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SECONDARY TUBERCULOSIS

SECONDARY TUBERCULOSIS. LECTURE doc . Kravchenko N.S. DISSEMINATED 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.

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SECONDARY TUBERCULOSIS

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  1. SECONDARY TUBERCULOSIS LECTURE doc. Kravchenko N.S.

  2. DISSEMINATED 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.

  3. PPATHOGENESIS PPATHOGENIC 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.

  4. Ways of MBT spreading. 1 – haematogenous 2 – lymphogenous 3 - bronchogenous

  5. MILIARY 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.

  6. PATHOLOGY 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.

  7. Miliary tuberculosis

  8. TABLE 1. Organ Involvement in Miliary Tuberculosis at Necropsy

  9. AS TO CLINICAL PROGRESS MILIARY TUBERCULOSIS IS CONDITIONALLY DIVIDED INTO: -LUNG -TYPHOID - MENINGEAL - SEPTIC FORMS.

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

  11. CHEST 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.

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

  13. Subacute 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.

  14. Clinical 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.

  15. Laboratoryinvestigation. 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 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.

  16. Disseminated lung tuberculosis (subacute)

  17. Disseminated lung tuberculosis (subacute)

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

  19. 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.

  20. Chronic disseminated lung tuberculosis

  21. X-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.

  22. Chronic disseminated lung tuberculosis

  23. 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.

  24. Bilateral nidus pneumonia

  25. Sarcoidosis of the lungs and intrathorasic limph. nodes

  26. Sarcoidosis of the lungs and intrathorasic limph. nodes

  27. Carcinomatosis

  28. Lung stagnation phenomena

  29. Lung stagnation phenomena. Left-side transsudate

  30. 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 1-2segment.

  31. Pathogenesis 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

  32. 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.

  33. fig. 1 Focal lung tuberculosis

  34. X-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: - Presence of foci in the lungs (shadows up to 1 cm); - Spreading in 2 segments.

  35. fig.2 Roentgenogram. Focal lung tuberculosis

  36. Differential diagnosis. Clinical symptoms of FLT may simulate: - flu; - chronic sepsis; - hyperthyreosis. But in all these diseases X-ray signs are absent

  37. Determination of activity of tuberculosis 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. .

  38. The most informative criteria of activity of tuberculosis process: - Finding of MBT; - X-ray criteria; - Involution of the process under the test treatment.

  39. 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.

  40. 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.

  41. Clinic. • 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.

  42. variants of infiltrate fig. 5. Cloudlike infiltrate

  43. fig. 6.Round shaped infiltrate

  44. Fig. 7.Lobitis.

  45. 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.

  46. Infiltrative tuberculosis

  47. fig.3 Roentgenogram. Infiltrative lung tuberculosis С6 left lung with decay

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