What is the diagnosis and management for a middle-aged adult with a history of treated Tuberculosis (TB), currently on Anti-TB treatment, presenting with generalized body swelling, productive cough, shortness of breath, decreased urine output with hematuria, and recent gastrointestinal symptoms of bloody diarrhea and skin lesions?

Diagnosis and Management of Suspected Disseminated Tuberculosis with Renal Involvement

This patient most likely has disseminated tuberculosis with genitourinary/renal involvement presenting as tuberculous tubulointerstitial nephritis (TB-TIN), and should continue standard anti-TB therapy while undergoing urgent kidney biopsy and comprehensive evaluation for multi-organ TB involvement. 1, 2, 3

Primary Diagnosis: Disseminated Tuberculosis with Renal Involvement

The constellation of findings strongly suggests disseminated TB with renal involvement:

• Generalized body swelling with hematuria and decreased urine output indicates renal involvement, most likely tuberculous tubulointerstitial nephritis (TB-TIN), which is the most frequent kidney biopsy finding in patients with renal involvement from tuberculosis 2, 3

• Respiratory symptoms (productive cough, SOB) in a patient on anti-TB treatment suggest either inadequate treatment response, drug resistance, or progression of disease to multiple organ systems 1, 4

• Recent bloody diarrhea and abdominal skin lesion raise concern for abdominal/gastrointestinal TB, which can present with nonspecific symptoms 1

• Facial puffiness worse in mornings with generalized edema is consistent with nephrotic-range proteinuria or acute kidney injury from TB-TIN 2, 3

Critical Diagnostic Workup Required Immediately

Renal Evaluation (Highest Priority)

Kidney biopsy should be performed urgently to confirm TB-TIN and guide treatment intensity, as this presents late with advanced disease and negative PCR does not exclude TB-associated TIN 2, 3. The biopsy findings typically show:

• Chronic granulomatous tubulointerstitial nephritis as the primary lesion 3
• Interstitial inflammation with eosinophilia 2
• Epithelioid granulomata (found in 60% of cases) 2
• Note: Acid-fast bacilli staining and PCR are frequently negative, so negative results should not exclude TB-TIN 2

Obtain comprehensive renal workup:

• Serum creatinine, BUN, electrolytes to assess degree of renal failure 3
• Urinalysis with microscopy to confirm hematuria and assess for proteinuria 1
• Urine culture for M. tuberculosis (positive in genitourinary TB) 1
• Renal ultrasound to assess for hydronephrosis or ureteral obstruction 1

Pulmonary Re-evaluation

Collect three sputum specimens for AFB smear microscopy, culture, and rapid molecular testing to assess current TB status and rule out drug resistance 1:

• The patient is on continuation phase but has ongoing respiratory symptoms, which is concerning for treatment failure or drug resistance 1
• Chest radiograph to assess for progression, cavitation, or miliary pattern suggesting disseminated disease 1, 4

Abdominal/GI Evaluation

Evaluate for abdominal tuberculosis given the history of bloody diarrhea and abdominal skin lesion 1:

• Abdominal CT scan to assess for peritoneal involvement, lymphadenopathy, or intestinal TB 1
• Consider colonoscopy with biopsy if intestinal TB is suspected 1

Assessment for Drug-Induced Complications

Check liver function tests (ALT, AST, bilirubin, alkaline phosphatase) immediately, as gastrointestinal symptoms could represent drug-induced hepatotoxicity from anti-TB medications 1:

• Drug-induced liver injury is the most frequent serious adverse reaction to first-line TB drugs 1
• Hepatotoxic drugs should be stopped if ALT ≥3× upper limit of normal with symptoms or ≥5× without symptoms 1

Management Strategy

Continue Anti-TB Treatment with Possible Intensification

Continue current anti-TB regimen while awaiting diagnostic results, but prepare to intensify treatment based on findings 1:

• For disseminated tuberculosis, a standard daily 6-month regimen is adequate, but supporting data are limited 1
• If kidney biopsy confirms TB-TIN, continue standard anti-TB therapy as renal tuberculosis is treated primarily with medical rather than surgical therapy 1

Consider adjunctive corticosteroid therapy if severe respiratory failure develops from disseminated disease, though the role in miliary TB remains unclear 1

Renal-Specific Management

Dose adjustment is required for patients with coexisting renal failure 1:

• Ethambutol and pyrazinamide require dose reduction in renal impairment
• Monitor for ureteral obstruction; if hydronephrosis occurs, renal drainage by stenting or nephrostomy is indicated 1

Monitor renal function closely, as 9 of 25 patients in one series required renal replacement therapy within 6 months despite treatment 3:

• Early recognition and treatment are critical to preserve renal function 3
• Even with treatment, renal function may improve initially but subsequently decline over time 3

Address Drug Resistance Concerns

If sputum cultures grow M. tuberculosis, perform drug susceptibility testing immediately 1:

• Ongoing symptoms despite being on continuation phase raises concern for drug resistance 1
• If drug resistance is confirmed, consultation with a TB expert is mandatory and treatment must be individualized based on susceptibility patterns 1, 5

Critical Pitfalls to Avoid

Do not delay kidney biopsy waiting for positive urine cultures or PCR, as these are frequently negative in TB-TIN but the diagnosis is critical for appropriate treatment intensity 2, 3

Do not assume symptoms are from drug toxicity alone without ruling out progressive or disseminated TB, as this patient has multi-organ involvement suggesting active disease 1, 3

Do not stop anti-TB treatment prematurely even if initial cultures are negative, as TB-TIN often presents with negative microbiological studies 2

Do not miss ureteral obstruction, which requires urgent intervention to prevent irreversible renal damage 1

Monitor for hepatotoxicity closely given the gastrointestinal symptoms and loss of appetite, and be prepared to modify the regimen if drug-induced liver injury develops 1