Extrapulmonary tuberculosis with multiple localizations in a patient with end‐stage renal disease

Abstract

The incidence of active tuberculosis among patients on long‐ term dialysis is higher than the rate in the general population. Case: 39‐year‐old male patient with ESRD was admitted to hospital with dyspnea, weight loss, cough without sputum and hemoptysis, and a palpable painless mass under the right areola. He was on maintenance hemodialysis three times a week for the last six months. PPD was negative. Chest X‐ray examination revealed a hyperdense lesion. On the computerized tomography a cystic mass at the inferior lobe superior segment near the thorasic vertebra was detected. Fine needle aspiration from each of the mass lesions revealed granulomas and acido‐resistant bacteria. Anti‐tuberculous therapy was initiated. After eight months he came back with paraplegia. Magnetic resonance imaging (MRI) revealed that the lesion which previously has been described by CT was extending to the spinal duct and pressing on the spinal cord. After a biopsy, granuloma was seen; however, mycobacterium tuberculosis did not grow in the culture. Discussion: Extrapulmonary tuberculosis is common in patients with ESRD. In the present case we established that the patient who presented a mass on the chest wall without pulmonary tuberculosis findings had indeed a tuberculous cavity mass. It is interesting to note that in this case this mass had no relationship to the tuberculous cavity in the lung tissue. Moreover, it is also interesting that paraspinal lesion occured during the period in which the patient was under treatment and it quickly progressed and led to paraplegia. Tissue biopsy with invasive procedures may be necessary. Thus, in areas with a high prevalence of tuberculosis, renal patients in high‐risk group (renal transplant recipients, hemodialysis and CAPD patients) should be examined periodically to exclude silent infection and reduce morbidity and mortality.