Renal tuberculosis is a form of extrapulmonary tuberculosis that occurs through hematogenous dissemination of Mycobacterium tuberculosis from a primary pulmonary focus, often latent or asymptomatic. Although more common in immunosuppressed patients, it may also occur in immunocompetent individuals, often with delayed diagnosis due to its nonspecific clinical presentation. Male, 61 years old, from a rural area, farm worker, previously healthy, sought emergency care 13 days after placement of a right-sided double-J catheter due to oliguria, progressing with purulent secretion at the surgical wound, associated with fever and chills. He was referred and admitted to a reference hospital, presenting a positive right-sided Giordano sign and laboratory tests within normal limits. Antibiotic therapy was escalated from ceftriaxone to tazocin, and urinary tract ultrasound was requested, showing no significant findings. He progressed with reversal of the circadian cycle, agitation, disorientation, and eventually decreased level of consciousness. Urinalysis showed pyocytes and hematuria, and urine culture showed no growth of microorganisms. Due to worsening of consciousness level, he was admitted to the intensive care unit (ICU) and underwent orotracheal intubation. Serological tests for HIV, syphilis, and hepatitis B and C were requested, all negative. He developed fever, justifying replacement of piperacillin-tazobactam with meropenem, associated with gentamicin and vancomycin. Sedation was weaned, but without awakening. Contrast-enhanced brain computed tomography revealed ischemic stroke. With clinical deterioration and review of previous surgical data, a lesion suggestive of tuberculosis was identified. Polymerase chain reaction testing for M. tuberculosis was performed, yielding a positive result, and treatment was initiated with rifampicin, isoniazid, pyrazinamide, and ethambutol. After stabilization in the ICU, the patient was transferred to the ward, remaining hospitalized for 12 days; however, he developed cardiorespiratory arrest due to asystole and did not regain spontaneous circulation. This case highlights the need for a broad and multidisciplinary diagnostic approach in prolonged febrile and urinary syndromes, even in patients without known immunosuppression.
Coelho et al. (Sun,) studied this question.