although pulmonary tb is the most common presentation , extrapulmonary tb is also an important clinical problem . patients present with dysuria and hematuria , which may be painless , flank pain , sterile pyuria , and recurrent urinary tract infection . in rare cases , other uncommon presentations include the following : nonhealing wounds , sinuses or fistulae , hemospermia and others . a 34-year - old woman presented with 1-month history of intermittent right flank pain and occasional fever . she did not have any history of pulmonary tb in the past . a marginally elevated erythrocyte sedimentation rate was noted . although urine culture was sterile , 10 - 12 pus cells were seen on microscopic urine examination . contrast - enhanced computed tomography ( cect ) showed a heterogeneously enhancing lesion 8  7 cm in dimension with areas of necrosis , involving the right kidney with enlarged aortocaval and paraaortic lymph nodes [ figure 1a and b ] . histopathology showed presence of acid - fast bacilli with multiple granulomas consistent with gutb [ figure 3a and b ] . patient recovered well , completed her antitubercular therapy , and after 1 year of follow - up she is free of tb . ( a ) computed tomography ( ct ) shows heterogeneous enhancing mass involving the upper and mid pole of the right kidney with aortocaval and paracaval lymphadenopathy(arrow ) and ( b ) contrast enhanced ct scan of the abdomen show presence of rim enhancement with central necrosis in lymph nodes ( arrow ) . section removed during right side nephrectomy shows normal looking kidney ( thin arrow and renal mass with pus around it ( thick arrow ) . 34-year - old woman with intermittent right flank pain diagnosed with genitourinary tuberculosis . histopathology slides ( a ) stained with hematoxylin and eosin ( 100 ) shows presence of multiple granulomas ( thick arrow ) and ( b ) stained with ziehl - neelsen stain ( 100 ) shows presence of acid - fast bacilli ( thin arrow ) . it continues to be an important diagnostic problem because of its nonspecific clinical presentation and variable radiographic appearances that often mimic many other pathologic lesions . urogenital tb  is more logical because kidney tb , which is usually primary , is diagnosed more often than genital tb . only 53% of patients with kidney tb had genital lesions , but in 61.9% patients with epididymorchitis and in 79.3% patients with tb of the prostate , a renal lesion could be diagnosed . in gutb , the kidneys are the most common sites of infection and are infected through hematogenous spread of the bacilli , which then spread through the renal and genital tract . gutb is the second most common form of extrapulmonary tb in countries with severe epidemic situations and the third most common form in regions with a low incidence of tb . the diagnosis of tb on images of the urinary tract depends on the stage of the infection . tubercular granulomas in the renal pyramids coalesce to form ulcers that discharge mycobacteria and pus in the urine . untreated lesions enlarge and a tubercular abscess may form in the parenchyma . later on , perinephric abscess is formed and the kidney is replaced by caseous material (  putty kidney  ) , which may become calcified (  cement kidney  ) and nonfunctional leading to renal failure . ct findings include focal caliectasis , hydronephrosis , calcifications , cortical thinning , and soft tissue masses . usually an enhancing renal mass is caused by renal cell carcinoma , metastasis , lymphoma , or an abscess . gutb rarely manifests as pseudotumors , which otherwise are usually due to hypertrophied column of bertin , renal dysmorphism , or unusually shaped kidney . in rare cases , patients with this form , known as the pseudotumoral type , present with variable - sized but well - defined parenchymal nodules on cross - sectional images . pseudotumoral gutb end up undergoing a surgical removal and diagnosis is suspected intraoperatively or histopathologically . renal tb should be suspected when atypical renal masses are seen in patients from tb endemic areas . preoperative fine - needle aspiration cytology ( fnac ) can be considered in highly suspicious cases .
genitourinary tuberculosis ( gutb ) is a rare extrapulmonary manifestation of tuberculosis ( tb ) . 
 various forms of presentation are described and in most cases the disease results in calcification , atrophy , or necrosis of the renal parenchyma . 
 the kidney is not generally palpable except in cases of hydronephrosis due to an upper ureteric stricture . 
 we present a case of gutb presenting as inflammatory pseudotumor . 
 this case was initially diagnosed as renal malignancy and managed accordingly . 
 histopathology confirmed the diagnosis of pseudotumoral renal tb .