Silent Renal Autodestruction: Incidental Discovery of End-Stage Genitourinary Tuberculosis (Putty Kidney) 14 Years...

Genitourinary tuberculosis (GUTB) is a prevalent yet frequently underdiagnosed form of extrapulmonary tuberculosis (TB), owing to its characteristically indolent and asymptomatic clinical course. In its most advanced form, renal TB culminates in complete destruction and dystrophic calcification of the renal parenchyma, a condition known as "putty kidney" or autonephrectomy. This entity can develop silently over many years, even in patients who have completed antitubercular therapy for pulmonary disease. A 44-year-old woman with a remote history of pulmonary TB treated 14 years prior presented to the gynecology outpatient department for the evaluation of menstrual irregularities. She denied all urinary symptoms. Incidental ultrasonography revealed gross hydronephrosis and calcification of the left kidney. Contrast-enhanced computed tomography (CT) of the abdomen demonstrated a calcified, nonexcreting left kidney consistent with a putty kidney, accompanied by calcified hepatic and splenic granulomas and calcified mesenteric lymph nodes. High-resolution CT of the thorax identified calcified pulmonary nodules consistent with healed pulmonary TB. Magnetic resonance imaging of the spine revealed lytic lesions at L4-L5 suggestive of healed spinal TB. A diethylenetriamine pentaacetic acid (DTPA) renal scan confirmed absent left renal function. The patient underwent open left simple nephrectomy. Histopathological examination demonstrated granulomatous inflammation with multinucleated giant cells and caseous necrosis, confirming renal TB. The postoperative course was uneventful. Renal TB is characterized by slow, progressive hematogenous dissemination of Mycobacterium tuberculosis, leading to granuloma formation, fibrosis, and ultimately parenchymal calcification. Renal TB may become clinically apparent years after treated pulmonary TB. The underlying mechanism may involve reactivation of dormant bacilli or progression of previously established latent genitourinary infection, and the exact mechanism cannot be determined in this case. The absence of urinary symptoms can result in years of undetected progression, rendering incidental imaging an important diagnostic pathway. Nephrectomy is indicated for a nonfunctioning tuberculous kidney to prevent complications such as recurrent infection, persistent pain, uncontrolled hypertension, or when malignancy cannot be excluded. This case illustrates that end-stage GUTB may remain clinically silent for years and be detected incidentally despite previous treatment for pulmonary TB. Long-term clinical vigilance should be maintained in patients with previous TB, particularly when new symptoms or suspicious imaging findings develop. Routine imaging surveillance for all patients is not established by current evidence.