Tuberculous pyelonephritis in children: three case reports

Tuberculous pyelonephritis is rare in children; three case reports are presented. Case 1 was an 11-year-old girl with a previous history of pulmonary tuberculosis who presented with flank pain and fever for 10 days. An ultrasound suggested focal pyelonephritis, and a contrast-enhanced computed tomography (CECT) scan demonstrated acute focal pyelonephritis and a perinephric collection. Mycobacterium tuberculosis was cultured in the urine. She responded well to anti-tuberculous treatment (ATT). Case 2 was a 13-year-old boy who presented with fever, haematuria, burning micturition, proteinuria (3+) and cervical lymphadenopathy. The Mantoux test was strongly positive. Chest radiograph demonstrated right hilar lymphadenopathy and ultrasonography showed evidence of acute pyelonephritis. Tuberculous lymphadenitis was diagnosed by fine-needle aspiration cytology (FNAC) from cervical lymph nodes and he responded to ATT. Follow-up urinalysis and ultrasound were normal. Case 3 was a 6-year-old boy, a known case of pulmonary tuberculosis (from 2 years of age) and a previous defaulter from ATT. He presented with symptoms of lumbar pain and dysuria. Chest radiograph demonstrated mediastinal lymphadenopathy and a CECT of the head showed a tuberculous granuloma. CECT of the abdomen showed an enlarged left kidney with focal pyelonephritis, an abscess in the upper pole and parenchymal calcification. FNAC of the cervical lymph nodes supported a diagnosis of disseminated tuberculosis with tuberculous pyelonephritis. He was given 8 months of ATT. Fifteen months later he presented again with clinical and urinary findings of urinary tract infection. CECT now demonstrated gross hydronephrosis of the left kidney, and it was confirmed to be non-functioning by a DMSA scan and magnetic resonance urogram. Diethylenetriaminepentaacetic acid showed a GFR of 44.3 ml/min/1.73 m(2). Nephrectomy was undertaken and the histology confirmed tuberculous pyelonephritis. Six months later he was well with an eGFR of 87.2 ml/min/m(2). In patients with symptoms of urinary tract infection but sterile urine who do not respond to antibiotics or have evidence of tuberculous elsewhere in the body, careful consideration should be given to the possibility of tuberculous pyelonephritis.