India accounts for the highest burden of both TB and multidrug-resistant tuberculosis (MDR TB) worldwide. India also accounts for about one-fourth of the global TB burden. In March 2017, Government of India announced that the new aim, with regard to TB in India, is to eliminate TB by 2025 [1].

Tuberculosis (TB) is among the top ten leading causes of death resulting from a single infectious cause worldwide. More than 90% of the infected individuals belong to the developing countries and more than 80% of these infected individuals belong to the adult age group [2]. Genitourinary tuberculosis accounts for 20–40% of EPTB cases. It is the second most common site in developing nations and third most common site in developed countries. It is rarely contagious. Except the epididymis and the prostate which are involved by hematogenous spread, rest of the genital organs are involved by canalicular, urinary, or contiguous spread [3]. The diagnosis of GUTB should be considered in a patient presenting with vague long-standing urinary symptoms and the cause has not been identified or is unknown.

Genitourinary tuberculosis (GUTB) is a major health problem in developing countries like India. World Health Organization (WHO) declared it as “public health emergency” in 1993 [4].

Genitourinary TB mimics other diseases. It has a very varied presentation that leads to a delay in diagnosis. Many times it presents with complications such as infertility, renal failure, or disseminated disease. So, high index of suspicion is needed for early diagnosis and prompt treatment. The presenting complaints could be loin/flank pain or it could be dysuria, increased frequency of urine, hematuria, renal or ureteric colic, scrotal pain and swelling, primary or secondary infertility, and ulceration or fistula in the genital area [5].

Isolated TB of ureter is rare. We here present a case of lower ureteric TB that mimicked a tumor in most of the aspects and will let you know how the patient was saved form undergoing a major surgery.

A 28-year-old male presented to us with complaint of dull and intermittent left flank pain with one episode of hematuria for past six months. He had no other urinary complaints. His past history was not significant. Physical examination revealed a normal examination. He was well built. Genitals were normal as was the prostate on digital rectal examination. All blood reports were normal including the serum creatinine, C-reactive protein, and erythrocyte sedimentation rate. Urine microscopic examination revealed acidic pH and microscopic hematuria. Urine culture and cytology were normal. The sonography of kidney ureter and bladder revealed left hydronephrosis and hydroureter. He came to us with three-month-old report of CT which suggested left lower ureteric tumor with ureteric wall thickness of 6 mm with periureteric fat stranding and enhancement of ureteric wall after intravenous contrast. There was no enhancement of the tumor post-contrast (Figure 1). The upper tracts and bladder were normal otherwise except for the left hydronephrosis and hydroureter. There was no lymph node enlargement. Because of all these reports we thought of a lower ureteric tumor. So, we planned a cystoscopic and ureteroscopic examination and biopsy of the tumor. Cystoscopy revealed normal bladder and a tumorous mass extension from left ureteric orifice. We took a biopsy from the mass. We did not do ureteroscopic examination because of fear of retrograde spread of the tumor to the upper tract. With all these findings with us, we planned the patient for surgery—resection of the ureteric tumor and ureteric reconstruction, but were awaiting the biopsy report. To our surprise the biopsy report showed abundant caseating necrosis with multi-nucleated giant cell formation suggestive of TB (Figure 2). It was after this report that we started thinking of TB. A urine protein to creatinine ratio (PCR) for TB was done and came positive. We then cancelled the surgery and started patient on anti-tubercular drugs as per the National TB Elimination Program. He was started six months of anti-tubercular drugs (2HRZE/4HRE). Till the last follow-up of three months, the patient is fine and is symptom free. He is now in the second phase of the anti-tubercular therapy.

Genitourinary tuberculosis (GUTB) accounts for 20–40% of EPTB cases. Renal involvement in TB is usually unilateral. It could be due to delayed reactivation of a solitary focus [5]. Ureteric involvement is contiguous to renal involvement. In the ureter, the vesico-ureteric junction is the first part to be involved in ureteric TB. Isolated ureteric involvement is very rare due to varied clinical symptoms and a lack of specific clinical signs. Only few cases have been reported [6],[7],[8],[9].

Pseudotumoral involvement of ureter by TB is rare. It could be due to fibro-inflammatory process in the thickening of the ureteral wall and proliferation of the mucosa as polypoidal growth. This thickening and proliferation can be confused with a ureteral tumor in high definition imaging like CT and in the direct visual white light cystoscopic examination. The same thing happened in our case. Ahmed-Amine Bouchikhi et al. also had the same case with pseudotumoral involvement of ureter by TB [7]. In our case, we found non-enhancing mass lesion within the ureter with all above findings. Dangi et al. had enhancing mass lesion within the ureter in their study [5].

Tuberculosis involves the intramural part of the ureter. The characteristic feature is ureteric wall thickening with post-contrast enhancement on contrast-enhanced CT [5]. In our case also, the ureteric wall was 6 mm thick with periureteric fat stranding and post-contrast wall enhancement.

The diagnosis of TB can be done by the examination of urine for the presence of bacillus or a PCR test. Pathological examination helps to confirm TB by showing a breach of epithelial giant cells below the mucosa with the presence of caseous necrosis. In our case the sequence of investigation was different due to no suspicion. We came to know about the TB after getting the biopsy report and then we confirmed the presence of bacillus in urine by a PCR test.

A good clinical examination is very important in the diagnosis of TB. We may find a lesion in the testis, epididymis, or the prostate which helps us in progressing forward to further investigation. But in our case, the clinical examination was completely normal and that was the reason that we did not suspect TB.

Cystoscopy and ureterorenoscopy are also the procedures of diagnosis which give us the option of taking a biopsy. Histopathology gives a conclusive evidence of caseating granuloma and necrosis [10]. Same happened in our case, we did cystoscopy and biopsy to know the type of ureteric tumor and we got to know about the TB.

The caseating necrotizing granuloma is almost always associated with TB. Rarely it can be associated with nocardiosis. But, the clinical features like no solid organ abscesses, responsiveness to anti-tubercular treatment (ATT), and confirmation with PCR in the urine are not consistent with the TB [6]. In our case also, there was no solid organ involvement, urine PCR was positive for TB, and the biopsy suggested caseating granuloma.

Tuberculosis can cause many complications in the genitourinary system. Isolated ureter involvement is rare even in countries like India. Ureteral TB should be suspected whenever there is ureteric wall thickening, periureteric fat stranding, or a ureteric tumor is suspected. In endemic countries like India, TB is more common than the rare things like ureteric tumor. So, all the investigations should be done before proceeding to any major surgery to confirm or refute the diagnosis of TB.