TUBERCULAR LYMPHADENITIS WITH POST STREPTOCOCCAL GLOMERULONEPHRITIS

TUBERCULAR LYMPHADENITIS WITH POST STREPTOCOCCAL GLOMERULONEPHRITIS - A Diagnostic and Therapeutic Dilemma
S S Galwankar*, M Khandelwal**, R A Sirsat***
*Senior Registrar; **Clinical Associate; ***Consultant Nephrologist; Dept. of Nephrology Medicine, PD Hinduja National Hospital and Medical Research Centre, Mahim, Mumbai - 400 016.

Two or more medical disorders of different aetiologies may co-exist and pose difficulties in diagnosis and management. We report one such occurrence where the patient was admitted with tubercular lymphadenitis, tubercular granulomas in the brain causing seizures and acute glomerulonephritis.

INTRODUCTION

Genitourinary tuberculosis can present with haematuria, flank pain, proteinuria and/or hypertension. Patients with post infectious gl omerulonephritis following streptococcal throat infection can also present with a similar spectrum. Tuberculosis is treated with antikochs treatment while PSGN resolves spontaneously.

CASE REPORT

A 13 year old male was admitted in post ictal state following five episodes of focal seizures involving left upper limb progressing to involve the left half body followed by loss of consciousness. Prior to the seizures the patient had low grade fever, loss of appetite and weight loss of 6 to 7 kg for 2 months. He had an episode of tonsillitis 3 weeks prior to admission which subsided with antibiotics. Patient’s mother had received treatment for pulmonary tuberculosis few years back and his sister is under treatment for pulmonary tuberculosis.

On examination, patient was drowsy with a blood pressure of 140/100 mm Hg. He had bilateral cervical lymphadenopathy and mild tonsillar congestion on oral examination. e systemic examination was essentially normal. His investigations on admission revealed Hb 12.1 g/dl; WBC 14.7 x 109/L; ESR 110 mm at end of 1 hr, malarial parasite was negative on peripheral smear. His serum sodium was 131 meq/L, serum chloride 100 meq/L, and serum potassium was 6.2 meq/L.

His urine examination showed pH 6.0, specific gravity (SG) 1.010, protein 80 mg/dl, RBC large nos, WBC 1-2/hpf, nitrite -ve. Blood urea nitrogen 18 mg/dl, creatinine 0.7 mg/dl. Chest X-ray was normal. Ultrasound of kidney urinary bladder revealed mild increase in kidney size. Right kidney was 10.2 x 4.4 x 4.24 cm, left kidney was 9.8 x 4.7 x 4.5 cm. A fine needle cytology aspiration of cervical lymphnodes revealed granulomatous lymphadenitis with focal necrosis consistent with tuberculous lymphadenitis.

In view of his seizures, MRI scan of brain was done which showed granular, nodular lesions in right frontoparietal lobe consistent with tuberculous granulomas. In view of history, of sore throat, hypertension, hyperkalaemia, haematuria, it was thought that patient had post streptococcal glomerulonephritis. However, since he also had tubercular lymphadenitis and cerebral tubercular granulomas, the possibility of genito urinary tuberculosis was also considered.

Patient’s complement level was 24 mg/dl (normal 88 to 201 mg/dl) and ASO titre was > 200 IU/ml. Urinary AFB smears and cultures were negative. Patient was put on 4 drugs anti kochs treatment with isoniazid, rifampicin, pyrazinamide and ethambutol, in adequate dose according to his weight. His liver function tests were normal. Patient was put on frusemide 20 mg/day with atenolol 12.5 mg daily for his hyperkalaemia and hypertension along with potassium restricted diet.

Patient was discharged and on follow-up visit 6 weeks later patient was normotensive, urine examination and C3 levels were normal. Frusemide and atenolol were withheld and patient continued to remain normotensive.

DISCUSSION

It is unusual for a patient to present with two different illnesses simultaneously. Though, the clinical features and urine examination were suggestive of post streptococcal glomerulonephritis, the possibility of renal tuberculosis was also kept in mind, in view of the presence of active tubercular lymphadenitis and a similar clinical presentation in genito urinary tuberculosis. [1,2]

Genito urinary tuberculosis is a disease of younger age group [2] and spreads through haematogenous route. [1] It presents with flank pain, haematuria, proteinuria and hypertension. The diagnosis is confirmed by urinary AFB cultures and the typical radiological changes. The urinary AFB cultures in our patient were negative. His C3 complement level were low and ASO titre was elevated suggesting the diagnosis of PSGN. [3] This was further substantiated 6 weeks later when patient became normotensive, with normalization of C3 level and urine examinations. [4]

REFERENCES

Leitils AG, Horne NW. Renal tuberculosis (ed) Oxford textbook of Clinical Nephrology. Oxford University Sum, Press Oxford. 1998; 4-5 : 1217-1285.

Grange JM, Yater M Ormerod LP. Factors determining ethnic differences in the incidence of bacteriologically confirmed genitourinary tuberculosis in South-East-England. Journal of infection 1995; 30 (37-40).

Brocklebark J. Trevor acute renal failure in a special sitting (ed) Oxford textbook of clinical nephrology. Oxford University Press, Oxford. 1998; 7-1 : 1693-1704.

Madio MP, Harrington JT. The diagnosis of acute glomerulonephritis. New England Journal of Medicine 1983; 309 : 1299-302.

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