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Primary disseminated MDR-TB in a Bangladeshi man: a silent and emerging clinical problem for clinicians.

A 26 years old Bangladeshi man experienced sudden gross haematuria for 10 days when he was working in Italy in June'07 that was resolved spontaneously. Six months' later he again developed haematuria and was admitted into an Italian hospital for its evaluation and management. In the mean time, he developed low grade fever, cough, back pain, spinal angulations, walking difficulty. His X-ray chest postero-anterior view revealed cavitary lesions in upper zones of both lung fields. Intravenous Urography (IVU) was done which revealed hydronephrosis and hydroureter of left kidney. Magnetic Resonance Imaging (MRI) of dorso-lumber spine revealed collapse of D10-12 and L4-5 vertebral bodies with perivertebral and epidural abscess. Sputum and urine smear for Acid-Fast-Bacilli (AFB) demonstrated the organisms on Z-N stain and AFB culture and sensitivity demonstrated that it was resistant to isoniazide, Rifampicin and streptomycin and diagnosed as primary disseminated multi-drug Resistant tuberculosis (MDR-TB). Second-line drugs were started in Italy on 15th January'08 and were continued thereafter in National Institute of Diseases of the Chest and Hospital (NIDCH). A ureteric stent which was given in Italy to get relief of hydro-ureter was removed in Dhaka. A neurosurgery (costo-transversectomy with decompression of spine) was done in Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka and patient get relief of back pain paresthesia. Lastly, his sputum and urine AFB smear and AFB culture became negative. So, primary disseminated MDR-TB with renal, spinal and pulmonary involvement was diagnosed in this Bangladeshi man who had a sputum AFB culture and sensitivity during his initial diagnostic work-up in Italy. It's an alarming case that demonstrated necessity of sputum AFB culture and sensitivity during initial diagnostic work-up.