Disseminated pulmonary tuberculosis

The disseminated pulmonary tuberculosis is characterised by presence of the plural tuberculous focuses formed as a result of dispersion Mycobacterium tuberculosis in lungs.

Among for the first time taped sick of a pulmonary tuberculosis a disseminated tuberculosis diagnose at 5 - 9 %, among consisting on the account in antituberculous dispensaries - for 12-15 %. Children and teenagers are ill with a disseminated tuberculosis was rarely. Revealing among them with this form of a tuberculosis specifies patients in the big prevalence of a tubercular infection contamination among humans surrounding them. A disseminated tuberculosis quite often tap at the persons of elderly and senile age receiving concerning various diseases immunodepressive preparations. As the cause of death a disseminated tuberculosis among all forms of a pulmonary tuberculosis compounds 3-10 %.

Pathogenesis

The disseminated tuberculosis results from diffusion Mycobacterium tuberculosis in lungs hematogenous, lymphogenous, lymphohematogenous and is is rare lymphobronchogenous pathes. Generalisation of tubercular process is possible at the complicated flow of a primary tuberculosis when the obligate bacteriemia, characteristic for this form, shows a plural focal dissimination in lungs. At an active primary tuberculosis a source of diffusion Mycobacterium tuberculosis (early generalisation) are the kazeozno-changed intrathoracic lymph nodes, topographicallies and functionally closely bound to vascular system. The disseminated tuberculosis can educe after many years after spontaneous or medicinal treatment of a primary tuberculosis (serotinal generalisation). Dispersion Mycobacterium tuberculosis descends from the struck lymph nodes, Ghon's focuses, from non-pulmonary tuberculous focuses.

Micobacteria from a lymph node inpour into blood at diffusion of a tubercular inflammation immediately on a side of the pulmonary pot or through a thoracal lymphatic duct, a subclavial vein, the right parts of heart, pulmonary veins and further in lungs. From non-pulmonary locus Mycobacterium tuberculosis get to pots of a lung after a previous bacteriemia. At a hematogenous dissimination tuberculous focuses are taped in both lungs symmetrically on all extent or in the top parts. From a lymph node of mediastinum Mycobacterium tuberculosis can extend in lungs on absorbent vessels retrograde. In this case there is mainly secund lymphogenous disseminated tuberculosis.

Tuberculosis in blood and a lymph still it is not enough hit Mycobacterium for occurrence of a disseminated tuberculosis - depression of natural body resistance and antituberculous immunodefence, and also rising of reactance of a pulmonary tissue, lung pots to a tubercular infection contamination is necessary. The disseminated tuberculosis educes at children who have been not vaccinated BCG, at persons with a congenital or acquired immunodeficiencyy, at patients, is long accepting immunodepressants, in natural hormonal rearrangement of an organism, at starvation, exogenous superinfection Mycobacterium tuberculosis, infectious diseases, at application of physiotherapeutic procedures (quartz, muds, etc.), insolations.

Single-step entering of big dose Mycobacterium tuberculosis in blood, for example, at break of a caseous lymph node in the vein, can cause development of a generalised disseminated tuberculosis with a lesion of lungs.

Pathological anatomy

There are some variants of a disseminated tuberculosis differing on clinical implications. Easy, individual tubercular hillocks in other organs clinically are usually amazed only, by means of various methods of diagnostics during lifetime of patients usually are not taped. The generalised hematogenous tuberculosis C exudative-caveous the locuses in many organs meets was rarely. Was exclusively rarely the disseminated tuberculosis proceeds with a clinical picture of a tubercular sepsis - on dissecting in such patients find in many organs the plural caseous locuses with considerable quantity Mycobacterium tuberculosis.

At an acute disseminated tuberculosis of a hematogenous genesis in lungs find numerous fine, about millet grain the locuses. Such form name a miliary tuberculosis. Appearance in lungs of hillocks is preceded by hyperergic reaction of capillars in the form of disorganisation of collagen and a fibrinoid necrosis of a side that leads to rising of permeability of a side of capillars. Conditions for penetration of micobacteria from blood in lungs and developments of vasculites of lymphangites are framed. Round capillars in alveolar septums and in alveoluses there are millet zheltovato-grey hillocks. In typical cases diameter of hillocks of 1-2 mm. At microscopic examination in the hillock centre it is found the caseoses, surrounded with epithelioid and individual colossal cells, and on periphery - cells, and on periphery - cells of a lymphoid number. Lymphocytes infiltrate and alveolar septums.

The dissimination in lungs can be accompanied by a lesion of larger pots - intralobular veins and interlobular branches of a pulmonary artery. In these cases lesion development has subacute character. In lungs are found large (to 5-10 mm in diameter) the locuses of a specific inflammation. The locuses at a miliary and macrofocal disseminated tuberculosis more often proliferative character without the expressed perifocal inflammation. Lungs are amazed symmetrically on all extent, is rarer - only the top parts (prominent feature of hematogenous dissimination Mycobacterium tuberculosis in lungs). The locuses settle down in cortical parts of the lungs rich with capillars and absorbent vessels in this connection the inflammation of a visceral layer of a pleura is possible. Interalveolar septums infiltrate cellular elements, are hydropic, that leads to loss of elasticity of a pulmonary tissue and development of a diffusive emphysema.

Thus, the basic place in a pathoanatomical picture of a fresh disseminated pulmonary tuberculosis is occupied with specific granulomas, vasculites and an alveolitis. In the subsequent stages of process in connection with productive character of an inflammation the intersticial mesh sclerosis starts to prevail.

The chronic disseminated pulmonary tuberculosis educes as a result of repeated hematogenous or lymphohematogenous dissimination Mycobacterium tuberculosis at patients, noneffectively treated concerning a fresh disseminated tuberculosis. The chronic disseminated tuberculosis is characterised by presence of the locuses different sizes, the form and morphological structure - from fresh with inflammatory reaction to calcinated. Caverns are found in some patients with a thin capsule of a trizonal constitution with a small perifocal inflammation - stamped caverns. Caverns are usually symmetrized in both lungs. Diversity of morphological changes the emphysema, cicatrixes on a pleura supplement a fibrosis of interalveolar septums, a perivascular and peribronchial tissue. As a result of a hypertensia of a small circle of a circulation the hypertrophy of a myocardium of a right ventricle educes. The locus of a non-pulmonary tuberculosis is found in some patients.

Semiology

The disseminated tuberculosis at 2/3 patients is taped at inspection in connection with appearance of various complaints, at 1/3 - at preventive fluorographic inspections.

At all variety of clinical implications of a disseminated tuberculosis it is possible to secure some clinical variants.

• Variant of an acute infectious disease: the body heat, sharply expressed delicacy, an adynamia, a headache, a dyspnea, a tachycardia, a cyanosis, dry tussis. It is possible and more expressed toxicosis with disturbance of consciousness which differentiate with a typhoid fever, an acute septic condition or with a pneumonia. For such patients diagnose widespread disseminated process in the form of a miliary or macrofocal pulmonary tuberculosis.
• Variant of chronic inflammatory or granulomatous disease - the most frequent at a disseminated tuberculosis. Patients address to the doctor with complaints to the general delicacy, fatigability, working capacity dropping, dropping of appetite and a weight loss, incidental liftings of a body temperature. Sometimes patients address to the doctor in connection with a pulmonary pneumorrhagia or a bleeding. At radiological inspection of patients the progressing chronic disseminated tuberculosis is taped the circumscribed miliary or macrofocal dissiminations.

The disseminated pulmonary tuberculosis can proceed asymptomatically and then disease at the patient is taped at preventive fluorographic research.

Symptoms of a non-pulmonary tuberculosis can be the first clinical implications of a disseminated tuberculosis: change of a voice and a pharyngalgia - at a larynx tuberculosis, a joint pain and a column at a load and walking - at a tuberculosis of bones and joints, a leukocyturia and a hematuria - at a genitourinary tuberculosis. The pleuritis can precede development of a disseminated pulmonary tuberculosis or to be its complication. The disseminated pulmonary tuberculosis becomes complicated a tubercular meningitis which can be the first implication of a generalised tuberculosis.

At survey and a palpation of a thorax at patients with a fresh disseminated tuberculosis of changes it is not taped. At patients with long chronic flow of a pulmonary tuberculosis owing to a pneumosclerosis over - and subclavial parts of a thorax sink down, and inferior owing to an emphysema extend.

At a percussion over lungs at patients with the miliary form the tympanic note, with macrofocal - the truncated note over places of the greatest clump of the locuses, with chronic - the truncated note over the top parts and tympanic - over inferior is defined.

At auscultation breath can be vesicular, enhanced, relaxed vesicular, rigid, and at appearance of caverns - bronchial. At separate patients wet finely nucleate rhonchuses are auscultated, at a pneumosclerosis and a chronic bronchitis - dry changeable rhonchuses. At appearance of a lumen of disintegration sometimes it is possible to auscultate not numerous wet average to nucleate rhonchuses.

Roentgenosemiotic

The radiological method is the core in diagnostics of a disseminated pulmonary tuberculosis and definition of variants of a dissimination. At an acute hematogenous dissimination roentgenological in 10-14 days from the disease beginning in both lungs are found symmetrically located fine (1-2 mm) the same locuses of the roundish form C by accurate enough contours. The locuses are located perivascular, in the form of a chain. At a subacute dissimination the locuses in diameter from 5-6 to 10-15 mm are symmetrized in lungs also, on a course of pots. The locuses of small and average intensity, with indistinct contours. Coalescence of such locuses to formation of locuses and disintegration is possible. At chronic flow the bunches of the confluent locuses more densely located in the top parts of lungs are taped. Because of a considerable quantity of the locuses fine vascular fulcrums are not visible.

At a chronic hematogenous dissimination symmetry of a locating of the locuses is broken. Focal shades are localised in the top parts of lungs, they polymorphic: different size and intensity. The pulmonary drawing is enhanced and deformed in the top parts, impoverished in inferior (a vicarious basal emphysema). If there are disintegration lumens, they settle down in the top lung lobes. In a X-ray pattern prevail hardness, netting against which the plural fine locuses are defined. The locuses are localised mainly in radical range of a lung. At tomographic research it is possible to find enlarged, particulate calcinated intrathoracic lymph nodes.

Tuberculinodiagnosis. Reaction to a tuberculin at sick of a disseminated tuberculosis can be from hyperergic however in process of advance of process it dies away and soon becomes negative (a negative anergy). At a chronic disseminated tuberculosis sensitivity to a tuberculin fluctuates from weakly positive to moderately expressed. With liquidation of flash of a tuberculosis tuberculine sensitivity decreases to level normergical reactions.

Laboratory researches

In a sputum, contents of bronchuses Mycobacterium tuberculosis are taped no more than at 50 % of adult patients and is even rarer at children. A bacterioexcretion usually poor. At the majority of patients excrete human kind Mycobacterium tuberculosis. However at presence and the non-pulmonary locus of a tuberculosis the bull kind of the originator can be taped.

In lungs Mycobacterium sick of a miliary tuberculosis tuberculosis are found was rarely in connection with absence of the tendency to formation of lumens of disintegration. Sick with a macrofocal tuberculosis in a disintegration phase, as a rule, excrete micobacteria. The chronic disseminated tuberculosis in a disintegration phase also is accompanied by abjection of bacteria.

In blood of patients with acute forms of a tuberculosis the leukopenia, depression of eosinocytes and lymphocytes, augmentation of band neutrophils, ESR rising are defined. At an exacerbation of a chronic disseminated tuberculosis - augmentation of leucocytes to (12-20 *109/l, band neutrophils, ESR rising.

At sick the disseminated tuberculosis, especially at acute forms, lowers an antibodyformation and a blast-cell transformant of lymphocytes. Research of reactions of immunodefence spend basically for the purpose of definition of indications to appointment of immunomodulating factors. As a result of a tubercular intoxication patients have an insufficiency of a cortex of adrenals which shows disturbance of secretion of glucocorticoids, mineralocorticoids, progesterone, Testosteron-Depotum and other hormones regulating formation of immunocompetent lymphocytes and other kinds of the immune answer. Appointment of corticosteroid preparations as such patient promotes correction of similar disturbances.

Bronchoscopic research

At a bronchoscopy at sick of a disseminated pulmonary tuberculosis it is possible to find a rash of hillocks on a mucosa of bronchuses which are the cause dry, sometimes excruciating tussis. It is possible to tap also an infiltrate or cicatrixes after the tolerated tuberculosis of a bronchus.

If data of a bronchoscopic picture are insufficient for statement of the diagnosis of a tuberculosis, an endoscopy supplement with a lung biopsy. At sick of a tuberculosis in a biopsy sample find specific granulomas.

Research of functions of breath and circulation

Disturbance of function of breath is a consequence of pathophysiological disorders at a disseminated pulmonary tuberculosis. They are caused by the big prevalence of pathomorphologic changes in a respiratory organs and the phenomena of an intoxication influencing system of ventilation - a blood stream, cardiovascular system and other mechanisms of an anoxemia and a hypoxia. At external respiration research tap reduction of vital capacity of lungs, respiratory minute volume, an oxygen utilisation quotient, hyperventilations and augmentation of a respiratory equivalent. In arterial and a venous blood drops the oxygen maintenance. At sick of a chronic disseminated pulmonary tuberculosis along with a restrictive type of ventilating insufficiency ventilating insufficiency of an obstructive type can educe also.

Diagnostics

Data about disease by a tuberculosis in monogynopaedium, for children and teenagers - a bend tuberculine reactions have great value. It is necessary to consider a previous or concomitant lesion a tuberculosis of other organs. Expression of an intoxication characterises not the form of a disseminated tuberculosis, but only its gravity and a process degree of activity. Radiological a picture: in both lungs the plural same locuses at a fresh dissimination of process and the polymorphic locuses with primary localisation in the top parts of lungs at the chronic; a lesion of lymph nodes of a mediastinum in the form of an inflammatory hyperplasia at early and calcinations at serotinal generalisation of a tuberculosis. Diagnostics of a disseminated tuberculosis is at a loss that with augmentation of acuteness and gravity of disease sensitivity to a tuberculin decreases up to negative reaction. Besides, at patients was rarely are taped Mycobacterium tuberculosis in contents of bronchuses. Difficulties of diagnostics of an acute disseminated tuberculosis are caused by that the characteristic X-ray pattern is taped later 10-14 days after appearance of clinical symptoms of disease. It is not enough often clinical data for statement of the diagnosis of a disseminated tuberculosis in this connection there is a necessity of its morphological acknowledgement.

Treatment

At acute disseminated and for the first time the taped chronic disseminated pulmonary tuberculosis prescribe Isoniazidum, rifampicin and streptomycin (or Ethambutolum), and at serious flow and in cases of a massive bacterioexcretion - also Pyrazinamidum. Treatment by the specified preparations spend to a resorption of a fresh dissimination, the infiltrative phenomena, abacillating and closures of caverns. Further patients accept Isoniazidum and Ethambutolum (or Pyrazinamidum) even 6-9 months At conservation of a lumen of disintegration prescribe other antituberculous preparations and the agents suscitating reparative processes, apply a collapsotherapy.

At treatment sick of a disseminated pulmonary tuberculosis with presence of caverns to an operative measure resort was rarely as process extended, bilateral and consequently it is impossible to execute a resection within healthy tissues of a lung.