Lecture 1 Lecture 1

Diagnoctics of Diagnoctics of tuberculosistuberculosis

(Stomat. F-t)(Stomat. F-t)

Prof. Prof. L.A. HryshchukL.A. Hryshchuk

EtiologyEtiology M. tuberculosisM. bovisM. africanum

Thin section transmission electron micrograph of Thin section transmission electron micrograph of Mycobacterium tuberculosisMycobacterium tuberculosis

The granuloma consists of a kernel of infected macrophages, The granuloma consists of a kernel of infected macrophages, surrounded by FOAMY GIANT CELLS and macrophages with a surrounded by FOAMY GIANT CELLS and macrophages with a

mantle of LYMPHOCYTES delineating the periphery of the mantle of LYMPHOCYTES delineating the periphery of the structurestructure

Automated screening molecular genetic test to Automated screening molecular genetic test to identify Mycobacterium tuberculosis and identify Mycobacterium tuberculosis and

resistance R - Xpert MBT / Rifresistance R - Xpert MBT / Rif

Cultures were on a liquid environment: Cultures were on a liquid environment: automated microbiological analyzer BACTEC automated microbiological analyzer BACTEC

MGIT 960MGIT 960 Performed in all patients Performed in all patients

with pulmonary with pulmonary tuberculosis (with tuberculosis (with positive and negative positive and negative sputum smear)sputum smear)

Test drug sensitivity to Test drug sensitivity to drugs and second rowdrugs and second row

Growth of Mycobacterium Growth of Mycobacterium tuberculosis in 7-14 days.tuberculosis in 7-14 days.

Increases confirm TB in Increases confirm TB in patients with negative patients with negative sputum smear at 20%sputum smear at 20%

At a molecular genetic test: At a molecular genetic test: GenoType MTBDRplusGenoType MTBDRplus

Detects DNK MBT , resistance to isoniazid and rifampin and isoniazid combination

Perform allpatients withPositive sputum smearCarried out in parallel

with the classical culture method

Planting on solid mediumPlanting on solid medium

Performed in all TB patientslungs (with positive and negative smearsputum):Bank of culturesTest drug sensitivitydrugs II series

Children and teenagers, in whom the Children and teenagers, in whom the following factors are diagnosed, following factors are diagnosed, compose compose a group of early revealeda group of early revealed::

1) tuberculin test range;1) tuberculin test range; 2) primary tubinfestation;2) primary tubinfestation; 3) hyperergic Mantoux test;3) hyperergic Mantoux test; 4) tuberculous intoxication.4) tuberculous intoxication.

Clinical examination of Clinical examination of tuberculosis patientstuberculosis patients

The methods of investigation of respiratory (tuberculosis) The methods of investigation of respiratory (tuberculosis) patients are conveniently divided into three groups. patients are conveniently divided into three groups.

The First groupThe First group – – compulsory (obligatory) methodscompulsory (obligatory) methods, , which which embrace clinical examination of a patient (complaints, embrace clinical examination of a patient (complaints, anamnesis, examination, palpation, percussion, anamnesis, examination, palpation, percussion, auscultation), thermometry, X-ray investigation auscultation), thermometry, X-ray investigation (fluorography, X-raygraphy, X-rayscopy), sputum analysis (fluorography, X-raygraphy, X-rayscopy), sputum analysis for MBT, Mantfor MBT, Mantououx tuberculin test (with 2 TU), general blood x tuberculin test (with 2 TU), general blood and urine test.and urine test.

The Second groupThe Second group – additional (supplementary) methods – additional (supplementary) methods, , which include repeated sputum analysis (bronchial lavage which include repeated sputum analysis (bronchial lavage water) for MBT, tomography of thewater) for MBT, tomography of the lungslungs and mediastinum, and mediastinum, protein-tuberculin tests, immunologic tests, instrumental protein-tuberculin tests, immunologic tests, instrumental examinations (bronchoscopy, biopsy, bronchography, examinations (bronchoscopy, biopsy, bronchography, pleuroscopy).pleuroscopy).

The Third groupThe Third group – facultative (optional) methods – facultative (optional) methods: : investigation of the outer breathing function, blood investigation of the outer breathing function, blood circulation, liver and other organs and systems.circulation, liver and other organs and systems.

The laboratory diagnostics of tuberculosis. Methods of The laboratory diagnostics of tuberculosis. Methods of revealing mycobacterium of tuberculosis. Atipical MBT. revealing mycobacterium of tuberculosis. Atipical MBT.

Sensitivity of MBTSensitivity of MBT

The source of infestation of human beings are The source of infestation of human beings are tuberculosis human patients and animals tuberculosis human patients and animals secreting tuberculosis mycobacteria. The material secreting tuberculosis mycobacteria. The material for revealing MBT are sputum, bronchial lavage for revealing MBT are sputum, bronchial lavage waters, faeces, urine, fistula pus (matter), pleural waters, faeces, urine, fistula pus (matter), pleural cavity exudate, spinal fluid, punctates and cavity exudate, spinal fluid, punctates and bioptates of various organs and tissues.bioptates of various organs and tissues.

Sputum examination for MBT is of great Sputum examination for MBT is of great epidemiological and clinical importance. When epidemiological and clinical importance. When there is no sputum or it is scarce, expectorants, there is no sputum or it is scarce, expectorants, irritant aerosol inhalations, bronchi lavage are irritant aerosol inhalations, bronchi lavage are administeredadministered (fig.1) (fig.1)..

Methods of Revealing Methods of Revealing Mycobacteria:Mycobacteria:

Culture ofCulture of mycobacteria mycobacteria tuberculosis at tuberculosis at hard egg hard egg

mediummedium

RadiologyRadiology Chest radiography is the most Chest radiography is the most

importantimportant

method to detect TB method to detect TB TB’s characteristics of a chest TB’s characteristics of a chest

radiographradiograph

favor the diagnosis of favor the diagnosis of tuberculosis tuberculosis

as following :as following :

Computer tomographyComputer tomography

Methods of the X-ray diagnostics of tuberculosis of Methods of the X-ray diagnostics of tuberculosis of respiration organs. Methodical of interpretation respiration organs. Methodical of interpretation

roentgenograms of lungs and description pathological roentgenograms of lungs and description pathological shadowsshadows

Roentgenologic examination is one of the Roentgenologic examination is one of the main methods of diagnostics of tuberculosis main methods of diagnostics of tuberculosis and unspecific respiratory diseases. The and unspecific respiratory diseases. The following methods of roentgenologic following methods of roentgenologic diagnostics are used: roentgenoscopy, diagnostics are used: roentgenoscopy, roentgenography, fluorography, tomography, roentgenography, fluorography, tomography, computer tomography, target computer tomography, target roentgenography, bronchography, roentgenography, bronchography, fistulography, angiopulmography and fistulography, angiopulmography and bronchial arteriography, pleurography, bronchial arteriography, pleurography, kymography and polygraphy.kymography and polygraphy.

(1)(1) shadows mainly in the upper zone shadows mainly in the upper zone(2)(2) patchy or nodular shadows patchy or nodular shadows(3)(3) the presence of a cavity or cavities, although these, of the presence of a cavity or cavities, although these, of course, can also occur in lung abscess, carcinoma, etc course, can also occur in lung abscess, carcinoma, etc (4)(4) the presence of calcification. although a carcinoma or the presence of calcification. although a carcinoma or pneumonia may occur in an areas of the lung wherepneumonia may occur in an areas of the lung where there is calcification due to tuberculosisthere is calcification due to tuberculosis(5)(5) bilateral shadows, especially if these are in the bilateral shadows, especially if these are in the upper zonesupper zones(6)(6) the persistence of the abnormal shadows without the persistence of the abnormal shadows without alteration in an x-ray repeated after several weeks alteration in an x-ray repeated after several weeks this helps to exclude a diagnosis of pneumonia or this helps to exclude a diagnosis of pneumonia or other acute infectionother acute infection

Primary complex

Milliary TuberculosisMilliary Tuberculosis

acute milliary tuberculosis

secondary pulmonary tuberculosis

infiltrate

Tuberculoma

Chronic fibro-cavitary pulmonary tuberculosis

cavity

Tuberculous effusion

Comruter tomograma patient Comruter tomograma patient with pulmonary TBwith pulmonary TB

FluorographyFluorography

BronchographyBronchography

Bronchoscopy Bronchoscopy examinationexamination

VideoVideo

Tuberculin Tuberculin testingtesting

A positive A positive tuberculin test tuberculin test although it is of although it is of

great use in children, great use in children, but it has limited but it has limited diagnostic significance diagnostic significance in older age groups in older age groups

TUBERCULINODIAGNOSTICSTUBERCULINODIAGNOSTICS

Old Tuberculin Koch

DryDry rectified tuberculin (50000 rectified tuberculin (50000 ТТUU), ), tthe solvent is isotonic solution of he solvent is isotonic solution of

sodium chloride – 1sodium chloride – 1ml with ml with the the

addition of 0,25 % carbolic acidaddition of 0,25 % carbolic acid

Positive Mantoux test.Positive Mantoux test.

DiagnosisDiagnosis

According to the history, clinical signsAccording to the history, clinical signs ,, chest X-ray chest X-ray

and some other examinations, we can diagnose TBand some other examinations, we can diagnose TB

A patient with tuberculous pulmonary diseaseA patient with tuberculous pulmonary disease will come to the physician for one of threewill come to the physician for one of three reasons:reasons: (1) Suggestive symptoms(1) Suggestive symptoms (2) A positive finding on routine tuberculin(2) A positive finding on routine tuberculin testingtesting (3) A suspicious routine chest roentgenogram(3) A suspicious routine chest roentgenogram

How to write the diagnosis How to write the diagnosis correctly?correctly?

Generally, we write the Generally, we write the diagnosis according to the site of diagnosis according to the site of TB, clinical patterns, the result TB, clinical patterns, the result of sputum examination and the of sputum examination and the history of chemotherapy.history of chemotherapy.

Differential Diagnosis Differential Diagnosis 1 1 2 2 3 43 4

BronchiectasisBronchiectasis may confused with may confused with chronic fibrocavenous pulmonary chronic fibrocavenous pulmonary tuberculosis. They also have chronic tuberculosis. They also have chronic cough, sputum production and cough, sputum production and hemoptysis. Usually we can use chest hemoptysis. Usually we can use chest x-ray examination and CT scan to x-ray examination and CT scan to distinguish them. distinguish them.

Cavitary lung abscessCavitary lung abscess often involves the often involves the dorsal segments of the lower lobes and posteriordorsal segments of the lower lobes and posterior segments of the upper lobes. segments of the upper lobes.

Typically lungTypically lung abscess causes litt1e in the way of abscess causes litt1e in the way of

physical physical findings, may have a fluid level, and is notfindings, may have a fluid level, and is not associated with patchy bronchogenic infiltrates.associated with patchy bronchogenic infiltrates. In contrast, physical findings are prominentIn contrast, physical findings are prominent over tuberculous cavities, fluid levels are rare.over tuberculous cavities, fluid levels are rare. And patchy infiltrates elsewhere are the rule.And patchy infiltrates elsewhere are the rule.

Differential DiagnosisDifferential Diagnosis 1 2 3 4

Acute bacterial pneumoniasAcute bacterial pneumonias may may resembleresemble

florid tuberculosis in all particulars florid tuberculosis in all particulars except forexcept for

the sputum examination and the sputum examination and response toresponse to

antimicrobial drugs.antimicrobial drugs.

Differential DiagnosisDifferential Diagnosis 1 2 3 4

Neoplasm Neoplasm may resemble tuberculosis. As may resemble tuberculosis. As inin

an isolated coin lesion. An obstructing an isolated coin lesion. An obstructing andand

inconspicuous endobronchial tumor inconspicuous endobronchial tumor causingcausing

distal cbronic inflammation or a distal cbronic inflammation or a cavitingcaviting

neoplastic mass. ( An irregular cavity neoplastic mass. ( An irregular cavity wallwall

suggests necorotic neoplasm. )suggests necorotic neoplasm. )

Differential DiagnosisDifferential Diagnosis 1 2 3 4

Differential DiagnosisDifferential Diagnosis 1 2 3 4 5

FeverFever caused by some other caused by some other diseases diseases

complicationscomplications

PneumothoraxPneumothorax BronchiectasisBronchiectasis EmpyemaEmpyema Extrapulmonary expansionExtrapulmonary expansion HemoptysisHemoptysis Chronic pulmonary heart diseaseChronic pulmonary heart disease