腎不全を契機に発見された尿路結核, 粟粒結核の1例

Abstract

51歳男性.夜間の微熱, 食思不振を主訴に近医を受診し, 腎不全を指摘されて精査加療目的で入院した.腹部超音波, 腹部CTで両側水腎症を認め, 腎後性腎不全を疑い, 逆行性腎盂造影及びダブルJステント留置目的で膀胱鏡検査を行った.膀胱内は全周性に黄白色の結節状所見を認めた.尿塗抹検査, 尿PCR検査, 培養検査は結核菌陽性であったため, 尿路結核と診断した.胸部X線, 胸部CTで, 肺野に多発性の顆粒状陰影を認め, 粟粒結核と診断した.イソニコチン酸ヒドラジド, リファンピシン, エタンブトール, ピラジナミドによる抗結核化学療法を開始した.1週間目の膀胱生検では, 黄色白斑調の結核結節はほとんど認めなかった.病理所見では, 類上皮細胞肉芽腫が認められ, 膀胱結核と診断された

A case of urinary and miliary tuberculosis in a 51-year-old male is reported. The patient with the complaint of low grade fever at night and appetite loss had visited another clinic. Laboratory data showed renal failure (serum creatinine 3.9 mg/dl, BUN 35.1 mg/dl) and he was referred to our hospital. Ultrasonography and computed tomography (CT) revealed bilateral hydronephrosis. Therefore we suspected postrenal renal failure. We performed cystoscopy in order to perform retrograde pyelography and to indwell double J stent. The bladder showed yellow-whitish nodules all over the bladder. Tuberculous bacilli were detected in the urine by smear, polymerase chain reaction (PCR) and culture. Chest radiography and CT revealed multiple granular nodules and so diagnosed miliary tuberculosis. Immediately combination chemotherapy of with isonicotinic acid hydrozide, rifapicin, ethanbutal and pirazinamide was administered. Histopathology by bladder biopsy showed epithelioid cell granuloma. Chemotherapy was effective, but the vesical capacity was contracted to less than 50 ml, and we suspect that the patient will need vesical augmentation.