CLINICALCLASSIFICATION
OF TUBERCULOSIS.
PRIMARY TUBERCULOSIS
Respiratory tuberculosis
Pulmonary tuberculosis: Primary tuberculosis complex Disseminated pulmonary tuberculosis Nodulary pulmonary tuberculosis Infiltrative pulmonary tuberculosis Fibrous-cavernous pulmonary
tuberculosis Tracheobronchial tuberculosis
Respiratory tuberculosis
Extrapulmonary tuberculosis: Pleural tuberculosis Tuberculosis of intrathoracic lymph
nodes Other forms of upper airway
tuberculosis
Extrarespiratory tuberculosis Tuberculosis of central nervous system Skeletal tuberculosis (bone and joint) Intestinal tuberculosis, tuberculous
peritonitis, Lymph node tuberculosis Genitourinary tuberculosis Cutaneous tuberculosis
Confirmation of the diagnosis by
direct microscopy of samples cultures histopathological examination clinic-radiological examination
Characteristics of tuberculous process:
Localization and extension: in the lungs: limited (1, 2 segments) and
extended (3 and more segments) in other organs
Phase
progressing (infiltration, destruction,dissemination)
regressing (desorption, consolidation) stationary (without roentgenological
dynamics) stabilization (recovery)
Complications
haemoptysis spontaneous pneumothorax respiratory failure pulmonary heart atelectasis amyloidosis fistula insufficiency of affected organs
Primary TuberculosisPrimary tuberculosis complex.
Background Tuberculosis (TB) is increasing among
adults in many areas TB is major cause of childhood morbidity
and mortality worldwide Limited information on epidemiology of TB
in children
Features of primary tuberculosis
Primary tuberculosis develops after thechild's first contact with theMycobacterium tuberculosis
It is mainly in children and adolescents With conversion of tuberculin test Develop delayed-type hypersensibility, so
appear hyperergical tuberculin tests
Features of primary tuberculosis
Paraspecifical reactions arecharacteristic :
erythema nodosum phlyctenular conjunctivitis poliarticular syndrome (Poncet’s
rheumatism is an “allergic” type of jointswelling which may disappear in two tothree weeks, and does not indicate thepresence of tubercle bacilli in the jointspace)
Features of primary tuberculosis
In the pathologic process is involved lymphaticsystem
Tuberculosis in infants and children younger than3 years old is much more likely haematogenousdissemination of the organisms occurs andspreads the organisms throughout the body,leading to acute disseminated TB (milliary TB)and tuberculosis meningitis, a very dangerousforms of the disease
Features of primary tuberculosis
In most cases, tuberculosis in children is amild disease and may heal on its ownwithout treatment
The record multidrogresistent primaryM.tuberculosis to antituberculosis drugs
The diagnosis can be establishedon the following considerations
history of contact with case ofpulmonary tuberculosis
significant reaction to the tuberculin skintest
absence of elevated white cell count inthe blood
absence of clinical and/or radiologicalimprovement after treatment with abroad-spectrum antibiotics
PRIMARY TUBERCULOSIS COMPLEX
is a form of primary tuberculosis inchildren and adolescents withmorphological substrate - specificinflammation of lung parenchyma(primary focus), involved in theprocess of lymphatic routes(lymphangitis) and mediastinallymphadenopathy
Lesions associated with primary tuberculosis
Initial infection with Mycobacterium tuberculosisin an immunocompetent individual usuallyoccurs in an upper region of the lung producinga sub-pleural lesion called a Ghon focus
Granulomatous involvement of peribronchialand/or hilar lymph nodes is frequent in primarytuberculosis due to lymphangitic spread fromthe Ghon focus
Lesions associated with primary tuberculosis
The early Ghon focus together with thelymph node lesion constitutes the Ghoncomplex
These lesions undergo healing and overtime usually evolve to fibrocalcific nodules
The combination of late fibrocalcific lesionsof the lung and lymph node which evolvedfrom the Ghon complex is referred to asthe Ranke complex
Clinical manifestationsof intoxication syndrome
the central nervous system - generalweakness, asthenia, excitability, headaches,sleep disturbances, feverish, night sweats
endocrine system - the growing disorderchildren, the dysfunction of the thyroid gland inthe age of puberty (hyperplasia of gr. II-III,hyperfunction), the disorder of the ovarianfunction (primary or secondary irregular of themenstrual cycle), decreased of the functionadrenal glands (adynamy, hypotonia)
Clinical manifestationsof intoxication syndrome
immune system - children are frail, oftenrespiratory tract infection (influenza,recurrent bronchitis and pneumonia),reactivation of chronic infections (sinusitis,tonsillitis, pyelonephritis etc.)
the heart – toxico-allergic myocarditis(tachycardia, cardiac tone I reduced,apical systolic functional murmur)
digestive system – diminished appetiteand progressive weight loss, subacidgastritis
Pulmonary syndrome
Cough - is most frequently, usually moremarked in the morning and is commonlyproductive
Chest pain – may result frominvolvement of the pleura
Dyspnoea – due to consolidation,cavitation, fibrosis and pleural affection
Haemoptysis - appears in complicatedcases with primary cavity, most commonin adolescents
Mucocutaneous manifestations
Erythema nodosum appears in theform of bluish red tender subcutaneousnodules several millimeters to severalcentimeters in diameter on the shins,sometimes on the backs of the armsand rarely on the front, in two to threebursts
They are painful, raised lesions that mayturn purple and take on the appearanceof a bruise
Mucocutaneous manifestations
Phlyctenular conjunctivitis begins withgeneralized pain and irritation in one eyeaccompanied by watering and photophobia
On examination, grey or yellow lesions can beobserved where the cornea joins the white of theeye; a number of blood vessels enter the lesions,giving an appearance of vascular engorgement ofthe conjunctiva
Each lesion persists for about a week, and thendisappears, to be replaced by others
In severe cases the cornea may ulcerate
Local symptoms
Often the chest physical examination -normal, with radiological discrepancy
Notice any limitation of movements onthe affected part
Dullness Harsh vesicular breathing and many
diffuse rales of small caliber
Radiographic picture of a primarytuberculosis complex
The primary complex has four stages ofdevelopment. There are four stages ofprimary complex development :
1. I stage – pneumonic2. II stage - resorption3. III stage - condensation4. IV stage - calcination
Pneumonic stage consists of a small area of
infiltration at any location in thelung parenchyma, accompanied byunilateral mediastinallymphadenopathy
The infiltration forms when thebacilli are first inhaled (as adefence reaction around thelocation at which the bacilli firstdeposit); it is characteristicallysmall (3 to 10mm in diameter)
This nodular shadow is sometimessurrounded by a lighter, less denseshadow with irregular edges
On lateral X-ray, mediastinallymphadenopathy appears as arounded or oval latero-tracheal orhilar shadow
Pneumonic stage On X-ray general view three
components of a complex arevisible:1) the focus in lung tissue bythe size 2-4 cm. in diameter ormore, of oval or irregular form,various intensity (more often -average and even high), with anindistinct, obscure contour;
2) the flow out to a root -lymphangitis, which is definedas linear tension bars from focusto the hilum;
3) in a hilum - enlargedinfiltrated lymphatic nodes.The hilum is represented to beextended, it’s structure) is blurry,the intensity is increased. Thecontours outlining lymphaticnodes, or are dim, or moreprecisely depict the increasednodes.
Stage of resorption
The radiologicalpicture is that of aprimary focus in thelung withaccompanyingmediastinal lymphnodes enlargementunited by an opaquetape (lymphangitis –the draininglymphatics becomebeaded bytubercles, distendedand tortuous)
Stage of resorption The size of the focus
in lung tissuedecreases, itsintensity raises, thecontours becomeprecise
The flow out to ahilum and infiltrationof lymphatic nodesdecreases
Stage of condensation On a place of focus area
remains with the size up to1 cm, inside of it inclusionsof calcinations appear asfine spots of sharpintensity
Same spots of calcinationsare noticeable and inlymphatic nodes of thelung hilum
Thin tension bars aredetermined between thefocus and the hilum
Stage of condensation
Calcination-stage The focus in lung tissue
becomes even smaller, moredensely, of high intensity, withdistinct contour, frequentlyrugged and rough
Calcinations are intensifiedalso in hilum lymphatic nodes
Calcinations in certain casesare represented by solid,dense formations, in others -they have less intensiveshadows of inclusions, whichtestify about incompletecalcifications of the focus andpreservation of caseousregions in it
Outcome of primary tuberculosis
At favorable course of primary tuberculouscomplex with time calcification increases up toossification at the place of former caseosislocated in peripheral parts of lungs. This isGohn's focus
When primary complex is revealed in time andthe patient receives valuable treatment,frequently could be achieved complete dissolutionof pathological changes in lung tissue and in root,with complete restoration of their initial structure
Gohn's focus
The lesion is small andusually cannot be detectedduring its active stage;not until calcium salts aredeposited in the healedlesion can its presence bedetected
In a large majority ofinstances healing takesplace with fibrosis andcalcification (Gohn's focuspointed be arrow)
The tuberculin skin test
in most cases is hyperergical andcoincides with a tuberculin conversion
Bacteriologic diagnosis Sputum can rarely be collected from
children Can try sputum induction in older children Bronchoalveolar lavage is invasive,
expensive and should be reserved forsituations where the diagnosis is in question
Gastric aspirates• people swallow mucus in their sleep• collect gastric contents before the stomach empties
TUBERCULOSISOF INTRATORACICLYMPHATIC NODES
Definition is a primary form of
extrapulmonary tuberculosis withspecific inflammation ofintratoracic lymphatic nodes, inchildren and adolescents
It affects mostly lymph nodes afterSuchenicov - Esipov scheme(paratracheal, tracheo-bronchial,interbronchial, bronho-pulmonarylymph nodes) and Engel (para-aorticlymph nodes)
Clinical-radiological forms
Infiltrative
Tumor-like (pseudotumor)
Traheobronchiallymphadenopathyof small volume
Infiltrative form
morphologically characterized by partiallymph nodes necrosis, predominateexudative inflammation type involvingadjacent tissue
In clinical picture prevails intoxicationsyndrome
Tumor-like (pseudotumor) form
is characterized by morphological totalcaseation of lymph nodes
In clinical picture predominatesbronchopulmonary syndrome withcompression bronchus (bitonalspasmodic cough), dyspnoea expiratory
Traheobronchial lymphadenopathyof small volume
is a variant of pseudotumor form and meet and youngadults
Clinical manifestations are moderate, or even missing This form should be suspected in children and
adolescents from foci of tuberculosis with syndrome ofintoxication, with conversion of tuberculin test ortuberculin tests hypererergical
Groups of affected lymph nodes has diameter up to 1 cmand are hidden in the shadows of mediastinum andheart, invisible on X-ray standard
To detect them is required chest x-ray in profile,mediastinal tomography, and computerized tomography
Infiltrative form• On chest x-ray the
shadow of the lunghilum is extended onthe damaged part, theoutside contour isunclear, the structure isheterogeneous andintensity is increased
• Shadows of enlargedlymphatic nodes areclearly come to light onx-ray tomogram
Infiltrative form
The pseudotumor form
The shadow of the hilum lookssame, as an infiltrative form,but its exterior contour is clear,regular or polycyclic. Theshadow of the upper part ofmediastinum is expanded at adefeat of para-tracheal andtracheo-bronchial lymphaticnodes
The defeat of bifurcationlymphatic nodes is revealedusually on the chest x-ray ortomograms
Pseudotumor form
Traheobronchial lymphadenopathyof small volume
Groups affected lymphnodes with diameter up to 1cm are hidden in theshadows of mediastinumand heart, invisible on X-raystandard
For detect them is requireda lateral chest radiograph,mediastinal tomography,computerized tomography.
Local complications of primary tuberculosis
Fistulation of the lymph node into thebronchi: the lymph node swells anderodes into the bronchus (usually betweenthe 4th and 7th month of development)
This can be a serious event for smallinfants, where the caseous material cancreate acute bronchial obstruction; inolder children it usually causes cough
Local complications of primary tuberculosis
The formation of a primarytuberculous cavity at the site ofinfiltration is a more unusual complication
Delayed local complications
Bronchiectasis may develop in thepoorly ventilated area of the lung,creating bronchial superinfections andrepeated episodes of haemoptysis.
The most characteristic feature of thistype of sequelae is “hilar disease” or“right middle lobe syndrome”:
Atelectasis hilar calcification recurrent haemoptysis.
Atelectasis
Differential diagnosis
sarcoidosis, st. I lymphogranulomatosis lymphosarcoma leukemiaadenopathy nonspecific
Infants may have acquired TB
• by trans placental spread through theumbilical vein to the fetal liver
• by aspiration or ingestion of infectedamniotic fluid
• via airborne inoculation from closecontacts (family members or nurserypersonnel)
• About 50% of children born to motherswith active pulmonary TB develop thedisease during first year of life ifchemoprophylaxis or BCG vaccine isnot given
Neonatal TB
The clinical presentation nonspecific Multiple organ involvement Usually fever, lethargy, respiratory
distress, hepatosplenomegaly, or failure tothrive may indicate TB in an infant with ahistory of TB exposure
For diagnosis: culture and smear oftracheal aspirates, urine, gastric washingsfor acid-fast bacilli, chest x-ray (milliaryinfiltrates)
Biopsy of the liver, lymph nodes, or lungand pleura may be needed
Skin test results may be negative
Cerebrospinal fluid analysis in TB meningitis
CSF is clear or opalescent, pressure is elevated CSF pleocytosis with lymphocytic
predominance: presence of more than 50 white cells/mm³on microscopic examination of the CSF, with morelymphocytes than polymorphonuclear cells
Decreased CSF glucose: value of CSF glucose 50% orless than simultaneous serum glucose determination.
Increased CSF protein: value of CSF protein more thanthe upper limit of normal of the performing laboratory'sreference values, i.e. > 0.45 mg/dl.
Abnormal CSF: presence of all 3 of the above CSF findings(CSF pleocytosis with lymphocytic predominance +decreased CSF glucose + increased CSF protein.
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