Tuberculosis: symptoms, treatment of pulmonary tuberculosis
- Factors contributing to the development of pulmonary tuberculosis
- Classification of pulmonary tuberculosis
- Tuberculosis of the lung: 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 certain pathogen - bacteria of the genus Mycobacterium. Along with a person, such a disease can suffer and animals (cattle, chickens, rodents, etc.).
The most common cause of human disease can serve as the following varieties 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. Becomes the main cause of tuberculosis in cattle. Fifteen percent of all cases of tuberculosis in humans - this causative agent. 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 for a human agent, but quite common among rodents.
- Mycobacterium. tuberculosis africanus. A regional subspecies that is important only for African countries, where it becomes the cause in 90% of cases.
According to the World Health Organization, one third of the world's population is infected with tuberculosis. This means that the mycobacterium is already in the human body, but the disease is still "asleep". Every year, 8-9 million diseases become acute. The death rate from complications of tuberculosis reaches 3 million people a year.
Penetration of the pathogen into the body occurs airborne, contact-household (through the things that the patient used) and food (milk of a sick cow, eggs, etc.) ways. The microorganism is very stable in the environment: in a temperate and humid climate, it remains viable throughout the year.
A distinctive feature of mycobacterium tuberculosis is extremely variable virulence. This means that the microorganism reacts to the host's resistance state.
The variety of reactive reactions of a person to the mycobacterium of tuberculosis, predetermines numerous clinical and morphological manifestations of the disease.
Without expressing himself in the normal state of the immune system, the agent rapidly multiplies and manifests aggression at the slightest decrease in its level. From the moment of infection, to the first developed clinical manifestations, in some patients it can take up to ten years.
The main processes occurring in the affected organ on the tissue (histological) level after penetration of the causative agent there:
- Infiltration. Arrival at the place of detection of "foreign agent" of blood cells (macrophages, lymphocytes, neutrophils), responsible for its neutralization.
- Death of soft tissues surrounding a cluster of mycobacteria.
- Reproduction of mycobacteria and spreading them around or with the flow of lymph and blood to distant organs.
- Activation of the immune system to remove dead tissue and replace it with scarring (sclerosing). This may be the final process of the disease with the death of all mycobacteria, but it may also serve to limit the remaining 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 disrupted. Sometimes in one organ, one can observe simultaneously scarring and fresh foci of tissue necrosis.
The main and most common form of human injury is pulmonary tuberculosis. Particular importance of this form of the disease is that it is the main source of the spread of the disease, because of the contamination of the surrounding space by patients during conversation, coughing.
Along with this, it is necessary to remember that tuberculosis of the lungs is a particular manifestation of the defeat of the whole organism. And the variations in the combination of lung and other organs and systems may be different.
Practical significance in predicting the severity of changes in the lungs is the individual characteristics of the pathogen (aggressiveness, sensitivity to antibiotics), the volume of microbial mass in infection, the status of the immune status of the infected and others.
Factors contributing to the development of pulmonary tuberculosis
1. Weakening of the immune system of different nature:
- chronic stress and fatigue;
- malnutrition and malnutrition;
- reception of steroid hormones, cytostatics and immunomodulators due to the presence of severe concomitant pathology (systemic and oncological diseases, conditions after organ transplantation);
- HIV infection.
2. Low indicators of social and living conditions and the nature of life. In this risk zone, for example, are the institutions serving a sentence; cities with a high degree of population density; people, leading an antisocial way of life associated with vagrancy; migrants; drug addicts; patients with mental illnesses. To the same group of risk are medical workers.
3. Chronic alcoholism.
4. Chronic inflammatory diseases of the lungs and upper respiratory tract.
5. Diabetes mellitus.
Classification of pulmonary tuberculosis
Initially, the division into primary and secondary pulmonary tuberculosis is used.
The disease develops immediately after infection and has a fairly active course, due to the pronounced response of the immune system to the pathogen. The most characteristic lesions in the lungs are easily ventilated areas, such as III, VIII, IX and X segments of the right lung. The zone of defeat is immediately necrotic, taking a characteristic curdled appearance. The very zone of necrosis, an inflammatory shaft around it and tuberculous lymphangitis, which manifests itself radiologically in the form of cords from the hearth to the basal lymph nodes of the lung - was called the "primary tuberculosis affect". This characteristic X-ray symptom of primary pulmonary tuberculosis is always detected.
The outcome of primary lung damage is:
- The growth of necrotic and inflammatory processes involving new areas of the lungs, followed by lymphogenous or hematogenous spread of the process to other internal organs and systems.
- Complete recovery with scarring of primary affect. In the area of the scar, calcium salts can be deposited in various amounts, which, in severe cases, is determined radiographically - as an "autograph" of a previously transferred latent form of tuberculosis. They are also called the foci of the Gon.
- Chronic 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 tubercular pleurisy. Chronic primary tuberculosis is characterized by the defeat of only one lung.
Generalization and chronicization of primary tuberculosis is most common in adult patients.
For a child's age is characterized by recovery with scar formation in the vast majority of cases. The disease proceeds influenza-like or under the mask of a lung bronchitis.
Secondary pulmonary tuberculosis
The transferred disease does not give permanent and permanent immunity, like some other infectious diseases. After a while, under certain conditions and factors, about which we spoke above, nothing prevents a person from having an ear infection with tuberculosis. The source can be both viable mycobacterium tuberculosis left in the lung tissue in place of the primary focus, as well as new microorganisms from outside. This will be secondary pulmonary tuberculosis.
Spreading it through the lung is bronchogenic and lymphogenic.
The difference between the secondary process and the primary one is the absence of the primary affect described earlier.
The most practical application was found in the classification, which combined the changes at the histological level and revealed during X-ray examination. Virtually all of the described forms are characteristic of the secondary form of pulmonary tuberculosis.
Clinico-morphological classification of pulmonary tuberculosis.
- Acute miliary tuberculosis
- Hematogenic disseminated pulmonary tuberculosis
- Focal pulmonary tuberculosis
- Infiltrative-pneumonic pulmonary tuberculosis
- Tuberculoma of the lungs
- Caseous pneumonia
- Cavernous pulmonary tuberculosis
- Fibrous-cavernous pulmonary tuberculosis
- Tuberculous pleurisy
- Cirrhotic tuberculosis
- Other forms (tuberculosis in combination with occupational lung lesions, etc.).
Isolate the course of the disease of mild, moderate and severe severity.
In the presence of complications, depending on the possibility of their correction, allocate a compensated, subcompensated or decompensated process.
Tuberculosis of the lung: symptoms
The disease can last for a long time secretly, with general manifestations and complaints about:
- weakness, chronic fatigue;
- night sweats;
- causeless subfebrile (about 37 ° C) temperature;
- lack of appetite;
- weight loss;
- general pallor.
The disease at this stage can be identified only when performing fluorography or performing chest radiography for other indications.
The first sign, which makes one suspect that something is amiss, 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 zone. The nodes are not welded together and with the surrounding tissue, painless. At the same time, the total blood test remains without pronounced changes, characteristic for inflammation. On the contrary, anemia and a decrease in the number of leukocytes (leukocytopenia) are determined in the blood.
The clinical picture of pulmonary tuberculosis lesions is diverse and depends on the amount of tissue damage.
For all forms of pulmonary tuberculosis the following symptoms are characteristic:
. 1. Cough . From dry to wet, with a massive separation of phlegm. Sputum can be curdled, purulent. With the addition of blood - takes the form of a "rusty" to an impurity liquid, unchanged (hemoptysis).
(чувство нехватки воздуха). 2. Shortness of breath (feeling short of air). It is caused by a reduction in the respiratory surface of the lungs due to inflammation and sclerosing (scarring).
. 3. Measurement of sound during percussion (tapping) of the chest wall . Dullness of sound - over the fields of inflammation or formation of cicatricial changes, effusion in the pleural cavities, filling of caverns with liquid contents. The "boxed" sound is in the projection of the formed hollow caverns.
. 4. Appearance of wheezing during auscultation (listening) of the lungs . Characteristics and intensity of their diverse. Distinguish dry and wet rattles. Above the cavities you can hear a special, "amphoric" tinge of breathing. Above some fields, breathing can be significantly weakened.
. 5. Increase in temperature . The temperature can rise to 41 ° C with aggressive progressive forms. The fever takes on a character of continuous or with significant differences, decreasing for a short time to 35-36 ° C. Outside the exacerbation, with a moderate process, the temperature does not exceed 37-37.5 ° C and rises, usually by evening.
. 6. Weight loss . The patient can lose weight to 15 or more kilograms.
. 7. Pain in the chest . They join in the advanced stages of the disease and during the transition of the tubercular process to the pleura.
Primary pulmonary tuberculosis:
- Prevalence of general symptoms.
- Cough occurs when the disease progresses.
1. Multiple lesions in the lungs from two sides.
2. The disease can be acute, with severe symptoms of intoxication and severe severity. In addition, subacute and chronic forms are isolated.
3. It occurs in individuals with a significant decrease in the immune status.
4. In terms of size and type of foci:
- 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, tubercular inflammation is detected in the heart, the brain and its membranes, in large joints and bones, in the spleen, liver and kidneys.
6. Light forms of miliary tuberculosis can take place under the mask of catarrhal diseases. The only difference is that, unlike the latter, the poor state of health persists for a long time.
7. In severe forms, along with coughing, shortness of breath, separation of sputum and pain in the chest, the manifestation of defeat of other organs gradually comes to the fore: severe headache, dizziness and convulsions in CNS lesions; restriction of motion and pain in the joints in the defeat of the osteoarticular system, etc. To this is added a pronounced intoxication syndrome.
- X-ray is characterized by a group of foci of lesions of lung tissue in one light diameter from a few millimeters to a centimeter.
- Clinically it resembles bronchitis or pneumonia, but unlike them - the flow is protracted and blood appears in the sputum.
Infiltrative-pneumonic pulmonary tuberculosis:
- It is manifested by exacerbation of the inflammatory process around the hearth that existed by that time.
- Occurs with secondary tuberculosis.
Tuberculoma of the lung:
- X-ray picture has a similarity with signs of lung cancer - hence the name.
- The small infiltrates that have appeared remain for a long time and can not resist anti-inflammatory treatment for a long time, which suggests a tumor-like origin.
- Characterized by an aggressive course: the common areas of inflammation of the lung tissue within a short time merge, forming fields of caseous necrosis.
- Often the first manifestation is hemoptysis, after which the temperature rises sharply and other common pulmonary symptoms join.
- Necrotic sites later quickly melt, forming cavities - caverns.
- May occur in primary and secondary tuberculosis.
- Characterized by frequent complications in the form of pulmonary bleeding and spontaneous pneumothorax (with a breakthrough into the pleura).
Fibrous-cavernous pulmonary tuberculosis:
- The result of the development of destructive forms of pulmonary tuberculosis.
- Radiologically defined single or multiple cavities with a dense wall formed as a result of sclerotic processes. In addition to the capsule of the cavity, a part of the surrounding pulmonary tissue undergoes diffuse fibrosis, replacing the alveoli with dense scars, thereby significantly reducing the area of the respiratory surface.
- It is possible to determine the bronchogenic spread of infection in the presence of it in the affected area. In these cases, the appearance of new lesions of different diameters and developmental periods in peribronchial space is observed.
- Appears as a complication of other forms of tuberculosis in the form of the spread of the process to the serous membrane of the lungs.
- There is a contact (with the location of the focus in the immediate vicinity), hematogenous and lymphogenic pathways of infection.
- Tuberculous pleurisy can be dry (with deposition of fibrin and minimal liquid component) and exudative (with the presence of serous or purulent fluid).
Cirrhotic tuberculosis of the lungs.
- The result of massive destruction of the lungs in the absence of adequate treatment of destructive forms.
- As the cause of the additional risk of tubercular cirrhosis of the lung, other chronic inflammatory lung diseases are considered.
- Rare form for the reason that most patients do not live to see it.
- As a result of destruction, a significant area of the lung is replaced by a connective (scar tissue).
- However, with all this, in the lung tissue, the foci of the preserved tubercular inflammatory process are also revealed.
- It is accompanied by signs of severe respiratory and heart failure.
Complications of pulmonary tuberculosis
- Pulmonary hemorrhage. Its massive nature and technical difficulties in stopping it - often cause death.
- Spontaneous pneumothorax. Penetration into the pleural cavity of air in a significant amount in cavernous forms can lead to a displacement of the mediastinum and a reflex stop of the heart.
- Tuberculous pleurisy. Exudative forms, with a gradual accumulation of fluid in the pleural cavity, also lead to the progression of respiratory and subsequent cardiac failure.
- Genitalization of the process through hematogenous spread with the development of tuberculosis sepsis.
- Development of a chronic "pulmonary heart" by increasing pressure in a small circle of circulation with significant changes in the tissues of the lungs.
Диагностика туберкулёза лёгких
Поликлинический, диспансерный этап .
- Анамнез заболевания и жалобы.
- Физикальное исследование (перкуссия лёгких; аускультация; прощупывание региональных, доступных пальпации лимфоузлов).
It should be noted that in the early stages of the disease and with small lesions - the information value of physical methods is low.
- General analysis of blood and urine.
- Examination of excreted sputum under a microscope.
Coloring on the method of Tsilya-Nelsen allows you to see the pathogen in its presence. This study, in the presence of negative results, is carried out three times.
- Radiography of the chest.
For better information, use a straight and side projection.
- The Mantoux test.
In a planned manner, it is produced annually as a method of screening diagnostics for the prophylactic medical examination of children and adolescents. The adult population is appointed according to the testimony.
Evaluation of results 72 hours after intradermal injection in the forearm:
- negative reaction - in the presence of a point reaction at the site of the injection not more than 2 mm in diameter;
- Doubtful reaction - when a clearly defined circular spot is detected 2-4 mm in diameter or diffuse light reddening of the skin of any size;
- positive reaction - spot 5-17 mm in diameter in children and adolescents and 5-21 mm in adults;
- Hyperergic reaction - papule more than 17 mm in diameter in children and adolescents and more> 21 mm in adults.
Infected tuberculosis is:
- the newly discovered positive reaction (in other words: the turn of tuberculin sensitivity);
- persons with an increase in a dubious or positive sample by> 6 mm;
- persons with hyperergic reaction (in this case the probability of primary tuberculosis is high).
- Sowing sputum on nutrient media, with simultaneous research on the sensitivity to antibiotics.
- Sputum examination on PCR.
A quick enough way to determine the presence of mycobacteria by reacting to an antigen.
- Immunoenzymatic blood tests for the detection of anti-tuberculosis antibodies and antigens.
- Computer tomography of the lungs.
- Ultrasound examination for the presence of pleurisy and in the detection of subpleurally located formations.
These studies are required to refine the diagnosis by using a material intake for a cytological and histological study in order to differentiate the process with tumors and tumor-like processes, the existence of which can occur together with tuberculosis or in lieu of presumptive tuberculosis.
- Carrying out bronchoscopy with biopsy or flushing of the bronchi (lavage) with further study of the wash fluid (cytology, seeding on nutrient media).
- Puncture of the pleural cavity and pleural biopsy.
- Thoracoscopy (examination by the optical device of the contents of the pleural cavity) with a biopsy of the lung.
- Intraoperative open lung biopsy.
Treatment of pulmonary tuberculosis
The treatment is carried out in a hospital and implies the fight against the causative agent of the disease, minimization of sclerotic phenomena and prevention of complications.
Treatment includes therapeutic (conservative) and surgical methods.
Certain difficulties introduce new strains (varieties) of mycobacteria, which show no reaction to antibiotics. This requires constant correction in the dosage and combination of different groups of antibiotics. It is necessary to continuously conduct various control studies to assess the effectiveness of treatment. Treatment is long (up to a year). There are different modes of combining medicinal substances, taking into account age and sex data.
In addition, two phases of antibacterial treatment are distinguished:
- The initial (intensive) phase of treatment. The combination of antibiotics and doses is aimed at effectively suppressing the intensity of multiplication of mycobacteria with a rapid development cycle and preventing the development of drug resistance.
- The phase of ongoing treatment. Effects on intracellular and dormant forms of mycobacteria to prevent their reproduction. In this phase, other medicinal substances that stimulate regenerative processes are added.
The presence of severe forms of tuberculosis requires compliance with bed rest.
Food includes a special diet, saturated with proteins. The purpose of therapeutic nutrition - correction of metabolic disorders.
A special form of treatment of pulmonary tuberculosis, which is not applicable any more under any diseases, is collapsotherapy. The essence of the method is the evocation of an artificial pneumothorax with the purpose of squeezing a sick lung. As a result of this - the existing decay cavities collapse, improve reparative processes, reduce the risk of dissemination of the infection. Assigned to an intensive stage of pharmacotherapy in any regimen.
Indications for collapse:
- Destructive types of tuberculosis, with the presence of caverns without signs of sclerosis.
- Pulmonary bleeding (with reliable data on localization).
Artificial pneumothorax is used mainly in the intensive phase of all regimens of pharmacotherapy.
It also uses pneumoperitoneum (increased pressure in the abdominal cavity to lift the diaphragm and limit its mobility to immobilize the lungs).
Indications for pneumoperitoneum:
- Cavernous tuberculosis.
- Infiltrative tuberculosis with the presence of cavities of decay.
We shall most often use this method for lower-lying localization of processes.
Indications for surgical treatment of pulmonary tuberculosis:
- The presence of single caverns.
- Cirrhotic and cavernous changes within one (several) lobes or within one lung.
In the presence of tuberculous empyema of the pleura, caseous pneumonia, caseous-necrotic lesion of lymph nodes - the appointment to the surgical method of treatment is strictly individual.
Prognosis of pulmonary tuberculosis
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 refers to specific methods of prevention).
Produced with a weakened strain of Mycobacterium tuberculosis (BCG) in order to develop immunity. In case of infection, tuberculosis in vaccinated people develops, if not easy. On average, the acquired effect lasts about 5 years. Vaccination is included in the calendar of scheduled childhood vaccinations and is carried out in the first week after birth, then repeated at the age of 7 and 14 years. According to indications, 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, reflecting the presence of good post-vaccination immunity
The Mantoux reaction in vaccinated patients serves as an indicator of the continuing immunity to tuberculosis. Up to 7 years after vaccination, the Mantoux reaction may be positive.
Reception of antibiotics according to the scheme. May be primary (performed by uninfected mycobacteria, but in contact with the patient) and secondary (infected or ill with tuberculosis).
- presence of household, family and professional contacts with a patient who has an open form of tuberculosis;
- persons who have given a tuberculin turn and hyperergic reaction in the Mantoux test;
- presence pottububercular changes in the lungs when taking steroid hormones and other immunomodulators for other diseases.
Screening method of annual survey. It allows in addition to tuberculosis, to detect other nonspecific lung diseases and tumors of the chest.
4. Changes in social factors affecting the incidence of tuberculosis (housing conditions, prevention of occupational diseases, nutrition, fighting alcoholism, etc.).
- Pneumonia: symptoms, signs, treatment of pneumonia of the lungs
- Pulmonary edema: causes, symptoms, treatment
- Abscess of the lung
- Whooping cough: photos, symptoms, treatment of pertussis
- Bronchitis: symptoms, treatment
- Pleurisy: symptoms, treatment