Tuberculosis and tubulointerstitial nephritis: an intriguing puzzle

Classical renal tuberculosis is a well-known cause of urinary tract scarring and calcification, and sometimes renal dysfunction. In the past two decades there have been reports, particularly from the United Kingdom among immigrants from the Indian subcontinent, of a more insidiously progressive form of renal disease. Ultrasound shows small smooth kidneys, and histology reveals tubulointerstitial nephritis including granulomas but not acid-fast bacilli. Evidence is mounting that the underlying cause may be tuberculosis, but the mechanism remains obscure.