History.............. 3 62
364 E pi demio l about and I.......... 36 5
Pathological anatomy.... 366
Pathogeny............. 3 67
Some features of displays
of tuberculosis........... 3 70
Philosophy of diagnosis 3 74 Philosophy of treatment.... 377
Rehabilitation and examination of working capacity........... 382
Tuberculosis (tuberculosis; lat. tuberculum a hillock - f - osis) — the chronic infectious disease caused by mycobacteria of tuberculosis.
Depending on localization of defeat allocate tuberculosis of a respiratory organs (see), a tuberculosis cutis, peripheral limf, nodes, bones and joints, urinogenital system, abdominal tuberculosis, etc. (see Tuberculosis extra pulmonary).
The HISTORY Tuberculosis it is known from an extreme antiquity. Tubercular damages of a backbone are found at a research of remains of the person of the period of the Neolithic (apprx. 5000 years BC), the Egyptian mummies (apprx. 2700 BC), mummies of the young priest in Thebes (apprx. 1000 BC). On walls of the Egyptian tombs (2160 — 1335 BC) figures of people with the changes characteristic of T are represented. a backbone and a hip joint *
drew the Greatest attention of doctors of the past with T. lungs, to-ry, apparently, it was eurysynusic, napr, in Ancient India and China. Classical wedge, picture T. lungs described in 2 century Aretaios from Cappadocia. However T. a respiratory organs was not allocated from among other diseases of lungs. About it, in particular, it is possible to judge by four ftiza forms described by Hippocrates. K. Galen carried T. lungs, as well as other pulmonary diseases, except lobar pneumonia, to «ulcerations» of lungs. T. did not consider an infectious disease. E.g., Ibn-Xing in «A canon of medical science» carried it to diseases, descendible. However he recognized influence on the course of a disease of the environment and recommended, in particular, healthy nutrition. For the first time the question of an external cause of illness and its transmissibility clearly delivered to J. Frakastoro.
T. it was eurysynusic in Russia. In chronicles and hand-written doctor books there are instructions on T. limf, nodes and its treatment. Tuberculosis is mentioned in chronicles of 16 century as a serious incurable disease — «an evil sukhota»; in historical documents of the second half of 17 century it is told about «a disease of sou of volition» and «griefs chakhotny». In 18 century messages on a pulmonary tuberculosis are especially frequent. Then were known «a stamp disease», «cannot in the swivel» (hip joint), «hair stone» (fistular forms T. bones and joints).
Silvius [F. Silvius (de 1e of Voyo)] for the first time noted communication of pulmonary hillocks (tubercular granulomas) with a pulmonary tuberculosis, including the last identical to a scrofula. In 1689 Moreton (R. Morton) described 14 forms of a pulmonary consumption and allocated
3 stages of process (an inflammation, tuberculation, an ulceration). Bailey (M. of Baillie) distinguished conglomerates of tubercular hillocks from caseous pneumonia. G. L. Bayle allocated a miliary hillock, carrying it to tumors, and distinguished 6 ftiza forms. R. Laennek created the unitary theory of T., including grumous and granulematozny processes by various phases of one disease. He was inclined to carry tubercular hillocks to malignant new growths and considered T. incurable it is endogenous caused, but a noncontagious disease. R. Virkhov put forward the trialistichesky theory, distinguishing tuberculosis, a ftiza and a scrofula; it did not connect a caseous necrosis with tubercular process.
An important role in development of the doctrine about T. played opening in 1882 by Koch of the activator T. (Koch's bacilli). However R. Koch did not attach due significance to social factors in development of a disease of T. Russian clinical physicians, pathologists and microbiologists (S. P. Botkin, A. A. Ostroumov, I. I. Mechnikov, V. K. of high-HIV, etc.) at once recognized value of opening of R. Koch, and in too time emphasized value of conditions of the environment, including social living conditions, in an etiology of T. High incidence of T. workers, the profession to-rykh is connected with inhalation of dust and «bad» air, G. I. Sokolsky (1837) noted, V. A. Manassein considered that importance in development of T. has a condition of an organism. According to
A. A. Ostroumov, the forecast at T depends on a condition of an organism of the patient and his food.
At the end of 19 century tuberculosis was eurysynusic among the poorest segments of the population. Extremely unfavorable conditions of work and life of industrial workers, density of the population in the cities, especially where the industry developed, created premises for infection with tuberculosis of the big contingents of the population. Value of unsatisfactory living conditions and work in distribution of T. preferential among working class and poor segments of the population found reflection in works of classics of Marxism-Leninism.
In 1891 at the Russian society of protection of national health (see) the commission on studying of measures of fight against T was organized. Because identification and accounting of sick T. pre-revolutionary Russia was absent, selective examination of various groups of the population, W was conducted. h in rural areas by forces of territorial doctors. Only in 1910 the All-Russian league of fight against tuberculosis was created, edges existed on means from donations. She managed to organize only 67 out-patient clinics for treatment of TB patients. From the beginning of World War I in 1914 activity of league stopped.
Creation of the state system of the organization of fight against T. became possible only after Great October socialist revolution. Already on December 2, 1917 the joint appeal of medical boards of national commissariats «About fight against incidence, mortality and insanitary living conditions of broad masses of the population» was published, in Krom as a priority the state organization of fight against T moved forward. The decree of Council of People's Commissars of January 24, 1918 signed by V. I. Lenin founded Council of medical boards, the tubercular commission to-rogo
3 directed. P. Solovyov. «It is impossible to separate a question of fight against tuberculosis — wrote 3. P. Solovyov — from a question of the government of the proletariat. Both of these questions are inseparably soldered... Only the state of workers — a fruit of dictatorship of the proletariat — has an opportunity to approach closely fight against tuberculosis». In 1918 in Narkomzdrava of RSFSR the section on fight against tuberculosis was founded. The organization, systematic development and centralization of social actions for fight against T was assigned to it., development and preparation of legislative rules and resolutions, the organization of antitubercular work on places, etc. In a basis of the organization of fight against T. the principles, general for the Soviet health care, were put: a preventive orientation, the state character, free of charge and general availability of medical aid (see Health care).
Since 1918 in Moscow, and then and in other cities the first antitubercular clinics, country boarding schools, hospitals, sanatoria, night dispensaries were organized. In 1918 the first was created Research by in-t of tuberculosis (nowadays Moscow scientific research institute of tuberculosis M3 of RSFSR), and in 1921 the Central scientific research institute of tuberculosis is open. The first events of the young Soviet power for the organization of ftiziatrichesky service were held in the heaviest conditions of civil war and the beginning of recovery of the national economy. After liberation of the Crimea from White Guard hordes and foreign interventionists
V. I. Lenin signed on December 21, 1920 the decree of SNK «About Use of the Crimea for Treatment of Workers». And July, 1921 signed by V. I. Lenin the resolution SNK «About Release and Transfer to Conducting Resort Managements of the Rooms and Buildings Suitable for the Structure of Sanatoria in Resort Areas» was issued. These documents were important for expansion of network of antitubercular sanatoria.
The essential role the organizations of fight against tuberculosis was played by creation of new type of an antitubercular clinic, to-ry differed from clinics in the capitalist countries in the fact that carried out not only registration of patients and sanitary scheduled maintenance, but also held diagnostic, medical events, selection and the direction of patients in sanatoria, examination of working capacity, employment of patients, etc.
With formation of the USSR ample opportunities for development of the ftiziatrichesky help in federal republics» During this period opened various methods of treatment — a collapsotherapy, the gigiyenodiyetichesky mode, sanatorium treatment, and also antitubercular vaccination were developed and implemented in practice. In 1934 according to the solution of Nar-komzdrava of RSFSR, after careful studying of the vaccine created And. Kaljmet-tom and Geren (the vaytsination it newborns became S. of Guerin), in the USSR obligatory. By 1940 in the USSR 554 antitubercular clinics and 18 scientific research institutes of tuberculosis functioned.
In days of the Great Patriotic War the Soviet government took the special measures directed to fight against tuberculosis. According to resolutions of Council of People's Commissars of the USSR of January 5, 1943 and Council of People's Commissars of RSFSR of January 31, 1943 additional food is entered and working conditions of TB patients are facilitated, the wide network of recreational child care facilities is created, in east districts the network of TB facilities extended.
In the first post-war fifth anniversary the network of TB facilities in the freed territory was recovered. During the period from 1945 to 1950 the number of beds for TB patients increased in hospitals from 40,6 to 85,5 thousand, in sanatoria from 58 to 124,4 thousand; the number of tuberculotherapists increased for the same period almost by 3 times and reached 9402. Considerably also hardware of TB facilities improved. Creation of the domestic photofluorograph allowed to inspect the population widely. Mass fluorographic inspections in days of the second and third post-war five-years periods (1951 — 1960) annually captured 40 — 50 million people that played a big role in early tuberculosis detection. Creation by the Soviet scientists of dry vaccine BTsZh with a long term of the validity promoted performing mass vaccination and a revaccination. Thanks to development and deployment in a wedge, practice of highly effective antituberculous remedies (see), chemoprophylaxis (see below), to improvement of methods of surgical treatment of T., to implementation of new organizational forms and methods of complex treatment of T. there was real a task a wedge., treatment of TB patients and elimination of T. as widespread disease.
According to the resolution of the Central Committee of the CPSU and Council of ministers of the USSR «About measures for further improvement of medical care and public health care of the USSR» (1960) the program of the actions directed to decrease in incidence of tuberculosis was developed. It included further improvement of diagnostic methods and treatment, significant increase in number of beds in-tsakh and sanatoria, creation of special network of institutions of sanatorium type for children with early displays of a tuberculosis infection, the organization of schools in all tubercular children's sanatoria. Also measures for further expansion and strengthening of network of TB facilities, including creation in rural areas of regional antitubercular clinics and dispensary departments in regional-tsakh were taken. By the end of 1961 the number of antitubercular clinics made 1448. Methods of continuous preventive inspections of the population by the territorial and territorial and production principle were developed and implemented in practice, the uniform intradermal method of vaccination of BTsZh is implemented (see), domestic standard tuberculine is developed (see). Questions of health protection of workers found bright expression in the resolution of the Central Committee of the CPSU and Council of ministers of the USSR «About measures for further improvement of health care and development of medical science in the country» (1968) and accepted by the Supreme Council of the USSR in 1969. «Bases of the legislation of USSR and federal republics about health care» (see the Legislation on health care).
In the ninth and tenth five-years periods (1971 —-1980) integration of TB facilities, a profiling and specialization of their bed fund is begun. In federal republics are constructed tubercular-tsy on 400 — 500 beds (see. Tubercular hospital). Expansion of an arsenal of antituberculous remedies promoted increase in efficiency of treatment of sick T., to broader out-patient use of chemotherapy. Progress of thoracic surgery (see) allowed to use more actively at T. methods of operational treatment. Need of improvement of organizational forms of fight against T. led to creation in 1973 in a number of federal republics of experimental bases for scientific justification of the operating and developed new forms and methods of fluorographic inspection of the population, the centralized control of diagnosis and treatment, centralization bacterial. services. In a number of the republics organizational forms of work according to local features, napr, a teamwork of inspection of the population, the comprehensive examination working at milk and commodity farms, etc. are developed and implemented. Highly effective was a centralized control of correctness of diagnosis at for the first time the revealed sick T., and also the periodic review of the contingents of the patients staying on the registry in TB facilities, which is carried out by regional antitubercular clinics. Considerably quality of inspection of sick T improved. Owing to improvement of specific diagnostic methods, centralization of antitubercular service and the organization of specialized departments service of patients out of-letochnymi forms T improved.
Reduction of number of sick T. and wide experience of work of antitubercular service allowed to expand sharply the volume of work on differential diagnosis of T. and other pulmonary diseases, differential and diagnostic departments in large tubercular would be organized; in the cities and areas with low indicators of incidence of T. the antitubercular service expanded the volume of the help to patients with nonspecific diseases of lungs. It demanded expansion of scientific research and professional development of doctors-ftiziatrok in the field of pulmonology.
Further decrease in incidence of T remains the main direction of antitubercular work in a crust, time. In the field of therapy of T. the main objective — a wedge, treatment of the diseased all for the first time, their medical, social and professional rehabilitation and increase in efficiency of treatment of patients hron moved forward. forms T.
Accrescence of economy of our country, improvement of working conditions and life, broad housing construction, radical improvement of material well-being and the cultural standard of living of the population, progress of medicine, and in particular phthisiology (see), holding broad recreational and special antitubercular events allowed to achieve considerable decrease in incidence, morbidity and mortality from T, «The main directions of economic and social development of the USSR Accepted by the XXVI congress of the CPSU for 1981 — 1985 years and for the period till 1990», decisions of the subsequent plenums of the Central Committee of the CPSU, the resolution of the Central Committee of the CPSU and Council of ministers of the USSR «About measures for further improvement housing, household and welfare living conditions of country people» (1982) and «About additional measures for improvement of public health care» (1982) create favorable conditions for further upgrading of prevention and treatment of TB patients.
In the USSR the accounting of all contingents of sick T. p the persons which are under dispensary observation it is conducted
in antitubercular clinics. In special registration forms data on the state of health and change of the diagnosis, group of the dispensary account, results of treatment, etc. are reflected. The analysis of these data allows to receive indicators as loudspeakers of incidence of T. among the population, and efficiency of the held antitubercular events. At the same time the persons which caught T. and the T which transferred primary., come to the end with recovery, call infected (skin tuberkulinovy test is positive). Chislo the infected persons, expressed as a percentage in relation to population of this or that territory, is an indicator инфицированное™. Number of sick T. within calendar year (on 10 or 100 you page of the population), revealed at the request for medical aid or during the carrying out mass preventive researches, call an indicator of incidence of T. Chislo of sick T., for the first time registered in the expired year and for the previous years (on 10 or 100 thousand population) which are under dispensary observation call an indicator of morbidity. Number of the dead from T. patients for each expired year (on 10 or 100 thousand population) are called by rate of mortality (see Mortality).
The quantitative characteristic of a tank of an infection is based on indicators of incidence (see Incidence) and the morbidities received by registration for the first time of the revealed sick T. (incidence) and all sick T which are available in this area., known to bodies of health care (morbidity). In size of these indicators it is possible to judge quality of diagnosis and prevention of T.
Despite progress in fight against T., it keeps the relevance as the international problem of health care. By approximate calculations, from among sick T. 2/3 inhabitants of Asia, Africa and Latin America make; the vast majority dying of this disease also is the share of these regions of the globe. In total annually on our planet 3 — 4 million people die of tuberculosis. By the made calculations of 4 — 5 million people in the world annually get sick with epidemiologically dangerous forms T. lungs, 4 — 5 million more again sick are made by patients with various forms T., in particular extra pulmonary, not followed by allocation of mycobacteria. In 1977 the number of bakteriovydelitel on 100 thousand population in Africa made 165, in Asia — 110, in Latin America — 80. Prick it -
the chestvo of sources of a vozouditelea of an infection constitutes danger and to residents of economically developed countries, especially in the conditions of a high level of population shift.
In the majority of the countries of Europe the high level of contamination of the population, especially advanced ages remains that maintains rather high incidence due to endogenous reactivation of residual changes of tubercular character. The concept stated in the late fifties by a number of the Western European epidemiologists about a possibility of elimination of T. as mass disease did not justify itself. Elimination of T. it was not succeeded to achieve in one country yet. In the countries of Asia, Africa and Latin America of reduction of prevalence of T. it is not noted. In the USA and countries of Western Europe in the conditions of reduction in general prevalence of T. high incidence among the poorest segments of the population, including the Black population and foreign workers takes place. Periodically T. it is observed at the persons which are in close contact with each other (in educational institutions, on vessels among crew members, etc.).
Causative agents of tuberculosis — Mycobacterium tuberculosis (a human look), Mycobacterium afri-canum (an intermediate look) and Mycobacterium bovis (a bull look) treat the sort Mycobacterium, the Mycobacteriaceae family, an order of Actinomycetales (see Mycobacteria). Mycobacteria of tuberculosis of a human look most often (in 92% of cases) are activators T. at the person, mycobacteria of tuberculosis of a bull look and an intermediate look cause development of T. at the person respectively in 5 and 3% of cases. In a modern mikrobiol. classifications of a mycobacterium of a bird's look (avium) carry to not tubercular mycobacteria
of the avium-intracellu-lare complex, to-rye can be activators of a mikobakterioz at the person and animals.
Mycobacteria of T. — thin, direct or slightly curved sticks 1 — 10 long (1 — 4 is more often) micron, 0,2 — 0,6 microns wide, homogeneous pl granular with slightly rounded off ends (fig. 1, a). They are not mobile, do not form endospores, conidiums and capsules. The morphology and the sizes of bacterial cells are subject to considerable fluctuations that depends on their age and especially on living conditions and composition of nutrient medium.
Mycobacteria of T. are very steady against influence of environmental factors, are characterized by the expressed variety of forms of existence, big polymorphism and broad range of variability biol. properties (polymorphism). Are described numerous morfol. options of mycobacteria: huge forms with kolbovidno reinforced branchings, threadlike, mitseliyepodobny and club-shaped, diphtheroid and actinomycotic forms (fig. 1, b). Mycobacteria of T. can be longer or shorter usual, more thickly or more thinly, homogeneous or granular. Sometimes they represent chains or separate accumulations of kokkovidny grains. Mycobacteria of T. the filtered forms, a biological and pathogenetic role to-rykh finally are capable to form it is not found out. Are described biol. properties the pathogenetic role of L-forms of mycobacteria of T is also studied. (see £-forms of bacteria), causing various a wedge, manifestations of process.
Along with morfol. variability to mycobacteria of T. wide variability and other signs, in particular is inherent to acid resistance. The last is shown by ability to keep coloring even at intensive decolouration to - that or acid alcohol and is the idiosyncrasy of all types of mycobacteria caused by high content in them mikolovy
Fig. 1. Microdrugs of a phlegm of the TB patient of lungs and culture of mycobacteria of tuberculosis: and — the mycobacteria of tuberculosis having an appearance of thin straight lines or slightly curved ^ sticks; — the huge forms of mycobacteria of tuberculosis which are grown up on a liquid medium; coloring across Tsil — to Nelsen; X 1350.,
to - you and lipids (see. Acid resisting bacteria). Partial or full loss of acid resistance leads to education mixed, consisting of acid resisting and not acid resisting individuals or completely of not acid resisting population.
At microscopic examination in a body of a mycobacterium of T. easily granular educations, number come to light to-rykh from 2 to 10 fluctuates. Mycobacteria of T. can exist in the form of not acid resisting granules (grains Mucha), the consisting hl. obr. from metaphosphate.
Electronic microscopically the microcapsule of a mycobacterium comes to light, edges it is separated from a homogeneous cell wall by an osmiofobny zone. The three-layered cytoplasmic membrane densely adjoins to a cell wall. In cytoplasm separate organellas are differentiated: granules, vacuoles, ribosomes,
polysom and nuclear substance.
Mycobacteria of T. are considered as aerobes though there are data that their nek-ry types can be considered as facultative anaerobes. Mycobacteria of T breed. very slowly (one cell division happens for 14 — 18 hours). Microscopically visible growth of the microcolonies cultivated on fluid mediums at t ° 37 ° comes to light on 5 —
the 7th days, the visible growth of colonies on the dense environments cultivated at the same temperature — on 14 — the 20th days.
For normal development of mycobacteria of T. special mediums (see), carbonic, nitrogen, oxygen, hydrogen, phosphorus, magnesium, potassium, sodium, iron, chlorine, sulfur are required. Mycobacteria of T. need also in a number of growth factors, to-rykh connections, related to vitamins of group B, biotin, nicotine, Riboflavinum, etc. are among. All these factors are a part of the mycobacteria of T applied to cultivation. special mediums; from their number proteinaceous allocate the Wednesdays containing glycerin (egg, serumal, potato) and protein-free (synthetic) environments, to-rykh are a part mineral salts. On a consistence distinguish dense, semi-fluid and fluid mediums. Dense egg circles of Levenstein — - Janszen, Ogava, Petranyani (see Petranyani Wednesday), Gelbera, various agar mediums of Middlbruk, synthetic and semi-synthetic circles of Soton (see Soton Wednesday), Dyubo, Proskauer — Beck, by Iiiuly, Shkolnikovy, etc. are most widely applied.
On liquid mediums of a mycobacterium of T. grow in a type of the dry wrinkled film (R-form) of cream color rising by vascular walls; Wednesday at the same time remains transparent. At intracellular development of mycobacteria of T., and also their cultivation on fluid mediums the characteristic cord factor well comes to light (trehalose-6,6-dimikolat). It is found on a surface of cells of many mycobacteria and, according to nek-ry researchers, is related to their virulence, promoting rapprochement of microbic cells and their growth in the form of serpantinoobrazny braids.
On dense environments of a mycobacterium of T. the deckle-edged colonies raised in the center grow in a type of a light-cream wrinkled or dryish scaly plaque; in process of growth they take warty the form reminding a cauliflower.
Under the influence of antibacterial agents of a mycobacterium of T. can gain medicinal stability. Cultures of such mycobacteria not always happen typical, they can be wet, soft (S-option), sometimes support the separate smooth or pigmented colonies.
Sources of contagiums are the suffering from tuberculosis person, and also suffering from tuberculosis animals. In a crust, time of T. occurs at mammal 55 types and at birds of more than 80 types. However the EDS we go a yole. danger to the person is constituted only by the few from them. It is hl. obr. cattle, camels, goats, sheep, pigs, dogs, cats, hens. Special value as a source of contagiums has cattle, suffering from tuberculosis.
Mycobacteria of T. can get to an organism through upper respiratory tracts, sometimes through mucous membranes and the injured skin. Rare observations of infection of a fruit through a placenta are described. The aerogenic way of infection is most widespread.
Infection with mycobacteria of T. not always causes development of tubercular process. Numerous researches proved the leading role in distribution of T., especially its severe forms, unfavorable conditions of life (wearisome work, hyponutrient, unsatisfactory living conditions, etc.). In process of implementation of the social polit.i-ka directed to growth of welfare of the people, its material security, improvement of living conditions, food, working conditions it is carried out iya profit the act ichesk them mero-p rpyat of ii, development of health care as it takes place in the USSR and other socialist countries, into the forefront the internal causes of reactivation of a tuberculosis infection changing reactivity of an organism (see) act. As shows experience of our country, such social transformations are followed by considerable decrease in prevalence of severe destructive forms T. At the same time the separate internal causes connected with an irrational way of life continue to play the known role in emergence and development of T. (see Prevention primary). To the factors promoting development of T., the diabetes mellitus, diseases belong, apropos to-rykh long purpose of corticosteroids, a peptic ulcer of a stomach of ii of a duodenum, and especially a state after a resection of a stomach, the mental diseases which are followed by a depression is required.
The main source of exogenous infection are the patients with active tuberculosis with existence of inflammatory and destructive changes allocating mycobacteria of T. (tank of an infection). Incidence of primary forms T. and contamination of the population depend on the size of a tank of an infection. At recovery of patients and the termination of a bakteriovyde-leniye contamination and incidence of tuberculosis decrease. As confirmation of it serves falloff of incidence of tuberculosis of the children's population (the most susceptible to this infection). contamination to-rogo in recent years considerably decreased. At the remaining tank of an infection risk of a disease to primary T. decreases at wasps of an ushchestvleniya of preventive inoculations vaccine BTsZh to newborns, children and teenagers, nein-fitsirovanny T. (see BTsZh).
A certain influence on incidence of tuberculosis of country people, especially cattle breeders, renders the level of a prevalence of T. cattle. The most convincing criterion epidemiol. dangers of tuberculosis of page - x. animals allocation from persons, sick T is., mycobacteria of tuberculosis of a bull look.
Sick animals allocate mycobacteria of T. with milk, a phlegm, a stake, urine. In places of maintenance of the sick cattle of a mycobacterium of T. find in washouts from walls, floors, cans, dressing gowns of milkmaids, towels. Nek-roye in transfer of contagiums also meat of sick animals can matter. About a possibility of infection of T. through milk it was known at the end of 19 century. The researches conducted in 20 — are the 30th 20 century in a number of the European countries, showed that the number of the tests of market milk containing mycobacteria of tuberculosis fluctuates from 4,8 to 36,6%. In a crust, time of a mycobacterium of T. in tests of market milk come to light extremely seldom. Mycobacteria of T. can remain a long time in dairy products (in oil — up to 240 days, in cheese — up to 200 days). Pasteurization of milk at f 85 ° within 30 min. guarantees its disinfecting.
Pathomorphologic changes at tuberculosis are diverse and hl depend. obr. from a form, a stage, localization and prevalence patol. process. Morfol. a picture of various forms of tuberculosis — see at the description of these forms in the articles Tuberculosis of a Respiratory Organs and Tuberculosis extra pulmonary.
The general for the majority of forms of tuberculosis are the specific changes caused by mycobacteria in combination with nespetspfiche-sky (paraspetsifichesknm) reactions. The tubercular inflammation belongs to specific changes, a cut it can be shown by formation of a tuberculous focus of various size and formation of a tubercular hillock, or granuloma (see). Nespetsificheskpmi changes are various reactions causing so-called masks of tuberculosis.
The morphology of a tubercular inflammation differs in a big variety. Depending on reactivity of an organism (see) and virulence of the activator in a tuberculous focus the phenomena of exudation (see), a necrosis can prevail (see) or proliferation (see), and the center according to it can be preferential exudative, necrotic or productive. According to V. I. Puzik (1966) and A. I. Strukova (1981), in development of a tubercular inflammation a big role belongs to immune processes. Therefore it is a classical example of the inflammation (see) proceeding on an immune basis. In the site of an inflammation the banal reaction which does not have the signs typical for T. V to it in different degree develops in the beginning the phenomena of alteration and exudation are expressed. In the following phase of inflammatory reaction — proliferative — appear specific to T. elements (epitet on there are ye also colossal cells of Pirogov — Langkhansa), form sites of a peculiar homogeneous caseous (curdled) necrosis in the center of a tuberculous focus (fig. 2). Eptttelioidny cells are formed of histiocytes and the macrophages accumulating in
Fig. 2. Microdrug of a tuberculous focus of a lung: the edge of the center of a caseous necrosis, is surrounded with growths of specific granulyatsionny fabric with epithelioid and colossal cells of Pirogov — Langkhansa, and also numerous lymphoid cells; 1 — caseous necrotic masses, 2 — colossal cells of Pirogov — Langkhansa; coloring hematoxylin-eosine; x 200.
the center of a tubercular inflammation in the first phases of inflammatory reaction. They have large a light kernel of an oval form, usually with one — two large kernels. Cytoplasm of these cells contains RNA in the form of fine grains that testifies to their functional activity, and also well developed system of tubules and tanks of a granular and not granular cytoplasmic reticulum, vesicles of a complex of Golgi (see Golgi a complex), in close connection about the Crimea there are lysosomes (see). The quantity of mitochondrions, lizosomalny inclusions and phagosomas varies.
Colossal cells of Pirogov — Langkhansa (see. Colossal cells) can be formed of epptelio-idny cells or macrophages at their proliferation, and also as a result of merge of epithelial cells. Cytoplasm of colossal cells contains a large number of the kernels which are usually located in a look iftsa or horseshoes on peripheries of a cell, RNA and respiratory enzymes (see). Colossal cells are capable to phagocytosis (see) and quite often in their cytoplasm various inclusions are found. Cytoplasm of the central part of colossal cell is rich with the mitochondrions, lysosomes and lizosomopodobny inclusions, elements of a granular cytoplasmic reticulum which are well developed by vacuoles.
Fig. 3. Microdrug of a lung with the organized tubercular granuloma:
in a midfield of sight the organized tubercular granuloma penetrated by dense network of the argyrophil fibers which are absent only in sites where colossal cells of Pirogov are located — Langkhansa is visible (are specified by shooters); impregnation by silver; X 280.
In addition to epithelial and colossal cells, tubercular granulyatsionny fabric contains usually significant amount of lymphocytes (see) different degree of a maturity, plasmocytes (see), segmentoyaderny leukocytes (see). In peripheral departments of a granulyatsionny layer between epitelnoid-ny and lymphoid cells fibroblasts come to light (see. Connecting fabric). Around the center of an inflammation usually there is a perifocal zone of nonspecific inflammatory reaction. During the progressing of process increase in a zone of a caseous necrosis, strengthening of infiltration of granulyatsionny fabric by lymphoid cells and segmentoyaderny leukocytes, expansion of a zone of a perifocal inflammation is observed.
gat sizes of grains of millet (millet-shaped hillocks), but can be and are slightly larger. In dependence
During the healing of a tuberculous focus of mass of a caseous necrosis are condensed and dehydrated, adjournment of salts of calcium in them in the form of fine grains is noted. In granulyatsionny fabric the quantity of fibroblasts increases, there are fibrocytes and collagenic fibers begin to come to light, to-rye create the connective tissue capsule around a tuberculous focus. In the subsequent specific granulyatsionny fabric is more and more replaced with fibrous fabric. The quantity of cellular elements between collagenic fibers decreases, sometimes collagenic fibers are exposed to a hyalinosis (see).
Another specific to T. a form of inflammatory reaction is formation of a tubercular hillock, or granuloma (see). In a crust, time a tubercular granuloma consider as the response of an organism to influence of a complex antigen — an antibody (see Antigen — an antibody reaction). At a prevalence of antigens in a granuloma the necrosis develops, and at dominance of antibodies — productive reaction.
Tubercular granulomas have rounded shape, their sizes dosti-from reactivity of an organism of a granuloma can be exudative, consisting preferential of lymphoid cells, ekssudativnoproduktivny, productive and necrotic; the last meet at sharp oppression of protective forces of an organism. Typical productive tubercular granulomas consist of epithelial cells and colossal cells of Pirogov — Langkhansa, and also the lymphoid cells located on the periphery. Sometimes in the center of a granuloma the site of a caseous necrosis forms. At impregnation by silver (see Silverings methods) in a granuloma out of colossal cells argyrophil fibers (fig. 3) come to light. Granulomas can merge, forming the centers, in to-rykh elements of a stroma of separate components them granulomas differ. During the healing cellular elements partially resolve and on site granulomas the small scar of the irregular arachnoid shape develops.
Nonspecific (paraspecific) reactions can form in a nervous system, forming so-called neurodystrophic masks, in cardiovascular system, the hemopoietic bodies, joints, serous covers, etc. In cardiovascular system and parenchymatous bodies they are shown by focal or diffusion histiocytic and lymphocytic infiltration (fig. 4, a), in limf, nodes — proliferation of reticular and endothelial cells, in lungs — formation of lymphocytic small knots (fig. 4, b). A. I. Strukov considers that these reactions have the toksiko-allergic nature. V. I. Puzik regards them as result of action of mycobacteria of T. during the early periods of development inf. process.
Due to the preventive antitubercular actions, favorable changes of living conditions of the population and use of specific treatment the considerable pathomorphism of tuberculosis is observed (see the Pathomorphism). Refer disappearance of caseous pneumonia to a true pathomorphism that demonstrates increase in immune forces of an organism, more frequent formation of tuberculomas (see). Acute forms became a big rarity in a crust, time it is lovely pair to T. and tubercular meningitis (see), especially at children. Manifestations of the induced pathomorphism caused by specific treatment are the isolated cavities (see the Cavity), around to-rykh the perifocal inflammation, a full rassasyvaniye or development of small star-shaped scars quickly resolves at hematogenous disseminated by T., rejection of @-zeozno-necrotic masses at fibrous and cavernous T. with formation on site cavities of a cystiform cavity.
Pathogeny of T. it is put and depends from a .mnogoobraziya of conditions, in to-rykh there is an interaction of a contagium and organism. In development of T. allocate primary and secondary periods. Primary period (primary T.) covers time from penetration into an organism of mycobacteria of T. before full healing of a tuberculous focus. Secondary T. time after a state a wedge, wellbeing develops later a nek-swarm. In a crust, time secondary forms T. a respiratory organs are considered as result of endogenous reactivation of the old centers. Development of T. owing to repeated infection it is observed extremely seldom. Primary and secondary T. develop in the conditions of various reactivity of an organism. For primary T. high sensitivity of fabrics to mycobacteria and their toxins is characteristic, edges the possibility of development toksiko-aller-gicheskikh thrombovasculites causes, tendency to generalization of process. In the secondary period tubercular process is usually localized in any body and prp adverse conditions for an organism can progress.
In a zone of penetration of mycobacteria of T. in an organism (a respiratory organs, went. - kish. the path, skin) or another the place, favorable for development of a tubercular inflammation, can arise the inflammatory center, or primary affect (see Affect primary). In response to formation of primary affect in connection with a sensitization of an organism specific process on the course of outflow of a lymph of primary center and in regional limf develops, nodes primary complex forms (see). It comes to light in easy and intrathoracic limf, nodes more often.
Fig. 4. Microdrugs of a liver (a) and lung with nonspecific reaction at tuberculosis: and — focal limfogistiotsitarny infiltrates (are specified by shooters):
coloring hematoxylin-eosine, X 270: — lymphocytic small knots (are specified by shooters): coloring hematoxylin-eosine: x 150.
A. I. Kagramanov (1952), V. I. Puzik (1958), Canetti (G. Canetti, 1954), etc. established that formation of primary complex is quite often preceded by the period of «a latent mikrobizm», at Krom of a mycobacterium of T., having got to an organism, a nek-swarm time do not cause inflammatory reaction. At the same time mycobacteria of T are more often. are found in limf, nodes, from to-rykh there can be their dispersion on an organism. In these cases local changes in easy or other bodies arise in later period of primary infection.
From the first days of penetration into an organism of mycobacteria of T. the functional and morphological changes of bodies of immune system directed to an otgranicheniye and destruction of a disease-producing factor develop.
In the course of formation of the centers primary T. limfogematogenny dissimination with formation of tuberculous focuses in various bodies — bones, kidneys, etc. Due to the hit of mycobacteria from limf, nodes in a lymphatic and blood channel and a sensitization of vascular walls primary in T can be observed., especially in the past, quite often was complicated by dissimination with development miliary T.
Healing of the centers primary T. is followed by immune reorganization of an organism, disappearance of the phenomena of an allergy, acquisition of immunity. However in these conditions dispersion of a contagium from the centers primary T is possible., especially from struck limf, nodes, and formation of the centers eliminations (postprimary centers of a reinfekt). Usually they are localized in easy or other bodies (kidneys, generative organs, bone system), as a rule, do not cause reaction regional limf, nodes and begin to live usually in parallel with the centers of primary infection. At decrease in immunity these centers can become more active and progress with development secondary T.
Vazhny at T. the question of an allergy is (see). With an allergy at T. phthisiatricians identify tuberkulinovy skin reactions, to-rye are classical tests of cellular immunity in vivo (see. Skin tests). It is known that an allergy, as well as other reactions of immunity, depending on a situation maybe useful, and harmful to an organism. Allergic reactions (as well as any other reactions of immunity) can be both the humoral (immediate), and cellular (slowed-down) type. Special researches of a role of allergic reaction of immediate type at T. are not numerous, however they showed, in particular, that IgE do not play an essential role in a pathogeny of a tuberculosis infection.
The question concerning allergic reaction of the slowed-down type is even more difficult. Substrate of this kind of allergic reaction is still unknown. There is an assumption that a certain subpopulation of T lymphocytes or their certain mediator causing, e.g., skin giperer-gichesky reactions and emergence of a necrotic component in tuberkulinovy reactions can be it.
At the heart of development of T., in addition to various external factors, naturally, the internal reasons caused, in particular, by a genotype of an organism can lie. One of the main ways of studying of a role of these mechanisms in the resilience of T. the research of communication of development of a disease with the known genetic units (loci) determining immunol is. recognition. Data on communication of various haplotypes of HLA (the main complex of histocompatability at the person) with sensitivity to T are obtained. Experiences on mice of 23 lines having different genetic characteristics showed existence of communication between sensitivity to tuberculosis and a genotype. It is established also that resistance to T. is under polygenic control and it is inherited on dominant type, and sensitivity — under monogenic control and is inherited on recessive type (see Inheritance).
Many years resistance to T. connected only with phagocytosis of mycobacteria, fabric reactions of encapsulation patol. the centers and partly with antibodies. Reflection of a ratio of antitubercular immunity and an allergy considered extent of manifestation of skin tuberkulinovy tests (see Tuberkulinodiag-iostik). Due to the development of immunology also new mekhaniz
we are revealed the acquired antitubercular immunity, its main phenomena. All variety of manifestations of immunity is generally provided by two ways of an immune response: humoral and cellular.
Effector immunocompetent cells at the same time are V-lymphocytes at gumoralnokhm and T lymphocytes at cellular immunity (see. And to a mm incompetent cells). The system of interaction of antigen and immunocompetent cells is rather difficult, several types of cells participate in it. All others immunol. phenomena are the derivatives of cellular and humoral immunity (see) taking various part in a pathogeny of a tuberculosis infection.
Numerous researches of dynamics of synthesis of various types of antibodies at T., and also at vaccinal (after introduction of BTsZh) process yielded quite contradictory results, however also nek-ry patterns are revealed. So, by means of methods of an immunofluorescence (see) at experimental T. and vaccinal process the maximum quantity of antiteloobrazuyushchy cells was found in cases of increase in resistance to an infection more often. The similar picture was observed also during the definition of nek-ry types of humoral antibodys. Definition of various types of antibodies (see) at a tuberculosis infection depends on its current. E.g., the antibodies directed against polysaccharides of mycobacteria in the greatest credits are defined at the favorable course of tubercular process and, on the contrary, the maximum credits of anti-protein antibodies are found during infiltrative flash of T. Nevertheless still it is not clear what in general antibodies in formation of resilience of a tuberculosis infection matter, or harmful their synthesis is useful whether they have onsoniziruyushchikhm properties concerning mycobacteria and whether influence phagocytosis. The question and of is disputable whether antibodies can directly act on a mycobacterium or oppress them reproduction by means of a complement (see). To increase resistance to T. intact animals at administration of immune serums do not work well.
Most of researchers consider antibodies to mycobacteria of T. «witnesses» of immunity also believe that their synthesis (its activity) reflects tension of resistance to T., but is not the cornerstone of fight against mycobacteria that antitubercular antibodies do not render the inhibiting effect on mycobacteria, Only single observations demonstrate that immune serums slow down reproduction of mycobacteria of T. in macrophages or macrophages protect from necrotizing action of mycobacteria. Possibly, nek-ry types of antibodies, napr, antibodies to a cord factor and to other factors of virulence of mycobacteria, can act on a mycobacterium toxic; others, napr, antibodies to polisakharidny components of mycobacteria, are capable to strengthen phagocytosis or to opsoni-rovat mycobacteria; the third, napr, antibodies to protein components of mycobacteria, can block effector mechanisms of cellular immunity.
Mechanisms and a role of cellular immunity at T. are studied more deeply, than antibodyformation. It is proved that reactions of cellular immunity consist in interaction of T lymphocytes with antigen of mycobacteria and the subsequent mobilization (usually by means of mediators) other populations of T lymphocytes or macrophages.
At T. and vaccinal process (after vaccination of BTsZh) there is a proliferation of T lymphocytes — effectors of cellular immunity in timuszavisimy zones of a spleen and limf, nodes, and the maximum of their proliferative activity matches the period of the maximum resilience of an infection.
During the use of tests of cellular immunity of in vitro it was established that their indicators change adequately the course of a disease. Expressiveness (in the presence of tuberculine) reactions of a blastotrans-formatsna of lymphocytes (see Blasto-transformation of lymphocytes, t. 15, additional materials) and cytotoxic action of lymphocytes on the target cells containing antigens of mycobacteria more correlate with a resilience to T., and expressiveness of reaction of macrophage fixation from capillaries in the presence of tuberculine — with prevalence and T. V activity the terminal period of a disease expressiveness of all tests of cellular immunity decreases.
It is established that at T. mediators of cellular immunity are formed (see) — the substances synthesized preferential T-limfotsi-tami after their contact with the corresponding antigens. Synthesis of nek-ry mediators (e.g., blastogenic, tsptotoksichesky factors) most actively happens at height of action of vaccine BTsZh, and such mediator as the factor inhibiting migration of macrophages — at widespread tubercular process. All this allows to assume that various manifestations of cellular immunity depend on activity of different subpopulations of T lymphocytes, to-rye have various functional purpose.
The leading role of cellular immunity at T. it is proved in animal experiments, the Crimea transferred a suspension of the lymphoid cells received from actively immunizirovanny BTsZh of animals. According to M. M. Averbakh et al. (1974), at the same time it is possible to increase their resistance to the subsequent infection. The cells causing this effect are T lymphocytes. At animals against the background of introduction of immunodepressive means (e.g., an imuran, anti-limfotsitnykh syvorotoj), influencing system of cellular immunity, tubercular process is more rapid and zlokachestven, at the same time the protective effect of vaccination of BTsZh decreases. Experiences are even more demonstrative, in to-rykh function of T lymphocytes suppressed by means of a thymectomy. At newborn tim-ektomirovanny mice and at besti-musny mice resilience to T. was much lower, than at intact animals. Adult timektomirovanny mice have a resilience to T. decreases with «extinction» of a pool of T lymphocytes. Moreover, at such mice introduction of vaccine BTsZh leads to development of the disseminated process with a lethal outcome. In a number of experiments also the possibility of increase in resilience to T is established. — prolongations of a tuberculosis infection by means of various actions, specifically or nonspecific strengthening cellular immunity (immunotherapy): replanting of a thymus, introduction of immune lymphocytes, Timosinum (extract of a thymus), levamisole (stimulator of T lymphocytes). These facts serve as the direct instruction on the fact that cellular immunity is the leading link in formation of resilience to a tuberculosis infection.
At the same time mycobacteria of T. collapse and breed exclusively intracellularly and preferential in macrophages and therefore phagocytosis is the basic (if not the only thing) the mechanism of destruction of mycobacteria. Phagocytosis at T. often is incomplete, i.e. the englobing cells take mycobacteria, but long do not destroy them.
This, testimonial that by means of immune antitubercular serums it is possible to strengthen phagocytosis of mycobacteria, very little, but at the same time results of repeatedly made experiments showed that immune lymphocytes, and also mediators synthesized by them increase phagocytal activity of macrophages concerning T. Ustanovleno's mycobacteria that T lymphocytes have ability to synthesize the mediators strengthening phagocytosis.
In a number of pilot studies it is shown that the combined administration of BTsZh polyantigen and Cyclophosphanum to mice can induce tolerance to the subsequent administration of antigens of mycobacteria with suppression of preferential cellular immunity. On this background vaccination of BTsZh is almost inefficient, it does not promote extension of life of mice at the subsequent infection with virulent culture. It is established also that at reproduction by means of tuberculine of one of options of tolerance — an immunological deviation (see unresponsiveness) synthesis of antitubercular antibodies inhibits development of cellular immunity that negatively influences the course of tubercular process, promoting its more bystry dissimination.
These pilot studies demonstrate that tolerance can play a part in a pathogeny of T. So, e.g., negative value of tolerance can be shown at vaccination of children with the immunocompetent system suppressed owing to various reasons when vaccine BTsZh does not stimulate immunity, and renders tolerogenic effect. Tolerance can also have the negative effect at hron. massive infection.
Immunity at T. earlier called unsterile, meaning need of a live contagium for maintenance of the increased resilience to superinfection. At the same time it is known that after vaccination of BTsZh the increased resilience to T. and sensitivity of skin to tuberculine remain much longer, than in an organism mycobacteria of BTsZh are found. It is established that «treatment» rifakhmpitsiny and an isoniazid of the animals vaccinated БЦЖ^ leads to elimination of mycobacteria of BTsZh, but does not exert impact on cellular immunity and resilience to the subsequent infection with virulent culture. It allows to assume that «immune memory» at T. (in sense of preservation of a certain level of the acquired resistance as a result of the previous contact with a contagium) depends not only on a persistention of live mycobacteria, and, as well as at administration of any other antigen, it is connected with function of immunocompetent
Variety morfol. and wedge, manifestations of T. forced to look for the main most general signs, to-rye would allow to combine patients in certain groups. At the beginning of 20 century when the so-called apiko-caudal theory of a pathogeny of T was generally recognized., was considered that its most precursory symptoms appear in upper parts of lungs, and in process of progressing process extends to their underlying departments. According to this representation Turban and Gebhardt (To. Turban, L. Gebhardt) in 1902 offered classification of T., on a cut all its manifestations are divided into three stages: The I stage — damage only of upper parts of lungs,
the II stage — defeat of upper and average parts of lungs, the III stage — total damage of all lung or both lungs. This classification with the additions made in 1925 by A. Ya. Shternberg was used in our country for a long time. Along with attempts to classify T. about a wedge, positions the classifications based on morfol were developed. signs. On the classification offered in 1917 to JI. Ashoff and Sh. Ni-koll, distinguished preferential ex-udat ivny,
preferential productive processes and processes with existence of caseous disintegration. Based on descriptions of primary, and also secondary and miliary forms T. as different manifestations uniform patol. the process caused by mycobacteria of tuberculosis, A. I. Abrikosov in 1923 suggested to allocate primary, secondary and is lovely pair (hematogenous) to T.
Great interest among clinical physicians was attracted by classification to the Wound (To. Ranke), to-ry suggested to divide T. on primary, arising in connection with primary infection, secondary, characterized by spread of a tuberculosis infection as a result of primary infection, and tertiary, or organ, T. easy or other bodies. Division of T. on primary and secondary in a crust, time it is conventional by most of phthisiatricians.
In 1934 in the USSR the special commission on development of classification (nomenclature) of tuberculosis was created. G. R. Rubenstein, A. E. Rabukhin, F. V. Shebanov, A. I. Abrikosov, B. M. Khmelnytsky, A. N. Chistovich, A. I participated in its activity. Strukov, etc. First option uniform wedge, classifications of T. it was approved in 1938 at a meeting of directors of scientific research institute of tuberculosis. Classification was based not on one any sign, and on several: were considered kliniko-rentgenol. features of forms T., phases of its current, bakteriovydeleniye, extent (localization) of process. Further at V, VI, VII and VIII all-Union congresses of the phthisiatricians who took place respectively in 1948, 1957, 1964 and 1973 in a wedge, classification of T. partial changes were made. So, from number a wedge, forms T. caseous pneumonia and miliary T were excluded., seldom in recent years meeting in practice, a tuberculoma and cavernous T are also entered. Names nek-ry wedge, forms and phases T. were changed or specified. Concepts about compensation of T are excluded from classification., it is added with the sections devoted to earlier not considered extra-pulmonary localizations of T., and also the characteristic of residual changes after treatment from T.; symbolical designation of localization of tubercular process is replaced by verbal. In recent years wedge, classification of T. it is brought into accord with the International statistical classification of diseases, injuries and causes of death of the IX review. Classification of T., accepted in our country, differs in universality and it can be used for clinical, statistical and other purposes.
Wedge, classification of T. consists of 4 parts. The first part contains the main a wedge, forms and consists of three groups covering all displays and localizations of tuberculosis:
The I group — tubercular intoxication at children and teenagers; The II group —> tuberculosis of a respiratory organs;
The III group — tuberculosis of other bodies and systems. The second part of classification (the characteristic of tubercular process) is created on the basis kliniko-rentgenol. and epidemiol. signs. In it the characteristic of both dynamics of tubercular process, and a bakte-rivvydeleniye is given; also the sign of localization and extent of tubercular process is used. The third part characterizes its complications connected with a current in T. or with metatuberculous changes. The fourth part contains the characteristic of residual changes after cured by T. Its introduction to classification in 1973 is connected with the fact that in a crust, time treatment is the natural result of tubercular process.
Clinical classification of tuberculosis
And. Main clinical
Group I forms. Tubercular intoxication at children and teenagers
Group II. Tuberculosis of a respiratory organs
Tuberculosis complex intrathoracic limf,
Disseminated Pulmonary Tuberculosis nodes Focal pulmonary tuberculosis Infiltrative pulmonary tuberculosis Tuberculoma of lungs Cavernous pulmonary tuberculosis Fibrous and cavernous pulmonary tuberculosis
Dirrotichesky pulmonary tuberculosis Tubercular pleurisy (including empyema)
Tuberculosis of upper respiratory tracts, tracheas, bronchial tubes, etc.
The tuberculosis of a respiratory organs combined with dust occupational diseases of lungs Group III. Tuberculosis of other bodies and
Meningeal tuberculosis systems and c. N of page. Tuberculosis of intestines, peritoneum and mesenteric limf, Tuberculosis of Bones and Joints Tuberculosis nodes of uric, generative organs Tuberculosis cutis and hypodermic cellulose Tuberculosis peripheral limf,
Tuberculosis of Other Bodies Tuberculosis of Eyes nodes B. Characteristic of tubercular process Localization and extent: in lungs on shares, and in other systems — on localization of defeat
the Phase: a) infiltration, disintegration, planting:
b) rassasyvaniye, consolidation, scarring, Bakteriovydeleniye's calcification: a) with allocation of mycobacteria of tuberculosis (BK4-): b) without
allocation of mycobacteria of tuberculosis (BQ —)
Pulmonary bleeding, spontaneous pheumothorax, pulmonary heart, atelectasis, amyloidosis, renal failure, fistulas bronchial, thoracic, etc.
Residual changes after the cured tuberculosis
of the Respiratory organs: fibrous, fibrous focal, violent changes, kal-tsinata in lungs and limf, at the evils, plevropnevmoskleroz, cirrhosis, bronchiectasias, states after an operative measure, etc.
Other bodies: cicatricial changes in various bodies and their effects, calcification, a state after operative measures.
In the majority of the countries there are clinical, pathomorphologic, statistical and other classifications of tuberculosis. In the USA there was a classification, according to a cut all manifestations of T for a long time. were distributed on minimum, widespread and far come with the subsequent their more detailed interpretation. In 1981 classification is entered into the USA, according to a cut allocate not - the infected persons, giperinfi-tsirovanny persons without symptoms of a disease, the TB patients, persons cured of tuberculosis and persons with suspicion of tuberculosis. In England, France, Germany, Italy and other countries clinical classifications represent in essence the short epicrisis characterizing displays of tuberculosis.
SOME FEATURES of DISPLAYS of TUBERCULOSIS
Klin, manifestations of T. are characterized by big variety and depend, first of all, on a form and a phase of a disease. They can be caused by the phenomena of the general intoxication and the functional, exchange disturbances, and also local changes in various bodies coming at the same time, complications of tubercular process. In modern conditions seldom there are quickly progressing forms T. It is more often noted incremental hron. current. T. arises at men more often, especially aged apprx. 50 years and is more senior. At this age it is quite often masked by associated diseases, especially if they are followed pronounced klnn. symptoms.
Most often the T meets. respiratory organs: easy, intrathoracic limf, nodes, bronchial tubes and pleura. Among extra pulmonary defeats the T is more often observed. urinogenital bodies, eyes, peripheral limf, nodes, bones and joints, is much more rare — T. skin, intestines, peritoneum, mezenterialny limf, nodes.
In a crust, time of T., as a rule * develops gradually; a nek-swarm time it proceeds imperceptibly for the patient and people around: are absent
pronounced a wedge, simptomyg the health of patients is almost not broken, remains or significantly working capacity does not decrease. Outward of patients does not change, the lose of weight and high temperature of a body is not noted. Expressed a wedge, symptoms of a disease appear only later a long time after the beginning of a disease. Therefore the great value gets active early identification of T. by routine maintenances of the population, and also comprehensive - inspections of the persons who saw a doctor, first of all, with symptoms of a disease of a respiratory organs. In the absence of adequate treatment a gradual oligosymptomatic current of T. can accept the progressing character. There are periodic aggravations, development of destructive process, its local distribution, and sometimes and defeat of other bodies is observed.
At all variety a wedge, manifestations of T. it is possible to allocate the syndrome of the general intoxication caused inf. the process caused by the breeding population of mycobacteria, their dispersion, including bacteremia. At the same time temperature increase, weakness * decrease in working capacity, perspiration, tachycardia, a loss of appetite, emaciation are noted. Degree of intoxication varies in wide prede-.yaa — from insignificant at early stages of a disease to a pronounced picture at the generalized and progressing forms • diseases, especially at the started process and in case of inefficiency to lay down. actions.
The wedge, manifestations caused by local tubercular process are even more diverse to-rye depend first of all on extent of defeat of this or that body. On degree of manifestation of local changes it is possible to allocate three a wedge, groups: 1) with limited
focal changes (so-called .maly forms T.), at to-rykh activity of tubercular process it can be proved or rejected • only after long observation, and sometimes and preventive treatment by antituberculous remedies; 2) with widespread it is changed by iya without destruction, including «with defeat (usually consecutive) several bodies; 3) with the progressing destructive process.
From the point of view of timeliness of detection allocate the processes revealed timely and started. Timely revealed consider small forms T. and destructive changes at early stages of their development. On later .etapa of development, at widespread process or the created destruction and fibrosis, the disease which accepted hron. the current, is regarded as started.
Thanks to preventive vaccination of BTsZh of newborns and a revaccination of children, teenagers and .litsa of young age at many caught T. persons the infection proceeds favorably, with the minimum morfol. changes, to-rye gradually spontaneously heal without residual kliniko-rents-henol. changes. The progressing current primary T., followed pronounced a wedge, symptomatology, meets seldom. Local manifestations primary T. in a crust, time come to light only at not vaccinated children, and also at children and teenagers • with symptoms of immunodeficiency (see. Immunological insufficiency), and also transferred various somatic and inf. ^болезни.
Primary forms T. meet at children and teenagers, especially among BTsZh which did not undergo a revaccination more often. Primary T. in a crust, time it is seldom shown by formation of primary complex, are more often observed bronkhadenit (see) and pleurisy (see). Seldom tuberculosis of a middle ear, language, palatine tonsils, a gullet, stomach, liver and spleen meets. Much less than before, tubercular meningitis and an encephalomeningitis meet. Seldom also generalized forms T develop. with multiple defeat of various bodies.
Secondary forms T. develop as a result of endogenous reactivation of an infection. At a part of patients the disease proceeds wavy with change of the periods of an aggravation and zatikhaniye, with the subsequent healing. Such disease is noted at rather high level of immunity. At a number of persons the disease gradually progresses, inflammatory, and then and destructive changes accrue.
At tubercular process of any localization the wedge, manifestations are characterized by a combination of symptoms. At T. a respiratory organs in a wedge, a picture so-called chest symptoms are observed (cough, expectoration, a pneumorrhagia, an asthma, etc.), expressiveness to-rykh depends on the extent of local process, character morfol. changes and a phase of a disease (see Tuberculosis of a respiratory organs). At patients with extra pulmonary T. the symptomatology is caused by local process (see Tuberculosis extra pulmonary).
At T. mental disorders are sometimes observed, to-rye, as a rule, depend on weight and prevalence of process. In the acute period of a disease symptoms of an adynamy most often meet. The physical adynamy prevails over mental, and weakness, fatigue, a febricula are expressed to hl. obr. in the mornings. At effective treatment the phenomena of irritable weakness, emotional instability and vegetative frustration are more expressed. The adynamy is quite often combined with reactions of the personality to a disease. At neozhidannokhm for the patient the fact of a disease of T. the reactive subde-pressivny state can develop. At fibrous and cavernous T. lungs bigger polymorphism of mental disorders of more expressed character with tendency to hron is observed. to a current. An asthenic syndrome (see) at these patients it can be combined with euphoria or apathy. As a rule, depth of an adynamy increases during the weighting of a somatic state. Extremely seldom at T. there are psychoses in the form of an amentia (see. Amental syndrome), a catatonic stupor (see. A catatonic syndrome), a depressive or maniacal syndrome (see. Depressive syndromes, Maniacal syndromes), a delirium (see. A delirious syndrome), hallucinosis (see Hallucinations). The delirious syndrome develops at sick T more often., abusing alcohol, and in its structure auditory hallucinations are expressed. The reason of mental disorders at T. first of all intoxication, and also the psychoinjuring factors and features of the identity of the patient is.
Development of tubercular process in many respects depends on age. So, at children the T is most often noted primary., to-ry has the features of a current unlike secondary. Often children have no sharply expressed local manifestations of T., and initial displays of a tuberculosis infection are expressed by the general symptoms of intoxication that is explained by anato-mo-physiological features of an organism of the child, especially with an intensive growth and insufficient morphological and functional development of bodies and systems, first of all c. N of page.
Classical signs primary T.: appearing and amplifying (usually within 1 — 5 years) positive tuberkulinovy reactions (see T of an uberkulinodiagnostik); defeat limf, systems (limf, nodes and limf, vessels), frequent involvement in process of bronchial tubes and serous covers (pleurisy); a high sensitization of fabrics and systems to the activator T. with possible generalization of process, emergence of paraspecific toksiko-allergic reactions (keratoconjunctivites, a knotty erythema, a scrofuloderma, etc.); tendency of specific changes in pulmonary fabric and limf, nodes to a caseous necrosis with the subsequent calcification and to self-healing.
Ability of an organism of the child, especially at early age to answer with considerable general functional frustration on rather small patol. the center creates conditions for emergence by the person inherent in children's age a wedge, forms T. — tubercular intoxication. Tubercular intoxication (T. without the revealed local defeats, «latent» tuberculosis) the characteristic wedge, the syndrome arising in the presence in an organism of the child (teenager) of fresh primary tuberculosis infection represents.
In a wedge, a picture functional frustration prevail: re
the benok quickly gets tired, its appetite is reduced, increase of body weight stops, periodic rises in temperature to 37,1 — 37,5 ° are noted. The so-called micropolyadenia — increase peripheral lshmf is characteristic. nodes in cervical, submaxillary, axillary, mental, elbow, inguinal areas. At a palpation these limf, nodes have a myagkoelastichesky consistence, the phenomena of a periadenitis are sometimes noted. At tsitol. a research of punctates peripheral limf, nodes in them also epithelial cells come to light lymphoid. Also increase in a liver is noted; it usually myagkoelastichesky consistence, painless at a palpation. Increase in a spleen is less often observed. In blood the eosinophilia, neutrophylic shift to the left, a lymphopenia and the accelerated ROE are found.
At rentgenol. a research of bodies of a thorax the expressed specific changes usually are not defined. Early detection of possible minimum damages of bronchial tubes and intrathoracic limf, nodes perhaps by means of a tomography (see) and the bronkhoskopiya which is carried out according to indications (see).
The diagnosis of tubercular intoxication is based not on one any symptom, and on their set. Similar symptoms can be caused by many nonspecific hron. diseases. Therefore at differential diagnosis it is necessary to exclude completely a nonspecific etiology of the disease of way deepened kliniko-rentgenol. and laboratory research.
Division of tubercular intoxication into early and chronic is conditional. Carry those cases when the above described symptom complex matches «bend» of tuberkulinovy reactions (see the Tuberculinodiagnosis) to early tubercular intoxication, to chronic — later period of development of primary tuberculosis infection when positive tuberkulinovy tests over a year come to light.
In modern conditions infection with mycobacteria of T. children and teenagers occurs against the background of the specific immunity caused by vaccination and a revaccination. Thanks to broad holding the general and specific preventive actions, in particular specific chemotherapy and chemoprophylaxis, also massiveness and virulence of a tuberculosis infection considerably decreased. Therefore at most of children and teenagers primary infection revealed at 0,5 — 1,4% inspected by means of Mantoux reaction proceeds asymptomatically. The disease develops only in 6 — 7% of cases, hl. obr. at long ago the infected children at it is long the existing endogenous infection. The major factors promoting revival of an endogenous tuberculosis infection are endocrine reorganization of an organism at prepubertatny and teenage age, and also hron. the nonspecific diseases reducing resistance of an organism (see).
Due to the favorable epide-miol. and immunol. shifts the specific hyper sensitization of an organism decreased that could not but be reflected on a wedge, a current and led to a pathomorphism of T. at children. Against the background of falloff of incidence the number of severe, acute and generalized forms miliary T considerably decreased., tubercular meningitis, caseous pneumonia, extensive hematogenous dissiminations with generalization of process in other bodies. Mortality of children from T. Naiboley often was sharply reduced tubercular is diagnosed for children bronkhadenit (see Vronkhadenit). Primary tubercular complex is seldom noted. Tuberkulinovy sensitivity decreased: at 25% for the first time the revealed children with local forms T. the negative Pirquet's test at a positive Mantoux test is noted.
In a crust, time a wedge, manifestations local T. at children are characterized by defeat limf, systems, hl. obr. in the form of specific morfol. changes in limf, nodes up to a caseous necrosis (bronkhadenit, lymphadenitis). At the same time the number of small forms T increases. intrathoracic limf, nodes. Careful rentgenol. diagnosis allows to distinguish small forms T. intrathoracic limf, nodes in a phase of infiltration. The chemotherapy of these forms leads to complete elimination patol. changes more than at 50% of patients. However the complicated current of T still meets. at children, generally connected with the expressed changes in limf, nodes.
Frequency of tubercular damages of bronchial tubes decreased. In most cases specific inflammatory changes of bronchial tubes proceed asymptomatically and have limited productive character; the infiltra-tivno-canker of bronchial tubes is seldom observed.
Residual changes in a look meta-and a post-tubercular pneumosclerosis after primary T. intrathoracic limf, nodes, complicated by bronchopulmonary defeat, are a source of a recurrence and base for development hron. nonspecific diseases of lungs.
In modern conditions the side between a wedge, manifestations primary and secondary in T is erased. at children at prepubertatny and teenage age. At for the first time the infected children of this age group of T. lungs proceeds not only in the form of a bronkhadenit or primary complex, but also in the form of limited focal and infiltrative forms.
At children at prepubertatny and teenage age the T is most often noted focal. lungs, development to-rogo more than in V4 of cases is connected with primary infection. Focal T. lungs at teenagers, arising during primary infection, it is characterized by a favorable current and often after antibacterial treatment comes to an end with a full rassasyvaniye of the centers in lungs.
Focal T. at teenagers, developing as a result of reactivation of a tuberculosis infection, it is frequent against the background of residual changes after primary T., it is characterized by less favorable, slowed-down and wavy current. The most part of patients after antibacterial therapy has expressed residual changes in a type of the large condensed centers, and in some cases at these patients flashes and a recurrence of process are noted.
At children and teenagers extra pulmonary the T is also observed., to-ry the T can be shown as the isolated defeat of this or that body and in the form of a complication pulmonary. (meningitis, lymphadenitis, mesadenitis, T. bones and joints, urinogenital system, tuberculosis of eyes, skin and hypodermic cellulose). The most frequent extra pulmonary localization of process in a crust, time is tubercular lymphadenitis (see). Tubercular meningitis in a crust, time meets hl. obr. at the children of early age who are in contact with sick active T., not vaccinated or poor vaccinated BTsZh in the period of a neonatality (not having postvaccinal scars on skin). T. kidneys at children and teenagers has the erased clinical laboratory symptomatology. Therefore in the presence of a microalbuminuria and a hamaturia at infected or the patient T. a respiratory organs of the child triple crops of urine on a mycobacterium of T are necessary. for the purpose of early identification of damage of kidneys.
In a crust, time for a current of T. at children of prepubertatny age along with other factors acceleration exerts impact (see). It is established that at the same time, on the one hand, the asymptomatic current of T is noted., the expert another — rather often (at 1/3 patients) quickly comes disintegration of pulmonary fabric at focal and infiltrative forms.
Considering that development of T. in children and teenagers it is caused by rather recent infection, the organization of early identification has it the features. The main method is the mass tuberculinodiagnosis (see), with the help a cut early manifestations and local forms T can be distinguished., and also groups of the increased risk are revealed. Fluorography (see) make to children from 13-year age and to teenagers for the purpose of identification of local forms T. at the persons infected with tuberculosis. At persons of advanced and senile age the symptom complex of a disease includes along with symptoms of T. manifestations of age changes in various bodies and systems (first of all, in the bronchopulmonary device), and also symptoms of associated diseases.
Results a wedge, observations of a number of researchers demonstrate that various associated diseases occur at most of patients of advanced and senile age — most often a pneumosclerosis (see), atherosclerosis (see), emphysema of lungs (see), coronary heart disease (see), is more rare — chronic pneumonia (see) and diseases went. - kish. a path, a diabetes mellitus (see a diabetes mellitus), arterial hypertension (see arterial hypertension). Need of carrying out by such patient of a complex of the actions directed not only on treatment of T is connected with it., but also associated diseases.
At persons of advanced and senile age the T is observed generally. respiratory organs. The most frequent complaints of patients — cough with a phlegm, an asthma, emaciation, tachycardia, the general weakness, decrease in a pla total absence of appetite, are more rare the subfebrile temperature, night sweats. In a wedge, a picture T. a respiratory organs at advanced and senile age, unlike that at patients of mature age, the considerable prevalence of the symptoms characteristic for hron is noted. nonspecific diseases of lungs. In these cases quite often instead of etiopatogenetichesky therapy mistakenly appoint a symptomatic treatment whereas the basic tubercular process a long time remains not distinguished.
T. at persons of advanced and senile age conditionally divide on old and senile.
Old T. usually begins at young and mature age, it is characterized by a long, wavy current (most often it hron. disseminated, fibrous and cavernous and cirrhotic T.). The current of a basic disease at the same time quite often becomes complicated hron. a pulmonary heart (see), insufficiency of external respiration (see. Respiratory insufficiency) and blood circulations (see), hron. bronchitis (see), etc.; their manifestations quite often become leaders in a wedge, a picture. Quite often the progressing pulmonary heart is a cause of death of such patients (see. Pulmonary heart).
Senile T. for the first time comes to light at persons at the age of 60 years and is more senior. Allocate two types its wedge, currents, to-rye are in close connection with features of a pathogeny. 1. The tuberculosis proceeding with nek-ry lines of primary infection (adenogenny bronchopulmonary T.). It is caused by an aggravation of residual changes in intrathoracic limf, nodes and has much in common with primary forms T. at adults (sharply accelerated ROE, an eosinophilia, high skin sensitivity to tuberculine, involvement in process of serous covers, frequent specific damage of bronchial tubes, etc.).
2. The tuberculosis developing owing to an aggravation of old after and primary (secondary) centers in lungs. Semiotics and a wedge, a current its same, as well as corresponding a wedge, forms T. at persons of young and mature age.
Features of a course of tuberculosis at pregnancy are important. Pregnancy at sick T., according to most of specialists, increases risk of progressing of process that depends on a form T., duration of gestation and social living conditions of the patient. Inactive and with firmness calmed down T. becomes aggravated seldom, and the process which arose during pregnancy well gives in to chemotherapy. Pregnancy and childbirth can provoke generalization of process at hron. destructive T., and also primary T. and tuberculosis of genitalias (see Tuberculosis extra pulmonary, tuberculosis of female generative organs). Approximately V3 of cases of deteriorations falls on the first 3 months of pregnancy and 2/3 cases — on the first half of the year after the delivery. Adverse for sick T. early durations of gestation (see) are when there is a hormonal reorganization of an organism. In the second half of pregnancy the health of patients usually good, and its last months quite often is even better, than before pregnancy. Childbirth (see) and a puerperal period (see) are most dangerous since, causing radical reorganization of an organism of the woman, they promote
T. V aggravation cases of an adverse course of process a wedge, manifestations of T. in the first weeks of pregnancy usually mask symptoms of early toxicosis (see Toxicoses of pregnant women) that complicates diagnosis. In the second half of pregnancy progressing of T., even followed extensive patol. changes of lungs, proceeds malosimntomno and without fever more often as the «cold» flash creating visibility of wellbeing. Puerperal aggravations of T. proceed violently, with the expressed intoxication and tendency of process to generalization.
At suspicion on T. in any period of pregnancy are necessary repeated bacterial. researches of a phlegm for the purpose of identification of mycobacteria of T. and a X-ray analysis with careful diaphragming of x-ray emission, antiactinic protection of area of a stomach and a basin of the patient.
Antibiotics (streptomycin, biomycin), to-rye are removed through kidneys, can have ototoksichesky effect on a fruit. Therefore at decrease in excretory function of kidneys at the pregnant woman these antibiotics are appointed with care and in smaller doses, and dihydrostreptomycin and Kanamycinum do not apply at all. Nek-ry specialists recommend, especially in the first 3 months of pregnancy, whenever possible, to abstain from use of streptomycin, replacing it with rifampicin. Possibly, use of Etioniamidum since, on ekspe-rimentalnvsh to data, it has teratogenic effect is also inexpedient. At the pregnancy which occurred in the first 3 years after the end of treatment of T., recommend to appoint with the preventive purpose of GINK in 1 month prior to childbirth and within 3 months after them.
The patient with widespread to destructive T. lungs the pneumoperitoneum (see) reducing danger of puerperal distribution of process can be after the delivery shown. According to vital indications make operational treatment (see Lungs, operations).
Abortion in the first 3 months is justified only at sick T., badly giving in to treatment, with widespread to destructive T. lungs when the previous pregnancies were followed by an aggravation of T., in the first 2 years after the postponed miliary tuberculosis and tubercular meningitis, at the accompanying diabetes mellitus, pathology of kidneys and a pulmonary heart. Late abortion (after 3 months) dangerously also the patient, cases is allowed only in exclusive, life-threatening. In the solution of a question of abortion at sick T. consider living and family conditions, desire to have the child; especially carefully it is necessary to treat the first pregnancy.
Breastfeeding is razresha-shat if at the patient mycobacteria of T are not allocated. In the absence of confidence in it of the child right after childbirth isolate and transfer to artificial feeding. When the lactation exhausts mother, feeding by a breast is stopped.
At mothers, sick T., full-fledged, almost healthy children with a normal weight and length of a body are born. Only at widespread destructive T. the body weight of newborns is a little reduced. These children are not infected and BTsZh needs to vaccinate them (see). The vaccinated child needs isolation from sick T. at least on 6 weeks.
Philosophy of DIAGNOSIS
Diagnosis of T. it is very difficult. Recognition of tuberculosis of a respiratory organs is based originally on selection of patients with various diseases of lungs from among all addressed for medical aid. For this purpose apply fluorography (see), to-ruyu recommend to carry out by everything to the persons who addressed to policlinic at the slightest pretext for the first time in this year. At absence in policlinic of the photofluorograph by way of exception make roentgenoscopy (see). Sick T. lungs can be revealed among the persons who addressed with complaints to cough of N expectoration. In these cases the research of a phlegm on existence of mycobacteria of T in it is important.
Further profound inspection of the selected patients with pulmonary pathology includes a number of methods of a research, the analysis of the acquired information, creation of the presumable diagnosis on the basis of the selected signs, carrying out differential diagnosis, a formulation developed a wedge, the diagnosis, validation of the established diagnosis in the course of observation and treatment of the patient.
Formulating the diagnosis, at first specify a wedge, a form T. (usually only one wedge, form T. a respiratory organs, and at defeat of several bodies list all localizations of tubercular process). At T. lungs give localization of defeat on shares or segments, and then characterize phases of process, existence or lack of a bakteriovydeleniye, complication.
At diagnosis use obligatory methods of a research (an obligatory diagnostic minimum), additional and optional methods.
The obligatory diagnostic minimum includes studying of the anamnesis and complaints of the patient, purposeful a wedge, inspection with use physical, rentgenol. researches, microscopic and bacterial. researches, tuberkulinovy tests, wedge, blood tests and urine. At the same time identification not only bright, but also malovy-razhenny symptoms, and also associated diseases is important. E.g., at detection of changes in a lung with fluorography it is necessary to carry out careful percussion and auscultation (the patient is asked to breathe more deeply, to cough, paying attention whether rattles appeared after that). The correct interpretation of data of percussion and auscultation at persons of advanced and senile age is important. It is necessary to consider age changes of a thorax and lungs, to-rye can weaken or shade completely characteristic of T. stetoakustichesky data.
At limited forms T., at early stages of its development, the disease can proceed with minimum a wedge, manifestations, on to-rye patients quite often do not pay attention. In these cases the disease can be revealed during the carrying out the prof. of surveys (see. Medical examination). However in the period of an aggravation of T. it can be found at the address of the patient to the doctor, most often concerning the appeared indisposition, weakness, temperature increase to subfebril-ny figures. Intoxication at such patients proceeds not for long and in 1 week — 2 months, as a rule, disappear. Obtusion of a pulmonary sound, change of nature of breath, rattles at limited tubercular process usually do not come to light. The expressed intoxication, cough, expectoration are noted at more extensive, especially cavernous, damage of lungs. Bronchial breath and rattles usually come to light at sick T. lungs at extensive destructive process, and it is even more frequent at hron. forms of a disease. At the same time changes of a shape of a thorax, obtusion of a pulmonary sound, wet and dry rattles of different caliber can be found.
The radiologist both che with to and y a method of a research is one of the main, especially at diagnosis of limited forms of tuberculosis of a respiratory organs (see), at to-rykh a wedge, manifestations are changeable and poorly expressed, and also at T. bones and joints, bodies of urinogenital system and some other (see Tuberculosis extra pulmonary). Rentgenol. the method allows to reveal localization of tubercular changes, to determine their extent and to estimate character morfol. changes — features of inflammatory reaction (productive or exudative), existence of disintegration, fibrosis, emphysema of easy, pleural unions, increase in the sizes intrathoracic limf, nodes, etc. Rentgenol. picture T. a respiratory organs at patients of advanced and senile age reflects a complex combination of T. with age features and residual changes after postponed patol. processes. As a rule, come to light emphysema of lungs (see) and a pneumosclerosis (see), is more rare — pleural stratifications, fibrosis of tops, developments of stagnation in lungs.
Bacteriologists che with to about e the research is directed to allocation of a contagium from a phlegm, the separated fistula, urine, etc. In the absence of a phlegm (see) it is possible to investigate rinsing waters of bronchial tubes, and also, according to a number of specialists, smears from a pharynx. Mycobacteria of T., as a rule, find in patients with destructive forms T., applying a method of crops on mediums. For this purpose, except microscopic examination of a phlegm or other material, it has to be produced triple bacterial. research. The age atrophy of mucous and muscular covers of a trachea and bronchial tubes, bronchiectasias, the complicated expectoration of a phlegm, etc. interfere with detection of mycobacteria of T. even in the presence of cavities. Therefore at patients of advanced and senile age along with bakterioskopiche-sky methods (a usual bacterioscopy, a method of flotation) follows? to repeatedly make crops of material on nutrient mediums. Perhaps single detection of mycobacteria of T. in a phlegm and in the absence of active T. lungs, napr, during the involvement in a zone of disintegration of a tumor or abscess of an old tuberculous focus.
Identification of mycobacteria of T. is an important diagnostic character of T. In many cases it plays a crucial role in diagnosis of this disease. Detection of mycobacteria, except diagnostic, has important epidemiol. value. Therefore in each case of identification of mycobacteria of T. the special notice shall be sent to a regional (city) antitubercular clinic and SES for registration of the patient constituting epidemic danger to people around and carrying out a complex of preventive measures in the center.
The Bakterioskopichesky method is least sensitive since it allows to reveal mycobacteria of T. in the presence of 100 — 500 thousand microorganisms in 1 ml of the studied material. Advantage of this method consists in speed of obtaining result and low cost of a research. Apply various ways of enrichment of material (flotation, sedimentation), and also advanced methods of coloring and microscopy to sensitization of a method (see. Microscopic methods of a research). The main method used for coloring of smears is the classical method of Tsil — Nelsena (see Tsil — Nelsena a method), at Krom of a mycobacterium of T. are painted by fuchsin in red color (see tsvetn. the tab. to St. Phlegm, t. 15, Art. 480, fig. 5). In recent years the method offered Murakhasi and yosidy gained distribution (T. Murahashi, To. Yoshida, 1957), allowing to differentiate in smears the live and died mycobacteria T. Mikroskopiya of the painted smears make in a light microscope under immersion.
For assessment of weight of process, efficiency of treatment and the forecast of a disease the great value is gained by quantitative assessment of mi-kobakterialny population by means of Gaffki's method — Stinkena and his various modifications. The principle of a method is that apply the dosed amount of material on the calibrated slide plate and in the smear prepared thus make calculation of number of mycobacteria in a certain number of fields of vision. The corresponding simple mathematical recalculation allows to define quantity of the mycobacteria allocated to patients per day and to estimate the quantity of vegetans mikobakterialny population which is usually characterizing activity of tubercular process.
In a crust, time by the most productive method of bakterioskopiche-sky diagnosis of T. the method of luminescent microscopy is (see), advantages to-rogo consist in its high sensitivity, especially at microscopy of the material containing trace amount of mycobacteria in an opportunity to reveal mycobacteria of T. with the changed cultural and tinktorial-ny properties.
Cultural methods of identification of mycobacteria of T. differ in bigger sensitivity, than bakte-rioskopichesky; they allow to allocate mycobacteria in the presence in the studied material of several tens viable mycobacteria, however the technique of pretreatment of material is quite difficult, for allocation special mediums (see), and for obtaining growth — a long span — from 1V2 to 12 are required week. The main advantage of a cultural method is the possibility of receiving pure growth of mycobacteria that allows to carry out its identification, studying of virulence, biochemical and biol. features and also to define sensitivity to pharmaceuticals.
One of the major stages lab. diagnoses of T. — identification of the marked-out cultures of microorganisms by means of a complex special mikrobiol. and biochemical methods of a research. It presents great difficulties since along with sharply changed and transformed mycobacteria of tuberculosis allocation of atypical or not tubercular mycobacteria, including acid resisting saprophytes is possible.
Definition of a range and degree of order of mycobacteria of T. to antituberculous remedies is one of the major and obligatory stages mikrobiol. T. Chuvstvitelnymi's diagnoses to antituberculous remedies consider those mycobacteria of T., on to-rye drug has bacteriostatic or bactericidal effect in the concentration reached in the center of an infection. Sensitivity of mycobacteria of T. growth at reference conditions is measured by the minimum concentration of drug, the detaining pix.
Medicinal sensitivity of mycobacteria of T. define bacterial with the help. methods of cultivations on dense or fluid medium. It can be established by means of direct and indirect methods. At a direct method existence in the material taken from the patient, a bakterioskogshcheska of the revealed mycobacteria is necessary; at an indirect method preliminary crops and obtaining growth of culture is necessary.
By the most sensitive method of identification of mycobacteria of T. in patol. material infection with it of Guinea pigs — biol is. test. Tubercular changes in bodies of a Guinea pig can be found at contents in 1 ld material even of single (1 — 5) mycobacteria. However in connection with emergence of drug resistant (especially izoniazidoustoychivy) mycobacteria of T. sensitivity biol. tests decreased since virulence of izoniazidoustoychivy mycobacteria is reduced or completely lost for Guinea pigs. For the purpose of sensitization biol. tests are offered various methods which are artificially reducing natural resistance of Guinea pigs to T.: introduction of high doses of a cortisone, an in-tratestikulyarny method of infection, etc., to-rye with success apply to allocation of the drug resistant and other changed forms of the activator
of T. Tuberkulinovye of test — intradermal introduction 2 THOSE standard tuberculine (see) or the graduated skin test with its various cultivations (see the Tuba a rka of a linodiagnostik). At persons of advanced and senile age the tuberculinodiagnosis has the features. Positive reaction to tuberculine at such patients appears later (in 72 — 96 hours instead of 48), papules have the small sizes, the zone surrounding them is not hyperemic, giperergichesky reactions are seldom observed.
Clinical blood tests and urine, as a rule, do not allow to reveal the specific characters characteristic only of T. Odnako in combination with other data they play an important role in establishment of the diagnosis and control of influence of pharmaceuticals on an organism of the patient. A certain impact on results of these researches is exerted by age changes and associated diseases. So, the accelerated ROE is not always an indicator of activity of specific process, especially at senile age, and shall be considered only in total with others of kliniko-rents-genol. data. Besides, at hron. destructive forms T. at the persons of advanced and senile age, and also at an aggravation accompanying hron. nonspecific diseases of lungs these changes can demonstrate activation of secondary flora.
Additional methods of a research. On the basis of the data obtained by means of the methods entering an obligatory diagnostic minimum the decision to apply these or those additional methods of a research is made. They are subdivided into two groups.
The first group includes a repeated research of a phlegm, rinsing waters of bronchial tubes, the separated fistula, urine, etc. on a mycobacterium of T. by method biol. tests (see the Phlegm), a tomography of lungs and a mediastinum, immunol. researches — reactions of a blastotransformation and braking of migration of lymphocytes (see Blastotransformation of lymphocytes, Macrophage fixation), etc., researches proteinogram-we and S-reactive protein (see). The known value belongs to a profound tuberculinodiagnosis (see) — to definition of limit of sensibility to tuberculine, its hypodermic introduction with carrying out bel-kovo-and gemotuberkulinovy tests.
Immunol. methods can give help in differential diagnosis of T. and other diseases of lungs, assessment of activity of tubercular process, efficiency of the carried-out treatment and to a certain extent the forecast of a zabolevniya, immunol. the status of an organism of the patient before an operative measure, and also in detection of the minimum activity of T. and in the solution of a question of the termination of treatment. With the help immunol. tests also an attempt to carry out differential diagnosis between a postvaccinal and infectious allergy, to reveal the pharmaceuticals which are the reason of allergic reaction is made.
In a crust, time use set immunol. the tests which are carried out by in vitro with blood of patients. Identification of antigens of mycobacteria, calculation of number and assessment of potential reactivity of T - and V-lymphocytes, quantitative assessment of T lymphocytes, specifically sensibilized to the corresponding antigens, and their subpopulya-tion, definition of factors of nonspecific reactivity concern to them.
Antigens of mycobacteria of T., and also other microorganisms causing diseases to-rye demand differential diagnosis with T., it is difficult to find both in serum, and in blood cells. They are revealed at dissociation of cell-bound immune complexes and use of reaction of an agregatagglyutination (RAGA), reaction of passive hemagglutination on Boydena (see Boyden reaction) with pretreatment of erythrocytes glutaraldehyde across Gorina (1975).
Calculation of number T - and V-lymphocytes make usually by means of methods of rosetting (see Rosetting tests). Potential reactivity T-and V-lymphocytes is determined by reaction to mitogens of T lymphocytes (fitogemagglyu-tinin — FGA, concanavalin A — the Game) and V-lymphocytes (bacterial lipoioliyeakharida — LPS). And reactions with these drugs put as in vitro — reaction of a blastotransformation (RBT), the reaction of braking of migration (RBM), and in vivo — skin tests.
For quantitative assessment of T lymphocytes, specifically sensibilized to the corresponding antigens, their subpopulations and mediators use the same methods, as at the characteristic of all population of T - and V-lymphocytes and their antibodies, but put these reactions with specific mikobakterialny antigens.
By the most sensitive and widely applied methods for identification of antibodies at T. reaction of passive hemagglutination (RPGA) on Boydena, reaction of an agregatagglyutination (RAGA), the reaction of binding complement (RBC) are.
During the definition of factors of nonspecific reactivity study first of all phagocytosis, reveal a lysozyme and components of system of a complement.
Use immunol. methods shows that at active T. usually both the condition of immune systems, and their specific answer to the tuberculine found in in vitro tests changes.
Informational content various immunol. methods substantially raises if specific humoral (e.g., RAGA) and (or) cellular immunity (e.g., RBT and RTM) to combine statement of tests with hypodermic administration of tuberculine (provocation). Immunol. reactions put before and after (in 48 hours) hypodermic administration of tuberculine (on average 20 THOSE to children and 50 — 100 THOSE the adult). It is especially necessary at diagnosis of T. in disputable cases and identification hidden T. (minimum activity). Indicators of tests of cellular immunity of in vitro happen characteristic of various phases and options of a current T. Tak, the results received during the use of RBT and RTM show that the first is most expressed at the favorable course of process and a bystry rassasyvaniye of specific defeats, and the second — during the progressing of process (indexes
lower than 0,4 — 0,5) and vice versa. The highest credits of antitubercular antibodies (1: 256 — 1: 1024) RAGA in case of the expressed activity of process are noted. In the same terms also the most high level of immune rosetting lymphocytes is found. At inactive T. the quantity and potential activity of T lymphocytes differ from those at healthy people more often a little, however at a disease outbreak the level of a blastoobrazovaniye and number of rosetting T lymphocytes usually decrease to 65 — 50 and 45 — 35% respectively. In an active phase T. are a little raised level rosetting In - lymphocytes (15 — 25%), and also IgG and IgA. Indicators immunol. tests depend not only on activity of process, but also on a number of other factors. Therefore they have a wedge, value only in a complex with kliniko-rentgenol. data. The most reliable judgments of a state and change of specific reactivity of an organism give repeated immunol. researches.
Using the initial parameters characteristic of various phases of activity of process, and especially defining various indicators of immunity in dynamics, it is possible to judge efficiency of the applied treatment. At effective treatment indicators of a specific blastoobrazovaniye increase, the RTM level decreases, and the level of antitubercular antibodies in most cases also tends to decrease.
Immunol. the research has essential predictive value: it is established that suppression of T-system of immunity at sick T. is an adverse predictive sign.
Second group. The total score of the data obtained by means of the methods making an obligatory diagnostic complex, and the additional methods of a research relating to the first group allows to make the diagnosis or to make deeper and complete idea of the nature of the revealed disease, to considerably narrow a circle of the pathology which is subject to differentiation. However at a part of patients even after use of these methods the diagnosis remains not clear and there is a need in morfol. its confirmation.
This task can be carried out by means of the second group of additional methods of a research. At diagnosis, e.g., T. a respiratory organs treat them a survey bronkhoskopiya (see) in combination with a transtracheal or transbronchial puncture biopsy, a direct biopsy of a mucous membrane of bronchial tubes and patol. educations in them; transthoracic aspiration biopsy of a lung, puncture biopsy of a pleura; a puncture peripheral limf, nodes (see the Biopsy, the Puncture). These methods can be combined if necessary with a bronchography (see). In nek-ry cases make a mediastinosko-piya (see), a mediastinotomy (see), an open biopsy of a lung (see Lungs, operations), a plevroskopiya (see Torakoskopiya) with an urgent laboratory research of the received material. A problem of each of these methods — receiving patol. material, during the studying to-rogo (cytologic, histologic, bacteriological *) the diagnosis can be specified.
Optional methods of a research are an important element of diagnosis, especially at patients with the complicated course of process and in the presence of associated diseases. They are directed to studying of function of various bodies and systems, disclosure of mechanisms of various functional changes, and also identification of exchange disturbances. At diseases of a respiratory organs of the most important optional methods are a research of function of breath (see) and blood circulations (see), conditions of protein and carbohydrate metabolism (see. A nitrogen metabolism, Carbohydrate metabolism), definition of a vitamin deficiency (see. A vitamin deficiency), profound studying of function of a liver (see), a research of a condition of coagulant system of blood (see) at a frequent blood spitting and bleedings.
PHILOSOPHY of TREATMENT
by the Main objective of treatment of sick T. permanent healing of tubercular changes due to development of reparative processes in the struck bodies and complete elimination of all a wedge, displays of a disease (clinical treatment) is. To achieve it, it is necessary to observe philosophy of treatment strictly.
Treatment of the patient T. shall be early. At limited focal changes (so-called small forms T.) and even the destructive processes revealed at earlier stages of a disease, efficiency of treatment is higher, than at patients
with T. V started fibrous and cavernous or c and r a mouth ichesk by it the crust, time are not developed the methods allowing to achieve treatment in short terms therefore treatment of the patient T yet. shall be long. On average treatment of the patient T. at successful therapy comes in 1 year. In some cases treatment continues 2 — 3 years and more. Communication between degree of neglect of tubercular process and duration of treatment is accurately traced. What more started tubercular process, especially treatment shall be long. In a crust, time the problem of reduction of terms of treatment of sick T is urgent. Prolonged treatment of the TB patient with his stay, as a rule, in several to lay down. institutions causes need of respect for succession. Treatment of patients, as a rule, begins in a hospital. On reaching kliniko-rentgenol. effect (the termination of a bakte-riovydeleniye, healing of destructive changes) for rehabilitation of patients send to sanatoria (local and climatic). Finish treatment in out-patient conditions.
Problem of the organization of treatment of sick T. in a crust, time is considered usually in a wedge, and epidemiol. aspects. The wedge, aspect includes questions of a technique of treatment, indications to use of these or those methods, providing a favorable result of tubercular process. Epidemiol. the aspect of this problem consists in the organization of treatment of sick T. so that to reduce probability of distribution of contagiums.
Treatment of the patient T. shall be complex. Main component of complex treatment of T. the chemotherapy is, about a cut the most important achievements of phthisiology are connected (see). Are reached, undoubtedly, positive takes in the field of search, testing and implementation in practice of various antituberculous remedies (see). Modern chemotherapy (see) allows to cure patients not only with limited, fresh forms T., but also with heavy, widespread process, with a recurrence of a disease, and also patients, at to-rykh T. it is combined with other diseases.
The therapeutic effect of chemotherapy is caused by antibacterial action on a mycobacterium of T. antituberculous remedies. Degree of therapeutic effect depends, on the one hand, from their tubercle of astatic activity, and with another — on a condition of bacterial population. At the same time it is important to consider that antituberculous remedies make impact not only on mycobacteria of T., but also on various bodies and systems of the patient. Level of bacteriostatic concentration of this or that drug substantially depends on its dose. Therefore during the carrying out chemotherapy the right choice of antituberculous remedies taking into account their tuberculostatic activity and use of these means in an optimum daily dose is of great importance.
In recent years the concept «mode of chemotherapy» is entered, under the Crimea mean use of a certain combination of drugs, the choice of a dose, frequency rate and a way of introduction to an organism of the patient (inside, intramusculary, intravenously, in the form of aerosols, endobronchial injections, rektalno), determination of optimum duration of chemotherapy.
Due to the different condition of bacterial population at different stages of a disease the period of chemotherapy can be divided into two phases or a stage. At the first stage carry out intensive chemotherapy for the purpose of suppression of reproduction of mycobacteria, reduction of their quantity. The second stage (a phase of an aftercare) — a stage of less intensive chemotherapy; its purpose — impact on the remained bacterial population, hl. obr. persistent forms of mycobacteria. The main task of this stage is the prevention of reproduction of the remained mycobacteria.
In the first days of treatment antituberculous remedies are appointed in small doses, to-rye quickly raised to therapeutic, optimum. Co-administration of various means in the pathogenetic relation can prevent their side effect.
The daily dose can be entered in one step or to divide into several receptions. Such drugs as an isoniazid (see), rifampicin (see Rifamycinums), streptomycin (see Streptomycin), Kanamycinum, (see), Ethambutolum (see), biomycin (see Florimitsin), apply 1 time a day. It allows to control better administration of drugs by medical staff, and, above all, creates high concentration of drug in blood. PASK (see), thioacetazone (see), Pyrazinamidum (see) it is possible to enter in one step or to divide a daily dose into several receptions. A daily dose of such means, as Etioniamidum (see) and Cycloserinum (see), because of their toxicity is applied generally in parts — 2 or 3 times a day.
Efficiency of chemotherapy in many respects depends on duration of treatment. If during emergence of the first antituberculous remedies duration of treatment was rather small —
1 — 3 month, then in the subsequent duration of chemotherapy gradually increased to 9 — 12 months, and sometimes and more. The premature termination of chemotherapy can lead to an aggravation of tubercular process owing to reproduction of the rest of bacterial population. Therefore determination of optimum duration of chemotherapy is of great importance both during the scheduling of treatment, and in its process (depending on dynamics of tubercular process). Antituberculous remedies enter daily, especially in an initiation of treatment, and further — 2 times or even once a week.
Not less important task, than the choice of the mode of chemotherapy, ensuring regular reception by the patient of the appointed drugs during the entire period of treatment is. The methods providing a regularity of chemotherapy are closely connected with organizational forms of treatment in hospital, sanatorium and out-patient conditions. In hospital and sanatorium conditions, reception of the appointed drugs shall be carried out in the presence of medical staff for the purpose of the exact accounting of the accepted pharmaceuticals. At treatment in out-patient conditions of the patient accepts drugs in the presence of medical staff in to lay down. establishment (antitubercular clinic, health center) or at home. Control of administration of drugs is facilitated at purpose of a daily dose in one step. The patient can also accept the antituberculous remedies given in an antitubercular clinic for a certain term, is more often for
10 days. Periodically carry out an inspection of a consumption of the medicines received by the patient, and also researches of urine on availability in it of antitubercular drugs or products of their metabolism.
«the mode of chemotherapy» of patients with for the first time to the revealed T has essential features. and the patients who were already receiving earlier antituberculous remedies.
For the first time the revealed TB patients do not represent homogeneous group. Among them there can be persons of various age, with different a wedge, forms of tuberculosis, with existence or lack of destruction and a bakteriovydeleniye. Schematically all for the first time the revealed TB patients can be divided into four groups. 1 group is made by patients with existence of destructive changes in lungs;
The 11th group — patients with the expressed forms of a pulmonary tuberculosis in a phase of infiltration, but without destruction; The III group — persons with so-called small forms T.; The IV group — persons with tubercular changes, activity to-rykh is doubtful. The technique of chemotherapy and organizational forms of its carrying out depend on what of these groups the patient with for the first time
the patients carried to the first and second groups revealed T. Himioterapiya treats carry out in two steps. At the 1st stage to the patient appoint three most active antitubercular drugs before the termination of a bakteriovydeleniye and closing of a cavity. The basis of a combination of these himiopreparat is made by a combination of an isoniazid (Tubazidum) and rifampicin; as the third drug streptomycin, Ethambutolum or Prothionamidum (Etioniamidum) can be used. However it is the most reasonable to appoint in these cases as the third drug streptomycin. At the 2nd stage of treatment at the termination of a bakteriovydeleniye and healing of a cavity (usually within the first 3 months after an initiation of treatment) streptomycin and rifampicin cancel and treatment continue by two drugs — an isoniazid and Ethambutolum or Prothionamidum (et an ion amide) within 6 months. At the remained cavity irrespective of results bacterial. researches, treatment continue by an isoniazid, rifampicin and Ethambutolum or Prothionamidum (Etioniamidum) of 3 more months. During the healing of a cavity and the termination of a bakteriovydeleniye in 6 months of treatment rifampicin is cancelled and continued chemotherapyyu an isoniazid and Ethambutolum or Prothionamidum (Etioniamidum) within 3 months. When such course of treatment does not lead to healing of a cavity, the issue of need of an operative measure shall be resolved. At nek-ry patients with existence of a tuberculoma or the created cavity operational treatment is carried out earlier.
To the patient included in the third group, the chemotherapy is carried out by three drugs (an isoniazid, streptomycin and Ethambutolum or Prothionamidum) within 1 — 2 month then streptomycin is cancelled and treatment is continued by two drugs — an isoniazid and Ethambutolum (instead of Ethambutolum it is possible to use Prothionamidum or PASK) 6 — 8 more months (in total up to 9 months).
In chemotherapy of the faces carried to the fourth group use three drugs — an isoniazid, streptomycin and PASK (or Ethambutolum) within 3 months. If at the same time it is observed positive rentgenol. dynamics, process it is necessary to consider as active and to continue treatment by the chosen combination of drugs before stabilization of process. In the absence of dynamics of process within 3 months (in total with negative tests for activity of process) the chemotherapy is stopped and the patient is transferred to dispensary observation.
Individualization to lay down. tactics the wedge, overseeing by the patient at all stages of chemotherapy is based on results careful. At the same time during treatment in some cases it is necessary to make changes to the program of chemotherapy made earlier. It is caused by side reactions on this or that drug, medicinal stability of mycobacteria of T. and lack of effect of the carried-out therapy. The last is most often expressed by the division and preservation of a cavity continuing bakteriovy-, and sometimes a slow rassasyvaniye of inflammatory changes in lungs. There are various opportunities of change of the mode of chemotherapy: replacement of drugs, change of a way of their introduction or use of different combinations of methods of administration of drugs. At later stages of treatment, especially at the slowed-down regression of process at already stopped bakterio-allocation, but with the remained cavity, appoint the means stimulating reparative processes.
In group of the patients who were earlier receiving antituberculous remedies, the greatest danger is constituted by patients to fibrous and cavernous T. lungs. At the patients who were earlier treated by antituberculous remedies not only the bakteriovydeleniye often is observed, but also medicinal stability of mycobacteria comes to light. Lech. tactics at these patients is defined by existence or lack of medicinal stability to these or those drugs.
With medicinal stability of mycobacteria of T. patients can appoint only those drugs, to the Crimea sensitivity remained. Data on medicinal sensitivity of mycobacteria can be obtained on average in
2 — 3 months after crops of a phlegm. If the patient comes to a hospital without these data, he begins to be treated, being guided by data on earlier used drugs. It is possible to accelerate definition of medicinal sensitivity of mycobacteria, applying a direct method of a research, but only at a massive bakteriovydeleniye. However results of direct definition of medicinal sensitivity of mycobacteria are inexact therefore along with a direct method it is necessary to carry out definition of medicinal sensitivity by an indirect method. After comparison of the results received by means of these methods make amendments to the initial conclusion and to lay down. tactics. At resistance of mycobacteria (especially polirezistent-nost, i.e. several drugs resistance) efficiency of chemotherapy decreases.
On all patients hron. forms T. with a bakteriovydeleniye it is recommended to get cards, in to-rye enter data on existence of allocation and medicinal sensitivity of mycobacteria to antituberculous remedies. The card file consisting of such cards shall be in a regional antitubercular clinic, and also in regional or interdistrict bacterial. laboratories. At arrival of the patient in an antitubercular hospital or sanatorium, and also need to carry out treatment in out-patient conditions it is necessary to request the data
on medicinal sensitivity of the mycobacteria allocated to patients, which are available in such card file. It allows to choose the most rational combination of drugs for each patient. When the bakteriovydeleniye is absent, are guided only by dynamics of tubercular process.
Drugs for chemotherapy of the patients who were earlier receiving antituberculous remedies should be selected individually. The complex of means including rifampicin and two other drugs is considered effective, to the Crimea sensitivity of mycobacteria remained.
For treatment of patients hron. forms T. it is possible to apply the following combinations of the existing antituberculous remedies including three drugs: Etioniamidum + Cycloserinum + Pyrazinamidum; Etioniamidum + Kanamycinum + Pyrazinamidum; Etioniamidum + florimitsin + Pyrazinamidum; Kanamycinum + Cycloserinum + Pyrazinamidum; florimitsin + Cycloserinum + Pyrazinamidum; Ethambutolum + Cycloserinum + Etioniamidum; Ethambutolum + Kanamycinum + Etioniamidum; Ethambutolum + florimitsin + Etioniamidum; rifampicin + Kanamycinum + Etioniamidum; rifampicin + florimitsin + Etioniamidum; rifampicin + Ethambutolum + Etioniamidum (Cycloserinum, Kanamycinum or florimitsin).
In addition to combinations from three drugs, combinations from two drugs are possible. Transition to treatment by two drugs is made in connection with reached a wedge, effect or in connection with bad portability of three drugs, or at emergence to one of the used drugs of medicinal stability of mycobacteria and impossibility to replace it with another.
The specified combinations of drugs can be applied daily, and at bad portability — every other day. Quite often after daily administration of drugs within
2 — 3 months pass to an intermittent method of their introduction — 2 times a week. At hron. forms T. prolonged treatment of the patient (not less than 12 — 18 months) is necessary.
By means of chemotherapy it is possible to suspend the progressing tubercular process and to achieve its relative stabilization with rare flashes even without bakterio-allocation or with a sporadic bakteriovydeleniye. The X imioterapiya gives the chance to avoid complications of T., but does not allow to try to obtain treatment of all patients. Therefore patients hron. forms T. in the presence of indications are subject to operational treatment. The last shall be applied before development of complications and before development of the state interfering performing surgery.
In view of the difficulties connected with prolonged use of antituberculous remedies, the commission of the International union on fight against tuberculosis made the decision to consider reduction of duration of chemotherapy a problem of paramount importance. At the same time as the main drugs it is offered to use an isoniazid and rifampicin. Streptomycin, Prothionamidum or Ethambutolum can be appointed the third drug. According to a number of researchers, except rifampicin and an isoniazid, Pyrazinamidum has the expressed effect, to-ry recommend to enter for chemotherapy with the shortened duration. According to V. A. Chukanov, addition of Pyrazinamidum as the fourth drug does not increase therapeutic effect and, apparently, unfairly.
Cancel antituberculous remedies only at their full intolerance or danger to cause heavy by-effects. Manifestations of side effect of the means applied in a crust, time to treatment of T., can be various — from minimum to heavy. Heavy medicinal complications seldom meet in a wedge, to practice and arise, as a rule, owing to disturbances of carrying out chemotherapy and insufficiently full inspection of the patient.
Frequency of side reactions depends also on the choice of drugs. In the conditions of the combined chemotherapy side effect of pharmaceuticals is more often observed at purpose of Etioniamidum, flori-mitsin, Cycloserinum, streptomycin, Kanamycinum. Serious danger to patients is constituted by reactions from system of blood, especially an agranulocytosis (see). At treatment by Pyrazinamidum, rifampicin, Etioniamidum, less often an isoniazid abnormal liver functions are possible. Cases of an acute renal failure at use of rifampicin are described.
The place, the second for value, after chemotherapy is taken by the pathogenetic methods of treatment directed to normalization of the broken functions of an organism, reduction of extent of inflammatory reaction, stimulation of processes of regeneration, elimination of exchange disturbances. Pathogenetic therapy is carried out by means of various pharmaceuticals: corticosteroids, tuberculine (see), BTsZh (see), means of fabric therapy, a lidaza (see Hyaluronidase), pyrogenal (see), etc. Perform vitamin therapy (see) since disturbance of vitamin balance at T. quite often leads to development of a hypovitaminosis (see. Vitamin deficiency). Widely apply anabolic means (see. Anabolic steroids) and some other the pharmaceuticals allocated for normalization of exchange processes. Carry to pathogenetic methods of treatment also methods, with the help to-rykh eliminate various dysfunctions of breath, cardiovascular system, kidneys, a liver, etc. Special means use for the purpose of the termination of a pneumorrhagia and other manifestations of T.
A specific place among means of pathogenetic therapy is held by adrenal hormones and their synthetic analogs — a cortisone (see), Prednisonum (see), dexamethazone (see), a hydrocortisone (see), Triamcinolonum, etc. They are shown at forms T. with the expressed exudative reaction — infiltrative process, acute it is lovely pair to T., tubercular meningitis (see), exudative pleurisy (see), peritonitis (see), a pericardis (see), a polyserositis (see), and also at a widespread tubercular endobronchitis and the giperergichesky reactivity of an organism caused by features of a course of tubercular process or allergenic influence of antituberculous remedies.
Treatment by corticosteroids is admissible only in combination with antituberculous remedies. In the course of treatment control of the ABP, a state is necessary went. - kish. a path, the level of sugar in blood. Average duration of treatment by corticosteroids from 3 to 8 weeks. At more prolonged treatment there is a danger of oppression of function of adrenal glands. Corticosteroids cancel gradually, reducing a daily dose during 3 weeks (for this period function of adrenal glands is generally recovered). Bystry drug withdrawal can cause a withdrawal — an indisposition, weakness, decrease in the ABP, a headache, nausea, vomiting, as a rule, passing in the next few days. During cancellation of corticosteroids it is reasonable to appoint Resochinum or delagil (see Chingaminum) on
0,25 g after food once a day.
Adrenal hormones are contraindicated at pregnancy, a peptic ulcer of a stomach and a duodenum, psychoses, Itsenko's disease — Cushing, heart failure, severe forms of a hypertension, syphilis, hron. alcoholism. Treatment of sick T by them. and the accompanying diabetes mellitus perhaps, but in the conditions of full antitubercular treatment and an insulin therapy.
A wedge, observations and pilot studies promoted widespread introduction in a wedge, practice of tuberculine (see). Being offending allergen, tuberculine depending on a route of administration renders as hyposensibilizing, and a promoting effect. Under the influence of tuberculine strengthening of a lymphokinesis, a trichangiectasia in a zone of defeat, increase in permeability of vessels and function of system of mononuclear phagocytes is observed, that eventually provides the best penetration of antituberculous remedies into the center of defeat and stimulation of processes of regeneration. An indispensable condition of a tuberculinotherapy is its carrying out against the background of full treatment by antituberculous remedies.
Tuberculine is shown at the slowed-down involution of specific changes in lungs, tendency to encystment at focal, infiltrative, disseminirovannokhm to T., small tuberculomas, damage of bronchial tubes, extra pulmonary localizations of specific process. It is reasonable to apply tuberculine for the purpose of desensitization at nek-ry forms primary and secondary T., proceeding against the background of a hyper sensitization of an organism. Use of tuberculine at a torpid current is possible hron. destructive T. lungs out of a phase of an aggravation.
There are uses given about expediency in complex treatment of sick T. vaccinotherapies. In diverse influence of vaccine BTsZh on an organism its ability to stimulate reactivity of an organism, to activate reparative processes and to increase thus efficiency of complex antibacterial therapy is especially important. Use of vaccine BTsZh is shown at a torpid current infiltrative, focal, disseminated, cavernous to T. lungs and it is contraindicated at all forms of process with existence of widespread destructive changes.
The vaccine is recommended to enter vnutrikozhno into the area of a hip (
3 — 4 injections on a course with an interval
of 3 — 4 weeks). Before the use it is parted with isotonic solution of sodium chloride according to the enclosed instruction. The injection of vaccine BTsZh, as a rule, on
4 — causes the 5th day local reaction — formation of a pustule with the crust which soon is tearing away with formation of a hem. To the 3rd week local reaction usually disappears. Also the focal reaction which is quickly taking place in conditions of antibacterial therapy is possible. Emergence of local and general reactions does not interfere with continuation of treatment.
During a pre-antibiotic era researchers noticed the fact of beneficial effect of insulin (see) on the general condition of sick T. — improvement of appetite, increase in body weight. In-depth studies allowed to open various parties of the mechanism of effect of this hormone, namely ability to increase utilization of glucose in fabrics, to influence processes of a fabric metabolnzkhm, function central and the autonomic nervous system, and indirectly thereof also other mechanisms — to increase gastric secretion, gastric acidity.
An insulin therapy is carried out by courses io 1 — 1V2 month in combination with antituberculous remedies in any combination. The daily dose of 5 — 8 PIECES is entered subcutaneously once a day in 30 min. prior to food. As a rule, drug is well transferred, in some cases in 1 — 2 hour after its introduction the perspiration, weakness, a tremor which are quickly passing after meal or 5 — 10 g of glucose are possible. In case of need repeated courses of an insulin therapy are appointed with intervals
of 1 — 2 month.
Use of insulin is shown at all forms T. lungs after elimination of signs of progressing and at sluggish, torpidnokhm the course of processes of a reparation; at T. at persons of advanced and senile age; at a razvrggiya of side effect of antituberculous remedies, in particular, dystrophic changes of a liver and other parenchymatous bodies, decrease in secretory function of a stomach, etc. An insulin therapy is contraindicated at increase of inflammatory changes in lungs, a combination of T. with stenocardia, a peptic ulcer or bronchial asthma because of danger of their aggravation, at tendency to obesity. Along with insulin
also the anabolic steroids (see) stimulating synthesis of protein in an organism are among drugs of anabolic action. In phthisiology most widely apply methandrostenolone (see), retabolil (see), Methylandrostendiolum (see), metiltes-tosteron (see). Anabolic steroids increase efficiency of complex treatment of sick T., reduce intoxication, strengthen reparative processes, improve portability of a number of antituberculous remedies, soften the phenomena of a hypocorticoidism at the otkhmena of corticosteroids.
Anabolic steroids recommend to apply along with antituberculous remedies during the course proceeding 2 months.
Anabolic steroids are shown at destructive processes, ostrotekushchy or chronic with the expressed intoxication and a disproteinemia; at the destructive processes which developed after operative measures on lungs; active T. at elderly people, at small forms T. lungs with a torpid current and accompanying zabolevaniyakhm (a diabetes mellitus, an ulcernny stomach disease and duodenum, hron. gastritis, hron. hepatitis). Drugs are contraindicated at the excess weight of a body, disturbances of a menstrual cycle.
Reception of anabolic steroids can have an adverse effect on a functional condition of a liver, promote increase in activity of serumal aminotransferases in this connection in the course of treatment periodic laboratory control is necessary.
The mechanism of effect of pyrogenal (see) it is studied not enough, however it is established that it promotes activation of pituitary and adrenal system, systems of mononuclear phagocytes, possesses antiallergic action, stimulates protective forces of an orga-nizkhm. Besides, it improves portability of antituberculous remedies and increases efficiency of treatment. Pyrogenal is entered intramusculary since a dose 25 — 50 MPD (minimum pyrogenic dose) every other day and gradually adding 25 — 50 MPD before achievement of a dose 1000 MPD. Course of treatment of 20 — 25 injections. The pyrogenic reaction arises usually in 3 — 4 hours after administration of drug and independently takes place in 12 — 24 hours without additional interventions. As portability of pyrogenal is various, selection of doses shall be strictly individual. At the expressed to fever, muscular and joint pains it is reasonable to reduce a dose of pyrogenal.
As the indication to use of pyrogenal serve destructive forms T. lungs in the absence of effect of antibacterial therapy, and also tendency of specific process in lungs to fibrosing or encystment. Treatment by pyrogenal in ostu-rum the period of all forms T is contraindicated. lungs with the expressed infiltrative changes, at large tuberculomas, hron. destructive process, cirrhotic T., at a pulmonary heart of the II—III degree, a blood spitting, at associated diseases (an idiopathic hypertensia of the II—III stage, a diabetes mellitus). It is not necessary to appoint drug at pregnancy; with care drug is appointed to persons 60 years are more senior.
In the course of treatment by pyrogenal emergence of focal reaction is possible, however the last, as a rule, acts under the influence of the continuing antibacterial therapy.
Prodigiosanum (see) increases bactericidal activity of blood and phagocytal activity of macrophages, has the antiallergic effect connected with stimulation of pituitary and adrenal system. At suffering from tuberculosis lungs increases efficiency of antibacterial therapy, especially at the slowed-down dynamics of specific changes in lungs. Promotes the expressed rassasyvaniye of infiltrative changes and the centers, reduction of a cavity with the subsequent its closing.
Prodigiosanum is shown at torpid-but the current processes in easy, band changes in lungs without the expressed inflammatory reaction and fibrosis; at infiltrative process with existence of caseous and necrotic focuses. Contraindications — insufficiency of cordial activity, disturbance of coronary circulation.
Methyluracil (see) increases nonspecific resistance of an organism, stimulates reparative processes, increases efficiency of antibacterial therapy at patients T. Preparat appoint inside 1 g 3 times a day, to persons 60 years — on 1 g 2 times a day are more senior. Course of treatment of 2 months. Repeated courses are possible in 3 — 4 months. Portability of drug good, the allergic reactions disappearing after the termination of administration of drug and purpose of the hyposensibilizing means are in some cases possible.
Indications to use methyluracil and — focal, infiltrative. disseminated by T. lungs with disintegration, limited fibroznokavernozny T. lungs at the slowed-down dynamics of process and at a combination to a peptic ulcer, gastritis, colitis, a diabetes mellitus. Methyluracil is contraindicated at sochetany T. with malignant new growths, at tuberculomas and cirrhotic T. lungs.
Among means of pathogenetic therapy the increasing attention of phthisiatricians attracts heparin (see). For the purpose of desensitization it is recommended to use heparin in a dose of 5000 PIECES intramusculary every other day within 1 — 1V2 month. To and in the course of treatment control of coagulative properties of blood is necessary (see Koagulogramm). Positive influence of heparin in combination with antibacterial therapy on the course of reparative processes at various forms T is established. lungs.
In a wedge, the drugs containing hyaluronidase found for practice application as means of pathogenetic therapy and among them domestic drug is a lidaza (see Hyaluronidase). The versatility of effect of drug, in particular increase under its influence of permeability of gistogematichesky barriers, phagocytal properties of connective tissue cells, braking of development of cicatricial fabric and some other, caused its broad use not only for adults, but also for children of sick T.
In the conditions of complex antibacterial therapy with use of a lidaza processes of healing at T. lungs and bronchial tubes develop earlier and are more perfect, in particular development of fibrosis is prevented.
The drug is administered every other day the adult in a dose of 64 conventional units intramusculary. Before introduction contents of an ampoule dissolve 0,5% of solution of novocaine in 1 ml. A course of treatment — 30 injections. Repeated courses with a break of 1 — 1V2 month are possible.
Indications to purpose of a lidaza: focal, disseminated by T. lungs, and also primary T. without the expressed caseous defeat limf, nodes.
As means of the stimulating therapy use ultrasound (see) and an inductothermy (see). The reflex strengthening of blood circulation and lymph drainage arising at the same time in lungs improves the course of reparative processes. At the same time strengthening of inflammatory reaction in the center of defeat is possible that promotes the best penetration in it of pharmaceuticals and increase in efficiency of treatment.
Ultrasound and an inductothermy are shown to patients with focal, infiltrative, limited disseminated by T. lungs, a tuberculoma with destruction after a rassasyvaniye of infiltrative changes; at cavernous T. in the conditions of insufficient efficiency of the previous therapy; at limited forms of tubercular process in lungs with a torpid current and tendency to an otgranicheniye. Contraindications: the acute course of tubercular process in lungs; extensive fibrous and cavernous and cirrhotic T.; tendency to a pneumorrhagia, combination of T. lungs with coronary heart disease, a thyrotoxicosis, tumoral process, in the presence of a pulmonary heart of the II—III degree.
Skillful use of means of pathogenetic therapy at different stages of complex antibacterial therapy creates premises for increase in efficiency of treatment of sick T.
Complex therapy of T. includes also a collapsotherapy (see), i.e. to lay down. pheumothorax (see) and a pneumoperitoneum (see). The collapsotherapy in a crust, time is applied very seldom, it is used at rather narrow group of patients, napr, at medicinal resistance or full intolerance of antituberculous remedies. The collapsotherapy can be applied to a stop of a pneumorrhagia if it does not manage to be reached by means of other methods (see the Pneumorrhagia).
When conservative treatment is inefficient, resort to diverse methods of operational treatment. At T. a respiratory organs most often use pneumonectomies (see Lungs, operations), a pneumonectomy (see), a decortication (see the Decortication of a lung) and a pleurectomy (see), but did not lose the value and a thoracoplasty (see), a cavernotomy (see), drainage of a pleura (see Byu-lau a drainage), etc.
Treatment of children, sick T., carry out according to the same schemes, as adults, expecting the appointed antituberculous remedies 1 kg of body weight. It is necessary to avoid use of PASK and to carefully appoint hormonal drugs.
The leading method of treatment of patients of advanced and senile age is the chemotherapy, the basic and antirecurrent courses a cut in most cases shall be carried out in the conditions of a hospital. To persons of senile age daily doses of antituberculous remedies reduce on 1/3 in comparison with optimum for persons of mature age; method of the choice at such patients is the intermittent chemotherapy. Along with the standard means of pathogenetic therapy by the patient of advanced and senile age it is necessary to appoint the drugs improving a metabolism and the general condition of an organism.
In treatment of the patient T. the hygienic mode and a diet adequate to its state is of great importance. The mode of absolute rest is applied seldom, only at serious condition of the patient, napr, after operation, at a blood spitting. In process of elimination of intoxication include the training factors in the mode, to-rye use fully during rehabilitation. It is wrong to consider that to cure the patient T. it is possible only by means of antibacterial and pathogenetic agents. The way of life of the patient, character of its food play very important role in the course of treatment. Food of the patient shall be high-calorific and digestible, with the high content of protein and vitamins, especially redoxons and group B (see clinical nutrition).
Dignity. - hens. treatment is shown, as a rule, in the period of involution of process. Use of advantage climatic factors, and also carrying out an air-cure (see), heliations (see), balneoterapiya (see) gives the good stimulating effect and promotes the fastest healing of process. In several weeks after an initiation of treatment at patients an impression of recovery can be made. It leads sometimes to the fact that they prematurely stop treatment, refuse an operative measure or a difficult diagnostic method of a research. It is important not to allow the premature termination of treatment since it is fraught with danger of an aggravation and progressing of tubercular process.
under the influence of treatment a wedge, displays of a disease at most of TB patients, as a rule, are quickly enough liquidated, there is a subjective feeling of health.
Existence of associated diseases, especially at persons of advanced and senile age, can reduce efficiency of treatment of T. Osobenno adverse influence on a current and an outcome of T. a respiratory organs renders a diabetes mellitus (see a diabetes mellitus). T. finds tendency to exudative and necrotic reactions in lungs in such patients, to early disintegration and bronchogenic planting.
Further at effective chemotherapy there are an involution of inflammatory changes and development of reparative processes. At the same time completely or substantially inflammatory and destructive changes in easy and other bodies resolve and disappear; the centers of a caseous necrosis resolve partially or encapsulated, i.e. active manifestations of tubercular process are liquidated. The most favorable outcome is the full rassasyvaniye without the residual changes seen (radiological). On site tubercular process there can be linear or star-shaped hems, the expressed fibrous changes, the single or multiple centers. The last type of healing is least favorable since in the centers the caseous and necrotic mass, residual inflammatory changes and mycobacteria of tuberculosis can remain. Sometimes it is usual mycobacteria, in other cases — L-forms (see L-forms of bacteria) or fragments of the destroyed microbic cells. Mycobacteria can stay in the dozing state, i.e. lose for a while ability to razmnozheripo, but support a condition of a sensitization, and in favorable conditions to start over again breeding and causing an aggravation or a recurrence of tuberculosis.
Residual changes can be more expressed, with indurative changes, fibrosis, deformation and disorganization of pulmonary fabric, to be followed by development of emphysema of lungs. These changes at individuals clinically are not shown, but in nek-ry cases development of a so-called metatuberculous syndrome is possible. At the same time at patients in some cases bronkhoektatichesky changes develop and on this background cough, expectoration remains, there can periodically be a pneumorrhagia, at the expressed cirrhotic changes — the flashes caused by multi-infection, perhaps preservation of intoxication on the soil is long the proceeding inflammatory process. Residual cavities sometimes suppurate, an aspergillosis develops in them (see).
Thus, character of a course of reparative processes and residual changes plays an essential role and influences the further state of health of the had T. Healing or development of reparative processes does not mean treatment of the patient T yet. lungs. Also normalization of the broken functions of an organism is necessary.
As a rule, at most of the patients who transferred T., the reactivity of an organism which changed in the course of a disease almost is never returned to a reference state. At the patients who transferred T., as a rule, almost for the rest of life positive tuberkulinovy reaction remains. At a number of patients if treatment is begun at the earliest stages of tubercular process, there can come so-called biological treatment, a cut is characterized by disappearance of a specific sensitization (tuberkulinovy reaction becomes negative).
In more detail about the forecast of various forms of tuberculosis see Tuberculosis extra pulmonary, Tuberculosis of a respiratory organs.
REHABILITATION AND EXAMINATION of WORKING CAPACITY
Medical rehabilitation is the first stage of full rehabilitation (see) patients of T. It is reached by carrying out a complex to lay down. - the prof. of actions at dispensary observation for patients. Specific treatment of patients with antituberculous remedies (see) using various schemes and the modes and observance of philosophy of chemotherapy of T first of all belongs to these actions.
Medical rehabilitation of sick T. comes at a wedge, treatment, a cut it is characterized by lack of activity of process that is established with the help klpniko-rentgenol. and lab. methods of a research; stabilization of residual changes and their type, existence of the burdening factors (associated diseases, etc.).
Modern methods of complex treatment of T. allow to achieve medical rehabilitation of the majority of sick T., especially among for the first time diseased at not started forms of a disease. At such patients medical rehabilitation occurs in 2 — 3 from an initiation of treatment. However - at a part of the patients who transferred T., the disturbances of functions of the struck bodies connected with residual post-tubercular changes can be revealed. At treatment of T. lungs not only function of breath, but also pulmonary blood circulation is quite often broken. Therefore recently attach especially great value of functional rehabilitation of sick T. Recovery of functions of the struck bodies is promoted by early use of the dosed exercise stress during stationary and sanatorium * treatments that promotes also accelerated and full regeneration in patholologically the changed body.
Social and labor, including and professional, rehabilitation of sick T. substantially depends on medical rehabilitation. However there is no full compliance between medical and social and labor rehabilitation since not all clinically cured of T. persons become able-bodied. Nek-rym from them disability owing to the respiratory insufficiency which developed as a result of residual post-tubercular changes in lungs is established, to-rye can be aggravated at emergence hron. nonspecific diseases of the lungs pathogenetic connected with the postponed T. Invalidnost comes also in connection with effects transferred T. other bodies and systems. Especially' the expressed functional disturbances after a wedge, treatment of T are often its reason. bones and joints with formation of a kyphosis (see), an anchylosis (see), contractures (see).
At the same time certain part, sick T., process at to-rykh remains active, but was stabilized or accepted the regressing current, starts work, including professional. Social and labor rehabilitation advances medical rehabilitation in these cases.
Social and labor rehabilitation depends also on age of the patient, his education, a profession, the nature of the performed work and working conditions. The persons who got sick with T. at a retirement age, rhedgehog are returned after a disease to socially poleznokhma to work. Professional rehabilitation at the persons occupied with brainwork is more often reached. Social and labor rehabilitation of the persons doing manual work, connected quite often • with the considerable physical tension and performance of work in unfavorable microclimatic conditions, happens less often, more slowly and often not in full. Quite often at their return to work after a disease it is necessary to change working conditions and its character or to change a profession to exclude influence of adverse factors. Thus, - social and labor rehabilitation at this contingent of persons does not include professional rehabilitation. Professional rehabilitation at persons is excluded, to-rye cannot be allowed to former work in connection with epidemiol. contraindications.
For the patient T. social and labor rehabilitation in the wide plan, i.e. its return to normal life, usual public relationship and performance of the socially useful work corresponding to state of his health has the greatest value.
Social and labor rehabilitation of the patient T. begins during treatment. At the same time also special events, napr, training of the patient in new professions according to his desire and an art can be held. Recovery of working ability of the patient T. is an important social and psychological factor.
The essential role in holding early actions on social and labor, and including professional, rehabilitations is allocated for VKK of TB facilities where the questions connected with work of the patient are considered: are studied character and the working condition satisfied by the patient to a disease and decisions on a possibility of its return to former working conditions or
on specific restrictions are made that it is made out by the relevant documents with the indication of period of validity of these restrictions (e.g., transfer into single-shift work, release from business trips, etc.).
Examination of temporary and permanent disability of sick T. has the features. It is caused by the fact that T. is chronic, quite often recurrent inf. a disease, treatment the cut demands long carrying out various to lay down. - the prof. and social actions. Determination of criteria of release of sick T. from work and an extract for work are made on the basis of assessment of medical and social factors. Medical factors are the form and a phase of tubercular process, a bakteriovydeleniye, the nature of disease, efficiency of the carried-out treatment, extent of disturbance of functions of an organism and the struck body, etc.; social factors — character and the condition satisfied work. Sometimes in release from work only medical factors have the leading value (the expressed intoxication, the progressing current of T., etc.), is more rare — only social (epidemiol. contraindications to work in this profession). Release from work is made on the basis of the sick-list issued by the attending physician, to-ry VKK lasts (see. Medical and consulting komissiya0, the delivery having the right for the first time to the revealed sick T. or at palindromias of sick-lists for up to 10 months from the date of approach of disability continuously or in total for 12 months. In some cases at the favorable clinical and labor forecast sick-lists can be prolonged for the term of St. 10 months (for an aftercare) according to the solution of VTEK (see Vrachebnotrudovaya commission of experts). At examination of working capacity of VKK also partial temporary disability can be defined (see) when is established that the patient during a certain period can perform only the facilitated work. The so-called labor or shortpaid sick-list granting the right for preservation of the salary by the main profession is issued for this term (but no more than for 2 months).
Examination of resistant disability at T. VTEK is carried out, on to-ruyu directs the patient to lay down. establishment in the terms determined by it, but not later than in 10 months from the date of approach of temporary disability. VTEK estimates working ability of the patient at his survey (see). During the definition of resistant disability the form, a phase, prevalence, character of a course of tubercular process and degree of manifestation of functional disturbances are considered. VTEK establishes existence and extent of disability taking into account education, the profession of the patient, character and working conditions which was carried out to a disease, group and the reason of disability (see), terms of re-examination and takes out recommendations about the rational labor device.
Examination of resistant disability of sick T., occupied on page - x. works, has the nek-ry features caused by character and working conditions of collective farmers (in big open land territories, under various weather conditions, etc.).
In the USSR in a basis of fight against T. broad development of the all-recreational and sanitary and preventive actions consisting in the prevention of infection, health protection of children and adults in a family, school on production, etc. was from the very beginning necessary (see Prevention). On the basis of the preventive principle the dispensary method of work on fight against T was developed and carried out. (see Medical examination). Antitubercular clinic (see) became the central link in system of TB facilities. Its functions include prevention, diagnosis and treatment of T., and also management of fight against tuberculosis of institutions of the general to lay down. - the prof. of network.
Prevention of tuberculosis includes sanitary and preventive actions and specific prevention.
Sanitary and preventive events are held by antitubercular clinics together with institutions of the general to lay down. networks and SES. An object of special attention of antitubercular clinics are not only patients with open forms T., the allocating mycobacteria, but also the persons surrounding them in the place of full-time residence, i.e. in the center of a tuberculosis infection. Epidemiol. danger of such centers is not identical. In this regard the volume and content of the preventive events held in them have certain distinctions.
Allocate three groups of the centers of a tubercular rshfektion. The following criteria are the basis for such division: massiveness of a bakteriovydeleniye, existence in the center of children and teenagers, housing and dignity. - a gigabyte. conditions.
To the first, epidemic to the most dangerous group carry all centers, in to-rykh patients with plentiful (constant or periodic) a bakteriovydeleniye, and also patients with a scanty bakteriovydeleniye, but in the presence live in the center of children and teenagers and (or) at least one of the following burdening factors: poor housing conditions and ignoring by the patient dignity. - a gigabyte. governed.
To the second, epidemic to less dangerous group carry the centers, in to-rykh patients with a scanty bakteriovydeleniye, constant or periodic, on condition of absence live in the center of children and teenagers, and also the listed above burdening factors. Such centers also concern to this group, in to-rykh the patient it is recognized formal (conditional) bakteriovydelite-ly, ii live in them children or teenagers or one of the burdening factors takes place at least.
To the third, potentially epidemic to dangerous group carry the centers, in to-rykh patients with a formal (conditional) bakteriovydeleniye live and there are only contacts with adults at absence in the center of the burdening factors. Private enterprises, in to-rykh it is revealed by T. at page - x. animals, admit epidemiologically dangerous (join in the third group). The persons contacting to a sick animal are under observation during 1 year after a face of an animal.
In a crust, time a considerable part for the first time the revealed sick T. and the patients allocating mycobacteria of T., make faces at the age of 60 years and is more senior. The contact with them, especially intra family, is very dangerous, in particular to children. Especially often contacting get sick in those centers where patients do not follow rules of personal hygiene, are not treated fully, and to the persons living together with the patient chemoprophylaxis is not carried out.
Considering insufficient coverage of persons of elderly and especially senile age routine maintenances, it is necessary to attract more widely them to rentgenol. to inspection at the appeal to out-patient clinics and policlinics of the general to lay down. networks concerning various diseases. For identification of T. at persons of senile age it is also necessary to use household and apartment bypasses, to make repeated researches of a phlegm in all suspicious on T. cases.
The complex of preventive actions in the centers includes carrying out the current and final disinfection, isolation of children from bakteriovydelitel by hospitalization of the patient of a pla of the placement of children to child care facilities, vaccination of newborns and a revaccination of not infected contact persons vaccine BTsZh, regular inspection of contact persons, performing chemoprophylaxis by it, hygienic education of patients and members of their family, improvement of domestic conditions, intensive treatment of the patient in the conditions of a hospital with the subsequent out-patient carrying out controlled chemotherapy.
One of precautionary actions in the center of a tuberculosis infection is improvement of living conditions of the patient with an open form T. (such patients have the right for first-priority receiving the isolated living space). It especially concerns the persons living in hostels and the multiinhabited apartments where there are children up to 14 years. It is significantly important that during the providing the isolated living space an opportunity to allocate in the apartment the certain room for the patient, being a bakterpovy-divider was provided. In rural areas where the most part of houses is in personal possession, the issue of the isolated living space can be resolved, naira., by an extension of the room at the expense of state farm, collective farm or local council of People's Deputies.
An important action is hospitalization of the patients representing epidemiol. danger to people around, before the permanent termination of a bakteriovydeleniye and closing of a cavity of disintegration and the subsequent out-patient treatment. This measure is important also concerning patients with hron. to destructive T. If stay in a hospital does not manage to be prolonged up to the moment of the termination of a bakteriovydeleniye, then it is possible to write out the patient not earlier than after noticeable reduction of quantity of the allocated mycobacteria of T is reached.
Hospitalization of the patients allocating mycobacteria of T., it is necessary also in cases when to the children consisting in contact with them vaccination and a revaccination of BTsZh, after an extract from maternity hospital for the term of not less than 6 — 8 weeks necessary for development of antitubercular immunity is carried out.
In the centers of a tuberculosis infection the current and final disinfection is carried out (see). It is necessary to carry out it with all care since mycobacteria of T. treat the microorganisms steady against various physical and chemical impacts. The current disinfection will be organized by an antitubercular clinic, at its absence — a tubercular office of policlinic, and in rural areas — the rural medical site. Final disinfection is carried out by workers of city and regional SES and disinfection stations.
Except measures all-hygienic and disinfection, value of periodic inspection of the persons communicating with the patient and performing specific prevention is big (vaccination and revaccinations of BTsZh, chemoprophylaxis). Actions matter also, to-rye are held for the purpose of prevention of infection of T. in conditions of production. A preventive measure is also prevention of the patients who are a bakter of i to a yda litas of la -
mi, to work on nek-ry productions and in a number of institutions. The list of these professions can be divided into three categories. Employees of child care facilities (day nursery, kindergartens, orphanages and nursing homes, schools) treat the first. Serious restrictions are set also concerning employees of educational institutions and educational institutions in which teenagers study. At the same time the most strict installations are available concerning personnel to lay down. - the prof., a dignity. - hens. and preschool institutions.
The second category is made by employees of catering establishments and the food industry, to-rye adjoin directly to raw materials, semi-finished products and finished products by their production, packaging, storage, transportation and implementation, and also the making repair, cleaning, a sink and disinfection of the production equipment, stock and a container. Also the workers of drugstores, the pharmaceutical plants and factories occupied with production and packaging of pharmaceuticals, the employees of waterworks and persons servicing water folding boxes and columns, plumbers, and also employees of the enterprises making children's toys treat this group.
The work connected with broad communication with the mass of the population is referred to the third category: employees
of the enterprises for household service of the population, directly with it adjoining (bathhouse attendants, hairdressers, manicurists, cosmetics bags), the persons working on drying, acceptance, sorting and delivery of linen in laundry and linen, conductors of passenger. - of cars, conductors of public transport, drivers of automobile taxi, stewards, etc.
Important element of prevention of T. sanitary education is (see). It includes as mass promotion of knowledge of prevention of T. among various groups there are population, and a gigabyte. education of sick T. and members of their families.
Specific prevention —
increase in resistance of an organism to a tuberculosis infection by active immunization (vaccination, a revaccination) or use of antibacterial agents (chemoprophylaxis).
Antitubercular vaccination is directed to creation of inoculative immunity on the basis of increase in natural resistance of an organism to a tuberculosis infection. In a crust, time antitubercular inoculations (vaccination and a revaccination vaccine BTsZh) are applied in the majority of the countries of the world as a recognized method of active specific prevention of T. Experience shows that success of vaccination depends generally on quality of a vaccine, a dosage, a method of introduction and the contamination of the population atypical mycobacteria reducing efficiency of vaccination of BTsZh. Incidence of T. at imparted 4 — 10 times below, than at not vaccinated. T. at the vaccinated BTsZh if develops, then proceeds more favorably, than at it is not vaccinated - nykh at the same time such severe forms of T, as a rule, are not observed., as miliary T., tubercular meningitis, caseous pneumonia. Primary forms T. at vaccinated in comparison with nevaktsini-rovanny persons proceed is more good-quality, without complications and lead to rather bystry favorable outcome. At the children imparted in the period of a neonatality, development of a disease is limited to hl. obr. T. intrathoracic limf, nodes while at not - vaccinated often primary tubercular complex in some cases proceeding on the complicated type and which is combined with extra pulmonary forms of tuberculosis develops.
Vaccination of BTsZh prevents development primary T., therefore among the T imparted contamination. in lVg — 2 times are lower, than at not vaccinated persons. Mass vaccination of newborns, children of advanced age, teenagers and adults to 30 years is carried out to the USSR. Ilo to a measure of decrease epidemiol. indicators scales of antitubercular inoculations, first of all due to reduction of number of revaccinations of BTsZh gradually decrease. So, in a number of regions of our country where low incidence of children of tuberculosis is noted, instead of 3 revaccinations in 7, 11 — 12 and 16 —-17 years only two are carried out — in 7 and 14 — 15 years.
In the USSR and the majority of the countries of the world the most effective intradermal method of vaccination is applied, at Krom it is possible to dose the administered drug precisely. At the same time a dose of domestic dry vaccine BTsZh (see) uniform both at primary immunization in the period of a noyorozhdennost, and at a revaccination. For receiving this dose the ampoule of a vaccine is parted in 2 ml of isotonic solution of sodium chloride. One inoculative dose (0,05 mg of microbic bodies) contains in 0,1 ml of a divorced vaccine.
Vaccination and a revaccination are appointed by the doctor of a maternity home, inoculative crew, school, MSCh of the industrial enterprise, etc. about the accountohm of medical contraindications. The revaccination is carried out to clinically healthy faces which have a Mantoux reaction about 2 THOSE the purified tuberculine in standard cultivation yielded a negative take.
Immunity comes approximately in 2 months after introduction of vaccine BTsZh to an organism. For this term it is necessary to isolate vaccinated, living in contact with the patient-bakteriovydelitelem. It is especially important to hold this event at newborns since primary T. at children of early age proceeds heavier, than at more advanced age. At the vaccinated children paraspecific and small specific changes, hl can develop. obr. in limf, nodes less often in other bodies.
Immunol. reorganization of an organism under the influence of vaccine BTsZh first of all is followed by emergence of positive skin tuberkulinovy reaction. In addition, also others are observed the wedge, changes indicating the reaction of an organism of the child arising in response to introduction of vaccine BTsZh: passing increase peripheral limf, nodes, perhaps insignificant increase in a liver and spleen, gematol. shifts (increase of content in blood of gistryu-monocytic elements, small neutrophylic shift to the left, eosinophilia). Unsharply expressed local reaction at high quality of an inoculation is noted at 90 — 95% vaccinated that demonstrates successfully carried out vaccination or a revaccination, indicates that the vaccine «took root».
Local inoculative reactions at the vaccinated and revaktsiniro-bathing children and teenagers are distinguished on terms of their emergence and character. At revaktsinirovanny children of advanced age and teenagers reaction on site of intradermal introduction of a vaccine appears usually earlier (on the 1st week after an inoculation), than at vaccinated, at to-rykh local inoculative reaction usually appears only on 3 — the 4th week after intradermal introduction of vaccine BTsZh.
Early local reaction is characterized by elements of a specific inflammation and demonstrates the accelerated processes of an immunogenesis. On skin small pink infiltrate to dia appears. 2 — 12 mm, formed by epithelial cells and macrophages, dense accumulations of lymphoid cells on the periphery. Single colossal cells of Pirogov — Langkhansa sometimes occur among epithelial cells. Sometimes such infiltrate turns into a small knot with characteristic cyanochroic ottenkokhm. In other cases skin over infiltrate becomes thinner, forming in the center a small enlightenment — a pustule. The last dries up and resolves or crusts as smallpox are formed. In some cases there are small ulcerations (no more than 5 — 8 mm in the diameter) with seroznognoyny separated, to-rye spontaneously begin to live. Involution of local changes occurs within 2 — 4 months; at a part of children — in more long terms. On site reactions remain superficial scars from 2 to 10 mm in the diameter. In the beginning the hem has a friable structure, in the depth of cicatricial fabric the residual partially calcinated necrobiotic masses contains. In deeper layers of skin the gentle fibrous tyazh connected with a hem remain. Lymphocytic small knots are determined by their course. In the subsequent the hem becomes dense, connective tissue, necrotic masses does not come to light any more. On the course departing from a hem fibrous tyazhy diffusion and focal lymphoid and histiocytic infiltration remains. Healing of changes on site of inoculative reaction (formation of a scar) demonstrates the processes of an immunogenesis which ended generally at come immunol. to reorganization of an organism. On these so-called skin signs it is easy to control correctness of the carried-out intradermal inoculation.
In regional limf, nodes proliferation of reticular and endothelial cells is observed, sometimes in their timuszavisimy zones the roundish small knots from macrophages connected with the reinforced sclerosed capsule are defined.
Antitubercular inoculations as well as overseeing vaccinated and revaktsinirovanny-m by children, teenagers and adults, is carried out by doctors and nurses of the general to lay down. - prof. of network, to-rye in
1, 3 and 12 months after vaccination or a revaccination check inoculative reaction with registration of the size and the nature of local reaction.
In addition to local inoculative reaction, the most available and objective indicator immunol. reorganizations of an organism under the influence of vaccine BTsZh development of a postvaccinal allergy is (see Tuberkulinovaya an allergy). To achieve a positive postvaccinal skin allergy from the majority of imparted — basic purpose of antitubercular vaccination and a revaccination of BTsZh.
The proved correlation communication between existence of a scar on site inoculations, development of a poslevaktsi-nalny allergy and incidence of T. formed the basis for the recommendation to use a posleprivi-vochny «skin sign» as criterion not only qualities, but also efficiency of an inoculation. At children and teenagers with «skin signs» incidence of T. is 6V2 times lower, than at those, at to-rykh these signs are absent.
It is reasonable to carry out a revaccination during this period when the new qualities acquired by an organism after the previous immunization weakened, but completely did not disappear yet. Usually inoculative immunity sharply weakens in
5 — 7 years.
Complications after vaccination and a revaccination of BTsZh usually have local character and are noted rather seldom. In our country their frequency does not exceed 0,01 — 0,03%. Disturbance of the technology of intradermal introduction of a vaccine, an allergy, the increased reactogenicity of vaccine BTsZh, immunodeficiency can be the reasons of complications (see. Immunological insufficiency), etc. Hypodermic cold abscesses, ulcers of 10 mm.i more in the diameter on site of intradermal introduction of vaccine BTsZh, lymphadenitis regional limf, nodes are considered as complications (axillary, cervical, supraclavicular and subclavial) at increase in a node up to 15 mm and more, keloid cicatrixes of 10 mm and more in the diameter on site of the begun to live inoculative reaction. In foreign literature among complications describe also osteomyelitis (see) and a tubercular lupus (see Tuberculosis vnelegoch-ny, a tuberculosis cutis and hypodermic cellulose). Extremely seldom at children with immunodeficiency the generalized infection of BTsZh is noted. In a crust, time wide-ranging scientific research according to the prevention of the specified complications is conducted.
An important role in the prevention of T. at healthy faces of group of the increased risk, especially among children and teenagers, chemoprophylaxis plays. Distinguish two types of chemoprophylaxis: primary chemoprophylaxis which is carried out to neinfitsiro-bathing persons with negative reaction to tuberculine, and secondary chemoprophylaxis — to the infected persons. For chemoprophylaxis use drugs isonicotinic to - you are (isoniazid). Amer. researchers consider expedient use long (within
12 months) continuous courses of chemoprophylaxis. In our country efficiency short (2 — 3-month-old) seasonal (in the spring and in the fall) courses of chemoprophylaxis is proved. Doses of an isoniazid at the same time 8 — 10 mg/kg a day (0,008 — 0,010 g), but no more than 0,5 g a day. The daily dose is appointed usually daily in one or two receptions after food. Side reactions are observed extremely seldom.
The correct organization of chemoprophylaxis since only controlled chemoprophylaxis is effective is important. Therefore at children and teenagers it is the best of all to carry out it in sanatorium institutions (sanatorium, a sanatorium day nursery gardens, sanatorium boarding school, country boarding school).
Chemoprophylaxis is shown in the following risk groups.
1. All clinically healthy children, teenagers and adults who were in contact with sick T., allocating mycobacteria; the children and teenagers having family contact with sick T. without allocation of mycobacteria. Duration of chemoprophylaxis is various depending on epidemiol. dangers of the center. If the child, the teenager or the adult who was in contact with the patient of T., it is not infected with T., primary chemoprophylaxis shall be carried out not earlier than through 11/2 — 2 months after vaccination (revaccination) of BTsZh — the term necessary for development of inoculative immunity. For this period they are subject to obligatory isolation. Decrease in 7V2 of time of incidence of T is established. among captured by chemoprophylaxis in comparison with not covered.
2. Children and teenagers from a healthy environment, at to-rykh transition of tuberkulinovy reaction from negative in positive and the hyperergy on tuberculine caused by a tuberculosis infection is noted (see the Tuberculinodiagnosis). This group is subject to once secondary chemoprophylaxis within 3 months
3. The children and teenagers infected with T., the transferred T., and also adults with residual changes in lungs after treatment by steroid hormones concerning various nonspecific diseases (collagenic diseases, leukoses, bronchial asthma, skin and other diseases). Secondary chemoprophylaxis in this group is performed within 3 months. At continuation of therapy by maintenance doses of steroid hormones chemoprophylaxis is not carried out.
4. Patients with a silicosis of the I stage, persons with considerable residual changes after transferred T. and associated diseases (diabetes mellitus, peptic ulcer, etc.). The persons belonging to this group are subject to secondary chemoprophylaxis by seasonal 2-month courses 2 times a year (in the spring and in the fall) within 2 years.
System of antitubercular actions in troops. The most important section of a complex of antitubercular actions in troops is the inspection by an army link of medical service of young replenishment allowing to prevent penetration of sick T. in military collectives to allocate groups of the servicemen with the increased risk of a disease of T., demanding dynamic observation to provide creation of immunity at not infected. For this purpose during 2 weeks after arrival of replenishment the fluorography of bodies of a thorax, primary medical inspection, statement of Mantoux reaction, a revaccination of BTsZh are carried out.
Planned preventive actions are active early identification of patients, medical overseeing by the military personnel included in group of the increased risk, a dignity. - a gleam, work. By the main method of active early identification of sick T. a respiratory organs the planned fluorography of staff is, to-ruyu carry out
2 times a year preferential by forces of mobile X-ray departments. By the serviceman coming on treatment to hospital it is carried out rentgenol. a research of lungs if from the moment of the previous fluorography there passed
more than 3 months.
The serviceman included in group of the increased risk of a disease of T., carrying out a three-months course of chemoprophylaxis, and also a purposeful unplanned X-ray or fluorographic inspection of lungs after grippopodobny diseases is provided.
In case of identification in military division of the patient to active T. it is immediately isolated and hospitalized, carry out disinfection in the center, epidemiol. inspection and medical overseeing contacting to it. Epidemiol. inspection is directed to identification of a possible source of infection and clarification of the conditions promoting distribution of a contagium. During the definition of group of people, endangered infection, are considered a form T. and a phase of process at the patient. At destructive T. lungs depending on massiveness and duration of a bakteriovydeleniye it is infected it (superin-fitsirutsya) to 60 — 80% of the military personnel living together with a bakteriovydelitel. It creates premises for developing of group diseases and causes expediency of performing chemoprophylaxis by all serviceman of division. At contact with the patient of T. lungs without radiological the defined destruction the military personnel preferential from the immediate environment of the patient is infected (neighbors in a bed in barracks, to a bunk room, a workplace, combat crew).
After treatment of patients direct to VVK (see. Military-medical commission) for the purpose of the solution of a question of degree of the validity to military service.
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Immunity — Averbakh M. M. and Litvinov V. I. Immunological bases of antitubercular immunity, M., 1970, bibliogr.; Aver
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man B, II, a.j N a m b a Y. On soluble mediators of immunologic regulation, Cell Immunol., v. 21, p. 161, 1976.
The main clinical manifestations — Bliznyanskaya A. I. Tuberkulez and pregnancy, M. — L., 1936, bibliogr.; Bronchopulmonary tuberculosis at children of early age, under the editorship of S. V. Rachinsky, M., 1970, bibliogr.; Bugaeva M. I. and Belyatsky N. G. Klinika, treatment and prevention of tuberculosis at children and teenagers, Saransk, 1975, bibliogr.; Kissel A. A. Tuberkulez at children, century 1 — 3, M., 1941 — 1949; Clinical
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with to and y Yu. V. Antibacterial drugs and a collapsotherapy in treatment of the pregnant women and women in childbirth having a pulmonary tuberculosis, Probl. tube., No. 6, page 33, 1957; Lazarevich A. I. Pregnancy at tuberculosis, M., 1961, Beebe
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1 — 4, M., 1959 — 1962; Nezlin S. E. Tu
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The principles of diagnosis and treatment — Alexandrov A. V. Radiological diagnosis of tuberculosis of a respiratory organs, M., 1983, bibliogr.; B about-gush JI. To., T r and in and A. A. N and Seven N e N to about in Yu. L. Operations on primary bronchi through a cavity of a pericardium, M., 1972; Perelman M. I. A resection of lungs at tuberculosis, Novosibirsk, 1962, bibliogr.; P about m e l c about in K. V. Radiological diagnosis of a pulmonary tuberculosis, M., 1971, bibliogr.; Prozorov A. E. Radiodiagnosis of a pulmonary tuberculosis, M. — L., 1940; R and -
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Surgical treatment of pulmonary tuberculosis, M., 1949, bibliogr.; F and -
l and p p about in V. P. Bronkhologicheskiye of a research in differential diagnosis of tuberculosis, M., 1979, bibliogr.; Chemotherapy of a pulmonary tuberculosis, under the editorship of A. G. Homenko, M.,
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Rehabilitation and examination of working capacity — Ayrapetov L. D. Labor therapy of TB patients, M., 1967, bibliogr.; Sh. A. alims. Experience of rehabilitation of suffering from tuberculosis lungs, Tashkent, 1974, bibliogr.; And r-Bath Yu. D., Sidor of kina of T. P. and Yakovlev of H. X. Examination of temporary disability at tuberculosis, M., 1978; Fireplace
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A. G. Homenko; M. M. Averbakh (immunity, immunological methods of a research, pathogeny), Ya. A. Blagodarny (epidemiological value of tuberculosis of animals), M. S. Greymer, V. A. Solovyova (ist.), I. R. Dorozhkova (etiol., laboratory diagnosis), Yu. V. Kulach-kovsky (gin.), L. A. Mitinskaya (specific prevention, ped.), H. M. Ruda (sanitary and preventive actions), V. V. Rybalko (soldier.), O. A. Uvarova (pathogeny, stalemate. An.), T. A. Hudushina (rehabilitation and examination of working capacity), M. A. Tsivilno (psikhiat.), B. P. Yashchenko (mister.).