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

2. DISSEMINATED TUBERCULOSIS 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 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 Organ (% involved): Spleen86% Liver91 Lungs100 Bone marrow24 Kidneys62 Adrenals14 Eye— Thyroid19

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

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

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

12. 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.

13. Clinical picture 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.

14. Laboratory investigation Laboratory investigation. 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 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.

15. Disseminated lung tuberculosis (subacute)

16. Disseminated lung tuberculosis (subacute)

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

18. 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.

19. Chronic disseminated lung tuberculosis

20. X-ray examination 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.

21. 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 not more 1-2 segment.

31. 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.

32. fig. 1 Focal lung tuberculosis

33. fig.2 RFocal lung tuberculosis fig.2 Roentgenogram. Focal lung tuberculosis

34. 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..

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

36. 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.

37. fig. 5. Cloudlike infiltrate variants of infiltrate

38. fig. 6. fig. 6. Round shaped infiltrate

39. Fig. 7. Fig. 7. Lobitis.

40. 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.

41. Infiltrative tuberculosis

42. R. Infiltrative lung tuberculosis fig.3 Roentgenogram. Infiltrative lung tuberculosis С6 left lung with decay

43. R. fig.4 Roentgenogram. Cloudlike infiltrate of left lung.

44. Main signsInfiltrative tuberculosis PneumoniaInfarct of lungEosinophilic 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 tuberculosis Differential diagnosis at infiltrative tuberculosis (table)

45. R. fig.8 Roentgenogram. Pneumonia of inferior part of left lung.

46. R. fig.9 Roentgenogram. Eosinophilic pneumonia.

47. R. Central cancer of left lung. fig.10 Roentgenogram. Central cancer of left lung.

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

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

50. . fig. 12 Lobar caseous pneumonia.

51. X-ray X-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. lobular During lobular 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.

52. . fig.13 Caseous pneumonia of left lung. Bronchogenic dissemination of right lung.

53. Caseous pneumonia

54. Staphylococcal pneumonia

55. LUNG TUBERCULOMA Lung tuberculoma is a distinct by genesis encapsulated caseous formation exceeding 1 cm in diametre and having a chronic torpid course.

56. Homogenous tuberculoma

57. Layer-by-layer tuberculoma

58. Conglomerate tuberculoma

59. Tuberculoma of the cerebellum

60. Tuberculoma

61. 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.

62. Fibrous- cavernous lung tuberculosis

65. Stages of destructive process in lungs. Fresh elastic cavity fibrous cavity disintegration

66. elastic cavity

67. Fibrous-cavernous lung tuberculosis

68. fibrous-cavernous lung tuberculosis

69. Possible ways of cicatrization of cavities. 1. scar; 2. hearths; 3. blocked cavity; 4. pseudocysts.

72. chronic abscess

74. 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 %).

75. Cirrhotic lung tuberculosis

77. Cirrhotic tuberculosis

78. Pleurogenic cirrhosis of the left lung