Journal of Postgraduate Medicine
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CASE REPORTS
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Year : 1993  |  Volume : 39  |  Issue : 1  |  Page : 37-8  

Tuberculosis of the renal artery.

C Madiwale, A Sivaraman, IM Vora 
 Dept of Pathology, Seth GS Medical College and KEM Hospital, Parel, Bombay, Maharashtra.

Correspondence Address:
C Madiwale
Dept of Pathology, Seth GS Medical College and KEM Hospital, Parel, Bombay, Maharashtra.

Abstract

A young female who underwent nephrectomy for renovascular hypertension was diagnosed on histology to have tuberculosis of the renal artery. This was an isolated finding as there was no tuberculous infection elsewhere including tissues in the vicinity of the vessels. A survey of literature did not yield any reports of tuberculous renal arteritis, making this the first such case.



How to cite this article:
Madiwale C, Sivaraman A, Vora I M. Tuberculosis of the renal artery. J Postgrad Med 1993;39:37-8


How to cite this URL:
Madiwale C, Sivaraman A, Vora I M. Tuberculosis of the renal artery. J Postgrad Med [serial online] 1993 [cited 2021 Dec 1 ];39:37-8
Available from: https://www.jpgmonline.com/text.asp?1993/39/1/37/651


Full Text




  ::   IntroductionTop


Tuberculosis of the aorta and its major branches has been reported[1]. However, there has been no case of tuberculosis renal arteritis manifesting as reno-vascular hypertension.


  ::   Case reportTop


A 23-year-old female who complained of weight loss, headache and weakness, was found to have a blood pressure of 150/100 mmHg, normal haemogram, renal chemistry and x-ray chest. Digital subtraction angiogram revealed a beaded left renal artery. Abdominal aortogram showed normal aorta, common iliac, coeliac, superior mesenteric and right renal arteries, with a tapered occulusion of the left renal artery and a small sized left kidney. A diagnosis of renovascular hypertension due to fibro-muscular dysplasia of the renal artery was made and the patient underwent nephrectomy. At surgery, the distal segment of the left renal artery appeared thickened with virtual obliteration of its lumen. There were no enlarged lymph nodes in the vicinity of the vessel.

The excised kidney was small and weighed 60 gms. The excised renal artery had a narrow lumen and a thick, white wall. The renal vein, ureter and pelvi-calyceal system were normal.

Histologic examination of the renal artery revealed intimal fibrous proliferation and fragmentation of the internal elastic lamina [Figure:1]. Lymphocytic infiltrates and caseating epithelioid granulomas with Langhans giant cells were seen in the media and adventitia [Figure:2]. Stains for fungus were negative. Ziehi- Neelsen stain did not reveal acid fact bacilli. Immunoperoxiclase staining[2] for M. tuberculosis antigen, using rabbit anti-Mycobacterium bovis (BCG) antibody (B 124, Dakopatts) revealed granular positivity in the epithelioid cells and Langhans giant cells. The kidney showed ischaemic changes, but no tuberculous lesion was detected.


  ::   DiscussionTop


Granulomas in the renal artery occur in giant cell rteritis, non-specific aorto-arteritis and tuberculosis. Giant cell arteritis is a disease of elderly females and the granulomas lack caseation[3]. Granulomatous renal arteritis in nonspecific aorto-arteritis is also non-caseous and is invariably associated with involvement of the aorta[4]. This diagnosis was not considered because abdominal aortogram showed only renal artery involvement. It is known that the granulomas in tuberculosis may not always demonstrate acid fast bacilli on Ziehi-Neelsen stain[5]. Identification of mycobacterial antigen in tissue sections is considered specific for the diagnosis of tuberculosis[6]. This was demonstrated in our case.

Tuberculosis arteritis usually results from direct spread of infection from adjacent tuberculosis tissues. Obliterative granulomatous endarteritis is known in tuberculous meningitis, pulmonary tuberculosis and in the coronary arteries in tuberculosis pericarditis and myocarditis[7]. Rarely, it is due to haematogenous dissemination of the organisms from a focus in the lung or elsewhere[3].

This case presents with certain unusual features. Occlusive diseases of the renal artery are a well-known cause of hypertension but hypertension due to tuberculosis of the renal artery, has not been reported. In fact, a survey of literature did not yield any case of tuberculosis renal arteritis. Tuberculosis lymph nodes were not present near the diseased artery, which excludes spread of infection from adjacent diseased tissues. Chest x-ray did not reveal pulmonary tuberculosis. However, it is known that haematogenous dissemination of the tubercle bacilli, invariably occurs as a part of the primary infection. These miliary foci may remain quiescent and clinically inocuous, but may at a later date reactivate, even though the chest x-ray does not reveal tuberculosis[8]. This case would therefore, represent an unusual example of isolated end organ tuberculosis.


  ::   AcknowledgmentTop


We wish to thank Dr PM Pai, Dean, Seth GS Medical College and King Edward Memorial Hospital, Mumbai, for permission to publish this case report.

References

1 Volini FI, Offield RC, Thompson JR, Kent G. Tuberculosis of the aorta. JAMA 1962; 181:78-83.
2Willey EL, Mulhollan TJ, Beck B, Tyndall JA, Freeman RG. Polyclonal antibodies raised against bacillus Calmette-Guerin, Mycobacterium duvallii, and Mycobacterium para tuberculosis used to detect mycobacteria in tissue with the use of immunohistochemical techniques. Am J Clin Pathol 1990; 94:307-312.
3Rose AG. Diseases of medium-sized arteries, including hypertension. In: Silver MD, editor. Cardiovascular Pathology, 1st ed. New York, Edinburg, London, Melbourne: Churchill Livingstone Inc; 1983, pp 739-776.
4Sen PK. Obstructive disease of the aorta and its branches. Indian J Surg 1968; 30:289-327.
5Von Lichtenberg F. Infectious diseases. In: Robbins SL, Cotran RS, Kumar V, editors. Pathologic Basis of Disease, 4th ed. Philadelphia: WB Saunders; 1989, pp 307-384.
6Humphrey DM, Weiner MH. Mycobacterial antigen detection by immunohistochemistry in pulmonary tuberculosis. Human Pathol 1987; 18:701-708.
7Kinare SG, Bhatia BI. Tuberculous coronary arteritis with aneurysm of the ventricular septum. Chest 1971; 60:613-616.
8Slavin RE. Late generalised tuberculosis: a clinical and pathologic analysis of a diagnostic puzzle and a changing pattern. In: Sommers SC, Rosen MD, editors. Pathology Annual. New York: Appleton-Century-Crofts; 1981; 16:81-99.

 
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