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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

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

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

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

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

  10. 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.

  11. 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.

  12. 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.

  13. Disseminated lung tuberculosis (subacute)

  14. Disseminated lung tuberculosis (subacute)

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

  16. 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.

  17. Chronic disseminated lung tuberculosis

  18. 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.

  19. Chronic disseminated lung tuberculosis

  20. 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.

  21. Bilateral nidus pneumonia

  22. Sarcoidosis of the lungs and intrathorasic limph. nodes

  23. Sarcoidosis of the lungs and intrathorasic limph. nodes

  24. Carcinomatosis

  25. Lung stagnation phenomena

  26. Lung stagnation phenomena. Left-side transsudate

  27. 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 1-2segment.

  28. 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.

  29. fig. 1 Focal lung tuberculosis

  30. fig.2 Roentgenogram. Focal lung tuberculosis

  31. 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. .

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

  33. 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.

  34. variants of infiltrate fig. 5. Cloudlike infiltrate

  35. fig. 6.Round shaped infiltrate

  36. Fig. 7.Lobitis.

  37. 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.

  38. Infiltrative tuberculosis

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

  40. fig.4 Roentgenogram. Cloudlike infiltrate of left lung.

  41. Differential diagnosis at infiltrative tuberculosis(table)

  42. fig.8 Roentgenogram. Pneumonia of inferior part of left lung.

  43. fig.9 Roentgenogram. Eosinophilic pneumonia.

  44. fig.10 Roentgenogram. Central cancer of left lung.

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

  46. Caseous pneumonia Caseous pneumonia is a clinical form of tuberculosos with massive caseous changes in lungs and severe, progressive clinical course.

  47. fig. 12 Lobar caseous pneumonia.

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