SECONDARY SECONDARY TUBERCULOSISTUBERCULOSIS

LECTURELECTURE

docdoc. . Kravchenko N.S.Kravchenko N.S.

DISSEMINATED TUBERCULOSISDISSEMINATED TUBERCULOSIS - APPERARS

DURING LYMPHOHEMATOGENOUS DISSEMINATION OF

THE INFECTION AND IS CHARACTERISED BY BILATERAL

SYMETRIC FOCAL LESION, WHICH IS LOCALISED IN

SUPERIOR AND CORTICAL PARTS OF LUNGS.

THERE IS ACUTE, SUBACUTE AND CHRONIC

DISSEMINATED TUBERCULOSIS OF LUNGS.

THIS FORM OF TUBERCULOSIS AFFECTS BONES,

KIDNEYS, GENITAL ORGANS , LARYNX, PLEURA, MORE

FREQUENTLY.

PPATHOGENESISPPATHOGENESISPPATHOGENIC FACTORS AREPPATHOGENIC FACTORS ARE:

1.   - Presence of tuberculous infection in the organism.2.   - Bacteriemia.

3.   - Hypersensibilization and hyperpermeability of pulmonary

vessels. More frequently mycobacteries appear in blood from

affected intrathoracic lymthatic nodes. Through thoracic duct

subvclavian vein in right ventricle and futher in pulmonary

bifurcation and lungs.

Ways of MBT spreading.1 – haematogenous2 – lymphogenous3 - bronchogenous

Miliary tuberculosis

TABLE 1. Organ Involvement in Miliary Organ Involvement in Miliary

Tuberculosis at NecropsyTuberculosis at Necropsy

Organ (% involved):

Spleen 86%

Liver 91

Lungs 100

Bone marrow 24

Kidneys 62

Adrenals 14

Eye —

Thyroid 19

AS TO CLINICAL PROGRESS MILIARY AS TO CLINICAL PROGRESS MILIARY

TUBERCULOSIS IS CONDITIONALLY TUBERCULOSIS IS CONDITIONALLY

DIVIDED INTO:DIVIDED INTO:

--      LUNGLUNG

--    TYPHOIDTYPHOID - - MENINGEALMENINGEAL - - SEPTIC FORMSSEPTIC FORMS..

FIGURE 1. Chest radiograph of a patient with miliary tuberculosis. Note the extensive, symmetrical distribution of 2- to 3-mm lesions

throughout both lungs.

FIGURE 2. Close-up view of the chest radiograph in Figure 1. Note the uniform distribution of nodules throughout the lung parenchyma.

Subacute disseminated tuberculosisSubacute disseminated tuberculosis

This form of the tuberculosis develops during decreased resistance of the organism, in senile age, during immunodepression therapy. Pathologic anatomy. Subacute disseminated tuberculosis appears during affection of intralobular veins and intralobular branches of pulmonary artery. It results formulation of great simetric focuses (5-10 mm) in the superior parts of pulmonary fields.

Clinical pictureClinical picture. The start of disseminated tuberculosis can be

acute or gradual. In case of gradual start there are such symptoms:

fatiquabiliti, general weakness, poor apetite, dry couph, then pus-

mucus couph, blood sputum, chest pain, dyspnea.

General state of the patient changes for the worse, develops

circulatory insufficiency, caused by overload of right heart

chambers.

In some cases onset signs can be larynx lesion (painful

swallowing, hoarse voice) or kidneys’ affection.

Objective investigation is characterized by symmetric dull sound

under upper and middle pulmonary parts, auscultation - of harsh or

vesicular-bronchial breathing, moist fine bubbling rales.

LaboratoryLaboratory investigationinvestigation. Hypochromic anemia, leucocytosis (12-17x109), neutrophils elevation (10-15%), lymphopenia, monocytosis, elevation of the erythrocyte sedimentation rate are observed in blood picture. During distruction process mycobacterium in sputum can be observed. Mantu`s test is positive. Negative unergic process appears during progressive of the process. X-ray examinationX-ray examination. It is characterized by large symmetric focal shadows with uneven outlines, total or subtotal affection. These X-ray changes are typical and imitate the picture of “dropping snow”. Then appear lightings with irregular shape situated symmetrically in the upper lung segments.

Disseminated lung tuberculosis (subacute)

Disseminated lung tuberculosis (subacute)

“Stamped cavern” in the apper part of the right lung

Chronic disseminated tuberculosis of lungs.Chronic disseminated tuberculosis of lungs.

Appears in case of not entirely effective therapy of the subacute

disseminated tuberculosis, its observed more frequently as

independent form. Characterized by presence of temporary

remission of a disease and acute condition, which is caused by

bacteriemia, dissemination and infiltrating changes in lungs.

Pathologic anatomy. The process has apica-caudal dissemination

calcific focuses are situated in the upper segments of lungs, but there

are lower fresh focuses. Symmetric cavities are formed in the upper

segments, emphysema prevails in lower segments.

Chronic disseminated lung tuberculosis

X-ray examinationX-ray examination. During hematogenic dissemination on the X-

ray we can observe symmetrically situated focal shadows with weak

intensity and unclear outlines of shadows. Typical X-ray picture of

chronic disseminated tuberculosis formulates during long course:

multishaped focal shadows, with different intensity in superior and

median segments of lungs, deformation of the lung picture. In the

inferior segments we observe particulary clear lung field and poor

lung picture, wich is caused by emphysema.

Old focuses are situated in the superior segments, they are more

intensive with well contured outlines. Fresh focuses are in the

inferior segments, characterized by low intencity. Deformation of the

roots of lungs with superior disposition ("sign of willow branches") is

observed.

Chronic disseminated lung tuberculosis

Differential diagnosis.Differential diagnosis.

More frequently differential diagnosis carries out with:

- bilateral focal pneumonia,

- carcinomatosis

-silicosis

- sarcoidosis

-pulmonary congestion

For the comfirmation of diagnosis of the tuberculosis it is neccessary to pay attention on contact with affected persons, enduring of primary tuberculosis, pleuritis, focuses in the superior and cortical segments.

Bilateral nidus pneumonia

Sarcoidosis of the lungs and intrathorasic limph. nodes

Sarcoidosis of the lungs and intrathorasic limph. nodes

Carcinomatosis

Lung stagnation phenomena

Lung stagnation phenomena. Left-side transsudate

Focal ( Nidus) lung tuberculosis (FLT)Focal ( Nidus) lung tuberculosis (FLT)

In this form of tuberculosis, foci of specific

inflammation are formed in the lungs with a size up to 1cm,

single or multiple, 1-side or 2-side, localized not more 1-2

segment.

  

FLT is divided into:

1- Soft focal (acute) with fresh foci of exudative or productive

character

2 - Fibrouse focal (chronic) at which foci are surrounded with a

connective tissue capsule, sometimes with elements of

calcination; but places of active inflammative process could be

found. Lung tissue is sclerotized; there is possible bronchial

deformation, and pleural layers. Fibrous-focal tuberculosis

may be the next stage of development of soft-focal

tuberculosis or involution of other forms.

figfig. . 1 1 Focal lung tuberculosisFocal lung tuberculosis

figfig.2.2 R Roentgenogram. Focal lung tuberculosisFocal lung tuberculosis

Determination of activity of Determination of activity of

tuberculosis processtuberculosis process

Active are such tuberculosis

change at which specific process is not

finished and may progress or regress. It

must be treated. For determination of

process activity these criteria are used. .

The most informative criteria of activity of

tuberculosis process:

- Finding of MBT;

- X-ray criteria;

- Involution of the process under the

test treatment.

 

Infiltrative lung tuberculosis (ILT)Infiltrative lung tuberculosis (ILT)

ILT is a zone of specific

inflammation mostly of exudative

character, with size more than 1 cm, with

ability to progressing and destruction.

fig. 5. Cloudlike infiltrate

variants of infiltrate

figfig. 6.. 6. Round shaped infiltrate

FigFig. 7.. 7. Lobitis.

X-ray examination.X-ray examination. 1. On X-ray there’s seen a shadow, with diameter more than 1 cm that in tuberculosis has some specialties. 2. Localization in 1, 2, 6 segments (on anterior lower X-ray-above, under the clavicle and parahillary). 3. Non-homogenic structure due to more intensitive foci conditioned by old fibrosis formations around which infiltrate developed or by caseoua foci. Areas of lighting also condition non-homogenic of infiltrate during formation of destruction cavities. 4. Focal shadows with unclear borders around the inlitrate and in other parts of this or that lung as a result of lympha- or bronchogenoc dissemination; 5. “Road” to the root often as double stripe of infiltrated walls of bronchus is revealed often at tuberculosis infiltrate in destruction phase.

Infiltrative tuberculosis

fig.3 RRoentgenogram. . Infiltrative lung tuberculosisInfiltrative lung tuberculosisС6 С6 left lung with decayleft lung with decay

fig.4 RRoentgenogram. . Cloudlike infiltrate of left lungof left lung. .

Main signs Infiltrative tuberculosis

Pneumonia Infarct of lung Eosinophilic infiltrate

Cancer of lung

ANAMNESIS

Sometimes contact with tb patients, previous tb

Caught a cold, catharrh of upper respiratory ways, angina

Operation, trauma, trombophlebitis, heart diseases

Allergic diseases, helminths

Patients are men after 40, smoking

COURSE

Beginning often is gradual, acute. At tuberculostatic therapy regress is slow

The beginning is acute, fast regress after antibiotics

The beginning is acute

The beginning is not visible, rare acute

Gradual beginning, progressive worse condition

SYMPTOMS

Moderate toxication, fever, sweating, cough. Few ausculatative changes

High temperature, dyspnea, cough. Full ausculataive picture (wet and dry rhonchi)

Pain in chest, dyspnea. Above the infiltrate zone, there is dullness, bronchial breathing

None complains, sometimes cough, impermanent dry or wet rhonchi

Pain in chest, dyspnea, cough, a big tumor or complicated with atelectasis – dullness, sometimes dry rhonchi above infiltrate

ROENTGENO-LOGIC PICTURE

Not homogenic infiltrate in1, 2 or 6 segment. Road to root, injured places on the background and around infiltrate

Shadow in most cases is homogenic

Triangle homogeny shadow, apex towards the root. Rare shadow is round or oval. High state of diaphragm

Shadow with unclear margins like cotton tampon, often homogeny. Rapid appearance and disappearance of infiltrate.

At peripheral cancer the shadow is homogenic and tuberose. At central one the shadow goes out of root

OTHER METHODS OF INVESTIGATION

Positive Mantu test. At bronchoscopy there is a specific endobronchitis

At bronchiscopy there is unspecific endobronchitis

On ECG there are signs of overloading of right heart

Positive skin tests with specific allergen

Direct and indirect signs of tumor at bronchoscopy

Differential diagnosis at infiltrative tuberculosisDifferential diagnosis at infiltrative tuberculosis (table)

fig.8 RRoentgenogram. . Pneumonia of inferior part of left lungPneumonia of inferior part of left lung..

fig.9 RRoentgenogram. . Eosinophilic pneumoniaEosinophilic pneumonia. .

fig.10 RRoentgenogram. . Central cancer of left lungCentral cancer of left lung..

fig.11 Tomogram of right lungTomogram of right lung. . Infarct of lung ..

Caseous pneumonia

Caseous pneumonia is a clinical

form of tuberculosos with massive

caseous changes in lungs and

severe, progressive clinical course.

fig. 12 Lobar caseous pneumonia..

X-rayX-ray investigation determines massive uneven darkness of entire lung lobe during caseuos pneumonia, there can be separate intensive foci on the background of it. While next progressing of process shadow becomes almost homogenic, than on its background lightening of cavity destruction appears or gigantic caverns form. Lower lobar shadow in other regions of either lung’s broncho-dissemination processes appear.

During lobularlobular caseous pneumonia big processes with irregular margins are defined (if lobular caseous pneumonia appears on the background of disseminative tuberculosis, they are localized symmetrically in both lungs). During the progressing of disease in pneumonic foci appears multiple lightening of cavity destruction, in other lungs there are new bronchogenic injured places, which are united rapidly and destruct.

fig.13 Caseous pneumonia of left lung..Bronchogenic dissemination of right lung.

Caseous pneumonia

Staphylococcal pneumonia

LUNG TUBERCULOMALung tuberculoma is a distinct

by genesis encapsulated caseous formation exceeding 1

cm in diametre and having a chronic torpid course.

Homogenous tuberculoma

Layer-by-layer tuberculoma

Conglomerate tuberculoma

Tuberculoma of the cerebellum

Tuberculoma

FIBROUS-CAVERNOUS LUNG TUBERCULOSIS

 Fibrous-cavernous lung tuberculosis is a chronic

destructive process, characterized by the presence of an old fibrous cavern, expressed fibrosis and nidi of bronchogenic dissemination in lung tissue, surrounding the cavern, or in other parts of the lungs; protracted undulant course with aggravations and remissions periods, constant or periodic bacterial secretion. In the social aspect fibrous-cavernous lung tuberculosis patients are invalids, predominantly of the 2-nd group.

Fibrous-cavernous

lung tuberculosis

Fibrous-cavernous lung tuberculosis

Stages of destructive process in lungs.

Fresh elastic cavity fibrous cavity disintegration    

elastic cavity

Fibrous-cavernous lung tuberculosis

fibrous-cavernous lung tuberculosis

Possible ways of cicatrization of cavities.

1. scar;      

2. hearths;      

3. blocked cavity;      

4. pseudocysts.

chronic abscess

CIRRHOTIC LUNG TUBERCULOSIS 

Cirrhotic lung tuberculosis is a clinical form, that is characterized by the development of connective tissue in lungs and pleura as a result of involution of various clinical forms of lung tuberculosis or specific pleurisy, with the preservation of signs of tuberculous process activity, inclination to periodic aggravations and meagre mycobacterial secretion, but without the presence of an active cavern.

In patients with firstly diagnosed lung tuberculosis cirrhotic tuberculosis is observed very rarely, somewhat more frequently among the contingents of antitu-berculous dispensaries (up to 1 %).

Cirrhotic lung tuberculosis

Cirrhotic lung tuberculosis

Cirrhotic tuberculosis

Pleurogeniccirrhosis of

the leftlung