Urology Department, University of Turin, Turin, Italy
Since 1967, renal tuberculosis has become less frequent and, as a result, surgery rare. In fact, compared to 15 years ago, there has been an increase in mild cases and conservative treatments. Renal and urogenital tuberculosis are always secondary or metastatic compared to pulmonary localization. The incidence of tuberculosis (TBC) among nations varies from 2 % to 20 % of the population, with an increase in proportion from industrialized to underdeveloped countries, where this infectious disease represents a real sanitary emergency. Comparative statistics from various institutions including the Health Ministry and National Institute of Statistics show a clear decrease in cases of TBC over the last 30 years, but they are not indicative of the situation regarding the urogenital localization of the disease, since non-infectious forms were not recognized for many decades after more general infectious TBC. Presumably the extra-pulmonary forms of TBC and, consequently the urogenital forms, have seen little increase in recent years. Among other things, renal TBC follows the first pulmonary or nodal infection by 15 or more years. This would explain at least partially the gap between the discovery of the two forms of infection.
It is worth revisiting the data of Gow [27, 28] from 1996, which show that of the total number of 3,000,000 global deaths from TBC, 3–4 % were from urogenital forms. Since menstrual blood examination has become routine, urogenital TBC in women seems to be much more frequent than in men .
Among developed countries, Japan has the most new cases: 24.8/100,000 reported by the Japan Antituberculosis Association in 2003. During the same period Sweden had 5/100,000 and Kazakhstan 181/100,000, to show a snapshot of the geographical differences. As of 2004, genito-urinary TBC in Japan was not frequent, with a total of 144 cases, corresponding to just 0.5 % of the total forms of TBC .
At present immigration creates a great problem, considering how widely TBC is endemic and the areas from which immigrants predominantly come – they are a major source of infection and pharmacoresistence. The latter represents a serious problem, given the inadequate dosage and short period of treatment that is the result of the high cost of medicines. That can mean contagion from resistant bacteria and diseases that are difficult to treat. In Europe in 2014, 58,008 cases of TBC were reported (12/100,000) from 29 EU members and members of the European Economic Area, of which 76.2 % were newly diagnosed and 26.8 % were from unknowns; the latter percentage had increased from 19 % in 2005 to 27 % in 2014.
The World Health Organization in1999 reported that 17 million people were infected worldwide, 20 % of whom developed the disease, and with 8 million new cases per year (13–33 % in Western countries). Of the 8 million new cases, 2.8 million resulted in death, 40,000 of which occurred in developed countries and 2.7 million in underdeveloped (or developing) countries.
In 2006, 9.2 million new cases were reported worldwide, with 700,000 occurring in HIV patients. Of these cases, 1.5 million resulted in death, which equated to around 4,400 per day. The overall global incidence of TBC is still increasing, due to the 1 % increase in Africa.
These data suggest that without control TBC will kill 35 million people in the next 30 years and a total of 2 billion people will be infected, practically one-third of the world’s current population. One in ten infected people will develop the disease and each infected patient will infect another 10–15 people each year. Multi-resistant TBC is present in 109 countries; in Eastern Europe 50 % of infected cases are multi-resistant.
In 2014 the Annual OSM Global Tuberculosis Report 2016 was published with a “Stop Tuberculosis Strategy” and an “End Tuberculosis Strategy” for reducing the 2015 mortality of infected person of 30 % to 15 % by the year 2030.
Fortunately Italy is a low-prevalence country with <10/100,000 inhabitants being infected. In 2006, 4,387 cases were reported, corresponding to 7.47/100,000 inhabitants, with a ratio of 1.47 male/female. Genito-urinary localization was 4.6 %.
The Report “Tuberculosis in Italy” of 3 November 2016, from the year 2008, shows that between 1955 and 2008 there was a reduction in the cases of TBC from 12,247 to 4,418. The crude rate went from 25.26/100,000 in 1955 to 7.4/100,000 in 2006. In the decade from 2004–2014 there were 4,300 cases each year, and 52 % of those were in non-Italian people (44 % in 2005, 66 % in 2014).
With regard to immigration, it is interesting to note that in big cities, like Milan, where there is a noticeable number of immigrants, the nationwide Italian ratio of 7/100,000 cases jumps to 20/100,000. Apart from the sheer number of cases, the immigrants create other problems, by way of pathology and care. In Germany, where there is perhaps the biggest immigrant community in Europe, Singh et al. have reported that among immigrants TBC was localized in the lymph nodes in 37 % of cases, in the bones in 20.5 %, in the central nervous system in 14.3 %, in the urogenital system in 8.5 %, in the lungs in 8.6 %, in the mediastinum in 5.7 %, and in the abdomen in 5.7 %. In 62.9 % of cases the chest X-ray was negative. It was clear that the common difficulties faced in recognizing the disease were intensified, not thanks to the unusual localization of it, but also because of its etiology and presentation. For example, the skin test was strongly positive until ulceration, the tuberculous interferon gamm release assay (IT-IGRA) was 100 % positive, while the nucleic acid complex of mycobacterium tuberculosis (NAAT) was only 35 % positive. In 91 % of cases mycobacterium tuberculosis was identified and mycobacterium bovis in 5.7 %. All reported cases were HIV negative. The delay in diagnosis was from 4–299 weeks. Suspected, presenting, and prevailing symptoms were: lymphadenitis in 37.1 %, weight loss in 28.6 %, night sweats in 25.7 %, neurologic symptoms in 22.9 %, cough and respiratory disorders in 14.8 %, bad back in 8.6 %, fever in 15.7 %, and other in 25.7 %. Urogenital localizations represented 3.18 % of cases.