A Long Journey to Be Diagnosed As a Case of Tuberculous Cystitis: a Bangladeshi Case Report and Review of Literatures

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Review Article

A Long Journey to be Diagnosed as a Case of Tuberculous Cystitis: A Bangladeshi Case Report and Review of Literatures

Tajkera Sultana Chowdhury1, Md. Fazal Naser1, Mainul Haque2 1Department of Urology, Shaheed Suhrawardy Medical College Hospital, Dhaka, Bangladesh, 2Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kuala Lumpur, Malaysia

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

Submitted: 30-May-2020 Revised: 25-Jun-2020 Accepted: 01-Jul-2020 Published: 28‑Aug‑2020

Introduction rifampicin‑resistant TB became an alarming global public health issue.[9‑11] The WHO reported that the incidence of Globally, tuberculosis (TB) is one of the principal causes worldwide TB cases and deaths had accounted for more than of death from a single infectious disease agent all over 90% of the total occurrence in the LMICs; of these TB patients, much of documented human history.[1] In addition, TB 75% are in the most frugally prolific age group.[1] causes around 40% mortality among patients with human immunodeficiency virus positive.[2] It has been estimated that TB has the potential to infect any part of the human body.[3,12‑14] globally around 10.4 million individuals freshly developed It has been reported that around 15%–40% of newly diagnosed TB, 1.3–1.8 million deaths, and 40% of these TB‑infected 10 million TB patients of every year were extrapulmonary patients remained undiagnosed and untreated in 2017.[1,3‑5] TB (EPTB). Common sites of EPTB include lymph nodes, TB is an international wide‑ranging disease. Nevertheless, pleura, bones, meninges, and the urogenital tract.[13‑16] BT the TB incidence rate reported much higher anyplace; the infection involving the kidneys, ureters, bladder, prostate, population density is high with poor sanitation and negative urethra, penis, scrotum, testicles, epididymis, vas deferens, social and economic markers. Around the globe, eight countries represent two‑thirds of 10 million TB patients from Address for correspondence: Prof. Mainul Haque, low‑middle‑income countries (LMICs). The countries were Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional India (27%), China (9%), Indonesia (8%), the Philippines (6%), Malaysia (National Defence University of Malaysia), Kem Perdana Sungai Pakistan (6%), Nigeria (4%), Bangladesh (4%), and South Besi, Kuala Lumpur 57000, Malaysia. E‑mail: [email protected] Africa (3%).[6] The Global TB Report 2016 assessed that 3.9% freshly identified and 21% of earlier spotted TB cases were ORCID: Mainul Haque: http://orcid.org/0000‑0002‑6124‑7993 multidrug‑resistant TB (MDR‑TB).[7,8] ,Thereafter MDR‑TB, extensively drug‑resistant TB, polydrug‑resistant TB, and This is an open access journal, and articles are distributed under the terms of the Creative Access this article online Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to Quick Response Code: remix, tweak, and build upon the work non‑commercially, as long as appropriate credit Website: is given and the new creations are licensed under the identical terms. www.ijmyco.org For reprints contact: [email protected]

DOI: How to cite this article: Chowdhury TS, Naser MF, Haque M. A long 10.4103/ijmy.ijmy_101_20 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.

Chowdhury, et al.: A case of tuberculous cystitis

ovaries, fallopian tubes, uterus, cervix, and vulva was primarily sooner or later substituted by fibrous tissue, accordingly form congregated and considered as genitourinary TB.[17‑21] At a thick fibrous bladder. Tubercles are sporadic in the bladder if present, the term “urogenital TB (UGTB)” is believed to be even found, typically seem at the ureteral orifice. Malignancy more suitable as kidney, and urinary tract TB becomes obvious should be well thought out with any out‑of‑the‑way tubercles more frequently than genital TB.[19,22] The first communication away from the ureteral orifices.[48] regarding UGTB was made by Porter in 1894 of Northwestern The diagnosis of UGTB is problematic and tough because Ohio Medical Association, Van Wert, Ohio, USA. In addition, its warning sign is broad based.[21,24,38] Multiple approaches more than forty years later, in 1937, Hans Wildbolz Swiss are required for the diagnosis of UGTB. The patient had urologists recommended the term “genitourinary TB”.[17,18,23] complaints of physical signs, histopathology, culture tests, UGTB is an age‑old public health issue but remains polymerase chain reaction (PCR), and various imaging unresolved.[24] UGTB remains the second top‑most cause techniques (ultrasound and laparoscopic cystoscopy) that are of EPTB, with a 90% incidence rate in LMICs.[25‑27] UGTB needed to combine to reach a proper diagnosis.[59‑63] Even in remain as clinical concerns because commonly maltreated, this modern age, proper clerking of patients’ history remains because of nonspecific symptoms, chronic, ambiguous, the most significant step in diagnosing UGTB.[27,64,65] In the puzzling, fluctuating clinical features, thereby, goes unnoticed majority of cases, UGTB patients had the possibility of a and undiagnosed.[12,20,28‑42] Moreover, general practitioners, history of a primary pulmonary TB (PTB) or an EPTB that nephrologists, urologists, and other responsible clinicians offers a piece of vital evidence at large.[27,66,67] Another side were unaware of the probability of the UGTB.[43‑46] The of the coin health professionals’ awareness regarding latent research study revealed that failure to diagnose UGTB timely TB remains an important issue as the reactivation of TB has consequences in increasing the possibility of developing been evident to even after 30 years.[68‑71] The aim of the study several complications of the mentioned disease. Those include was to create awareness among the health professionals when ureteral strictures, contracted bladder, obstructive nephropathy, a case of repeated cystitis, to think may be TB cystitis, has renal parenchymal destruction, irreversible organ damage, and been reported. end‑stage renal failure.[19] UGTB can be classified into four groups: (i) urinary Case Report TB, (ii) male genital TB, (iii) female genital TB, and A 37‑year‑old male patient was reported with history of TB, [19,22,24] (iv) generalized UGTB. Urinary bladder TB (UB‑TB) despite he rarely had any close contact with PTB patients in is alienated into four different stages: (1) tubercle infiltrative; his life. The patient was a professional truck driver. He had a (2) erosive ulcerous; (3) spastic cystitis (bladder contraction history of sex with professional sex workers 13 years back, and false microcystitis); in fact, overactive bladder; and (4) followed by chronic urethral discharge, dysuria, and recurrent [22,47] real microcystitis up to full obliteration. Renal TB usually lower urinary tract symptoms. The patient received treatment serves as the primary site of all UGTB; later, it involves earlier multiple times by a senior consultant urology surgeon. as another urogenital anatomy, for example, UB to cause Nevertheless, patients’ symptoms minimized occasionally, but UB‑TB, through the hematogenous spread of the TB bacilli recurrence came back soon. The patient repeatedly underwent and typically commences at the ureteral orifice and is found in various investigations to diagnose the cause for lower urinary [27,48‑51] nearly one‑third of the patients. Besides, preliminary TB tract infections. However, the patient was diagnosed as a case infection in the renal cortex, subsequently, TB bacilli persist of the overactive UB. After that, antimuscarinics, β3‑agonists, as dormant for years together. Then these dormant TB bacilli behavioral therapy, and lifestyle changes were frequently wait till finds the way out to be active owing to the limitation employed. Eventually, the patient was not at all improved. of the weak immune system of the host, especially among The patient’s symptoms got worse around 3 (December 2019) those patients suffers from incapacitating diseases leading months back. The patient needs to void 15–20 times a day, to weak cell‑mediated immunity. Those diseases include and additional had nocturia, fever, and painful micturition. shock, trauma, use of glucocorticoids or immunosuppressives, This time, the patient was referred to Shaheed Suhrawardy diabetes, or acquired immunodeficiency syndrome (AIDS). Medical College Hospital (SSMCH), Dhaka 1207, Bangladesh. [27,52‑54] Furthermore, it has been estimated that around 1.7– The patient (Hospital ID 36100/19) reported on December 10, 2 billion globally exits as latent TB cases, which epitomizes 2019, in the outpatient department, urology section of SSMCH. a vast pool of potential reactivation TB to spread among people of the community.[54,55] UB‑TB primarily reveals as The patients complained about the abovementioned symptoms. tuberculous infective inflammation with bullous edema and On initial examination, the patient was found mildly anemic; granulation, later chronic inflammatory process eventually there was no gross hematuria; the lower abdomen was ended golf-hole forming[49,56‑58] ureteral orifice, fibrosis and tender, weight 85 kg, blood pressure 100/60 mmHg, no causes stricture formation with hydronephrosis or scarification lymphadenopathy was found, and on auscultation of the chest, with vesicoureteral reflux.[48] If the patient remains untreated or no abnormality was detected. The total lymphocyte count was irrationally treated UB‑TB, consequently turn to severe cases 12,000 per cubic mm, differential lymphocyte count was 82% involving the entire bladder wall, deep layers of muscle are neutrophil, and erythrocyte sedimentation rate was 60 mm.

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Urine examination revealed microscopic hematuria with infections persisted the fatal infectious disease, triggering pyuria that was suggestive of cystitis. Tuberculin skin test was 3.0 million deaths 2016.[73] The number of deaths due to TB weakly positive (erythema: 50 mm × 30 mm, no induration). had decreased; nonetheless, the death toll has been reported Ultrasonography revealed mild irregular thickening with a to be 1.3 million per year, from the year 2000 to 2016.[73] In typical capacity (408 ml) of the UB [Figure 1]. Plain X‑ray of addition, in 2018, TB has claimed 1.5 million life.[74] TB is the kidney, ureter, and bladder revealed no urinary calculus. an immense societal delinquent, not only a medical issue, Chest X‑ray did not found any significant opacity or calcified because both PTB and EPTB often cause male and female shadow. PCR study of the 24‑h urine sample detected TB. infertility and sexually transmitted diseases.[12,69,75‑89] UGTB PCR study was conducted in the reference laboratory of is one of the earliest‑reported infectious diseases but remains Programmatic Management of Drug‑Resistant Tuberculosis, to be an unresolved public health issue.[17,18,23,24] Clinical National TB Control Program, Government of the People’s features of UGTB are supple, stretchy, and inconstant and Republic of Bangladesh, Mohakhali TB Gate, Mohakhali, often imitators of abundant other diseases, which consequences Dhaka 1212, Bangladesh. The details of the study included in deferring diagnosis.[24] In PubMed 5215, articles available patient Reference no. D24 17.12.19, Specimen ID: 19/22298/M. dated March 21, 2020, 1.22 PM (Malaysian Time) with the Urethrocystoscopic examination was not done initially. At this keywords “urogenital, genitourinary, TB.” Another study point, considering all facts that were found clinically and reported that although there is a lot of research studies being of laboratory findings, the patient was diagnosed as a case published, “there are no good multicenter studies with a high of tuberculous cystitis. Subsequently, anti‑TB medication level of evidence on UGTB. UGTB is an embodiment of was given in correct dose, and combination as therapeutic contradictions: from terms and classification to therapy and intervention and trial (oral four‑drug anti‑TB therapy [INH, management.”[24] pyrazinamide, ethambutol, and rifampicin]) was started as The current case TB cystitis symptoms, signs, standard [72] per national guidelines. The patient was strictly observed laboratory reports where mimicking recurrent cystitis[90] and and monitored for the next 2 weeks. Urethrocystoscopic overactive bladder.[91] Thereafter, the diagnosis was delayed.[92] examination done 1 month after receiving antitubercular In addition, they were treated irrationally or imprudently. therapy revealed mildly trabeculated UB wall, with multiple Multiple studies reported that the diagnosis deferment TB patchy healed ulcer anatomy with the capacity (about 500–600 cystitis was because of the furtive progression, rareness or ml) [Figure 2]. Patient symptoms such as frequency, nocturia, nonspecific of symptoms of the disease, deficient cognizance fever, and dysuria have relieved, and the appetite of the patient of medical doctors, the neglected care‑seeking attitude of has subsequently improved. The patient was further advised patient,[93] and poor access to proper health‑care system.[94] to continue the same treatment for 6 months. On subsequent Consequently, diagnosis is seldom completed before severe visits, the patient’s overall health condition starts growing with urogenital complications developed.[93‑98] The patient was weight gain after 4 months of medication. typically frustrated and depressed only at that time was referred to tertiary care medical school hospital, and probably, the first Discussion time was clerked by a consultant urology surgeon. The patient TB remains as an existing public health delinquent, was asked to wait sometime because the consultant had an idea to give enough time to this particular long time suffered. After enduring one of the top ten global causes of death from the finishing all outpatients for that day, the consultant listened transmittable disease.[73,74] Internationally, lower respiratory to all the stories of sufferings and asked to repeat all routine

Figure 1: Ultrasonography photo showing irregular thickening wall of Figure 2: Urethrocystoscopic photo after 1‑month antitubercular therapy the urinary bladder revealed improved urinary bladder wall anatomy

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