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 TUBERCULOSISMILIARY TUBERCULOSIS

Miliary tuberculosis defines the presence of innumerable,

tiny, discrete tuberculous lesions in the lungs and other organs

owing to the seeding of these tissues by blood-borne tubercle

bacilli. The word "miliary" was used originally by John Jacob

Manget in 1700' to denote the small size of such lesions, generally

less than 2 mm in diameter, or approximately the size of millet

seeds. "Lymphohematogenous dissemination" designates the entry

of tubercle bacilli, usually from a parenchymal pulmonary focus,

into the lymphatics, lymph nodes, and ducts, with ultimate

drainage into the bloodstream, producing bacillemia.

PATHOLOGYPATHOLOGY

The pathologic features of miliary tuberculosis are similar but

with certain specific characteristics. Grossly, the lungs or other

organs have small, punctate, rounded lesions of more or less uniform

size. Their color varies from gray to reddish-brown, depending on

the organ examined and their stage of development. Мал 1

Miliary foci lead to the classic changes de scribed as tubercles.

Lymphocytes and macrophages are intermixed with epithelioid cells

ar ranged in roughly spherical dimensions. Caseation necrosis affects

the central core of some lesions, whereas others are entirely free of

caseation. With appropriate staining, acidfast bacilli may be found

within macrophages or epithelioid cells or in the central caseum.

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.

CHEST RADIOGRAPHSCHEST RADIOGRAPHS The chest radiograph is the single most important means for detecting miliary tuberculosis. The classic pattern of diffuse, bilateral, symmetrical, discrete, pinpoint 2- to 3-mm densities is illustrated in Figures 1 and 2. Figure 1 illustrates the typical appearance of miliary lesions in a standard chest radiograph. Some of the apparent variations in the size of the lesions are due to densities in various depths of the lung parenchyma superimposed on the chest film. Figure 2 is the magnified view of a portion of this chest radiograph. Computed tomography (CT) often is useful to demonstrate tiny miliary lesions that are too small to be visualized on a conventional radiograph. This is especially important in the early stages of the disease when chest radiographs can be read as normal.

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 in 1-2 segment.

Pathogenesis and pathanatomyPathogenesis and pathanatomy. FLT belongs to

secondary tuberculosis, meaning that it develops in long-time

infected organisms the with presence of some infectious

immunity and has features of limited organ injury.

Theories of secondary tuberculosis development:

- exogenic super infection;

- endogenic reactivation of remining foci of infection;

- formation of focal tuberculosis is involution of other

forms – infiltrative, disseminated and even cavernous

  

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

X-ray examinationX-ray examination plays first role for diagnosis of

FLT. As the most frequent localization at the clavicles,

focal shadows are often covered with bone formations,

that’s why, besides common fluorographic investigation,

it is necessary to provide fluorogram in posterior angled

position, roentgenogram, tomograms on optimum

section.

The main X-ray criteria of FLT diagnosis:The main X-ray criteria of FLT diagnosis:

- Presence of foci in the lungs (shadows up to

1 cm);

- Spreading in 2 segments.

figfig.2.2 R Roentgenogram. Focal lung tuberculosisFocal lung tuberculosis

Differential diagnosisDifferential diagnosis.

Clinical symptoms of FLT may simulate: - flu;

- chronic sepsis; - hyperthyreosis.

But in all these diseases X-ray signs are absent

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.

Pathogenesis and pathanatomy.

1 - Infiltrate develops as a result of perifocal inflammation

around fresh foci that appeared due to exogenic

superreinfection or endogenic reactivation. Thus it may be

continuation of soft-focal tuberculosis.

2 - Tuberculosis infiltrate may be a result of perifocal

inflammation around severed old foci formed at involution of

lung tuberculosis. Fast development of infiltrate is a result of

hyperergic reaction of lung tissue to a high quantity of virulent

MBT that quickly reproduces. Different endogenic and

exogenic factors also have some value, they decrease the

organism’s resistance.

Clinic.Clinic.

1)In 21-40 % of cases it has acute onset and simulates flu or pneumonia. Body temperature is increased to 38-39C, there develops general weakness, sometimes appear chest pain, cough with excretion of sputum, sometimes with blood inclusions.

2) At the subacute disease’s development (in 40 % of cases) patients complain of tiredness, decreased appetites, general weakness, sweating, subfebrile temperature, coughing. Often patient don’t pay attention to these symptoms, connecting them with overtiredness, smoking.

3) The beginning may be without any symptoms (inapercept) onset of ILT, but in detailed questioning in such cases there may be revealed trivial functional disorders (tiredness, disorders of sleep etc.). In such cases ILT is revealed in prophylactitic fluorographic investigation.

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.

Variants of caseous pnemonia:

1. Lobar is a total caseous necrosis of cloudlike infiltrate or

lobitis.

2. Lobuluar:

- As a result of aspirative pnemonia after bleeding;

- Malignant course of subacute disseminative tuberculosis

of

lung;

- Complications of terminal stages of chronic form of

tuberculosis;

- Spreading of caseous masses in bronchi and lungs

through the

fistula with lymphatic nodes.

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.

Differentiated diagnosisDifferentiated diagnosis of lobar caseous pneumonia

should be made with simple (croup) pneumonia, which is

also develops acute, but sometimes begins with rhinitis,

herpes; those are not specific signs for caseous

pneumonia. Body temperature during croup pneumonia is

persistent, while during caseous pneumonia it is irregular

with remissions. For caseous pneumonia profuse night

sweat is usual, while during croup pneumonia it appears

during crisis. More expressed leukocytosis (20-40*1012/l)

can be during croup pneumonia.

Caseous pneumonia

X-ray signs of croup pneumonia are the following:

Homogeny shadow limited in a lobe.

X-ray signs of caseous pneumonia:

1. Uneven shadow, that can be spread;

2. Appearing of lightening because of emptiness

destruction;

3. Injured places of bronchogenic dissemination in

other

places in the same lung or another lung.

For full determination of tubercular origin of disease

multiple searching of mycobacterium tuberculosis in sputum

is necessary. Diagnosis of lobular pneumonia, which

develops as a complication of other forms lung tb is difficult.

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.

Pathomorphism. Fibrous-cavernous tuberculosis is formed

at the unfavourable course of infiltrative, disseminated, nidus lung tuberculosis. Lung changes spreading may be various and the

progress is both unilateral and bilateral with the presence of one or several caverns, as well as pneumosclerosis, emphysema and

bronchoectases.The cavern wall has a three-layer structure:

inner-piogenous, middle-granulation, outer-fibrous.

Fibrous-cavernous

lung tuberculosis

Fibrous-cavernous lung tuberculosis

Stages of destructive process in lungs.

Fresh elastic cavity fibrous cavity disintegration    

elastic cavity

Clinic. Clinical manifestations of fibrous-cavernous

tuberculosis are varied. They are caused by both tuberculosis itself, the process spreadness and phase, changes in lung tissue and complications.

Several clinical variants of fibrous-cavernous lung tuberculosis course are discriminated:

1. Limited fibrous-cavernous lung tuberculosis with a stable course (progress);

2. Limited or wide-spread fibrous-cavernous lung tuberculosis with a progressing course;

3. Fibrous-cavernous lung tuberculosis with complications.

Fibrous-cavernous lung tuberculosis

fibrous-cavernous lung tuberculosis

Possible ways of cicatrization of cavities.

1. scar;      

2. hearths;      

3. blocked cavity;      

4. pseudocysts.

The diagnostics is based on the anamnesis data, roentgenologic picture (presence of caverns, fibrosis and nidi), deformity of thoracic cage, physical data, blood changes, MBT presence in sputum.

 The differential diagnostics is done with: chronic abscess, polycystosis, cancer in the decay phase, bronchoectasia.

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

Pathomorphism. Cirrhotic tuberculosis develops as a result of involution of fibrous-cavernous, chronic disseminated, infiltrative tuberculosis of lung, pleura, tuberculosis of intrathoracic lymphatic nodes complicated with atelectasis.

Cirrhotic tuberculosis

Pleurogeniccirrhosis of

the leftlung