Presented by : Dr.Talal Alanzi

1. TB Presented By : Dr.TalalAlanzi Supervised by: Dr. Mohammad Zaher JahraHospital Dr.HasanAlewa TB center Presented by : Dr.TalalAlanzi

2. History of disease. • Geographic distribution. • Incidence in worldwide+ Kuwait. • Transmission. • Pathogenesis. • Signs & symptoms. • NICE + European guideline. • Management. • Article review • Therapeutic trail of anti-TB. • Common organs, sites, surgical procedure. • New modality for investigating GU TB.

3. History Akhenaton and his wife Nefertiti died of TB. TB was identified march.24.1882 by RobortKoch. The 4th most common killing in UK.

4. Epidemiology World Health Organization. Global tuberculosis control 2012.

6. Incidence In 2012, 8.6 million people developed TB. 1.3 million died ,including 320 000 (HIV). The rate of decline (2% per year) remains slow. Globally by 2012, the TB mortality rate had been reduced by 45% since 1990. World Health Organization. Global tuberculosis control 2012

7. Incidence GUTB is the second most common form of extrapulmonary TB (EPTB). EPTB accounts for ~10% of overall TB. GUTB TB accounts for 30% to 40% of all extrapulmonary TB. World Health Organization. Global tuberculosis control 2012

8. Kuwait World Health Organization. Global tuberculosis control 2012

9. KUWAIT

10. Transmission Usually hematogenous dissemination. Kidney,epididymis,fallopian tube can be primary site. Prostate can get infected by urine. Sexual transmission of TB is rare. World Health Organization. Global tuberculosis control 2012

11. Other route Intravesical BCG. BCG is a live attenuated strain of Mycobacterium bovis. Asymptomatic granulomatous prostatitis 20-30%.  epididymitis (0.2%) R. Spence, R. Hay, and P. Johnston, Infection in the Cancer Patient a Practical Guide, Oxford University Press, 2006.

12. Microbiology Most common mycobacterium tuberculosis bacillius. Followed by tubercles bovis. Mycobacterium avium

13. Mycobacterium characteristic Non motile rod-shaped Obligate aerobe Divides every 15–20 hours Survive in a dry state for weeks Murray PR, Rosenthal KS, Pfaller MA (2005). Medical Microbiology. Elsevier Mosby.

14. Pathogenesis Inhaled tubercle bacilli implanted in bronchioles and alveoli. Interaction between bacteria and host immunity. Infection: mycobacteria slowly divide within alveolar macrophage (12 week). Spread through lymph node or blood stream. Intact immunity: macrophages, T & B, fibroblast aggregate to form granuloma. Prevent dissemination.

15. Genitourinary TB is very uncommon in children because the symptoms of renal TB do not appear for 3 to 10 or more years after the primary infection. Warren D, Johnson JR, JohnsonCW, Franklin C. Lowe: Genitourinary TuberculosisCampbell’sUrology. 8th ed. Saunders; 2002.

16. Pathology : Kidney: Hematogenous. Lodge in renal capillaries(cortex) good blood and O2. Leucocyte T,B cell infiltration. Causing dormant TB foci. Results in: sloughing of papilla-infundibular narrowing- PUJ scarring. Gibson MS, Puckett ML, Shelly ME. Renal tuberculosis. Radiographics2004;24:251-6.

17. Adrenal: Less than 6%. Usually B/L. Lead to necrosis and addision disease. Gland enlarge-thickened capsule-irregular nodular surface-calcification. 56% subnormal cortisol response.

18. ureter: Direct extension from kidney. Usually low 1/3 ureter. (UVJ). Mucosal ulceration-fibrosis- and obstruction.

19. Beaded ureter

21. Bladder: 2nd to kidney. Urothelium is very resistant to TB. Takes years to develop UB TB. Common site (surrounding ureter-trigone). Rarely lead to ulceration. (Worm-eaten). Figueiredo AA, Lucon AM, Junior RF et al: Epidemiology of urogenital tuberculosis worldwide. Int J Urol 2008; 15: 827.

23. Epididymis (head) • Hematogenous spread. • Inflammation and fibrous narrowing and obliteration of the lumen. • Sinus can occur at post surface of scrotum. • Wise GJ and Shteynshlyuger A: An update on lower urinary tract tuberculosis.CurrUrol Rep 2008; 9: 305.

25. Testis • 2nd to epididymis • Lead to caseous material and fibrosis. • Diff to distinguish from testicular mass.

26. Prostate: • Rarely affected. • Hematogenous spread. • Often incidentally found in TUR specimen. • Lead to noticeable reduction of semen volume. FigueiredoAA, Lucon AM, Arvellos AN et al: A better understanding of urogenital tuberculosis pathophysiology based on radiological findings. EurJ Radiol2009; Epub ahead of print.

27. Seminal vesicle: Spread from epididymis Rare. The classical finding is that of a beaded (dense fibrosis).

28. Penis and urethra: Rare. 2nd to kidney and bladder. Formation of infected granulation tissue, infiltrate glandular and cavernous body and urethra. Can present as an ulcer at the genitalia in both sex.

29. Penile TB Has been reported in young Jewish boys following circumcision !!!!! Gesundheit B, Grisaru-Soen G, Greenberg D, et al. Neonatal genital herpes simplex virus type 1 infection after Jewish ritual circumcision: modern medicine and religious tradition. Pediatrics 2004;114:259–63.

31. Orthodox Judaism prescribes circumcision as a religious ritual, to be performed according to strict Talmudic laws. According to those laws, the man who circumcises the infant, the mohel, must suck the infant's bleeding penis with his mouth!!!

32. Babylonian Talmud, Tractate Shabbath 133aSoncino 1961 Edition, pages 668-669. Mezizah: By this is meant the sucking of the blood from the wound. The mohel takes some wine in his mouth and applies his lips to the part involved in the operation, and exerts suction, after which he expels the mixture of wine and blood into a receptacle provided for the purpose. This procedure is repeated several times, and completes the operation, except as to the control of the bleeding and the dressing of the wound. 

36. Clinical finding Tuberculosis can often mimic a wide range of nonspecific urologic symptoms. Many cases of genitourinary TB are easily overlooked. M 2:1 f 4th decade

37. Symptoms 50% present with LUTS 1/3 LOIN PAIN+hematuria. 10% passage of caseousmaterial,necrotic renal papillary tissue,clots,stone 20% constitutional symptoms. recurrent hemospermia (???) Testicular pain. Infertility.

38. Examination: Limited value in diagnostic process. Most abnormal finding is scrotal examination. Beaded vas deference Epididymal + kidney fistula late sign. Prostatic nodule on exam.

39. Lab inv 25% present with sterile pyuria. 13% gross or microscopic hematuria. Renal impairment in 7.4% Tb should be considered in all cases of recurrent hemospermia.

40. Lab inv Urinalysis and c/s: Ziehl-neelsen staining of urine for acid fast bacilli often negative. GUTB : often have sterile pyuria+ hematuria+ proteinuria. 20% superimposed bacterial infection.

41. Urine c/s: egg-base(Lowenstein-Jensen medium) or agar based media. With use of aniline dyes inhibit growth of bacterial contamination. Agar facility diagnosed within 4-6 wk.

42. Intermittent release of organism in urine makes multiple sampling necessary. 3-5 sample early morning should be c/s soon after collection.

44. Chronic renal lesion may no longer discharge TB material . Urine c/s sensitive 80%-90%. Specific 100%.

45. Radiometric detection: inoculation of specimen with radiolabelled 14c-palmitate, result in liberation of 14 co2 by mycobacteria. Detected by BACTEC 460TB.

46. 14,745 clinical specimens 1,381 strains  81.5 and 99.6%  sensitivity 85.8 and 99.9% specifity. 1990 to June 2003 .

48. FLUOROMETRIC TECHNOLOGY : detect o2 consumption. MGIT. The BBL MGIT System creates and environment suitable for rapid mycobacterial growth. Positive tests emit a vivid orange fluorescent glow at the tube base .

49. Sensitivity 95.2% and specificity 99.2%  10 to 14 days 3,832 specimen. 755 were MGIT growth positive.