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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 3  |  Page : 248-253

A long journey to be diagnosed as a case of tuberculous cystitis: A Bangladeshi case report and review of literatures


1 Department of Urology, Shaheed Suhrawardy Medical College Hospital, Dhaka, Bangladesh
2 Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kuala Lumpur, Malaysia

Date of Submission30-May-2020
Date of Decision25-Jun-2020
Date of Acceptance01-Jul-2020
Date of Web Publication28-Aug-2020

Correspondence Address:
Mainul Haque
Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kem Perdana Sungai Besi, Kuala Lumpur 57000
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_101_20

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  Abstract 


Urinary bladder tuberculosis (UB-TB) is one of the gravest public health issues of renal TB, and it is diagnosed with <50% of urogenital TB. Unsatisfactory and delayed diagnosis with imprudent medications for bladder TB frequently resulted in several urinary and complications, including contraction of the UB. The objectives of this research were to build awareness among medical professionals and subsequently minimize the sufferings of patients. This was a case report-based study regarding UB-TB. All routine tests for cystitis were conducted. In addition, 24-h urine sample for TB identification, including a polymerase chain reaction test, was performed. Twenty-four hours of urine sample revealed confirmatory findings of TB. The patient had responded well with the national TB guideline-designated medication. Recurrent cystitis had a higher possibility of tuberculous origin. Medical doctors must rethink when a patient visited multiple times for cystitis for the etiology of the disease.

Keywords: Diagnosis delay, failure, imprudent prescribing, irrational medication, prolonged suffering, tuberculosis, urinary bladder


How to cite this article:
Chowdhury TS, Naser MF, Haque M. A long journey to be diagnosed as a case of tuberculous cystitis: A Bangladeshi case report and review of literatures. Int J Mycobacteriol 2020;9:248-53

How to cite this URL:
Chowdhury TS, Naser MF, Haque M. A long journey to be diagnosed as a case of tuberculous cystitis: A Bangladeshi case report and review of literatures. Int J Mycobacteriol [serial online] 2020 [cited 2020 Oct 29];9:248-53. Available from: https://www.ijmyco.org/text.asp?2020/9/3/248/293533




  Introduction Top


Globally, tuberculosis (TB) is one of the principal causes of death from a single infectious disease agent all over much of documented human history.[1] In addition, TB causes around 40% mortality among patients with human immunodeficiency virus positive.[2] It has been estimated that globally around 10.4 million individuals freshly developed TB, 1.3–1.8 million deaths, and 40% of these TB-infected patients remained undiagnosed and untreated in 2017.[1],[3],[4],[5] TB is an international wide-ranging disease. Nevertheless, the TB incidence rate reported much higher anyplace; the population density is high with poor sanitation and negative social and economic markers. Around the globe, eight countries represent two-thirds of 10 million TB patients from low-middle-income countries (LMICs). The countries were India (27%), China (9%), Indonesia (8%), the Philippines (6%), Pakistan (6%), Nigeria (4%), Bangladesh (4%), and South Africa (3%).[6] The Global TB Report 2016 assessed that 3.9% freshly identified and 21% of earlier spotted TB cases were multidrug-resistant TB (MDR-TB).[7],[8] Thereafter, MDR-TB, extensively drug-resistant TB, polydrug-resistant TB, and rifampicin-resistant TB became an alarming global public health issue.[9],[10],[11] The WHO reported that the incidence of worldwide TB cases and deaths had accounted for more than 90% of the total occurrence in the LMICs; of these TB patients, 75% are in the most frugally prolific age group.[1]

TB has the potential to infect any part of the human body.[3],[12],[13],[14] It has been reported that around 15%–40% of newly diagnosed 10 million TB patients of every year were extrapulmonary TB (EPTB). Common sites of EPTB include lymph nodes, pleura, bones, meninges, and the urogenital tract.[13],[14],[15],[16] TB infection involving the kidneys, ureters, bladder, prostate, urethra, penis, scrotum, testicles, epididymis, vas deferens, ovaries, fallopian tubes, uterus, cervix, and vulva was primarily congregated and considered as genitourinary TB.[17],[18],[19],[20],[21] At present, the term “urogenital TB (UGTB)” is believed to be more suitable as kidney, and urinary tract TB becomes obvious more frequently than genital TB.[19],[22] The first communication regarding UGTB was made by Porter in 1894 of Northwestern Ohio Medical Association, Van Wert, Ohio, USA. In addition, more than forty years later, in 1937, Hans Wildbolz Swiss urologists recommended the term “genitourinary TB”.[17],[18],[23]

UGTB is an age-old public health issue but remains unresolved.[24] UGTB remains the second top-most cause of EPTB, with a 90% incidence rate in LMICs.[25],[26],[27] UGTB remain as clinical concerns because commonly maltreated, because of nonspecific symptoms, chronic, ambiguous, puzzling, fluctuating clinical features, thereby, goes unnoticed and undiagnosed.[12],[20],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42] Moreover, general practitioners, nephrologists, urologists, and other responsible clinicians were unaware of the probability of the UGTB.[43],[44],[45],[46] The research study revealed that failure to diagnose UGTB timely consequences in increasing the possibility of developing several complications of the mentioned disease. Those include ureteral strictures, contracted bladder, obstructive nephropathy, renal parenchymal destruction, irreversible organ damage, and end-stage renal failure.[19]

UGTB can be classified into four groups: (i) urinary TB, (ii) male genital TB, (iii) female genital TB, and (iv) generalized UGTB.[19],[22],[24] Urinary bladder TB (UB-TB) is alienated into four different stages: (1) tubercle infiltrative; (2) erosive ulcerous; (3) spastic cystitis (bladder contraction and false microcystitis); in fact, overactive bladder; and (4) real microcystitis up to full obliteration.[22],[47] Renal TB usually serves as the primary site of all UGTB; later, it involves as another urogenital anatomy, for example, UB to cause UB-TB, through the hematogenous spread of the TB bacilli and typically commences at the ureteral orifice and is found in nearly one-third of the patients.[27],[48],[49],[50],[51] Besides, preliminary TB infection in the renal cortex, subsequently, TB bacilli persist as dormant for years together. Then these dormant TB bacilli wait till finds the way out to be active owing to the limitation of the weak immune system of the host, especially among those patients suffers from incapacitating diseases leading to weak cell-mediated immunity. Those diseases include shock, trauma, use of glucocorticoids or immunosuppressives, diabetes, or acquired immunodeficiency syndrome (AIDS).[27],[52],[53],[54] Furthermore, it has been estimated that around 1.7–2 billion globally exits as latent TB cases, which epitomizes a vast pool of potential reactivation TB to spread among people of the community.[54],[55] UB-TB primarily reveals as tuberculous infective inflammation with bullous edema and granulation, later chronic inflammatory process eventually ended golf-hole forming[49],[56],[57],[58] ureteral orifice, fibrosis and causes stricture formation with hydronephrosis or scarification with vesicoureteral reflux.[48] If the patient remains untreated or irrationally treated UB-TB, consequently turn to severe cases involving the entire bladder wall, deep layers of muscle are sooner or later substituted by fibrous tissue, accordingly form a thick fibrous bladder. Tubercles are sporadic in the bladder if even found, typically seem at the ureteral orifice. Malignancy should be well thought out with any out-of-the-way tubercles away from the ureteral orifices.[48]

The diagnosis of UGTB is problematic and tough because its warning sign is broad based.[21],[24],[38] Multiple approaches are required for the diagnosis of UGTB. The patient had complaints of physical signs, histopathology, culture tests, polymerase chain reaction (PCR), and various imaging techniques (ultrasound and laparoscopic cystoscopy) that are needed to combine to reach a proper diagnosis.[59],[60],[61],[62],[63] Even in this modern age, proper clerking of patients' history remains the most significant step in diagnosing UGTB.[27],[64],[65] In the majority of cases, UGTB patients had the possibility of a history of a primary pulmonary TB (PTB) or an EPTB that offers a piece of vital evidence at large.[27],[66],[67] Another side of the coin health professionals' awareness regarding latent TB remains an important issue as the reactivation of TB has been evident to even after 30 years.[68],[69],[70],[71] The aim of the study was to create awareness among the health professionals when a case of repeated cystitis, to think may be TB cystitis, has been reported.


  Case Report Top


A 37-year-old male patient was reported with history of TB, despite he rarely had any close contact with PTB patients in his life. The patient was a professional truck driver. He had a history of sex with professional sex workers 13 years back, followed by chronic urethral discharge, dysuria, and recurrent lower urinary tract symptoms. The patient received treatment earlier multiple times by a senior consultant urology surgeon. Nevertheless, patients' symptoms minimized occasionally, but recurrence came back soon. The patient repeatedly underwent various investigations to diagnose the cause for lower urinary tract infections. However, the patient was diagnosed as a case of the overactive UB. After that, antimuscarinics, β3-agonists, behavioral therapy, and lifestyle changes were frequently employed. Eventually, the patient was not at all improved. The patient's symptoms got worse around 3 (December 2019) months back. The patient needs to void 15–20 times a day, and additional had nocturia, fever, and painful micturition. This time, the patient was referred to Shaheed Suhrawardy Medical College Hospital (SSMCH), Dhaka 1207, Bangladesh. The patient (Hospital ID 36100/19) reported on December 10, 2019, in the outpatient department, urology section of SSMCH.

The patients complained about the abovementioned symptoms. On initial examination, the patient was found mildly anemic; there was no gross hematuria; the lower abdomen was tender, weight 85 kg, blood pressure 100/60 mmHg, no lymphadenopathy was found, and on auscultation of the chest, no abnormality was detected. The total lymphocyte count was 12,000 per cubic mm, differential lymphocyte count was 82% neutrophil, and erythrocyte sedimentation rate was 60 mm. Urine examination revealed microscopic hematuria with pyuria that was suggestive of cystitis. Tuberculin skin test was weakly positive (erythema: 50 mm × 30 mm, no induration). Ultrasonography revealed mild irregular thickening with a typical capacity (408 ml) of the UB [Figure 1]. Plain X-ray of the kidney, ureter, and bladder revealed no urinary calculus. Chest X-ray did not found any significant opacity or calcified shadow. PCR study of the 24-h urine sample detected TB. PCR study was conducted in the reference laboratory of Programmatic Management of Drug-Resistant Tuberculosis, National TB Control Program, Government of the People's Republic of Bangladesh, Mohakhali TB Gate, Mohakhali, Dhaka 1212, Bangladesh. The details of the study included patient Reference no. D24 17.12.19, Specimen ID: 19/22298/M. Urethrocystoscopic examination was not done initially. At this point, considering all facts that were found clinically and of laboratory findings, the patient was diagnosed as a case of tuberculous cystitis. Subsequently, anti-TB medication was given in correct dose, and combination as therapeutic intervention and trial (oral four-drug anti-TB therapy [INH, pyrazinamide, ethambutol, and rifampicin]) was started as per national guidelines.[72] The patient was strictly observed and monitored for the next 2 weeks. Urethrocystoscopic examination done 1 month after receiving antitubercular therapy revealed mildly trabeculated UB wall, with multiple patchy healed ulcer anatomy with the capacity (about 500–600 ml) [Figure 2]. Patient symptoms such as frequency, nocturia, fever, and dysuria have relieved, and the appetite of the patient has subsequently improved. The patient was further advised to continue the same treatment for 6 months. On subsequent visits, the patient's overall health condition starts growing with weight gain after 4 months of medication.
Figure 1: Ultrasonography photo showing irregular thickening wall of the urinary bladder

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Figure 2: Urethrocystoscopic photo after 1-month antitubercular therapy revealed improved urinary bladder wall anatomy

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  Discussion Top


TB remains as an existing public health delinquent, enduring one of the top ten global causes of death from the transmittable disease.[73],[74] Internationally, lower respiratory infections persisted the fatal infectious disease, triggering 3.0 million deaths 2016.[73] The number of deaths due to TB had decreased; nonetheless, the death toll has been reported to be 1.3 million per year, from the year 2000 to 2016.[73] In addition, in 2018, TB has claimed 1.5 million life.[74] TB is an immense societal delinquent, not only a medical issue, because both PTB and EPTB often cause male and female infertility and sexually transmitted diseases.[12],[69],[75],[76],[77],[78],[79],[80],[81],[82],[83],[84],[85],[86],[87],[88],[89] UGTB is one of the earliest-reported infectious diseases but remains to be an unresolved public health issue.[17],[18],[23],[24] Clinical features of UGTB are supple, stretchy, and inconstant and often imitators of abundant other diseases, which consequences in deferring diagnosis.[24] In PubMed 5215, articles available dated March 21, 2020, 1.22 PM (Malaysian Time) with the keywords “urogenital, genitourinary, TB.” Another study reported that although there is a lot of research studies being published, “there are no good multicenter studies with a high level of evidence on UGTB. UGTB is an embodiment of contradictions: from terms and classification to therapy and management.”[24]

The current case TB cystitis symptoms, signs, standard laboratory reports where mimicking recurrent cystitis[90] and overactive bladder.[91] Thereafter, the diagnosis was delayed.[92] In addition, they were treated irrationally or imprudently. Multiple studies reported that the diagnosis deferment TB cystitis was because of the furtive progression, rareness or nonspecific of symptoms of the disease, deficient cognizance of medical doctors, the neglected care-seeking attitude of patient,[93] and poor access to proper health-care system.[94] Consequently, diagnosis is seldom completed before severe urogenital complications developed.[93],[94],[95],[96],[97],[98] The patient was typically frustrated and depressed only at that time was referred to tertiary care medical school hospital, and probably, the first time was clerked by a consultant urology surgeon. The patient was asked to wait sometime because the consultant had an idea to give enough time to this particular long time suffered. After finishing all outpatients for that day, the consultant listened to all the stories of sufferings and asked to repeat all routine laboratory tests with 24-h urine for TB identification with PCR in the reference laboratory of the government of Bangladesh. PCR findings were positive and treated according to the public guidelines.[72] After receiving 1-month antitubercular therapy, endoscopic urethrocystoscopy examination was done and found improved bladder wall mucosa with increased urinary compliance.[99] UB capacity returned to 500–600 ml after 1-month anti-TB medication, but the earlier study reported that it was about 408 ml capacity.[99]


  Conclusion Top


TB cystitis is rarely diagnosed early because of similar symptoms mimicking with other forms of chronic cystitis. This study revealed that while dealing with a case of recurrent cystitis patients, medical professionals must keep thinking regarding the possibility of having TB cystitis. As delayed diagnose may cause irreversible bladder wall damage leading to thimble or spastic bladder. This study recommends that if a patient with recurrent lower urinary tract symptoms presents as resistant to all conventional therapeutic interventions, physicians should adopt to do some minimal invasive investigations such as urethrocystoscopy evaluation taking tissue biopsy of the bladder mucosa and do the histopathological examination, collection of urine sample directly from the bladder to detect acid-fast bacilli under microscopic study, and culture with PCR.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In this way, the patient himself had given his consent for images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and outstanding efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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