Case presentation

A 44-year-old woman presented to the gynecology outpatient clinic with complaints of irregular menstruation. She did not report any urinary symptoms such as flank pain, hematuria, dysuria, fever, or weight loss. Her medical history was significant for pulmonary TB 14 years earlier, for which she had completed a full one-year course of antitubercular therapy.

A routine ultrasonographic examination incidentally revealed marked hydronephrosis with calcification in the left kidney. Laboratory tests indicated normal renal function. A contrast-enhanced computed tomography (CT) scan of the abdomen demonstrated a heavily calcified, nonfunctioning left kidney, consistent with a putty kidney (Figure 1).

Figure 1: Contrast-enhanced CT of abdomen and pelvis showing a calcified left kidney (solid white arrows)Axial contrast-enhanced CT image (A) showing a calcified left kidney and (B) at an adjacent level, again showing the calcified left kidney with associated arrow markingCT: computed tomography

Additionally, multiple calcified granulomas were noted in the liver and spleen, along with calcified mesenteric lymph nodes (Figure 2).

Figure 2: Contrast-enhanced CT scan of the abdomen and pelvis showing multiple calcified granulomas in the (A,B) liver (solid arrows) and (C,D) spleen (solid arrows)

A chest X-ray (Figure 3) and high-resolution CT (Figure 4) of the thorax showed multiple calcified pulmonary nodules suggestive of previously healed TB.

Figure 3: Chest X-ray showing multiple calcified pulmonary nodulesSolid white arrows show the multiple healed calcified nodules suggestive of prior pulmonary tuberculosis

Figure 4: HRCT of the thorax (coronal view) showed multiple calcified pulmonary nodulesCoronal HRCT image (A) showing calcified pulmonary nodules, with the solid white arrow indicating a representative calcified nodule; (B) at a subsequent level showing additional calcified pulmonary nodules; (C) showing further calcified nodules distributed through the lung parenchyma; and (D) showing the extent of calcified nodular involvement bilaterallyHRCT: high-resolution computed tomography

Magnetic resonance imaging of the spine revealed lytic lesions at the L4-L5 vertebral levels, also indicative of healed spinal TB (Pott's spine) (Figures 5, 6).

Figure 5: MRI LS spine (coronal view) showing multiple lytic lesions in L4-L5 vertebrae (solid arrow)MRI: magnetic resonance imaging; LS: lumbosacral

Figure 6: MRI LS spine (sagittal view) showing multiple lytic lesions in L4-L5 vertebrae (solid white arrow)MRI: magnetic resonance imaging; LS: lumbosacral

A DTPA renal scan confirmed that the left kidney was nonfunctional (Figure 7).

Figure 7: DTPA scan showing a left nonfunctional kidney (solid white arrow)DTPA: diethylenetriamine pentaacetic acid

The patient subsequently underwent an open left simple nephrectomy through an incision along the left eleventh rib. On gross examination, the kidney was found to be largely replaced by approximately 50-60 mL of caseous necrotic material (Figure 8).

Figure 8: (A) Intraoperative photograph of left simple nephrectomy: exposure and mobilization of the left kidney through the 11th rib bed incision. (B) Gross specimen of nephrectomy: excised left kidney showing contracted, irregular kidney consistent with chronic renal tuberculosis. (C) Cut section of nephrectomy specimen (putty kidney): thick-walled kidney cavity filled with caseous material (putty). Extensive calcification and destruction of renal parenchyma. (D) Close-up cut section of the nephrectomy specimen showing the thick-walled cavity filled with caseous (putty) material and extensive parenchymal destruction

Histopathological analysis demonstrated granulomatous inflammation with multinucleated giant cells and areas of caseous necrosis, confirming the diagnosis of renal TB (Figure 9).

Figure 9: Histopathological study showing granulomatous inflammation with multinucleated giant cells and areas of caseous necrosis

Ziehl-Neelsen staining for acid-fast bacilli was negative. The patient’s postoperative recovery was uneventful.