Pauci-symptomatic widespread nodal extra-pulmonary tuberculosis in end-stage kidney disease.

An elderly Ethiopian-born patients developed end-stage kidney disease and haemodialysis was started. Shortly after, she developed some weight loss, lassitude, and diffuse body pain attributed to the ESKD, but also brief febrile episodes with non-contributory examination and work-up except for acute-phase response and mild cholestatic liver enzyme disturbance. Imaging revealed enlarged necrotic lymph nodes above and below the diaphragm. Needle biopsy was consistent with mycobacterium tuberculosis (TB) infection by pathology, PCR, and culture. TB is endemic in Africa and our patient had latent TB with reactivation due to her advanced age and especially, ESKD. The relatively subtle symptoms easily ascribed to ESKD are notable, as is the value of imaging, tissue diagnosis and PCR in establishing her widespread nodal extra-pulmonary tuberculosis. Current guidelines support screening foreign-born individuals who have recently immigrated. We suggest that when risk factors accumulate as in our patient (e.g. origin in an endemic area, ageing, hemodialysis), a routine interferon gamma release assay test is prudent, and positive patients may well benefit from chemoprophylaxis.