Tuberculosis: symptoms, treatment of pulmonary tuberculosis
- Factors contributing to the development of pulmonary tuberculosis
- Classification of pulmonary tuberculosis
- Pulmonary tuberculosis: symptoms
- Complications of pulmonary tuberculosis
- Diagnosis of pulmonary tuberculosis
- Treatment of pulmonary tuberculosis
- Prognosis of pulmonary tuberculosis
- Prevention of pulmonary tuberculosis
Tuberculosis is an infectious disease (capable of being transmitted from a sick person to a healthy one) caused by a specific pathogen, bacteria of the genus Mycobacterium. Along with a man, animals (cattle, chickens, rodents, etc.) may suffer from this disease.
The most common cause of human disease can be the following types of bacteria:
- Mycobacterium. tuberculosis humanus. The most common subspecies. It is this microorganism that causes the disease in 85% of cases of tuberculosis.
- Mycobacterium. tuberculosis bovines. It becomes the main cause of tuberculosis in cattle. Fifteen percent of all cases of tuberculosis in humans are accounted for by this pathogen. It is worth noting that it was this bacterium that became the source for the synthesis of the BCG vaccine (BCG).
- Mycobacterium tuberculosis microti. Rare pathogen for humans, but quite common among rodents.
- Mycobacterium. tuberculosis africanus. Regional subspecies, relevant only for African countries, where it becomes a cause in 90% of cases.
According to the World Health Organization, a third of the population of our planet is infected with tuberculosis. This means that mycobacterium is already in the human body, but the disease is still “dozing”. Every year, 8-9 million, the disease becomes acute. Mortality from complications of tuberculosis reaches 3 million people a year.
The penetration of the pathogen into the body occurs through airborne, contact-household (through the things the patient used) and food (sick cow's milk, eggs, etc.). The microorganism is very stable in the environment: in a temperate and humid climate, it remains viable for a year.
A distinctive feature of mycobacterium tuberculosis is extremely variable virulence. This means that the microorganism responds to the state of resistance of the host organism.
A variety of human reactive reactions to Mycobacterium tuberculosis predetermines numerous clinical and morphological manifestations of the disease.
Without expressing itself in the normal state of the immune system, the pathogen multiplies rapidly and shows aggression at the slightest decrease in its level. From the moment of infection, to the first developed clinical manifestations, in some patients it may take up to ten years.
The main processes occurring in the affected organ at the tissue (histological) level after the penetration of the pathogen there:
- Infiltration. Arriving at the site of detection of "alien agent" of blood cells (macrophages, lymphocytes, neutrophils), responsible for its neutralization.
- Death of soft tissues surrounding the mycobacterial cluster.
- The reproduction of mycobacteria and their spread around or with the current of lymph and blood in distant organs.
- Activation of the immune system in order to remove dead tissue and replace them with scars (hardening). This can be as the final process of the disease with the death of all mycobacteria, but it can also serve to limit the surviving bacteria from healthy cells and the whole organism. In the second case, the vital activity of bacteria is preserved and at any time they can cause a new aggression.
The sequence of these processes in tuberculosis is constantly disturbed. Sometimes scarring and fresh foci of necrosis of the tissue can be observed simultaneously in one organ.
The main and most common form of human injury is pulmonary tuberculosis. The particular importance of this form of the disease is that it is the leading source of the spread of the disease, due to the contamination of the surrounding space by the patient when talking, coughing.
Along with this, it is necessary to remember that pulmonary tuberculosis is a particular manifestation of the defeat of the whole organism. And variations in the combination of damage to the lungs and other organs and systems may be different.
The practical features in predicting the severity of changes in the lungs are the individual characteristics of the pathogen (aggressiveness, sensitivity to antibiotics), the volume of the microbial mass during infection, the state of the infected person's immune status, and others.
Factors contributing to the development of pulmonary tuberculosis
1. Weakening of the immune system of various nature:
- chronic stress and fatigue;
- inadequate and inadequate nutrition;
- use of steroid hormones, cytostatics and immunomodulators due to the presence of severe comorbidities (systemic and oncological diseases, conditions after organ transplantation);
- HIV infection.
2. Low rates of social and living conditions of life and nature of life. Penitentiary institutions, for example, fall into this risk zone; cities with a high degree of population density; people leading an asocial lifestyle associated with vagrancy; migrants; drug addicts; patients with mental illness. This group of risk also includes medical workers.
3. Chronic alcoholism.
4. Chronic inflammatory diseases of the lungs and upper respiratory tract.
Classification of pulmonary tuberculosis
Initially, the division into primary and secondary pulmonary tuberculosis is used.
The disease develops immediately after infection and has a rather active course due to a pronounced reaction of the immune system to the pathogen. The most characteristic areas of lesions in the lungs are easily ventilated areas, such as the III, VIII, IX, and X segments of the right lung. The affected area is immediately necrotic, taking on a characteristic cheesy appearance. The zone of necrosis itself, the inflammatory shaft around it and the tuberculous lymphangitis, radiologically manifested as cords from the focus to the basal lymph nodes of the lung, has been called the “primary tuberculous affect”. This characteristic radiological symptom of primary pulmonary tuberculosis is always detected.
The outcome of the primary lung lesions are:
- The growth of necrotic and inflammatory processes involving new areas of the lung, followed by lymphogenous or hematogenous spread of the process to other internal organs and systems.
- Full recovery with primary affect scarring. Calcium salts in various amounts can be deposited in the scar area, which, in severe cases, is determined radiographically - as an “autograph” of a previously transmitted latent form of tuberculosis. They are also called Gon foci.
- Chronization of tuberculosis. This means the formation of a cavity next to the process, the periodic exacerbation of tuberculosis in the form of caseous pneumonia, the expansion of the zone of primary affect and the presence of constant intoxication. The process can spread to the pleura, causing tuberculous pleurisy. Chronic primary tuberculosis is characterized by damage to only one lung.
Generalization and chronicization of primary tuberculosis is most common in adult patients.
For children, recovery is characteristic with scar formation in the overwhelming majority of cases. The disease is flu-like or under the guise of light bronchitis.
Secondary pulmonary tuberculosis
The transferred disease does not give a stable and permanent immunity, like some other infectious diseases. After some time, under certain conditions and factors, which we talked about above, nothing prevents a person from re-becoming ill with tuberculosis. The source can be either viable Mycobacterium tuberculosis remaining in the lung tissue at the site of the primary focus, or new microorganisms from outside. This will be secondary pulmonary tuberculosis.
It is spread through the lungs bronchogenic and lymphogenous.
The difference between the secondary process and the primary process is the absence of the primary affect described earlier.
The greatest practical application was found by the classification, combining changes at the histological level and emerging during X-ray examination. Almost all of the forms described are characteristic of the secondary form of pulmonary tuberculosis.
Clinical and morphological classification of pulmonary tuberculosis.
- Acute Miliary Tuberculosis
- Hematogenous disseminated pulmonary tuberculosis
- Focal pulmonary tuberculosis
- Infiltrative pneumonic pulmonary tuberculosis
- Pulmonary tuberculoma
- Caseous pneumonia
- Cavernous pulmonary tuberculosis
- Fibrous-cavernous pulmonary tuberculosis
- Tuberculous pleurisy
- Cirrhotic tuberculosis
- Other forms (tuberculosis in combination with occupational lesions of the lungs, etc.).
Distinguish the course of the disease of light, moderate and severe severity.
In the presence of complications, depending on the possibility of their correction, allocate a compensated, subcompensated or decompensated process.
Pulmonary tuberculosis: symptoms
The disease for a long time can proceed covertly, with common manifestations and complaints about:
- weakness, chronic fatigue;
- night sweats;
- unreasonable low-grade (about 37 ° C) temperature;
- lack of appetite;
- weight loss;
- general pallor.
The disease at this stage can be detected only when performing x-rays or performing an x-ray examination of the chest organs for other indications.
The first sign that makes one suspect that something was wrong is an increase in the size of the lymph nodes of the axillary, supraclavicular, or cervical groups. It is worth emphasizing that the enlargement of the lymph nodes is often limited to only one area. Nodes are not soldered to each other and with the surrounding tissue, painless. At the same time, the complete blood count remains without marked changes characteristic of inflammation. On the contrary, anemia and a decrease in the number of leukocytes (leukocytopenia) are determined in the blood.
The clinical picture of lung tuberculosis is varied and depends on the extent of tissue damage.
The following symptoms are characteristic of all forms of pulmonary tuberculosis:
. 1. Cough . Dry to wet, with massive sputum. Phlegm may be a cheesy, festering look. When joining blood - takes the form of "rusty" to the impurity of the liquid, not changed (hemoptysis).
(чувство нехватки воздуха). 2. Shortness of breath (feeling short of breath). It is caused by a decrease in the respiratory surface of the lungs during inflammation and hardening (scarring).
. 3. Measurement of sound during percussion (tapping) of the chest wall . Sound dullness - over the fields of inflammation or the formation of cicatricial changes, effusion in the pleural cavities, filling of cavities with liquid contents. The “boxed” sound is in the projection of the formed hollow cavities.
. 4. The appearance of wheezing during auscultation (listening) of the lungs . Characteristic and intensity of their varied. There are dry and wet rales. Above the cavities you can hear a special, “amphoraic” shade of breathing. Over some fields, breathing can be significantly weakened.
. 5. Temperature increase . Temperatures can rise to 41 ° C with aggressive progressive forms. Fever takes on the character of continuous or with significant differences, decreasing briefly to 35-36 ° C. Outside the exacerbation, with a moderate process, the temperature does not exceed 37–37.5 ° C and rises, as a rule, in the evening.
. 6. Weight loss . The patient can lose weight up to 15 kilograms or more.
. 7. Chest pain . Joined in advanced stages of the disease and the transition of the tuberculous process on the pleura.
Primary pulmonary tuberculosis:
- The predominance of common symptoms.
- Cough occurs when the disease progresses.
1. The multiplicity of lesions in the lungs on both sides.
2. The disease can be acute, with severe symptoms of intoxication and severe severity. In addition, subacute and chronic forms are distinguished.
3. Occurs in individuals with a significant decrease in immune status.
4. In terms of the size and appearance of the lesions, they distinguish
- miliary (up to the size of a pinhead);
- large focal (more than 1 cm in diameter);
- cavernous (with cavities).
5. In addition to pulmonary manifestations, tuberculous inflammation is detected in the heart, brain and its membranes, in large joints and bones, in the spleen, liver and kidneys.
6. Mild forms of miliary tuberculosis can occur under the guise of colds. The only difference is that, unlike the latter, poor health persists for a long time.
7. In severe forms, along with coughing, shortness of breath, sputum and chest pain, manifestations of other organs are gradually coming to the fore: severe headache, dizziness and convulsions with damage to the central nervous system; restriction of movement and pain in the joints with the defeat of the osteo-articular system, etc. To this is added another pronounced intoxication syndrome.
- Radiographically characterized by a group of lesions of the lung tissue in one lung with a diameter of several millimeters to a centimeter.
- It is clinically reminiscent of bronchitis or pneumonia, but unlike them, the course is prolonged and blood appears in the sputum.
Infiltrative pneumonic pulmonary tuberculosis:
- Manifested by an exacerbation of the inflammatory process around the nidus existing by that time.
- Occurs in secondary tuberculosis.
- The X-ray picture is similar to the signs of lung cancer, hence the name.
- The small infiltrates that have appeared persist for quite a long time and do not respond to anti-inflammatory treatment for a long time, which suggests a tumor-like origin.
- It is characterized by an aggressive course: common areas of inflammation of the lung tissue in a short time merge together, forming fields of caseous necrosis.
- Often the first manifestation is hemoptysis, after which the temperature rises sharply and other common pulmonary symptoms join.
- The necrotic sites then quickly melt, forming cavities — caverns.
- May occur in primary and secondary tuberculosis.
- It is characterized by frequent complications in the form of pulmonary hemorrhages and spontaneous pneumothorax (with a breakthrough into the pleura).
Fibrous-cavernous pulmonary tuberculosis:
- The result of the development of destructive forms of pulmonary tuberculosis.
- Single or multiple cavities with a dense wall formed as a result of sclerotic processes are determined radiographically. In addition to the cavity capsule, a part of the surrounding lung tissue is exposed to diffuse fibrosis, replacing the alveoli with dense scars, thereby significantly reducing the area of the respiratory surface.
- You can determine the bronchogenic spread of infection in the presence of it in the affected area. In these cases, the emergence of new lesions of various diameters and development time in the peribronchial space is observed.
- Appears as a complication of other forms of tuberculosis in the form of the spread of the process on the serous membrane of the lungs.
- Occurs contact (at the location of the hearth in close proximity), hematogenous and lymphogenous ways of infection.
- Tuberculous pleurisy can be dry (with fibrin deposition and minimal liquid component) and exudative (with the presence of serous or purulent fluid).
Cirrhosis of pulmonary tuberculosis.
- The result of massive destruction of the lungs in the absence of adequate treatment of destructive forms.
- As a cause of additional risk of tuberculous cirrhosis of the lung, the presence of other chronic inflammatory diseases of the lung is considered.
- A rare form for the reason that most patients do not live to see it.
- As a result of destruction, a significant area of the lungs is replaced by connective (scar tissue).
- However, with all this, foci of intact tuberculous inflammatory process are detected in the lung tissue.
- Accompanied by signs of severe respiratory and heart failure.
Complications of pulmonary tuberculosis
- Pulmonary bleeding. Its massiveness and technical difficulties in stopping it are often the cause of death.
- Spontaneous pneumothorax. Penetration into the pleural cavity of air in a significant amount with cavernous forms can lead to a displacement of the mediastinum and reflex cardiac arrest.
- Tuberculous pleurisy. Exudative forms, with a gradual accumulation of fluid in the pleural cavity, also lead to the progression of respiratory and subsequent heart failure.
- Generalization of the process by hematogenous spread with the development of tuberculous sepsis.
- Развитие хронического «легочного сердца» путём повышения давления в малом круге кровообращения при значительных изменениях в тканях лёгких.
Диагностика туберкулёза лёгких
Поликлинический, диспансерный этап .
- Анамнез заболевания и жалобы.
- Физикальное исследование (перкуссия лёгких; аускультация; прощупывание региональных, доступных пальпации лимфоузлов).
Надо отметить, что в ранних стадиях заболевания и при малых очагах поражения – информационная ценность физикальных методов невелика.
- Общий анализ крови и мочи.
- Исследование выделяемой мокроты под микроскопом.
Окраска по методу Циля—Нельсена позволяет увидеть возбудителя при его наличии. Это исследование, при наличии отрицательных результатов, проводят трёхкратно.
- Рентгенография органов грудной клетки.
Для лучшей информативности, используют прямую и боковую проекцию.
- Проба Манту.
В плановом порядке производится ежегодно как метод скрининговой диагностики при диспансеризации детского и подросткового возраста. Взрослому населению назначается по показаниям.
Оценка результатов через 72 часа после внутрикожного введения в предплечье:
- отрицательная реакция — при наличии точечной реакции в месте укола не более 2 мм в диаметре;
- doubtful reaction - when detecting a clearly limited round spot 2-4 mm in diameter or diffuse light redness of the skin of any size;
- a positive reaction is a spot 5-17 mm in diameter in children and adolescents and 5-21 mm in adults;
- hyperergic reaction - papule is more than 17 mm in diameter in children and adolescents and more than 21 mm in adults.
Infected with tuberculosis are:
- the first positive reaction detected (otherwise: the turn of tuberculin sensitivity);
- individuals with a doubtful or positive increase of> 6 mm;
- persons with hyperergic reaction (in this case, the probability of the disease is primary tuberculosis).
- Cultivation of sputum on nutrient media, with simultaneous research on sensitivity to antibiotics.
- Sputum examination for PCR.
A fairly quick way to determine the presence of mycobacteria by reacting to an antigen.
- ELISA blood tests for the detection of anti-tuberculosis antibodies and antigens.
- Computed tomography of the lungs.
- Ultrasound examination for the presence of pleurisy and the detection of subpleural formations.
These studies are required to clarify the diagnosis by taking material for cytological and histological examination in order to differentiate the process with tumors and tumor-like processes, the existence of which can occur together with tuberculosis or instead of suspected tuberculosis.
- Bronchoscopy with biopsy or bronchial lavage (lavage) with further examination of the washing liquid (cytology, culture on nutrient media).
- Puncture of the pleural cavity and pleural biopsy.
- Thoracoscopy (optical examination of the contents of the pleural cavity) with lung biopsy.
- Intraoperative open lung biopsy.
Treatment of pulmonary tuberculosis
The treatment is carried out in a hospital and involves the fight against the causative agent of the disease, the minimization of sclerotic phenomena and the prevention of complications.
Treatment includes therapeutic (conservative) and surgical methods.
Certain difficulties are introduced by the emergence of new strains (varieties) of mycobacteria that do not show any reaction to antibiotics. This requires constant correction in the dosage and combination of different groups of antibiotics. It is necessary to constantly conduct various control studies to assess the effectiveness of treatment. Treatment is long (up to a year). There are various modes of combination of medicinal substances, taking into account age and sex data.
In addition, there are two phases of antibacterial treatment:
- The initial (intensive) phase of treatment. The combination of antibiotics and doses are aimed at effectively suppressing the reproduction rate of mycobacteria with a rapid development cycle and preventing the development of drug resistance.
- Phase of ongoing treatment. Impact on intracellular and dormant forms of mycobacteria to prevent their reproduction. In this phase, other medicinal substances are added that stimulate the regeneration processes.
The presence of severe tuberculosis requires compliance with bed rest of the patient.
Nutrition includes a special protein-rich diet. The purpose of therapeutic nutrition - correction of metabolic disorders.
A special form of treatment for pulmonary tuberculosis, which is not used for any other diseases, is collapsotherapy. The essence of the method is the induction of artificial pneumothorax in order to compress the diseased lung. As a result, the existing decay cavities fall down, reparative processes are improved, the risk of dissemination of the infection is reduced. Appointed in the intensive stage of pharmacotherapy in any regimens.
Indications for collapse therapy:
- Destructive types of tuberculosis, with the presence of cavities without signs of hardening.
- Pulmonary hemorrhage (with reliable localization data).
Artificial pneumothorax is used mainly in the intensive phase of all modes of pharmacotherapy.
Pneumoperitoneum is also used (an increase in pressure in the abdominal cavity to raise the diaphragm and limit its mobility in order to immobilize the lungs).
Indications for pneumoperitoneum:
- Cavernous tuberculosis.
- Infiltrative tuberculosis with the presence of decay cavities.
This method will be most used in the case of lower lobe localizations of processes.
Indications for the surgical treatment of pulmonary tuberculosis:
- The presence of single cavities.
- Cirrhotic and cavernous changes within one (several) lobes or within one lung.
In the presence of tuberculous empyema, caseous pneumonia, caseous necrotic lesions of the lymph nodes - the appointment to the surgical method of treatment is strictly individual.
Prognosis of pulmonary tuberculosis
The lack of treatment of the active process leads to death in 50% of cases of pulmonary tuberculosis within two years.
Prevention of pulmonary tuberculosis
1. Vaccination (it belongs to the specific methods of prevention).
Produced using a weakened strain of Mycobacterium tuberculosis (BCG) in order to produce immunity. In the case of infection, tuberculosis in the vaccinated, if it develops, then to an easy degree. On average, the acquired effect lasts for about 5 years. Vaccination is included in the calendar of planned childhood vaccinations and is carried out in the first week after birth, then repeats at the age of 7 and 14 years. According to the testimony, BCG vaccination every five years can last up to 30 years of age.
After BCG vaccination for the next 5-7 years, the normal Mantoux reaction may be positive, which reflects the presence of good post-vaccination immunity.
The Mantoux reaction in vaccinated individuals is an indicator of persistent immunity to tuberculosis. Up to 7 years after vaccination, the Mantoux reaction can be positive.
Acceptance of antibiotics according to the scheme. It may be primary (carried out by an uninfected mycobacterium, but in contact with the patient) and secondary (infected or ill with tuberculosis).
- the presence of household, family and professional contacts with a patient with an open form of tuberculosis;
- persons who gave tuberculin bend and hyperergic reaction during the Mantoux test;
- the presence of pottuberculosis changes in the lungs when taking steroid hormones and other immunomodulators for other diseases.
Screening method of the annual survey. Besides tuberculosis, it allows detecting other nonspecific lung diseases and tumors of the chest organs.
4. Changes in social factors affecting the incidence of tuberculosis (living conditions, prevention of occupational diseases, good nutrition, the fight against alcoholism, etc.).
- Pneumonia: symptoms, signs, treatment of pneumonia of the lungs
- Pulmonary edema: causes, symptoms, treatment
- Lung abscess
- Whooping cough: photo, symptoms, pertussis treatment
- Bronchitis: symptoms, treatment
- Pleurisy: symptoms, treatment