NDT Advance Access originally published online on February 7, 2006
Nephrology Dialysis Transplantation 2006 21(4):1113-1116; doi:10.1093/ndt/gfl009
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© The Author [2006]. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org
Nephroquiz
(Section Editor: M. G. Zeier)
Uraemia, psychosis, young patient: an uncommon link
1 Urology Clinic St Elisabeth Hospital Straubing, Germany2 Department of Nephrology University of Turin, Italy
Correspondence and offprint requests to: Dr med. Florian Martin Erich Wagenlehner, Urology Clinic, St Elisabeth Hospital, St Elisabeth Str. 23, D-94315 Straubing, Germany. Email: Wagenlehner{at}AOL.com
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The case |
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A 31-year-old white, obese male with mild mental retardation was referred to the Nephrology Department because of a full-blown uraemic syndrome.
At referral, serum creatinine was 13.2 mg/dl, urea 400 mg/dl, sodium 128 mmol/l, potassium 6.7 mmol/l, with severe acidosis (blood pH 7.301, base excess of –11.4 mmol/l), mild anaemia (haemoglobin 12.0 g/dl). Urinalysis showed 125 white blood cells/µl, 200 red blood cells/µl, proteinuria 100 mg/dl and the urine culture revealed Staphylococcus aureus 105/ml.
His recent clinical history was uneventful, except for severe weight loss in the previous months (over 30 kg) due to nausea and vomiting; however, the body mass index at referral was still 31.1 kg/m2. His family was of German origin, he lived in the local area, had no foreign travel history and was a metalworker in a workshop for handicapped people.
The physical examination showed a pale, conscious man, heart rate 130/min (sinusal tachycardia), blood pressure 130/90, low grade fever (37.8°C), normal auscultation of the lung, normal physical abdominal findings, no costovertebral tenderness, no skin abnormalities, no meningism and without focal neurological signs.
Kidney ultrasound showed a right kidney of 12.8 x 7.3 cm, with a 1.2 cm dilatation of the ureter and a moderate dilatation of the pelvis, resistance index 0.71 (Figure 1); left kidney 9.6 x 6 cm, no dilatation of the pelvis, resistance index 0.65.
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Haemodialysis was started immediately; because of the positive urine culture, antibiotic treatment with ciprofloxacin 500 mg/day was started. His general condition improved within the first few days.
The patient was then transferred to the Urology Department to continue the investigation of the morphology of the urinary tract. The urethrogram showed stenosis in the bulbar urethra (Figure 2), while the cystogram revealed normal bladder filling, with left vescico-uretheral reflux grade II. Because of the urethral stricture, a suprapubic catheter was inserted and a urethrotomy was performed. During the procedure, a retrograde pyelography was performed followed by ureterorenoscopy on the right side, revealing multiple stenoses and dilatations in the right ureter and an irregular, dilated right renal pelvis (Figure 3A–C). Cytology and biopsy of ureteral tissue revealed unspecific inflammation. A double J-stent was inserted to relieve the obstruction.
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The day after the intervention, the patient developed moderately severe fever (maximum 38.8°C). Blood cultures showed S. epidermidis, while urine culture showed 103 cfu/ml mixed infection. Blood leukocytes were 9300 µl, CRP was 6.4 mg/dl. Chest X-ray was normal apart from decreased height of the 3rd and 4th thoracic vertebrae.
Six days later, the patient experienced an acute generalized epileptic seizure, followed by acute acoustic hallucinations and acute psychosis. A cranial CT scan was normal, EEG revealed a non-specific, diffuse 
-pattern.
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Questions |
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What is your diagnosis?
What is your differential diagnosis?
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Answers to the quiz on the preceding page |
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The patient was affected by urinary tract and miliary tuberculosis.
After the development of acute psychosis, the patient (still febrile, temperature 38.2°C) was transferred to a psychiatric ward, but soon after transfer his general condition deteriorated further, with high fever (39.5°C) and a catatonic state.
He was then transferred to the intensive care unit of another hospital and, after stabilization and exclusion of cerebral lesions by CT scan, to an internal medicine ward, with a diagnosis of sepsis of unknown origin in a dialysis patient. Since blood and urine cultures were repeatedly negative, empirical antibiotic therapy was continued with piperacillin/tazobactam and tobramycin.
The multiple stenosis and dilatation in the urinary tract suggested the presence of tuberculosis, which was confirmed by the finding of acid-fast bacteria by microscopy and by a positive PCR for Mycobacterium tuberculosis complex; in cultures, the bacterium was susceptible to all tested drugs. Upon questioning, the patient's father reported having been affected by tuberculosis 24 years earlier, but he was apparently completely healed.
A bronchial lavage revealed upper respiratory flora, but no acid-fast bacteria. A thoracic CT scan showed multiple miliary and nodular lung infiltrations and a picture compatible with spondylodiscitis in the 6th and 7th thoracic vertebrae, confirmed by nuclear magnetic resonance imaging (MRI) (Figures 4 and 5).
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Tuberculostatic treatment was started with isoniazid, rifampicin, pyrazinamid and ethambutol, with a prompt clinical response.
Two months later, a paravertebral abscess was drained and spondylodesis was performed. Microscopy and PCR of the vertebral tissue revealed acid-fast bacteria and M. tuberculosis complex. The further clinical course was uneventful, but the patient's renal function did not recover and he is at present still on chronic dialysis.
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Comment |
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This case presents some ‘classic’ findings suggestive of urinary tract tuberculosis, together with some rather unusual aspects that were misleading and delayed the diagnosis.
The young age of the patient, the initial urinary tract infection with S. aureus and the psychotic reaction were misleading: in fact, urinary tract tuberculosis usually leads to end-stage kidney disease in the 5th–7th decade, and it is not commonly suspected in a young patient, even though the family history revealed that the patient's father had suffered from tuberculosis more than two decades earlier.
The main diagnostic clues were the presence of multiple strictures and dilatations in the urinary tract [1–3]. Tuberculosis of the urinary tract can occur both as miliary tuberculosis, usually involving both kidneys in the course of a generalized disseminated disease, and caseating and ulcerating tuberculosis, which usually originates in the renal medulla and may perforate into the collecting system. The further course is characterized by inflammation and scarring of the downstream collecting system, leading to stenoses and dilatations of the suprastrictural segments, as found in this patient [1–3].
In this case, the post-primary renal tuberculosis disseminated again, leading to miliary tuberculosis, with cerebral involvement, psychiatric symptoms and spondylodiscitis, with a protean clinical presentation. The acute psychosis could be due either to the tuberculosis infection, or to an adverse effect of ciprofloxacin, as it was recently described in a few cases, who were treated by ciprofloxacin for various diseases, including multidrug-resistant tuberculosis [4–6].
Attention to this once common disease is probably too low in the present generations of physicians. However, tuberculosis is increasing in western Europe, mainly because of migration from eastern Europe and from settings where the disease is much more common [7]. However, the patient was of German origin, was not hospitalized for long periods and did not live in a nursing home, thus lacking these relatively common risk factors in the new rising tide of tuberculosis in Europe.
The present case shows that one should always consider this differential diagnosis, particularly in the presence of strictures and dilatations in the urinary tract combined with fever or unexplained symptoms in any organ or body system.
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Acknowledgments |
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Figures 4 and 5 are reproduced by kind permission of B. Roßmüller, Institute of Clinical Radiology, Ludwig Maximilian University, Munich, Germany.
Conflict of interest statement. None declared.
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References |
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- Wang LJ, Wu CF, Wong YC, Chuang CK, Chu SH, Chen CJ. Imaging findings of urinary tuberculosis on excretory urography and computerized tomography. J Urology 2003; 169: 524–528[CrossRef][Medline]
- Engin G, Acunas B, Acunas G, Tunaci M. Imaging of extrapulmonary tuberculosis. RadioGraphics 2000; 20: 471–488
[Abstract/Free Full Text] - Harisinghani MG, McLoud TC, Shepard JA, Ko JP, Shroff MM, Mueller PR. Tuberculosis from head to toe. RadioGraphics 2000; 20: 449–470
[Abstract/Free Full Text] - Norra C, Skobel E, Breuer C, Haase G, Hanrath P, Hoff P. Ciprofloxacin-induced acute psychosis in a patient with multidrug-resistant tuberculosis. Europ Psych 2003; 18: 262–263[CrossRef]
- Kisa C, Yildirim SG, Aydemir C, Cebeci S, Goka E. Prolonged electroconvulsive therapy seizure in a patient taking ciprofloxacin. J ECT 2005; 21: 43–44[Medline]
- Farrington J, Stoudemire A, Tierney J. The role of ciprofloxacin in a patient with delirium due to multiple etiologies. Gen Hosp Psy 1995; 17: 47–53
- Carballo M, Divino JJ, Zeric D. Migration and health in the European Union. Tropical Medicine & International Health 1998; 3: 936–944
Accepted in revised form: 10. 1.06
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