Q: My 43 years old wife is suffering from hyperthyroidism for the last 7-8 years. As on date her T3 is 110, T4 is 8.4 and TSH is 6.12. She also suffered from typhoid in childhood and twice in the last 4 years. Now for the last 3 years she is having recurrent urine infection; she takes antibiotics for the same every time. Last year the doctor operated her for PAP. Eight months ago her:

• AFB x 3 staining smear show no AFB in entire smear - negative
• AFB Culture is sterile after 6 weeks of incubation
• Sugar – nil
• Albumin – positive
• Erythrocytes - 10-15
• Hb g/dl - 12.4
• Platelets/ul - 277x10
• ESR mm 1st hour 25
• ESR - 40
• Urine TB PCR - negative.
• Liver function test is found normal
• Mantoux - (24 x 26 mm in 72 hours)

Then the doctor started tuberculosis treatment (AKT4 then Rlinex 300 mg). Now it has been detected that her kidney is shrinking. Ten months back her left kidney was 7.6 cm, calyceal separation was 9 mm, pole measure was 9 mm and upper ureter was 11 mm. Then six months back the left kidney was 7.5 cm, calyceal separation was 7 mm, pole measure was 9 mm and upper ureter was 9 mm and now three months back left kidney was only 6.6 cm, calyceal separation was 7 mm, pole measure was 9 mm and upper ureter was 7 mm. Her ultrasound impression - sonographic findings are suggestive of left hydro uretero nephrosis with small left kidney. CECT impression - CT scan findings are suggestive of a small-scarred left kidney showing mild hydronephrosis with dilated thickened left ureter. As she is a patient of typhoid, thyroid, TB, kidney shrink, little aggressive, very touchy in emotions, urine infection (very often), what could be the reason for these illnesses and what is the treatment for the same? Her urine examination showed colour - deep yellow, transparency - mild turbid, specific gravity - 1.030, albumin – trace, sugar – nil, blood - ++, bilirubin – nil, urobilinogen – nil, ketone bodies/acetone – nil. Microscopic examination showed - epithelial cells - 2-3, pus cells - 70-80, RBC's - 3-4, crystals – nil, casts – nil. What is the treatment for the same? Should we go for kidney removal to avoid the recurrent urinary infection?

A:Your wife has obstruction of her left side of urinary tract (characterised by swelling of the tract called hydro uretero nephrosis) possibly from either kidney stone or recurrent infection involving the tract. Infections like tuberculosis of urinary tract can cause stricture formation of the tract resulting in the obstruction. Obstruction from whatever cause would make one prone to recurrent urinary tract infection unless the obstruction is relieved. Her left kidney is now non-functioning as obvious from its shrunken size, a fall out of persistent obstruction with resulting back pressure and damage to the left kidney. Next step should be an evaluation of the anatomy of left side urinary tract by Intravenous pyelogram and Cystoscopy. It would help address the obstructive lesion under the guidance of a urologist. Removal of left kidney is sought as a last resort if the patient continues to have recurrent urinary tract infection involving primarily the kidney not responding to repeated courses of antibiotics. Lastly, it would be helpful to know her underlying kidney function as obvious from serum creatinine level which if within the normal range would suggest well preserved right kidney function.