Renal tuberculosis in infancy.

We report a case of congenital renal tuberculosis in a 34-day-old child presenting as severe hematuria. Adequate antitubercular treatment may provide protection to fetus in subsequent pregnancies.

INTRODUCTION

Renal tuberculosis is rare in children.[1] Genitourinary tuberculosis is one of the late reactivation or complication of pulmonary tuberculosis, which is most prevalent in young adults and middle aged. We report an infant aged 34 days with acute onset painless severe exsanguinating hematuria attributed to congenital tuberculosis.

CASE REPORT

A male child aged 34 days presented with painless hematuria of 48 hours duration. He was born to a primigravida mother at term. The patient was on breast feeds and was thriving well. There was no fever. On examination, he was grossly pale. The abdominal examination showed hepatomegaly. The hemoglobin was 3.4 g%. Coagulopathy and malaria were ruled out. The chest radiograph was normal. An ultrasonography revealed a 14 × 15 mm lesion with cystic areas within the left renal pelvis. Possibility of renal abscess/mass was kept. Contrast-enhanced computed tomogram (CECT) [Figure 1] showed a well-defined, well-marginated hypodense mass lesion involving interpolar region of left kidney, causing compression of renal pelvis and dilation of upper pole calyces with blood clot within the urinary bladder.

Figure 1

CECT showing hypoechoic lesions in left kidney

Blood was transfused to improve hemoglobin to 10.2 g%. The child was taken up for renal exploration in view of life-threatening hematuria. With an upper abdominal transverse incision, the peritoneal cavity was entered. Hepatomegaly was noted although the surface was normal. The left kidney was enlarged and congested, with areas of hemorrhage on the surface. The renal pelvis was opened after achieving vascular control. It was full of clots and necrotic tissue. An unexpected hemorrhage from within the renal pelvis started, which could not be controlled by packing. In order to prevent exsanguination, left nephro-ureterectomy was performed. The postoperative course was uneventful and the child was discharged 9 days later.

Histopathology revealed focal inflammation comprising lymphocytes, histiocytes and foamy macrophages with granulomas and Langhans type giant cells with central caseation [Figure 2]. Multiple epitheloid cell granulomas in the renal pelvis showed central caseation (HPE ×100).

Figure 2

Multiple epitheloid cell granulomas in the renal pelvis showing central caseation (HPE ×100)

On further investigation for congenital tuberculosis, gastric aspirate for acid-fast bacilli and Mantoux test were negative. The parents and other family members were investigated for tuberculosis by chest radiograph and tuberculin skin test. No source of contagion could be found. Endometrial biopsy of the mother revealed tubercular histopathology. A diagnosis of congenital renal tuberculosis was made on the basis of age of presentation, hepatomegaly and histopathology of the kidney and the endometrial biopsy of the mother. Antitubercular treatment as per the World Health Organization (WHO) protocol was given to the baby and the mother. On follow-up at 6 months, the child was thriving well and has gained 4 kg weight.

DISCUSSION

Tuberculosis of the genitourinary tract is a late reactivation or complication of pulmonary tuberculosis and mostly prevalent in 25–40 years.[2] Renal tuberculosis is rare in children[3] and represents less than 5% of cases of pediatric extrapulmonary disease.[4] Reports of renal tuberculosis in infancy are very sparse. Alexander and Carol in 2009 had reported a 5-month-old infant with renal and miliary tuberculosis.[5] Lattimer et al. in their case series found 2–3 years as the earliest age of presentation.[6] Chattopadhyay et al. reported a series of cases in the age range of 5–12 years.[7]

In our case, the dilemma was the time the baby had acquired tuberculosis – prenatal, perinatal or postnatal. Congenital tuberculosis has three possible modes of infection: hematogenous via the umbilical vein from infected placenta or endometrium, fetal aspiration of infected amniotic fluid and fetal ingestion of infected amniotic fluid.[89] It is difficult to distinguish congenital tuberculosis from the more frequent acquired neonatal TB, where the infant is infected after birth. In over 60% cases of perinatal tuberculosis, maternal disease was diagnosed after it was found in the offspring.[10] In one review, 24 of 32 mothers were asymptomatic.[11] Congenital tuberculosis of spine at the age of 8 weeks, but with an asymptomatic mother, has been reported where the endometrial biopsy had revealed tuberculosis.[12] In 1935, Beitzki laid down diagnostic criteria for congenital tuberculosis, which were subsequently revised by Cantwell in 1994.[13] As per Cantwell, tuberculosis is congenital if there is a proven tubercular lesion in the infant in addition to one of the following: (i) lesions occurring in the first week of life, (ii) a primary hepatic complex, (iii) maternal genital tract or placental tuberculosis, and (iv) exclusion of postnatal transmission by thorough investigation. Our case had proven tuberculous lesion in renal tissue with endometrial biopsy showing tuberculoma and postnatal transmission was excluded by thorough investigation. However, a liver biopsy was not done. In retrospect, liver biopsy would have further substantiated the diagnosis although still it is fulfilling the Cantwell's criteria for diagnosis,

Our case report highlights the fact that congenital renal TB may be considered as a differential diagnosis in infants presenting with life-threatening hematuria. Antitubercular therapy cures the disease in the child and the mother, thereby preventing future vertical transmission.