tuberculous and parasitic infections of genitourinary tract

Question 1

All of the following mycobacteria cause tuberculosis (TB) EXCEPT: a. Mycobacterium bovis. b. Mycobacterium avium-intracellulare. c. Mycobacterium africanum. d. Mycobacterium microti. e. Bacille Calmette-Guérin (BCG).

Answer 1

b. Mycobacterium avium-intracellulare. M. bovis, M. africanum, and M. microti are members of the M. tuberculosis complex (MTBC) and can cause TB disease. BCG is derived from M. bovis and can cause TB in certain individuals. Of the mycobacteria listed, M. avium-intracellulare is one of the many nontuberculous mycobacteria.

Question 2

Which of the following routes of infection is the most common in genitourinary tuberculosis? a. Hematogenous seeding b. Lymphatic spread c. Direct inoculation d. Sexual transmission e. Ascending or retrograde infection

Answer 2

a. Hematogenous seeding. Each of the answers is a known route of infection for the development of GU TB. However, hematogenous seeding is by far the most common one.

Question 3

4. Which of the following is a not a late complication of genitourinary tuberculosis? a. Infertility b. Scrotal fistula c. Autonephrectomy d. Thimble bladder e. Papulonecrotic tuberculid

Answer 3

Papulonecrotic tuberculid. Papulonecrotic tuberculid is the only manifestation listed that can present early in the course of TB disease. The tuberculids are hypersensitivity reactions to MTBC antigens that were disseminated to the skin from other infectious foci, and as such, they are culture negative and typically PCR negative.

Question 4

Which of the following persons is LEAST likely to have tuberculosis infection?

a. A patient with fibrosis on chest radiograph and a tuberculin skin test (TST) of 5 mm
b. A patient with HIV infection and a TST of 3 mm
c. A recent immigrant from Vietnam with a TST of 11 mm
d. A BCG-vaccinated patient with a TST of 14 mm
e. A healthy U.S.-born teacher with a TST of 11 mm

Answer 4

e. A healthy U.S.-born teacher with a TST of 11 mm. Refer to Table 60.1 for the Centers for Disease Control and Prevention guidelines on TST interpretation. Patients (a), (b), and (c) are likely TB infected. A BCG-vaccinated person is likely from a country with high enough incidence of TB to warrant vaccination; hence a cutoff of 10 mm is likely to apply for this person. Patient (e) has no clear risk factors for TB; hence a cutoff of 15 mm would apply for this person. However, TST cutoffs may be set differently in local public health jurisdictions according to local epidemiology.

Question 5

Which of the following results most specifically diagnoses genitourinary tuberculosis?

a. A positive interferon γ release assay b. A positive urine polymerase chain reaction (PCR) for Mycobacterium tuberculosis complex c. A TST reaction of 25 mm d. A positive urine acid-fast bacilli (AFB) culture e. A renal biopsy showing AFB

Answer 5

d. A positive urine acid-fast bacilli (AFB) culture.

Question 6

Which of the following first-line antituberculosis agents does not cause hepatic toxicity? a. Isoniazid b. Rifampin c. Pyrazinamide d. Ethambutol e. Streptomycin

Answer 6

d. Ethambutol. Ethambutol is rarely hepatotoxic. Its main toxicity is ocular, such as decreased visual acuity or red-green color blindness. Streptomycin is not considered hepatotoxic either, but it is also not considered a first-line agent in the United States

Question 7

Which of the following drugs might have efficacy against extensively drug-resistant (XDR) tuberculosis? a. Isoniazid (INH) b. Rifampin c. Pyrazinamide d. Moxifloxacin e. Amikacin

Answer 7

c. Pyrazinamide. By definition, MDR TB is resistant to INH, rifampin, any quinolone, and at least an additional injectable aminoglycoside. Hence, of the choices, pyrazinamide is the most likely to have efficacy against XDR TB.

Question 8

Which of the urological interventions is emergently indicated? a. Nephrectomy of nonfunctional kidney in medically resistant hypertension b. Bladder augmentation of a contracted bladder in a patient with severe dysuria c. Percutaneous nephrostomy of obstructive hydronephrosis in acute renal failure d. Balloon dilatation and ureteral stenting of a proximal ureteral stricture e. Boari flap for a lower ureteral stricture that requires excision

Answer 8

Percutaneous nephrostomy of obstructive hydronephrosis in acute renal failure. All of the choices are appropriate indications for urological intervention. However, only (c) is emergently indicated. For the other interventions, waiting at least 4 to 6 weeks after initiation of medical therapy is preferred

Question 9

Which of the following statements is FALSE about genitourinary (GU) TB patients? a. Magnetic resonance imaging (MRI) is often used to help diagnose patients with GU TB. b. Computed tomography (CT) is most useful in extensive TB disease when other organ systems might be involved. c. The most common finding of GU TB on plain film is calcification. d. Intravenous urography (IVU) is the best test to detect early renal changes due to TB. e. The most common finding on IVU is obstructive uropathy from scarring.

Answer 9

a. Magnetic resonance imaging (MRI) is often used to help diagnose patients with GU TB. Although MRI has potential uses in the diagnosis of GU TB, it is not sufficiently superior to CT or IVU to warrant its frequent use.

Question 10

Of the following drugs, the most effective to treat schistosomiasis is: a. albendazole. b. praziquantel. c. mebendazole. d. diethylcarbamazine. e. ivermectin.

Answer 10

b. Praziquantel. Although all of the drugs listed are antiparasitic agents, only praziquantel is used to treat schistosomiasis. In fact, praziquantel is the only drug approved for schistosomiasis by the World Health Organization (WHO). 2. c. The cercariae. The worm and egg st

Question 11

The life cycle stage of Schistosoma haematobium that infects humans transdermally is: a. the worm. b. the schistosomule. c. the cercariae. d. the egg. e. the sporocyst

Answer 11

c. The cercariae. The worm and egg stages (Fig. 60.1) are found in chronically infected humans but are intravascular or deposited in tissues such as the bladder, respectively. Cercariae infect humans by burrowing through the skin, whereupon they transform into schistosomules.

Question 12

S. haematobium infections are estimated to affect the following number of people: a. 1.1 billion b. 1.1 million c. 900,000 d. 112 million e. 11 million

Answer 12

d. 112 million. Although an estimated 1 billion people are at risk of contracting schistosomiasis because they live in endemic areas, only 112 million are actively infected with S. haematobium.

Question 13

The life cycle stage of S. haematobium that induces the majority of human tissue pathology is: a. the worm. b. the schistosomule. c. the cercaria. d. the egg. e. the sporocyst

Answer 13

The egg. The majority of human tissue pathology caused by urogenital schistosomiasis is induced by the host immune response against S. haematobium eggs (see Fig. 60.1). In comparison to eggs, worms, schistosomules, and cercariae are much less immunogenic and are thought to correspondingly cause much less chronic tissue pathology.

Question 14

The eponym for acute schistosomiasis is: a. Katayama fever. b. Bilharz syndrome. c. Barlow fever. d. Toshiro syndrome. e. Tan’s triad.

Answer 14

A

Question 15

The diagnostic, first-line gold standard for urogenital schistosomiasis is: a. polymerase chain reaction. b. serology. c. cystourethroscopy with bladder biopsy. d. rectal biopsy. e. urine egg counts.

Answer 15

Urine egg counts. Although PCR and serology are highly sensitive for detecting infection, they are not considered first-line diagnostic modalities. Cystourethroscopy (Fig. 60.2) with bladder biopsy and rectal biopsy are highly invasive and reserved for difficult-to-diagnose cases or suspected cancer. Microscopic enumeration of S. haematobium eggs shed in urine are the diagnostic, first-line gold standard (albeit slow and impractical in many field settings).

Question 16

. Although there have been reports that some schistosome worms can live for several decades, on average they are believed to only live for ___

Answer 16

. Although there have been reports that some schistosome worms can live for several decades, on average they are believed to only live for 3 to 5 years.

Question 17

Surgical options for reconstruction of irreversible ureteral lesions caused by urogenital schistosomiasis include all of the following EXCEPT: a. renal autotransplantation. b. Boari flaps. c. ureteroureterostomies. d. ileal ureter. e. suprapubic intravesical ureterostomy.

Answer 17

a Renal autotransplantation is reserved for reconstruction of the urinary tract in the setting of multiple and/or large renal tumors. There are much less morbid surgical options for reconstruction of schistosomiasis-associated ureteral lesions

Question 18

Intermediate snail hosts for S. haematobium are members of the following genus: a. Biomphalaria. b. Oncomelania. c. Bulinus. d. Helix. e. Achatina.

Answer 18

c. Bulinus. Biomphalaria and Oncomelania are host snails for Schistosoma mansoni and S. japonicum, respectively, but not S. haematobium. Helix and Achatina snails are terrestrial and not considered hosts for human-specific schistosomes.

Question 19

Untreated genitourinary TB can lead to irreparable tissue damage and extensive ___, with serious consequences such as __ and ___.

Answer 19

Untreated genitourinary TB can lead to irreparable tissue damage and extensive fibrosis, with serious consequences such as renal failure and infertility.

Question 20

Untreated genitourinary TB can lead __ and ___, with serious consequences such as __ and __.

Answer 20

Untreated genitourinary TB can lead to irreparable tissue damage and extensive fibrosis, with serious consequences such as renal failure and infertility.

Question 21

Genitourinary TB is associated with nonspecific symptoms and can be indolent, with fewer than __ presenting with constitutional symptoms.

Answer 21

Genitourinary TB is associated with nonspecific symptoms and can be indolent, with fewer than 20% presenting with constitutional symptoms.

Question 22

___% of genitourinary TB occurs in the kidney, and typical laboratory findings include sterile pyuria or hematuria.

Answer 22

Eighty percent of genitourinary TB occurs in the kidney, and typical laboratory findings include sterile pyuria or hematuria.

Question 23

Ureteral TB can lead to strictures throughout the ureter and impart a __ and __ appearance on imaging; bladder TB can lead to severe contracture and is a late complication more common in developing countries

Answer 23

Ureteral TB can lead to strictures throughout the ureter and impart a pipestem or beaded corkscrew appearance on imaging; bladder TB can lead to severe contracture and is a late complication more common in developing countries

Question 24

Another common presentation of genitourinary TB is ___ that persists despite multiple course of antibiotics.

Answer 24

Another common presentation of genitourinary TB is chronic prostatitis that persists despite multiple course of antibiotics.

Question 25

The gold standard for diagnosis of genitourinary TB is a ___ from urine or tissue biopsy. ___ urine is the best sample for culture.

Answer 25

The gold standard for diagnosis of genitourinary TB is a positive AFB culture from urine or tissue biopsy. First void urine is the best sample for culture.

Question 26

Genitourinary TB can also be made with alternate methods of diagnosis such as ___ of M. tuberculosis or the presence of granulomas on histopathology examination of tissue.

Answer 26

Genitourinary TB can also be made with alternate methods of diagnosis such as nucleic acid amplification of M. tuberculosis or the presence of granulomas on histopathology examination of tissue.

Question 27

Genitourinary TB generates a wide spectrum of imaging findings. The test of choice depends on disease location. All patients should also have a ___

Answer 27

Genitourinary TB generates a wide spectrum of imaging findings. The test of choice depends on disease location. All patients should also have a chest x-ray to exclude concomitant infectious pulmonary TB.

Question 28

Surgical interventions are performed: (5)

Answer 28

Surgical interventions are performed to relieve urinary obstruction, to drain infected material, to remove nonworking infected kidneys in cases resisting cure, to improve medically resistant hypertension secondary to a functionally excluded kidney, or to reconstruct the urinary tract.

Question 29

The optimal timing of surgery is __ after the initiation of therapy. This delay allows active inflammation to subside, the bacillary load to decrease, and lesions to stabilize

Answer 29

The optimal timing of surgery is 4 to 6 weeks after the initiation of therapy. This delay allows active inflammation to subside, the bacillary load to decrease, and lesions to stabilize

Question 30

t/f Monitoring for relapse is important after treatment of genitourinary TB

Answer 30

true: Monitoring for relapse is important after treatment of genitourinary TB because it can occur in up to 22% of cases

Question 31

Rifampin resistance serves as a surrogate marker for __

Answer 31

Rifampin resistance serves as a surrogate marker for MDR TB.

Question 32

S. haematobium has a terminal spine and dwells principally in the __

Answer 32

S. haematobium has a terminal spine and dwells principally in the perivesical venous plexuses

Question 33

Schistosomiasis may cause: (5)

Answer 33

Schistosomiasis may cause inflammatory polyps of the bladder, sandy spots in the bladder (which represent submucosal egg deposition), calcification of the entire outline of the bladder, and strictures of the ureter (usually in the distal portion) with hydronephrosis. It may be associated with bladder cancer (SCCa)

Question 34

__ results in chyluria and filarial hydrocele and occasional extensive scrotal and penile lymphedema.

Answer 34

W. bancrofti results in chyluria and filarial hydrocele and occasional extensive scrotal and penile lymphedema.