuberculosis over 20 years].

BACKGROUND: Tuberculosis is a serious medical and social problem that does not lose its importance, despite all the advances in pharmacology and surgery. Diagnosis of urogenital tuberculosis (UGTB), as a rule, is delayed due to low index of suspicion to tuberculosis and the absence of pathognomonic symptoms. AIM: Determining the change in the ratio of clinical forms of renal tuberculosis from 1999 to 2020. MATERIALS AND METHODS: A retrospective cohort comparative non-interventional study on the spectrum of the incidence of extrapulmonary tuberculosis (EPTB) was carried out. Among all 13852 extrapulmonary tuberculosis patients which were diagnosed from 1999 to 2020, patients with renal tuberculosis were selected, and the spectrum of their clinical forms in three periods was analyzed: 1st period 1999-2004 (1155 patients), second period 2005-2014 (2657 patients), and the third period 2015-2020 (671 patients). The clinical features of nephrotuberculosis in 88 patients was also estimated. RESULTS: Over the 20 years of the analyzed period, the number of patients with UGTB decreased by 80.6%; for the year of the COVID-19 pandemic, this figure fell by another third. In the first period, destructive complicated forms of nephrotuberculosis prevailed (922 patients - 79.8%), while the so-called "minor forms" were diagnosed in 233 patients (20.2%). In the second period, the situation was statistically significantly more favorable: the proportion of destructive and complicated forms of renal tuberculosis decreased to 43.8% (1124 patients), "small forms" were diagnosed in 1443 patients (56.2%). In the third period, destructive and complicated forms of nephrotuberculosis were diagnosed in 531 patients (77.6%), and the proportion of "small forms" in comparison with the previous period decreased by half, to 22.4%. Analysis of the clinical features of renal tuberculosis, depending on the prevalence of the destruction, showed that an asymptomatic course is possible, and pain, dysuria, intoxication and renal colic are present with different frequencies, and the clinical picture of tuberculosis of the renal parenchyma differs significantly from the clinical picture of tuberculous papillitis, cavernous nephrotuberculosis and symptoms of renal tuberculosis as whole. CONCLUSION: Currently, there is no screening on urogenital tuberculosis at all. Patients are diagnosed by referral, with a long history, after receiving multiple courses of antibacterial treatment; mainly through the pathomorphological examination of the operating material. Thus, a sharp decrease in the proportion of UGTB patients does not mean the disappearance of tuberculosis of this localization, but only states the tragic defects in timely diagnosis and low index of suspicion of medical doctors in relation to UGTB.

[Tuberculosis of the male genital organs].

INTRODUCTION: Tuberculosis of the genitourinary system is still of importance. The observed decrease in the incidence of urogenital tuberculosis is largely due to the inaccuracies of registering this disease. MATERIALS AND METHODS: A retrospective cohort comparative non-interventional study of the structure of urogenital tuberculosis in the Siberian and Far Eastern federal districts was carried out. We analyzed statistical reports from 2003 to 2015, which included data for a total of 456 patients, as well as extended questionnaires compiled specifically for this study. In addition, outpatient records of 95 patients with urogenital tuberculosis who were registered at the Novosibirsk Regional Tuberculosis Dispensary by 01/01/2022 were evaluated. RESULTS: An analysis of the structure of urogenital tuberculosis from 2003 to 2015 showed that urinary system was affected in the most of cases (n=314, 68.8%). Tuberculosis of male and female genital organs took the second place (n=101, 22.2%) patients. Generalized urogenital tuberculosis was diagnosed in 41 (9%) patients. From 2003 to 2008, the proportion of renal tuberculosis increased by 12.6%, but then a significant decrease in its proportion was found (82.2% in 2008 vs. 48.6% in 2015 [2 =12.71; =0.0004]). On the contrary, in 2003 the proportion of genital tuberculosis was 18% (n=18) compared to 29.1% (n=3) in 2015 (2 =3.46; p=0.06). In 2015, generalized forms of urogenital tuberculosis were diagnosed in 23 (22.3%) patients, which is approximately 2.5 times more than in 2003 (n=9; 9%) and 2008 (n=7; 6.6%) (2> 6.46; p<0.01). The proportion of prostate tuberculosis ranged from 0 in 2003 and 7.1% in 2008 to 54.2% in 2013. In 2003, tuberculosis of the scrotum was diagnosed in 100% of men with genital tuberculosis, while in 2013 and 2015 its proportion was 25%. In total, scrotal tuberculosis during whole follow-up was diagnosed in 26 patients, which accounted for 41.9% of all male genital tuberculosis. The combination of tuberculosis of the scrotum and prostate also varied significantly from 17.3 to 35.7%. Generalized urogenital tuberculosis was diagnosed with a minimum proportion (1.4%) in 2008, then there was an upward trend with a maximum rate in 2015 (22.3%, 2 =29.38; <0.0001). Among 95 patients with tuberculosis of the urinary and male reproductive system, who were followed by the phthisiourologist of Novosibirsk Regional Tuberculosis Dispensary, 34 (35.8%) had a diagnosis of kidney tuberculosis, 42 (44.2%) had isolated tuberculosis of the male genital organs, and the remaining 19 (20.0%) men had generalized urogenital tuberculosis. In total, HIV infection was detected in 23 (24.2%) patients with urogenital tuberculosis, and among patients with kidney tuberculosis, it was diagnosed in 7 (20.6%) cases compared to 9 (21.4%) cases in those with male sexual tuberculosis. In patients with generalized urogenital tuberculosis, HIV infection was detected almost 2 times more often, namely in 7 (36.8%) cases. CONCLUSION: Patients with urogenital tuberculosis are under follow-up of urologists for a long time with erroneous diagnoses, and only when the disease becomes irreversible and requires surgical intervention, the pathomorphological study of the surgical material will allow to make a proper diagnosis.

Imaging findings of prostate tuberculosis by transrectal contrast-enhanced ultrasound and comparison with 2D ultrasound and pathology.

OBJECTIVES: This study aimed to investigate the contrast-enhanced ultrasound (CEUS) appearances of prostate tuberculosis (PTB) and its correlation with histopathology. METHODS: Clinical, transrectal ultrasonography (TRUS) and CEUS data of 12 PTB patients confirmed by pathology were retrospectively analyzed, and compared to the pathological findings to identify the pathological structures corresponding to different image enhancement areas. RESULTS: No specific characteristics could be found for the clinical appearances. Enlarged gland, hypoechoic lesions and calcification due to PTB could be found by TRUS, which were also non-specific. CEUS showed hypo- or non-enhanced lesions with varying size, which were related to different pathological stages of PTB. The incidence rate of non-enhanced lesions was 83.3%. The detection rate of suspected lesion by CEUS was significantly higher than that by TRUS (χ2 = 8.000, p = 0.005). Histopathology showed that the hypoenhanced area consisted of tuberculous granulomas, caseous necrosis and incomplete destruction of the glands, while the non-enhanced area consisted of caseous or liquified necrosis. CONCLUSION: CEUS could improve the detection rate of PTB lesions, and the diversity of its manifestations was related to different pathological structures. An enlarged, soft gland with non-enhanced on CEUS may provide valuable information for the diagnosis of PTB, but it is not a substitute for biopsy due to the diversity of CEUS findings. ADVANCES IN KNOWLEDGE: When the lesions of prostate gland are unclear in TRUS examination, CEUS is an ideal option for the detection of lesions, which is conducive to targeted guidance of biopsy areas.

Clinical characteristics and outcome of genitourinary tuberculosis in Sri Lanka: an observational study.

BACKGROUND: Although genitourinary Tuberculosis (GUTB) is the second commonest source of extrapulmonary TB in most countries, the reported rate of GUTB in Sri Lanka remains low. The characteristics of GUTB in Sri Lanka have not been studied and documented so far. We aimed to study the clinical and imaging characteristics, treatment modalities and outcome of GUTB in Sri Lanka. METHODS: Data collected from patients treated by a single urological surgeon in two institutes consecutively over a period of 21 years were analysed. All patients with a microbiological and/or histopathological diagnosis of GUTB were included. Median duration of follow-up was 24 months (range: 6-96). RESULTS: There were 82 patients and 45 (54.9%) were men. The median age was 51 (range: 26-75) years. Most patients (39%, n = 32) had vague non-specific symptoms at presentation. Common specific symptoms at presentation were haematuria (15.8%, n = 13) and scrotal manifestations (15.8%, n = 13). Mantoux test was done in 70 patients and was > 10 mm in 62 (88.5%). Erythrocyte sedimentation rate was available in 69 patients and was > 30 mm in 54 (78.3%) patients. Chest x-ray and x-ray kidney-ureter-bladder (KUB) abnormalities were detected in 9 (11%) and 6 (7.3%) respectively. CT-urography was performed in 72 patients and abnormalities were detected in 57 (79%) patients. Forty-two patients underwent cystoscopy and 73.8% (n = 31) had abnormal findings. Microbiological diagnosis was feasible in 43 (52.4%) and rest were diagnosed histopathologically. Commonest organs involved were kidney (64.6%, n = 53), ureter (51.2%, n = 42), bladder (43.9%, n = 36) and testis/epididymis (15.8%, n = 13). One patient had TB of the prostate. All were treated primarily with anti-TB drugs however, 50 (61%) required ancillary therapeutic interventions. The majority of interventions were reconstructive surgeries (n = 20, 24.4%) followed by excisional surgeries (n = 19, 23.2%) and drainage procedures (n = 11, 13.4%). Seven patients developed serious adverse reactions to anti-TB drugs. Five patients developed a thimble bladder with disabling storage symptoms. Eight patients had deranged renal functions at diagnosis and three patients developed progressive deterioration of renal function and two patients died of end stage renal disease. CONCLUSIONS: The combination of urine for acid-fast bacilli, Mantoux test, CT-Urography, cystoscopy and histopathology is necessary to diagnose GUTB in resource-poor settings. Most ureteric strictures, non-functioning kidneys and epididymal masses need surgical treatment. Long-term follow up is essential to detect progressive deterioration of renal function.

Serologic and urinary characteristics of laboratory-confirmed genitourinary tuberculosis at a tertiary hospital in the Philippines.

BACKGROUND: Genitourinary tuberculosis (GUTB) is known to cause high rates of structural organ damage, however, literature on its biochemical manifestations is limited. Additionally, local studies in the Philippine setting, where cases are rampant, are few and dated. This study aimed to determine the serologic and urinary profile of patients with GUTB admitted at a tertiary hospital within January 2009 to March 2020 and their association with short-term outcomes. METHODS: This retrospective study included 112 patients with laboratory-confirmed GUTB (i.e., positivity in acid-fast smear, polymerase chain reaction, culture, or histology). Demographic data, clinical characteristics, laboratory and radiologic findings, histopathology reports, treatment, and short-term outcomes were recorded. RESULTS: Bladder (54.5%) and kidney (36.4%) were the most affected organs. The male:female ratio was 1:1.15, and the mean age was 35.79 ± 18.29 years. Weakness (14.29%) was the most common chief complaint. A majority presented with anemia (83.04%), while several had leukocytosis (41.96%) and thrombocytosis (26.79%). Hypoalbuminemia (58.10%), impairment of renal function (36.94%), and electrolyte abnormalities such as hyponatremia (50.93%), hypercalcemia (20.19%), and hypokalemia (21.82%) were common. Proteinuria (67.96%) and pyuria (67.96%) were the most frequent abnormal findings, followed by hematuria (51.46%), acidic urine (45.63%) and low specific gravity (31.07%). Age, leukocytosis, and the need for pressors were all significantly associated with mortality (p values of <0.001, 0.010, and <0.001, respectively). CONCLUSIONS: The young age at presentation with severe clinical and laboratory manifestations may reflect local epidemiology as TB continues to be widespread in the country. Apart from the more commonly cited abnormalities in literature, multiple electrolyte imbalances and urinary concentration defects were also observed in many cases, possibly indicating tubulointerstitial involvement-a complication increasingly mentioned in case reports. As several patient characteristics were found to be associated with the high mortality rates observed in the study, further research is recommended to explore predictive modeling.

[Surgical treatment of patients with urogenital tuberculosis].

Despite the modest positive trends in the epidemic situation for tuberculosis, the incidence of extrapulmonary tuberculosis is not consistent. The relevance of urogenital tuberculosis remains high, as well as its social significance. Tuberculosis of the kidneys and urinary tract is often diagnosed late, when drug therapy is not enough and surgical treatment is required. A total of 78 national and foreign publications dedicated to surgical treatment of patients with urogenital tuberculosis were analyzed. Various surgical techniques for renal and bladder tuberculosis are described with a comparison of their advantages and disadvantages. Tuberculosis of the urinary system, like any infectious disease, can and must be cured with drug therapy. Unfortunately, there are complicating subjective (low alertness of doctors regarding tuberculosis, low adherence to national and international guidelines) and objective (absence of pathognomonic symptoms of urogenital tuberculosis, which results in late diagnosis, increased drug resistance of the pathogen, high comorbidity) factors. The advancements in surgical techniques and modern drugs for neoadjuvant therapy give patients the opportunity to receive minimally invasive treatment that saves not only life, but also provides them acceptable quality of life.

Presentation, management and outcomes of pediatric urogenital tuberculosis: 20 years' experience from a tertiary center.

BACKGROUND: Urogenital tuberculosis (UGTB) has traditionally being a diagnosis of adulthood and is supposed to be rare in children, as it is believed that the symptoms of renal tuberculosis do not appear for 10 or more years after the primary infection. While this may be true in developed countries, where childhood pulmonary tuberculosis is a rarity nowadays. In developing countries, childhood pulmonary tuberculosis is still a major issue and hence, UGTB is not an uncommon diagnosis in younger children and adolescents in these countries. Considering this dearth of data on childhood UGTB, we retrospectively evaluated our series of children with this disease, with special emphasis on the role of surgery. OBJECTIVE: To analyze the clinical presentation, management strategies and outcomes of pediatric UGTB managed in a tertiary care center. MATERIALS AND METHODS: Case records of children and adolescents ≤18 years diagnosed with UGTB during the period July 1998 to June 2018 at our center were reviewed. Clinical features, organ involvement, investigations, treatment and outcome of therapy were studied. RESULTS: There were 41 children and adolescents (M: F = 22:19) identified, with a mean age of 14.8 ± 3.9 years who fulfilled the inclusion criteria. The most common presentation was flank pain and irritative storage symptoms. Mycobacterium tuberculosis was identified on urinary examination in only 17 (41.5%) cases. Six patients were lost to follow up after initial diagnosis. A total of 45 procedures (35 primary and 10 secondary) were performed in 35 children. Initial diversion in the form of PCN and DJS were done in 11 and 12 patients respectively, of which 8 were managed with stenting alone. Surgical management was done mostly in the form of nephrectomy (15), nephrectomy along with reconstruction (5) and reconstruction only (6). On univariate analysis, factors associated with nephrectomy were poor initial function and nephrostomy as initial diversion. Overall median follow-up was 25 (IQR 15.5-74.25) months. During follow up, chronic renal failure developed in nearly 53.8% of patients who underwent major reconstruction. CONCLUSIONS: Urogenital tuberculosis presents with a wide spectrum of clinical features and pathological lesions. Diagnosis is often delayed because of late presentation and many children present with cicatrization sequelae. Antitubercular drug therapy and judicious application of minimally invasive diversions and surgery (both ablative and reconstructive) achieve satisfactory results in the majority of cases. Children undergoing major surgical reconstruction in particular need to be followed up rigorously and counselled about possibility of development of renal failure.

Urethral Tuberculosis: A Forgotten Cause of Urethral Stricture.

We describe the clinical features of a 75-year-old man who presented to our hospital with frequent urination for 3 months. Retrograde urethrography showed extended and continuous narrowing of the stricture in the anterior urethra. Cystourethroscopy showed extended narrowing of the urethral lumen without normal membrane. Urine acid-fast bacillus culture and polymerase chain reaction assays indicated a diagnosis of urethral tuberculosis. Anti-tuberculosis therapy was initiated. Urethral tuberculosis is a very rare cause of urethral stricture in developed countries that can be diagnosed by cystourethroscopy. Urethral tuberculosis should be considered in the differential diagnosis of urethral stricture.