TUBERCULOSIS EXTRA PULMONARY.
Tuberculosis of peripheral
lymph nodes....... 388
Tuberculosis of uric and generative organs.................................. 390
Tuberculosis of bones and joints.... 39 4
Tuberculosis of eyes.......... 400
Tuberculosis cutis and hypodermic
Tuberculosis of intestines, peritoneum and mesenteric lymph nodes (abdominal tuberculosis) 40 7
Meningeal tuberculosis and central nervous system. 409
Tuberculosis tuberculum vnelegoch-ny (Latin a hillock + - osis) — the name combining forms of tuberculosis of various localization except tuberculosis of a respiratory organs. T. differs from tuberculosis of a respiratory organs century (see) not only localization patol. process, but also features of a pathogeny, epidemiology, wedge, manifestations; diagnostic methods and treatments at T. century also have the specifics. By data I. N. Petrova (1977), T. century in the general incidence of tuberculosis occupies on average from 12 to 17%.
According to the classification accepted in the USSR distinguish tuberculosis of uric and generative organs (urogenital tuberculosis), tuberculosis peripheral limf, nodes, a tuberculosis cutis and hypodermic cellulose, tuberculosis of eyes, a tuberculosis of bones and joints, a meningeal tuberculosis and c. N of page, tuberculosis of intestines, peritoneum and mesenteric limf, nodes (abdominal tuberculosis) and tuberculosis of other bodies. Depending on prevalence patol. process allocate limited and generalized T. century, depending on a pathogeny — metastatic and allergic; from morfol. manifestations — granulyatsionny and destructive, or cavernous; distinguish also early and started forms of extra-pulmonary tuberculosis.
Feature of T. century infection of bodies in the presence of the mycobacteria of tuberculosis circulating in blood is endogenous (hematogenous, lymphogenous) (see Tuberculosis). Features of very tectonics of a microcirculator bed and disturbance of microcirculation (see) promote a delay of mycobacteria of tuberculosis in fabrics and to development of inflammatory reaction in various bodies. According to E. N. Bel-lendir (1976), at the same time have major importance: extensiveness of the microcirculator pool, the slowed-down blood stream and existence of a time in walls of the capillaries causing a direct exit of mycobacteria of tuberculosis from a microcirculator bed in fabric. For T. century also leading role of initial (primary) focal defeats of bodies which is most accurately revealed by P. G. Kornev at a tuberculosis of bones and joints, but inherent and to its other extra pulmonary localizations is characteristic. An important role in development of T. play defeats of allergic character century, being leaders at nek-ry forms T. century.
In rare instances at a tuberculosis cutis, an eye, generative organs and intestines infection can happen in the exogenous way.
Wedge, manifestations of T. are characterized, as a rule, by late development and slow increase of symptoms century that complicates its early diagnosis. For T. century existence of the long period from the moment of infection before emergence of the first a wedge, manifestations is characteristic. Duration of T. century of various localizations makes from
1 year to 30 years and more. Special attention to T. is defined by its serious consequences having great social value century (a blindness, infertility, etc.).
TUBERCULOSIS of PERIPHERAL LYMPH NODES
Tuberculosis peripheral limf, nodes (tubercular lymphadenitis) can be an independent form of a disease or be combined with other forms of tuberculosis. If earlier the disease came to light hl. obr. at children's and teenage age, in a crust, time the disease is shown at more advanced age in connection with broad holding preventive antitubercular actions, in particular vaccination and revaccinations. Distinguish the localized and generalized tuberculosis peripheral limf, nodes. Most often locally are surprised submaxillary and cervical limf, nodes (70 — 80%), are more rare — axillary (12 — 15%), inguinal (apprx. 3%) and other groups lpmf. nodes. Generalized defeat with involvement of several groups limf, nodes (not less than three) makes apprx. 15 — 16%. Danger to people around as sources of infection present open (fistular) forms of a disease, to-rye to a crust, time meet more and more seldom. One of epidemiol. features of tuberculosis peripheral limf, nodes rather slow decrease in incidence and morbidity in comparison with other localizations of T is. century (on a nek-eye to data, approximately twice). In an etiology of tubercular lymphadenites the important place is taken by mycobacteria of tuberculosis of a bull look.
Pathogeny. Feature of a pathogeny of tuberculosis peripheral limf, nodes is first of all their frequent defeat at primary tuberculosis. The mycobacteria of tuberculosis which got to an organism are brought by current of an intercellular lymph in limf, vessels also reach the next limf, nodes. For a long time limf, nodes can serve as a tank of a tuberculosis infection, representing sources of limfogematogenny dissimination. The most frequent localization of tubercular lymphadenitis are cervical and submaxillary limf. nodes. Preferential defeat of these limf, nodes is connected with the fact that mycobacteria of tuberculosis get to an organism, as a rule, through a mouth and upper airways, for to-rykh these limf, nodes are regional. At the same time primary tuberculous focus manages to be found (approximately, in 5% of cases) in palatine tonsils, on a mucous membrane of gums, cheeks. Lack of the similar centers in most cases of tuberculosis peripheral limf, nodes is explained with either their healing, or ability of mycobacteria of tuberculosis to get through the loosened or damaged fabrics without formation of the specific centers in the field of implementation. Infection of this zone happens also sputogenno at tuberculosis of a respiratory organs, but a thicket gema-togenno to the subsequent lymphogenous distribution of contagiums in limf. nodes.
Along with primary tuberculosis limf, nodes, arising limfogenno, secondary tubercular defeats peripheral limf, nodes, the generalized forms of tuberculosis observed at an aggravation of process in other bodies or accompanying are described (mi-lparny, disseminated, etc.). Secondary tuberculosis of peripheral lymph nodes most often develops as a result of endogenous reactivation of the centers of any localization at low body resistance and testifies (especially its generalized forms) to the heavy course of tuberculosis.
Lymphadenitis axillary limf, nodes can develop as a complication of vaccination of BTsZh (see). This so-called betsezhit is expression of individual reaction, develops in an organism with the changed general reactivity and has allergic character. At the same time partial or full fusion limf, a node with the subsequent its calcification and encapsulation is observed. The formed at the same time small tubercular granulomas usually have productive character and further are exposed to fibrosis. Along with a specific inflammation also nonspecific can be observed.
Pathological anatomy. On the basis of features of a pathomorphologic picture distinguish hyperplastic, fibrocaseous and fibrous forms of tubercular lymphadenitis (according to Shmelyov respectively — infiltrative, caseous and indurative forms). At a hyperplastic form in a lymph node of ¡$ a background of proliferation of cells of an adenoid tissue find tubercular granulomas sometimes with a caseous necrosis. The fibrocaseous form is characterized by existence of the centers of a caseous necrosis sometimes occupying all limf, a node (it is more often observed at primary tuberculosis). On the periphery of the centers of a caseous necrosis the tubercular granulyatsionny fabric surrounded with the fibrous capsule is located. Own capsule limf, a node is usually thickened, sclerosed. The fibrous form of tubercular lymphadenitis along with healing and a rassasyvaniye of tuberculous focuses and granulomas is characterized by development of connecting fabric.
During the progressing of process of mass of a caseous necrosis can be exposed to fusion. Inflammatory and necrotic changes can extend to the capsule limf, a node and surrounding fabrics with break of caseous masses outside and formation of fistulas (see). At the same time in walls of the fistular courses specific inflammatory reaction is usually observed.
Clinical picture. Specific damage of peripheral lymph nodes usually happens at primary tuberculosis. In 80 — 90% of cases tuberculosis peripheral limf, nodes proceeds is long, wavy, weight a wedge, manifestations is defined by existence of a caseous necrosis in limf a node.
At the beginning of a disease against the background of a febricula, fervescence, a moderate leukocytosis and acceleration of ROE increase peripheral limf, nodes is found (to 5 — 10 mm in the diameter). At a palpation limf, nodes soft, painless, not soldered with each other. During the involvement in process of surrounding fabrics limf, nodes form large «packages» — so-called tumorous tuberculosis peripheral limf, nodes. The periadenitis is a characteristic symptom of tubercular lymphadenitis. At a palpation of such nodes morbidity, sometimes fluctuation owing to fusion of caseous masses is noted. Skin over increased limf, nodes is hyperemic, thinned, in some cases breaks with formation of fistulas and ulcers. Openings it is long not healing fistulas and a surface hron. ulcers have typical skin crossing points. Further on site these defeats the disfiguring hems with growths of skin in the form of nipples and tyazhy (fig. 1), as form at a secondary collie-kvativnom a tuberculosis cutis. Because of tuberculosis peripheral limf, nodes the true tuberculosis cutis in the form of a tubercular lupus can develop (see below the section Tuberculosis cutis and hypodermic cellulose).
At a zatikhaniye of process limf, nodes decrease in sizes, are condensed, the phenomena of a perifocal inflammation disappear, fistulas are closed. Palpated dense increased limf, nodes often are the only expressed symptom of a disease at such patients. However similar most often the seeming wellbeing happens temporary, it is replaced by the exacerbation of a disease which usually have seasonal nature (in the spring and in the fall). Patol. the center in limf, nodes is a source of continuous toxic impact on an organism, and also aggravations and dissimination of tubercular process.
The diagnosis is based on the data of the anamnesis confirming the contact of the patient with a source which was available earlier tubercular infek-
Fig. 1. Bottom of the face and neck of the patient tubercular lymphadenitis: on skin of a side surface of a neck and submaxillary area the rough hems formed on site fistulas and ulcers are visible.
a tion or existence of displays of tuberculosis of other localizations at it, and also on results a wedge, inspections and special methods of a research. An important role in diagnosis of tuberculosis limf, nodes plays rentgenol. a research of bodies of a thorax, and also identification on roentgenograms calciphied limf, nodes. The most reliable results can be received by means of a biopsy limf, nodes with the subsequent bacterial. and gistol. a research of the received material. A little the puncture limf, nodes with the subsequent tsitol concedes to it. research of punctate. Tuberkulinovy reactions (Mantoux reactions and the Tuberculine test) allow to establish contamination of an organism by mycobacteria of tuberculosis, and hypodermic tuberkulinovy test of Koch taking into account a prick of internal, general and focal reactions can supply with the valuable information for diagnosis of tuberculosis peripheral limf, nodes (see the Tuberculinodiagnosis). Blood tests, biochemical tests, immunol have auxiliary value. and other laboratory researches.
Differential diagnosis is carried out with inflammatory diseases limf, nodes, first of all, with nonspecific, and also with a goose (see Lymphadenitis, Syphilis), noninflammatory diseases, among to-rykh the important place occupies a lymphogranulomatosis (see), with inborn cysts and fistulas of a neck, dermoid cysts (see the Dermoid), and also metastasises of cancer in peripheral limf. nodes. At the same time the important role belongs to a biopsy of lymph nodes with the subsequent research of material, to a tuberculinodiagnosis, and also existence of a periadenitis at tubercular lymphadenitis.
Treatment is complex, it is carried out by the general rules of treatment of tuberculosis (see). Shall accept antituberculous remedies (2 — 3 drugs) of the patient within
10 — 12 months to a zatikhaniye of process. Topical treatment consists in systematic evacuation of pus from limf, nodes with introduction of 5% of solution of Saluzidum, 5 — 10% of solution of Tubazidum, obkalyvaniya limf, a node streptomycin. Apply also hyposensibilizing means (calcium chloride, Dimedrol), vitamins of group B, ascorbic to - that, etc., according to indications — a tuberculinotherapy, UF-radiation, and in sanatorium conditions — aero - and heliation.
The main method of treatment of the localized and fibrocaseous tuberculosis peripheral limf, nodes is surgery — excision all struck limf, nodes together with their capsule at the minimum traumatization of surrounding fabrics. In cases of operational treatment antibacterial therapy is carried out both to, and after operation.
Operational treatment is contraindicated at a serious general condition of the patient, active inflammatory process in limf, nodes with the expressed perifocal reaction, generalized tuberculosis peripheral limf, nodes. In these cases carry out conservative antitubercular treatment using antibacterial agents then the question of operation can be repeatedly raised.
The forecast depends on prevalence of tubercular process and character morfol. changes (existence of a caseous necrosis). At timely diagnosis and full treatment the forecast favorable.
Prevention of tuberculosis peripheral limf, nodes is a part of prevention of tuberculosis as inf. diseases (see Tuberculosis, prevention). Special prevention consists in fight against tuberculosis of cattle and an exception of consumption of the livestock products infected with mycobacteria of tuberculosis.
TUBERCULOSIS of URIC AND GENERATIVE ORGANS
Tuberculosis of bodies of urinogenital system results from primary or secondary hematogenous dissimination of the causative agent of tuberculosis. Makes apprx. 37% among all forms of extra pulmonary tuberculosis. Usually it develops when primary tuberculosis loses the activity, i.e. in 5 — 12 years after the first a wedge, displays of tuberculosis in other bodies. More than it is possible to find signs of earlier postponed tuberculosis in 80% of suffering from tuberculosis bodies of urinogenital system: most often
pulmonary tuberculosis, limf, nodes, backbone. Simultaneous defeat of uric and generative organs occurs at men approximately in half of cases, at women this combination is much more rare (5 — 12% of cases).
Tuberculosis of kidneys — the most common form of tuberculosis of uric bodies. At 65% of patients it develops at the age of 30 — 55 years. At men it is several more often than at women.
Distinguish the following forms of a nephrophthisis: tuberculosis of a renal parenchyma, tubercular papillitis, cavernous nephrophthisis, fibrous and cavernous nephrophthisis, renal caseomas, or tuberculomas, tubercular pyonephrosis.
Pathogeny. Hematogenous distribution of mycobacteria of tuberculosis leads to infection of both kidneys, however development of specific process, as a rule (70 — 75% of cases), is observed in one of them, in another — focal changes are in an abeyance and at high reactivity of an organism or under the influence of treatment are exposed to involution.
Pathological anatomy. Initial focal educations are localized preferential in cortical departments of a renal parenchyma. They usually different size, consist of the sites of a caseous necrosis surrounded with the specific granulations containing epithelial, colossal and lymphoid cells. At further progressing the centers merge among themselves, involving in patol. process new sites of a renal parenchyma. Caseous masses in the center of the center is exposed to fusion, the cavity is formed, from a cut the pochechna forms furtherI am a cavity. The bacteriuria which is observed at the same time is the reason of contact infection of uric ways.
At partial healing of a renal cavity the rassasyvaniye of perifocal inflammatory changes is observed, process becomes fibrous and cavernous, in outside departments of a wall of a cavity there are fibrous fibers, and the wall becomes three-layered.
The renal pelvis is usually involved in process at fibrous and cavernous tuberculosis of kidneys. It is expanded, her mucous membrane is rough, is sometimes edematous, vessels are sharply full-blooded. In walls of a pelvis specific and nonspecific inflammatory changes in a type of tubercular granulomas of various structure, infiltrates from lymphoid and epithelial cells with nonspecific infiltration are observed, it is preferential from segmentoyaderny leukocytes, eosinophils and plasmocytes. Involvement in specific process of a neck of a renal cup leads to its narrowing, an obliteration of a gleam and «switching off» of a cavity.
Renal caseomas, or tuberculomas, are formed of the «switched-off» cavities as a result of treatment of a caseous detritis by salts of calcium. Caseomas can be single, multiple, occupy the whole segment, there comes the total caseous necrosis of a kidney less often. As a result of the cicatricial strictures of an ureter developing owing to defeat by tubercular process of its wall and obliteration of a gleam arises staz urine, leading to development of a tubercular pyonephrosis.
Clinical picture. Tuberculosis of a renal parenchyma is called by subclinical tuberculosis of kidneys owing to scanty by a wedge, symptoms. As quite often only display of a disease serves detection of mycobacteria of tuberculosis in urine (bacteriuria). At nek-ry patients the febricula, periodically subfe-brilny temperature, dull ache in lumbar area is noted. Reaction to tuberculine doubtful or poorly positive. The phenomena of intoxication are usually not expressed.
Radiological decrease in release of contrast medium a kidney, an atony of an ureter, caused by it-rotrofichesky changes in a kidney can come to light.
A tubercular papillitis (tuberculosis of a renal nipple) — a destructive form of renal tuberculosis. It is observed approximately in 5 — 10% of cases. One of early symptoms of ulcer changes of renal nipples is the total short-term gross hematuria. Also the leukocyturia, a bacteriuria, acid reaction of urine are characteristic.
The multiple papillitis flows less favorably with the expressed intoxication and a resistant bacteriuria. On a piyelogramma deformation of cups owing to destruction of a renal nipple or a cavity of a pear-shaped form as result of fusion of a top of a renal pyramid is noted. At a multiple papillitis as a result of extensive nephrosclerotic changes radiological the sizes of a kidney are reduced, contours its uneven. cups are deformed.
The cavernous nephrophthisis forms as a result of progressing patol. process with formation of typical cavities — cavities. Distinguish two main forms of cavernous tuberculosis of kidneys: the tuberculosis pathogenetic
connected with a tubercular papillitis and the cavernous tuberculosis which resulted from progressing of specific process in cortical departments of a parenchyma.
Involvement in patol. process of a neck of a cup and a lokhanochno-ureteric anastomosis conducts to long obturation and scarring of these departments. At the same time overlying sites of an urinary system are switched off. «Switching off» of a cavity radiological is expressed by a symptom of «amputation» of a renal cup. During this period of a disease the composition of urine is normalized, allocation of bacteria stops. However process in the «switched-off» cavity remains active, and penetration of antituberculous remedies through» thick, bessos ud an isty wall of a cavity is complicated. The nephrophthisis can become complicated secondary hron. pyelonephritis, formation of stones, arterial hypertension.
The fibrous and cavernous nephrophthisis develops as a result of reactive fibroplastic, nephrosclerotic reparative processes in a zone of a tubercular inflammation. One of a wedge, signs of such process is wrinkling of a pole of a kidney or development of a segmented pyonephrosis that radiological is defined as a symptom of «amputation» (fig. 2). At a granular kidney the expressed arterial hypertension is observed.
A wedge, manifestations of renal caseomas, or tuberculomas, as a rule, are absent. In the presence of intoxication, bacteriurias, arterial hypertension, danger of break of the center arise indications to operational treatment.
The tubercular pyonephrosis is completion of process and is characterized by total destruction of a renal parenchyma and formation of a purulent bag. The patient complains of feeling of weight and pain in the affected kidney. At a palpation the increased kidney is defined. The phenomena of intoxication, a leukocyturia, a bacteriuria can be noted. The kidney ceases to function. Radiological the shadow of a kidney is increased.
Tuberculosis of kidneys at children makes 0,2% of total number of children, TB patients, and 2,2% of total number of the children having extra-pulmonary tuberculosis. Tuberculosis of kidneys meets at teenagers more often. The disease proceeds, as a rule, asymptomatically. At children unlike adults activity of process remains at the same time in kidneys and other bodies (lungs, limf, nodes).
Diagnosis. Early diagnosis of preclinical forms of tuberculosis of kidneys is possible only during the carrying out mass repeated bacterial. researches sterilely the taken urine at the infected contingents of the population. Than frequency rate of researches and amount of the taken material, that a high probability of receiving a positive take is more. Early examination is conducted by doctors of the general to lay down. - the prof. of network (therapists, urologists, etc.) and local phthisiatricians.
Fig. 2. A retrograde piyelogramma at fibrous and cavernous tuberculosis of a right kidney: an upper big cup
do not contrast I — a symptom of «amputation» of an upper big cup,
Diagnosis of a nephrophthisis is difficult since process proceeds is hidden and comes to light accidentally when the kidney partially or completely lost the function. Causeless increase in the ABP at young age can be an indirect sign of a nephrophthisis.
For specification of the diagnosis, definition of a degree of activity of process use the provocative tuberkulinovy test — hypodermic administration of tuberculine in individually picked up dose (Koch's test). Most often enter 20 THOSE tuberculine, but according to indications 50 and 100 THOSE can be entered. Focal reaction is estimated on increase in leukocytes and erythrocytes in urine (across Nechiporenko) and to detection of mycobacteria of tuberculosis in urine by method of crops.
Detection of mycobacteria of tuberculosis in urine is the most valuable to establishment of the diagnosis. At negative takes make biol. test. However its informational content is less, than data triple bacterial. researches of urine on a mycobacterium of tuberculosis.
Rentgenol. the research allows to define topography and prevalence patol. process in a kidney. Already at a survey X-ray analysis it is possible to find the centers of calcification in a projection of kidneys, an ureter, a prostate,
Fig. 3. A retrograde piyelogramma at-veryoznom tuberculosis of a left kidney: 1 —
a cavity in the lower pole of a kidney; 2 — cicatricial strictures of an ureter.
cicatricial retractions and protrusions of contours of a kidney. In the absence of contraindications carry out excretory urography (see). In not clear cases rentgenol. the research is supplemented with a retrograde piyelografiya (see) with a polyposition X-ray analysis (fig. 3). The right and left kidneys are inspected separately at an interval of 5 — 7 days. At suspicion on the switched-off kidney, a stricture of an ureter resort to a renal angiography (cm:), antegrade piyelografiya. Tracer techniques of a research — a renografiya radio-isotope (see), scanning (see), and also ultrasonic scanning (see. Ultrasonic diagnosis) supplement a complex of diagnostic testings.
Considerable difficulties arise at diagnosis of initial forms of tuberculosis of kidneys when it is necessary to distinguish a specific papillitis from pyelonephritic, from a reflux, a diverticulum of a renal cup, anomalies of a structure of renal cups (see Kidneys). In the absence of allocation of bacteria with urine it is difficult to reveal a combination of tuberculosis to such diseases as an urolithiasis, a polycystosis and other anomalies of kidneys. In these cases conduct dynamic overseeing by patients and repeatedly (to 12 times a year) investigate urine. In nek-ry cases use trial treatment (test therapy) by means of the means which do not have a broad spectrum of activity (drugs of the GINK group, thio-semicarbazones, PASK). In case of efficiency of the carried-out treatment the tubercular etiology of a disease is confirmed.
The differential diagnosis is carried out with a nephrolithiasis (see), pyelonephritis (see), a hydronephrosis (see), anomalies of development and tumors of a kidney (see Kidneys).
Treatment of tuberculosis of kidneys complex also includes use of specific antibacterial agents (see. Antituberculous remedies), pathogenetic fortifying means, dignity. - hens. treatment and operational treatment. Antibacterial therapy is based on the uniform principles of chemotherapy of tuberculosis (see Tuberculosis). For the choice adequate to lay down. tactics consider not only a form and a phase of a course of process, but also its prevalence, a degree of activity about what indirectly judge by degree of a specific bacteriuria, growth rate of mycobacteria of tuberculosis, their sensitivity to antituberculous remedies.
Treatment of tuberculosis of a renal parenchyma drugs of 1 row allows to reach full a wedge, treatment (without residual changes) almost in all cases. The term of a leche-cheniye — 6 — 9 months.
At a tubercular papillitis conservative treatment is carried out within 10 — 12 months. In the presence in urine of the mixed flora appoint drugs of a broad spectrum of activity, in particular rifampicin.
Treatment of cavernous forms includes conservative and operational methods. The long complex chemotherapy using rifampicin, Ethambutolum, and also the means preventing development of sclerous changes is shown. According to indications make a cavernotomy, a resection of a segment of a kidney, at a lolikavernoza in most cases delete a kidney (see Kidneys, operations).
At a tubercular pyonephrosis (see) treatment operational — a nephrectomy (see). Absolute indications to a nephrectomy at a pyonephrosis remain even at not expressed a wedge, a picture in order to avoid generalization of process and accession of consecutive infection. Conservative treatment is carried out during
3 — 4 weeks as preoperative before a nephrectomy (see). Duration of postoperative treatment is defined by a degree of activity of process. At accession of consecutive infection sepsis develops. In these cases the urgent nephrectomy is shown, edges it is carried out according to vital indications.
At all patients with hron. a renal failure (see) in the course of treatment it is necessary to control function of kidneys and at its deterioration to reduce a dosage of antituberculous remedies or to pass to their reception every other day or 2 times a week. In an end-stage hron. a renal failure (see) at most of patients the chemotherapy can be continued on condition of regular use of a hemodialysis (see).
The forecast for life depends on a current and prevalence of tuberculosis in kidneys and in other bodies, including in adrenal glands, existence of secondary complications and first of all banal pyelonephritis (see), hron. a renal failure, an amyloidosis (see).
At tuberculosis of a renal parenchyma and a tubercular papillitis at timely and full treatment the forecast favorable, however at a multiple papillitis process can be complicated by depression of function of a kidney and arterial hypertension.
At single cavities and a renal kazeokhma the forecast for life favorable, at polikavernoz-number tuberculosis in most cases there are indications to a nephrectomy.
At a tubercular pyonephrosis in case of accession of the phenomena of sepsis the forecast for life doubtful.
Prevention consists in timely vaccination and a revaccination of the population, and also early identification and full treatment of TB patients.
Tuberculosis of uric ways. The t at - e r to at l e z an ureter
would arise only for the second time, limfogenno or as a result of contact with the infected urine, in many respects defines a current and an outcome of tuberculosis of kidneys. With damage of kidneys it occurs at patients in 35 — 46% of cases. Walls of an ureter are thickened, the plethora of vessels, lymphocytic infiltration and hypostasis of fabrics are observed. On a mucous membrane of an ureter tubercular granulomas and ulcers form, to-rye then lead to narrowing, and in some cases obliterations of its gleam (see fig. 8, 9, 10 to St. Ureter, t. 15, Art. 545).
At tuberculosis of an ureter the symptoms characteristic of a nephrophthisis and a bladder are observed. At 15 — 20% of patients with the first sgshptom the renal colic caused by disturbance of removal of urine as a result of obstruction of a gleam of an ureter a clot of a pla of fibrin, and also hypostasis of a mucous membrane of an ureter or its narrowing is. Most often the predpuzyriy department of an ureter (a pelvic part) is surprised,
defeat lokhanochno-mochetoch-nikovogo a segment, proceeding with wrinkling of a pelvis is on the second place. At a tsistoskopiya the focal hyperemia and reactive violent hypostasis of a mucous membrane of a bladder in the field of an ostium ureteris of the affected kidney is noted.
Plays an important role in identification of defeat of ureters rentgenol. a research, at Krom find a so-called chetkoobrazny ureter. The differential diagnosis is carried out with the diseases conducting to a stenoziro-vaniye of an ureter (an ureteritis, a nephrolithiasis, a disease of Or-monda, etc.).
In an initial stage of tuberculosis of an ureter treatment is directed to the main center which is localized in a kidney. The general tuberculostatic treatment is supplemented with antiinflammatory and resorptional therapy. Apply bougieurage of an ureter, an endovesical obkalyvaniye of its mouth a hydrocortisone. At resistant strictures of an ureter and the functioning kidney resort to reconstructive and recovery plastic surgeries on an ureter (see. At a rezher about plastics). In case of death of a kidney, progressing of specific process and at secondary pyelonephritis removal of a kidney and all ureter (a total nephroureterectomy) is shown.
The t at e r to at a lcha z a bladder would be observed at 5 — 10% of TB patients of a kidney. It arises during the progressing of tuberculosis of kidneys when the mucous membrane of a bladder is involved in process (see). Tubercular hillocks, infiltrates are most often formed around openings of ureters. On a mucous membrane, edges becomes plethoric, reinforced, edematous, tubercular ulcers can form (see fig. 15 to St. Bladder, t. 15, Art. 512). At the same time along with epite-liondno-giant-cell reaction the expressed lymphocytic infiltration with impurity of polymorphonuclear leukocytes is observed. Scarring of fabrics leads to wrinkling of a bladder, sharp reduction of its volume. Capacity of a bladder decreases sometimes to 50 — 30 ml, in connection with increase in intravesical pressure and change in the switching device of openings of ureters (mouths of an ureter) there is a vesicoureteral reflux (see), dynamics is broken at ro, upper uric ways are infected that leads to secondary pyelonephritis and depression of function of kidneys.
A basis of diagnosis is detection of mycobacteria of tuberculosis in urine, and also these tsistoskopiya and rentgenol. researches of kidneys and uric ways (see the Bladder).
Treatment includes use of chemotherapeutic means, vitamins, fortifying means, a dignity. - hens. treatment.
At the progressing wrinkling of a bladder the ureterohydronephrosis develops, function of kidneys is broken. In these cases increase in capacity of a bladder is shown in the operational way (see. Intestinal plastics).
Tuberculosis of an urethra develops at TB patients of a bladder and specific prostatitis. The mucous membrane of an urethra is edematous, on it there are tubercular granulomas and ulcerations. The result of ulcer changes is the stricture of an urethra (see. Urethral Caenit is scarlet), edges it is more often localized in prostatic department. The diagnosis in the presence of tubercular defeat of other bodies of urinogenital system does not present difficulty. Treatment conservative — specific in combination with resorptional therapy, and also local — instillations, bougieurage. At formation of a stricture treatment operational: a resection of a stricture with sewing together of pieces of an urethra on a catheter the end in the end (see the Urethra, a stricture).
Tuberculosis of men's generative organs develops as a result of hematogenous infection both in the period of primary, and in the period of secondary tuberculosis or can arise intrakanalikulyarnsh in the way at defeat of an ureter, a bladder. First of all the prostate (see), further — an epididymis, a small egg, seed bubbles, a deferent duct is surprised.
Distinguish tuberculosis of a prostate (focal, cavernous), seed bubbles, an epididymis (caseous kavernoz-ny, cicatricial), a small egg (focal, cavernous), a deferent
duct (erosive and ulcer, cicatricial).
In a prostate tuberculous focuses can form at hematogenous generalization of process or at far come tuberculosis of uric system. In fabric of gland at the same time find the different size the centers of a caseous necrosis surrounded with growths of specific granulyatsionny fabric. Tuberculosis of seed bubbles and an epididymis is characterized by formation in them the caseous centers and hillocks. In a small egg (see) tubercular hillocks and the caseous centers can form, to-rye during the progressing increase in a size, the mass of a caseous necrosis in them melts with formation of a cavity. During the healing of tuberculous focuses cicatricial fabric develops.
Tuberculosis of a prostate in a phase of infiltration and disintegration causes crotch, rectum, urethra pains. At defeat of a vesical (average) share of a prostate and related back urethra the dysuria is expressed. At cavernous changes in iron in urine mycobacteria of tuberculosis, the second portion of urine — purulent usually find.
The diagnosis is based on data of a palpation, at a retrografiya, identification in an ejaculate and prostatic juice of mycobacteria of tuberculosis. In case of focal changes the surface of a prostate gland melkobugristy, in some cases larger sites of consolidations are palpated, over the emptied cavities on the surface of a prostate gland define retractions or sites of fluctuation if the cavity was not emptied. In a stage of scarring of iron it is reduced in a size, flattened, density it is increased, the groove is maleficiated, separate kaltsinata can be palpated. At the descending uretro-grafiya it is possible to reveal signs of destruction of a prostate.
Tuberculosis of seed bubbles as an independent form does not meet, and accompanies tuberculosis of a prostate. It is characterized by a painful ejaculation and a hemospermia. At a vezikulografiya destructive changes are defined.
Distinctive feature of tuberculosis of a deferent duct is the chetkoobraznost of a channel which is defined at a palpation.
Tuberculosis of an epididymis (tubercular epididymite) — the most often found form of tuberculosis of men's generative organs. Approximately in V3 of cases bilateral defeat is observed. Most often the disease is shown with approach of puberty. The tubercular epididymite proceeds chronically more often, but also the acute current is possible (see the Epididymite). The diagnosis in the presence of a chicken skin of an appendage, a chetkoobrazny deferent duct, changes in a prostate and tuberculosis in the anamnesis usually does not present difficulty.
In diagnosis of tuberculosis of men's generative organs the important place is taken by a tuberculinodiagnosis (see). Mantoux reaction about 2 THOSE standard tuberculine (PPD-L) happens giperergichesky if process proceeds sharply, and positive — at hron. current. In not clear cases make a microbe a yole. a research of an ejaculate on a mycobacterium of tuberculosis or for the purpose of identification of the mixed flora, tsitol. research of punctate of a small egg, biopsy or gistol. research of a remote appendage.
Treatment of tuberculosis of men's generative organs consists in carrying out chemotherapy; at the same time the combination of drugs, duration of treatment are defined by a form and a stage of process. At damage of a prostate gland, in addition to chemotherapy, inside appoint spirit solution of vitamin D on 30 — 50 thousand ME a day within 3 — 4 months for stimulation of calcification of tuberculous focuses, and also instillation of antituberculous remedies and corticosteroid hormones in a back urethra. The forecast for life favorable, however a disease often comes to an end with infertility.
Tuberculosis of female generative organs. From all displays of tuberculosis at women, according to E. N. Co-lachevskoy (1975), damage of genitals makes 2,55%. Most often tuberculosis comes to light at the women having infertility.
Tubercular process in generative organs of women usually is secondary and results from hematogenous or lymphogenous dissimination of causative agents of infections from primary center of any localization.
The disease most often arises at pubertal age that is connected with the expressed endocrine reorganization and immunol. immaturity of an organism. The disease more often at the age of 20 — 40 years, and also in the postclimacteric period — after 50 years is diagnosed.
Most often ampoules and fimbrias of uterine tubes are surprised that it is connected with features of their blood supply (deposition of blood in them). From here process extends on a uterine tube (a podepi-telialny layer and interfabric cracks) to its mesentery, an endometria, a myometrium, and also to an ovary. Damage of a neck of uterus, vagina and vulva are rare forms of tuberculosis of genitalias and are usually observed in combination with defeat of an endometria. In nek-ry cases process extends to a serous cover of pipes, a uterus and a peritoneum, causing the phenomena of a pelviperitonitis. In uterine tubes inflammatory tumorous educations form, commissural process develops, their passability is broken, uterine tubes look chetkoobrazno-is thickened-nymi. Tuberculosis of ovaries meets seldom, is shown by formation of granulomas of tuberculous focuses of the different size in them, in the subsequent exposed to fibrosing.
Tuberculosis of genitalias at women irrespective of localization is characterized long hron. a current with the periods of an aggravation and zatikhaniye. Development of commissures in a small basin causes emergence of pains and quite often leads to unjustified surgeries. The acute beginning of process is less often observed. It is possible to find instructions on the postponed tuberculosis in the anamnesis, it is the most frequent — serous covers (peritonitis, pleurisy). Patients show complaints to the late beginning of periods, disturbance of menstrual function or the expressed algomenorrhea (at the kept menstrual cycle), infertility, pains in the bottom of a stomach, and also the general weakness, bystry fatigue.
The genital tuberculosis can be complicated by development of specific peritonitis, formation of fistulas, dissimination of mycobacteria of tuberculosis in other bodies, etc.
The diagnosis is made on the basis of comprehensive examination: bimanual ginekol. researches, tsitol., gistol. and bacterial. researches of scraping of an endometria, repeated crops on a mycobacterium of tuberculosis of menstrual blood. Carry out rentgenol. research: a survey X-ray analysis of a small pelvis, edge the X-ray contrast research (see Metro-saljpingogr an afiya), a bikontrastny ginekografiya allows to reveal the caseous centers in appendages of a uterus, (see). The tuberculinodiagnosis is important. In confirmation of the diagnosis focal reaction at statement of test of Koch about 20 and 50 THOSE tuberculine has a big role, edges it is shown by strengthening of pains in the bottom of a stomach, the expressed local morbidity at ginekol. survey, pastosity of the arches, increase in rectal temperature; approach of periods before estimated term is observed. Test with endo-pervikalny administration of tuberculine in various dosages is most informative: 20 — 50 THOSE. In cases, difficult for diagnosis, carry out trial treatment.
Treatment of tuberculosis of female generative organs consists in performing causal antibacterial and pathogenetic treatment according to the general principles of treatment of tuberculosis (see).
Along with the general apply topical treatment: at defeat of an endometria solutions of streptomycin and Saluzidum soluble enter into a myometrium, at tuberculosis of a neck of uterus — obkalyvany necks the specified solutions. The expressed tendency to cicatricial and commissural processes demands use of the appropriate pathogenetic means (a lidaza, a vitreous) already in an initiation of treatment.
At development of a tubercular pelviperitonitis and accumulation of ascitic liquid in a small basin through vaults of the vagina make a puncture of a cavity of a small pelvis for the purpose of evacuation of liquid, and then through the same needle enter solutions of streptomycin and Saluzidum soluble.
At hron. the tubercular inflammation of appendages of a uterus which is not giving in to conservative treatment sometimes resort to removal of ovaries together with the affected uterine tubes.
At detection of a disease at early stages of its development and adequate therapy recovery of generative function is possible. At cicatricial and commissural processes the forecast concerning generative function less favorable.
The TUBERCULOSIS OF BONES AND JOINTS
the Tuberculosis of bones and joints (tuberculosis of a skeleton) is the specific inflammatory disease arising in the conditions of hematogenous dissimination of tubercular process.
Dynamics of incidence, age structure and a wedge, the course of a tuberculosis of bones and joints underwent considerable changes for the last quarter of the century: annually incidence of this form of tuberculosis decreases, among again sick 92 — 93% adults make, and the specific weight of persons of advanced and senile age increases, the frequency of the complicated forms of a disease decreases. Occurred change and in the ratio a tuberculosis of bones and joints of various localization. According to P. G. Kornev and 3. BB. Rolye (1960), this ratio remained stable for a long time: damage of a backbone made 40%, a hip joint — 20%, a knee joint — 20%, other bones and joints — 20%. Recently accurately increase of a share of a tubercular spondylitis (apprx. 60%) was defined whereas about 7 — 8% are the share of a share for the first time of the diagnosed tuberculosis of coxofemoral, knee and talocrural joints approximately. However despite considerable decrease in incidence of a tuberculosis of bones and joints, 20 century made edges in the 60th apprx. 10% of all cases of tuberculosis, and at the beginning of the 80th — apprx. 3%, fight against it is the major task in connection with a high invalidism of patients with this form of extra pulmonary tuberculosis.
Pathogeny. The leading role in a pathogeny of a tuberculosis of bones and joints belongs to initial focal defeats — so-called primary osteitises across Kornev, the developing hematogenous way. According to experimental data of E. N. Bellendir (1962), tubercular damages of bones and joints in the conditions of hematogenous generalization of an infection begin almost always with emergence of tubercular granulomas in red marrow. As a rule, these granulomas resolve or cicatrize further, however nek-ry of them under unfavorable conditions increase in sizes and are exposed to a caseous necrosis. The tuberculous focuses (primary osteitises) created on their place are encapsulated therefore they badly give in to a resorption and can remain isolated for many years. In some cases the center increases in sizes and specific inflammatory process extends to the next joint where tubercular arthritis develops, or on a backbone where the tubercular spondylitis develops. Primary osteitis is a source of spread of true (bacterial) tuberculosis on various bones and joints. In development of primary and synovial forms of tuberculosis of joints the large role is played by an allergic (immune) inflammation.
Fig. 4. Gistotopografichesky cuts of an epiphysis of a tubular bone are normal («) and at bone tuberculosis (about): the general decrease in vascularization of the bone affected with tuberculosis in comparison with norm is visible (1 — an avascular zone; 2 — vessels of a wall
of the pathological center).
Distribution patol. process at a tuberculosis of bones and joints there is a hl. obr. as a result of growth of tubercular granulyatsionny fabric, specific morfol. the cut is an element a tubercular granuloma (see Tuberculosis). Besides, distribution of mycobacteria of tuberculosis on limf, to vessels and peri-vaskulyarno with formation of new tuberculous focuses in the field of the struck department of a skeleton or is watched its limits. Distribution of specific inflammatory process on soft tissues leads to education so-called cold (without sharply expressed temperature and vascular reactions) the abscesses which were earlier called congestive (see Na-technik). At spontaneous or operational opening of these abscesses fistulas are formed.
One of the most important pathogenetic features of a tuberculosis of bones and joints are the expressed dystrophic changes in the fabrics surrounding a tuberculous focus since in a microcirculator bed of a bone around the center or in a distance from it the reduction of vascular network (fig. 4) is noted. Develop characteristic of a tuberculosis of bones and joints osteoporosis (see) and a muscular atrophy, to-rye find not only in the affected joint, but also throughout all extremity.
Pathological anatomy. According to P. G. Kornev, at a tuberculosis of bones and joints distinguish three phases of development patol. process: preartritichesky (prespondiliti-chesky), arthritic (spondylitic) and post-arthritic (post-spondylitic). In a preart-ritichesky phase in a bone the center of a tubercular inflammation forms, process in Krom under unfavorable conditions progresses. The most frequent localization of the centers are bodies of vertebrae, the epiphysis and metaphyses of bones containing red marrow. The arthritic phase begins with distribution of process on a joint or its exit out of limits of one vertebra. In process of a zatikhaniye of tubercular process there is a rassasyvaniye of an iyerifokalny inflammation, scarring of the centers and a partial osteanagenesis. Characteristic signs of a post-arthritic phase are the expressed deformations of a skeleton and functional frustration. In this phase quite often there are aggravations of process — torpidno the current process.
The tuberculosis of bones and joints can be complicated by formation of abscesses (see Abscess) and fistulas (see). Abscesses arise at break patol. the center from a bone in surrounding soft tissues. Abscesses contain granulyatsionny fabric, pus, caseous masses and are surrounded with the fibrous capsule. At break of caseous masses fistulas form. Tubercular abscesses can exist a long time, and at a zatikhaniye of basic process to be exposed to calcification. It is long the current bone and joint tuberculosis with abscesses and especially fistulas can be complicated by an amyloidosis of internals (see the Amyloidosis).
The primary and synovial forms of damage of joints proceeding as tubercular toksiko-allergic arthritis — so-called polyarthritis of Ponce are possible (see Arthritises). In these cases in a synovial membrane (a synovial membrane, T.) nonspecific (paraspecific) inflammatory reaction in the form of vasculites, lymphocytic infiltrates, a hypertrophy vorsin prevails, can lead edges in nek-ry cases to formation of commissures and other residual phenomena.
Clinical picture. The main localizations of a tuberculosis of bones and joints are a backbone (see the Spondylitis), a knee joint (see. Drives), a hip joint (see the Coxitis). Tuberculosis can affect also other joints (see Arthritises) and bones, including a diaphysis of tubular bones in the form of spina ventosa (a so-called wind awn). At spina ventosa process is localized in phalanxes of fingers of brushes and feet, metacarpal and plusnevy bones; however also long tubular bones can be surprised.
In most cases the tuberculosis of bones and joints is characterized by the slow imperceptible beginning, long (quite often long-term) persistent current and expressed posledstviye (deformation of a skeleton, abscesses, fistulas and nevrol. frustration). The gyudostry beginning of a disease caused by the mixed genesis of the inflammatory process caused by mycobacteria of tuberculosis and nonspecific microflora is less often observed.
At the beginning of a disease the febricula, slackness, bystry fatigue, lack of appetite, irritability is noted. Subfebrile temperature, acceleration of ROE, increase in leukocytes in the blood and other changes characteristic of tuberculosis of other localizations are possible (see Tuberculosis).
In a preartritichesky phase of a tuberculosis of bones and joints of the complaint to pains in a joint (backbone) or the fabrics surrounding them hl can be absent or appear. obr. at a pristenochny arrangement patol. center. The swelling, local morbidity at a palpation of fabrics over the center are sometimes noted, restriction of movements. At the same time in a joint the exudate can appear. The first sign of spina ventosa is deformation of a finger in the form of a spindle or a swelling of soft tissues in the affected bone. At palpation of a bone morbidity, a thickening of a diaphysis is noted. All these symptoms quite often spontaneously disappear, but through a nek-swarm time appear again. Process can stop in a preartritichesky phase. However distribution of tubercular process and its transition to the subsequent phases of development is, as a rule, observed.
The following triad of symptoms is characteristic of an arthritic phase of a disease: pain, dysfunction of the struck department of a skeleton and a muscular atrophy. At the beginning of this phase of a disease pain can have not expressed character, not clear localization. Gradually pain concentrates in the struck department of a skeleton and is followed by reduction of its mobility as a result of tension (rigidity) of muscles. Rather seldom (at sudden break patol. the center) symptoms of a disease are shown sharply. Later in the struck department of a skeleton the changes caused by test
Fig. 5 develop. Outward of the child with a tubercular spondylitis: «bellied» you -
standing of an acantha as a result of wedge-shaped deformation of the corresponding chest vertebra (it is specified by an arrow).
ruktsiy bone and cartilage and the congruences of joint surfaces which are expressed disturbance or deformation of vertebrae that limits the volume of movements in a joint. At damage of the lower extremities and pelvic bones there is a non-constant, and then more and more amplifying lameness in the beginning. Trophic frustration are shown by slackness (hypotonia) of muscles of extremities, and then their atrophy in the beginning. Trophic frustration at a so-called dry caries (caries sicca) which is the most often found at a tubercular omarthritis are especially expressed, for to-rogo wrinkling of a joint bag of a shoulder joint and a sharp atrophy of muscles is characteristic. Usually process gains the expressed proliferative character with the plentiful growths in a synovial membrane leading to sharp increase in volume of a joint. One of early symptoms of a tuberculosis of bones and joints is the thickening of a skin fold on the affected extremity — Alexandrov's symptom, and at a tubercular spondylitis — tension in the muscles going from shovels to the affected vertebras — a symptom of «reins» of Kornev (see the Spondylitis). In process of development of a disease deformation of the struck departments of a skeleton accrues. In the beginning there is a swelling of a joint, its contours smooth out that in combination with an atrophy of muscles of an extremity gives to a joint the characteristic spindle-shaped form. At a spondylitis the vystoyaniye of one of acanthas appearing during the formation of an ugloobrazny kyphosis is defined only at a palpation in the beginning, then the «bellied» vystoyaniye of a shoot (fig. 5) is observed. Skin over the center changes a little (a «cold» inflammation) though in a stage of a heat of arthritis temperature of skin over area of the affected joint increases. At damages of joints the contracture increases, the extremity or its segment is fixed, as a rule, in vicious situation. At children growth of an extremity is slowed down that leads to its shortening, quite often considerable. The «dried», shortened extremity fixed in vicious situation during the doanti-bacterial period was a typical outcome of the disease which arose at children's age (fig. 6, a). At a spinal tuberculosis at late begun treatment kyphotic deformation (hump), most often acute-angled with top in the affected vertebras develops that brings, especially during the developing of a disease in children's age, to the expressed deformation of a thorax, and at damage of lumbar vertebras — to a kyphosis on site fiziol. lordosis (fig. 6,6). At spina ventosa, even at the complicated current, mobility of nearby joints remains that is connected with existence of a wide zone of the epiphyseal cartilage interfering distribution of tubercular process on a joint. At localization of the center near a zone
of Fig. 6. Outward of patients: and — at
a tubercular coxitis, the shortened lower extremity on the party of defeat; — at a tubercular spondylitis, kyphotic deformation of lumbar department of a backbone.
growth of an epiphyseal cartilage its perhaps temporary expansion.
The cold abscesses having an appearance of fluctuating painless or low-painful swellings can develop in various places, sometimes remote from the main center (see Natechpik). Skin is not changed in the beginning, but can gradually be involved in inflammatory process, become thinner and break with formation of fistulas. At break of abscess in internals formation of the bronchial or intestinal fistulas complicating the course of a disease and worsening its forecast is possible. Quite often consecutive infection joins. At the long course of a disease development of an amyloidosis of internals is possible (see the Amyloidosis). At a tubercular spondylitis contents of abscesses can break to the vertebral canal, causing damage to c. N of page (see below the section Tuberculosis of the Central Nervous System).
Began stages and a heat of a disease pass into a stage of a zatikhaniye of process. At the same time the exudate in a joint disappears, the swelling, morbidity, the sizes of cold abscesses decrease, there is their consolidation. However after the period of a zatikhaniye there can come the aggravation patol again. process with further increase in deformations of a skeleton and functional frustration. In cases of a resistant zatikhaniye of an inflammation the disease passes into the following, postartri-tichesky (post-spondylitic) phase.
The post-arthritic phase of a tuberculosis of bones and joints is characterized by a combination of residual tubercular changes to deformations of a skeleton and functional disturbances. Nevrol. the frustration resulting from a prelum of a spinal cord and its vessels demand, as a rule, operational treatment. In a post-arthritic phase of a tuberculosis of bones and joints residual tuberculous focuses, abscesses and others patol can remain. the changes which are not effects of tubercular process,
and display of the disease as specific inflammatory process.
Diagnosis. During the collecting the anamnesis
pay attention to the beginning of a disease, its communication with the postponed infections, contact with TB patients. At survey (it is surely completely naked
a leg of the patient) pay attention to change of skin, deformation of a skeleton, disturbance osanky, etc. Define local temperature increase, painful points, a tone of muscles, Alexandrov's symptoms, Kornev, etc. Note restriction of volume of movements in joints, morbidity. Direct inspection of area of defeat is made with obligatory measurements by means of a centimetric tape, a goniometer and special devices. Surveys are repeated for identification of dynamics of changes.
From laboratory methods of inspection blood tests, bacterial have the greatest value., bio-chemical and immunol. researches. Bakteriol. contents of abscesses and the centers of destruction, and also a discharge from fistulas are subject to a research for the purpose of identification of mycobacteria of tuberculosis. Tuberkulinovy tests (A tuberculine test and Manta) allow to establish contamination of an organism and shall be considered during the definition of an etiology of a disease; have the greatest value positive reaction to administration of tuberculine at children and teenagers and negative — at adults (see the Tuberculinodiagnosis).
Radiodiagnosis. Early diagnosis is directed to identification of initial stages of a tubercular osteitis (a preartritichesky phase). For this purpose inspect the patients having diseases of a musculoskeletal system of an unspecified etiology, being under observation of therapists, surgeons and neuropathologists, or revealed at professional surveys. For this purpose the large picture frame fluorography of bones and joints is successfully used (see Fluorography).
All patient make a survey X-ray analysis of the struck department of a skeleton (see the X-ray analysis), as a rule, not less than in two projections. After definition of localization patol. process and the general nature of defeat usually make a tomography (see) for the purpose of identification of intra bone tuberculous focuses (osteitises). Others rentgenol. methods of a research apply according to indications depending on localization, a phase and a stage of a disease.
In a preartritichesky phase usually reveal the centers of an osteoporosis or loss of bone structure. Borders of the center can be indistinct, vague (fig. 7) or, on the contrary, condensed, accurately outlined that depends on a stage of process, degree of its otgranicheniye. In the centers inclusions of various density can be defined (sequesters, sites of calcification, etc.). Primary center can have the small sizes and be defined hardly on roentgenograms. Osteoporosis (see), characteristic of a preartritichesky phase complicates detection of the bone centers.
Fig. 7. The roentgenogram of the left hip joint at a tubercular coxitis (a direct projection): the arrow specified a tuberculous focus in a body of an ileal bone.
In an arthritic phase of a disease rentgenol. changes are caused by distribution of tubercular process out of limits of a bone and along with increase of osteoporosis are shown by narrowing of a joint crack or intervertebral space as a result of reduction of thickness of an intervertebral disk close patol. center. However the joint crack can extend, e.g., in the presence of an exudate in a joint. The form of destruction of the joint ends of bones and vertebrae depends on localization and the sizes of primary bone centers. In process of a zatikhaniye of process of border of a zone of destruction of bones become more accurate, osteoporosis decreases, and on its background there are dense bone crossbeams oriented on lines of power loadings (reparative osteoporosis).
In a post-arthritic phase searches of residual specific tubercular defeats are important. Rentgenol. the picture at the same time can be very motley as a result of a combination of destruction to the recovery processes which are quite often perverted. Displays of metatuberculous arthroses are characteristic of damages of joints: a defor
a mation of the joint ends of bones (see Arthroses) % sometimes final fracture of a joint with formation fibrous, seldom bone, an anchylosis of a joint in vicious situation (see the Anchylosis), and for damage of a backbone — a kyphosis (see), a kyphoscoliosis with destruction and deformation tetg
Fig. 8. The roentgenogram of a brush of the patient with the periosteal spina ventosa form (a direct projection): extensive periosteal stratifications (are specified by shooters) around a diaphysis of I and III metacarpal bones.
vertebrae, existence of defects between them or kostnsh the block of the destroyed bodies of vertebrae.
Because idiosyncrasy of spina ventosa of short tubular bones is simultaneous damage of several bones, at this pathology it is necessary to carry out roentgenograms of all brush or foot. At damages of long tubular bones the struck area can be limited to a research only. Radiological distinguish the hyperplastic, periosteal and destructive spina ventosa forms. The hyperplastic form is characterized by increase in volume of a bone and change of its structure throughout, edges as a result of formation of a set of the smallest centers of destruction becomes melkosotovy. Owing to increase in volume the bone gets a cylindrical form. Changes of a periosteum make an impression of swelling of a bone. During the progressing of process and merge of the separate centers of destruction the structure of a bone becomes more rough, krupnosotovy. Cortical (compact)
Fig. 9. The roentgenogram of a forearm of the patient from spina ventosa (a direct projection): a large cavity with sequesters (it is specified by an arrow), in a proximal part of an ulna.,
substance of a bone becomes thinner. The periosteal form is characterized by formation of periosteal stratifications, to-rye in one cases are hardly noticeable and expressed preferential in a middle part of a diaphysis, in others are localized throughout a bone, giving it the spindle-shaped form (fig. 8), or bones are expressed on the one hand (the bone has bedded structure). During the progressing of a disease the destructive process taking sometimes all bone is followed by formation of small and large sequesters (fig. 9). Quite often the necrosis covers all phalanx or a metacarpal bone. At this spina ventosa form osteoporosis of bones of a brush and foot is noted. In process of treatment the structure of a bone is reconstructed, and periosteal stratifications resolve.
At the destructive spina ventosa form often the diaphysis of a bone completely collapses. In this regard the affected finger is shortened. Sometimes process passes to the next bone. In the next bones osteoporosis and an atrophy clearly are visible. At incomplete destruction of a bone its recovery is possible, but the regenerated bone takes irregular shape.
Great value rentgenol. the research has for diagnosis of complications of a tuberculosis of bones and joints. Abscesses are defined in the form of shadows of various density in soft tissues near the affected bones or at distance from them (see Natechnik). In the latter case connection of abscesses with the center of destruction can be established with the help of a contrast abstsessografiya (see). In the presence of fistulas make a fistulografiya (see) with use rentgeno-or a stereox-ray analysis (see). At nevrol. frustration the contrast miyelografiya (see) or pneumo-miyelografiya is widely applied (see). Besides, according to indications use an angiography (see), a venospondilografiya (see Flebografiya) and other special methods rentgenol. researches.
Differential diagnosis is carried out with inflammatory and noninflammatory diseases of a musculoskeletal system of other etiology. It is necessary to apply a complex of informative diagnostic techniques to differentiation of the erased and atypical displays of osteomyelitis, tuberculosis of bones and joints, primary and metastatic malignant tumors: clinicoradiological, gistol. and bakteriosko-pichesky, radio isotope, napr, a gammastsintigrafiya (see Stsintigra-fiya) at a computer tomography (see
the Tomography computer). Nonspecific osteomyelitis (see) differs in the acute beginning and bystry rate of destructive process, localization of defeats preferential in a diaphysis. Radiological at osteomyelitis absence of sharply expressed and widespread osteoporosis, bystry destruction of a joint cartilage, big comes to light, than at tuberculosis, sclerous changes of a bone. In crops of pus nonspecific flora comes to light. At differential diagnosis with syphilis of bones and joints consider results of reaction of Vasserkhman (see Wasserman reaction). Are most characteristic rentgenol. changes: syphilis unlike tuberculosis often leads to development of specific syphilitic periostites and gummous osteitises (see Syphilis). Among noninflammatory diseases of bones from the point of view of differential diagnosis with a tuberculosis of bones and joints fibrous osteodystrophies and tumors of bones are of the greatest interest (ShM. Bone). Both that and others have the characteristic signs caused by their noninflammatory nature, however for differential diagnosis the biopsy with the subsequent gistol has crucial importance. research of material. At the deforming arthroses (see Arthroses) unlike a tuberculosis of bones and joints there are no circumarticular primary bone tuberculous focuses, bone growths in the field of joint surfaces are more developed, osteoporoses and the wedge, signs of inflammatory process are expressed to a lesser extent. Spina ventosa most often should be differentiated with a pseudorheumatism (see). At spina ventosa there is no inflammatory reaction in interphalangeal joints. Nonspecific osteomyelitis (see) differs from spina ventosa in an acute current, the sequestration of the bone expressed by endosteal and periosteal reaction early coming. At a syphilitic dactylitis along with a periostitis there is an expressed reaction of an endosteum not characteristic of spina ventosa.
Treatment. Complex treatment of a tuberculosis of bones and joints includes conservative and operational methods. The chemotherapy is an obligatory and major component of treatment of a tuberculosis of bones and joints. It forms a basis for carrying out all others to lay down. actions as conservative, and operational. The general antibacterial therapy at the same time has no essential features in comparison with treatment of tuberculosis of other localizations (see Tuber-
kulez, philosophy of treatment). It shall be complex, whenever possible early and long. Besides, according to indications, antibacterial agents apply locally, enter vnutrikostno, vnu-triarterialno and intravenously, including by partial perfusion, into abscesses after their puncture, into fistulas and postoperative cavities, in the form of superficial applications etc. When a radical operative measure cannot be carried out, antibacterial therapy becomes the main method of treatment.
An obligatory component of conservative treatment of a tuberculosis of bones and joints is the orthopedic treatment which is carried out for the purpose of unloading and an immobilization of the struck segment of a skeleton for all the time of treatment to a resistant zatikhaniye of process (see the Immobilization). For the purpose of an immobilization of the struck department of a backbone appoint a high bed rest in a plaster bed. After cancellation of a bed rest patients carry the constant plaster corset later replaced on removable (see the Spondylitis). The philosophy of an immobilization of joints — the early movements at late loading. Terms of orthopedic treatment were considerably reduced in connection with existence of effective antituberculous remedies (see) and operative measures.
Dignity. - hens. treatment of a tuberculosis of bones and joints is carried out as in all-union resorts (The Black Sea coast of the Caucasus, the Crimea, the Baltics, etc.), and in specialized local sanatoria (see. Sanatorium selection, t. 29, additional materials). Feature dignity. - hens. treatments of a tuberculosis of bones and joints broad use natural is to lay down. factors, first of all air and sunlight. Treatment in local sanatoria has the advantages, in particular there is no need for adaptation to unusual climatic conditions, to-ruyu not all patients well transfer. The role a dignity is especially big. - hens. treatments after operative measures.
In the entire periods of treatment of a tuberculosis of bones and joints great attention is given to LFK and massage on specially developed complexes and techniques, various for each localization, a form and a stage of a disease.
Use of antibacterial agents leads to treatment with a favorable anatomo-funktsional-nym an outcome only at early detection of a disease before formation of destruction. At patients with widespread destruction of joints and a backbone resort to operational treatment. Antibacterial therapy is rational in the preoperative period for removal of the phenomena of intoxication and perifocal changes and in the postoperative period to 'involution of tubercular process.
In a preartritichesky (prespondili-tichesky) phase of a disease of the main operation the necretomy (see) consisting in opening of the center and its careful scraping (curettage) is. Such operations call radical preventive. In an arthritic (spondylitic) phase of a tuberculosis of bones and joints apply a big arsenal of the operational radical and radical recovery interventions chosen depending on localization, a form and a stage of a disease. Intra joint necretomies with plastics of defects of the joint ends of bones or without that, economical and reconstructive resections of joints, resections of bodies of vertebrae with a spondylodesis (see) or without that, etc. concern to them.
In the history of development of operational methods of treatment of a tuberculosis of bones and joints the resection of a knee joint across Kornev, edges in a crust was of great importance, time is applied seldom. At synovial forms of tuberculosis of a knee joint, and also at tuberculosis elbow (see. An elbow joint) and nek-ry other joints make an extirpation of the joint capsule, or a synovectomy (see).
In a post-arthritic (postspon-dilytic) phase of a disease the volume and types of operative measures are even more various. They set as the purpose not only final elimination of tubercular process, but also recovery of function of the struck department of a skeleton — recovery operations. Operations of radical and radical recovery character, and also corrective osteotomies (see the Osteotomy), verte-brotomiya (see the Backbone, operations) are applied to correction of deformations of extremities and a backbone. Function of joints in some cases is recovered by means of an alloplasty (see) and endoprosthesis replacements (see).
Operational treatment of complications is carried out usually along with operation on the main bone center. The excision of abscesses and fistulas applied before is nowadays replaced by not less effective, but less traumatic scraping of their piogenic cover. Medical and auxiliary operations (a back spondylodesis) are applied by hl. obr. as additions to radical interventions or at contraindications to them.
Rehabilitation of patients includes broad system of the actions directed to recovery of working capacity and social activity (see Tuberculosis, rehabilitation and examination of working capacity). It is carried out by hl. obr. in specialized TB facilities, in to-rykh along with rendering medical aid, components a cut radical and recovery operations are, carry out big educational work, labor therapy, recovery of an art and training of patients in new specialties in cases if such need arises in connection with change of a condition of their health and restriction of working capacity.
The forecast at a tuberculosis of bones and joints, as a rule, from the point of view of preservation of life of the patient favorable. However on an indicator of an invalidism of patients the tuberculosis of bones and joints is kept by the value as the main reason for disability at T. century. From among the suffering from tuberculosis bones and joints staying on the registry apprx. 70% suffers hron. common forms of a disease, among to-rykh take different place of deformation of a musculoskeletal system, usually and the disability which is the reason. Thus, in view of special disease severity, duration and complexity of treatment the forecast concerning working capacity can be favorable only on condition of timely diagnosis, the full qualified complex treatment.
Prevention includes the prevention of the disease and prevention of its severe forms and complications. Prevention of incidence of a tuberculosis of bones and joints comes down to the general epidemiol. to antitubercular actions and elimination of the conditions promoting defeat of a musculoskeletal system at the persons infected with tuberculosis: to fight with
hron. nonspecific inflammatory diseases of bones and joints, to the prevention of possible allergic reactions, increase in resistance of an organism, prevention of flashes of tubercular process and its generalization. Prevention of development of severe forms and complications of a tuberculosis of bones and joints consists in early diagnosis and full complex treatment of patients on condition of timely use of the operative measures shown in various phases and stages of a disease.
See also And rtrodez, the Coxitis, the Knee joint, the Osteotomy, the Shoulder joint, the Spondylitis, Spopdilo-dez, Joints, the Hip joint.
TUBERCULOSIS of EYES
Tuberculosis of eyes — one of forms of extra pulmonary tuberculosis, is characterized by a variety a wedge, manifestations, persistent, quite often recurrent current. In structure of extra-pulmonary forms of tuberculosis tuberculosis of eyes makes about 18%. At patients with active tuberculosis (pulmonary and extra pulmonary) tuberculosis of eyes comes to light in 5,5 — 7,3% of cases, and is more often at patients with extra pulmonary tuberculosis. At the same time active tubercular process in lungs is found in suffering from tuberculosis eyes in 6 — 21,8% of cases. There are data that approximately at 51% of the patients having tuberculosis of eyes, tubercular process in an eyeglobe proceeds against the background of the tubercular changes poorly expressed, but not lost activity in easy or radical bronchial limf, nodes.
Pathogeny. Depending on a pathogeny allocate metastatic (hematogenous disseminated) tuberculosis of eyes, to-rogo falls to the share 2/3 all cases of tuberculosis of eyes and the tubercular and allergic defeats making V3 of all cases of tuberculosis of eyes.
At metastatic tuberculosis of eyes of a mycobacterium of tuberculosis get to tissues of an eye from the centers of extra-eye localization in the hematogenous way, on perineural and perivascular spaces of an optic nerve (at tubercular meningitis), and also kontaktno (from adjacent areas, napr, skin, adnexal bosoms of a nose) from where tubercular process extends to appendages of an eye (eyelids, slezoprovodyashchy ways, etc.) and its outside cover (cornea, conjunctiva and sclera). Nek-ry forms of tuberculosis of eyes, napr, a sclerite (see) and a keratitis (see), arise at distribution of causative agents of tuberculosis from the centers which are available in an adjacent horioidea or a ciliary body.
The main way of distribution of causative agents of tuberculosis is hematogenous. The mycobacteria circulating in a circulatory bed can be brought in tissue of an eye in any period of development of a tuberculosis infection, to a thicket in secondary Mycobacteria of tuberculosis originally settle, as a rule, in a layer • vessels of average caliber of a horioidea (an idiovascular cover of an eye) where they can not cause diseases, cause the abortal, latentno proceeding inflammation, a trace to-rogo in the form of the atrophic chorioretinal center with adjournment of a pigment around it can be accidentally found at routine maintenance or lead to development of the centers of the expressed inflammation. From a layer of vessels of average caliber of a horioidea the inflammation can extend to a choriocapillary layer of a horioidea, a retina and other tissues and environments of an eye.
The variety of forms of metastatic tuberculosis of an eye depends on localization of tubercular process in an eyeglobe, its degree of manifestation and manifestations of the accompanying perifocal inflammation caused by a condition of the general and specific immunity and level of a sensitization of tissues of eye.
Characteristic distinctive feature of a pathogeny of tuberculosis of eyes, in comparison with other forms of tuberculosis, according to A. I. Strukov, is more expressed role of the allergic reactions which are leading to emergence of independent tubercular and allergic defeats or acting as the factor in many respects defining polymorphism a wedge, displays of metastatic tuberculosis of eyes.
At the heart of the inflammation which is observed at a tubercular allergi-cheskikh damages of eyes immune responses antigen — an antibody lie (see Antigen — an antibody reaction). The disease develops at patients, an organism and tissues of an eye to-rykh a sensibilizirovana to tubercular antigen. Antigen gets to sensibilized tissues of an eye gema-togenno, as a rule, from the centers of a tuberculosis infection remote, not lost activity which are available in an organism (most often from limf, nodes). More rare the intraocular centers which are localized in horioidy can be a source of a sensitization.
If the organism and tissues of an eye of a sensibilizirovana to mycobacteria of tuberculosis or products of their life activity, the accompanying allergic inflammation can have giperergichesky character, being followed by the expressed exudation and hemorrhages, to-rye mask the main center in a choroid of an eye.
Pathological anatomy. At metastatic tuberculosis character morfol. manifestations depends on the period of development of a tuberculosis infection, in Krom there was a tubercular process in tissues of an eye. At primary tuberculosis the inflammation in a vascular uveal path of an eye (an iris, a ciliary body, horioidy) can proceed on exudative type. At the same time dense fibrinous exudate, in Krom polinukleara can meet, impregnates the struck fabric. Diffusion lymphoid infiltration of a vascular path of an eye, accumulation of macrophages, histiocytes, epithelial and colossal cells of Pirogov — Langkhansa, in the absence of grumous reactions and the centers of a caseous necrosis can be observed.
At the heavy course of primary tuberculosis which is followed by a condition of an anergy of an organism in a choriocapillary layer of a horioidea as a result of dissimination of mycobacteria of tuberculosis the miliary centers of a caseous necrosis without cellular reaction form.
At secondary tuberculosis in morfol. to a picture of tubercular process in an eye the productive type of an inflammation with formation of typical tubercular granulomas prevails. In the center of a granuloma the caseous necrosis can be formed. At the favorable course of process of the centers of a necrosis can not be, at involution they are exposed to fibrosing and scarring. During the progressing of an inflammation merge of granulomas and formation of the large, so-called konglobirovanny center — a tubercle is observed. Around this center reactive changes of vessels up to a specific periarteritis and a periphlebitis are observed. At a favorable current tubercular changes resolve, leaving in horioidy the atrophic centers surrounded with a pigment. Large tuberculous focuses are replaced with rough cicatricial fabric. In the started cases the tubercular inflammation can kontaktno extend to fabrics and cameras of an eyeglobe and sometimes leads to perforation of its walls (more often in the field of a limb). The extensive necrosis of tissues of eye leads of it to death. In a crust, time perforation and death of an eye at tuberculosis meet seldom.
At tubercular and allergic defeat against the background of hypostasis of fabrics in them along with histiocytic reaction lymphoplasma infiltration, with dominance of lymphatic is observed. Quite often in infiltrate define eozinof.i-la. On this background change of vessels in the form of their moderate ectasia, swelling of vascular walls and disturbance of their structure is noted.
Morfol. the picture of tuberculosis of eyes, treated antituberculous remedies, differs in a stertost of specific changes, dominance of lymphoid infiltrates, stratification of allergic vascular changes and the expressed processes of scarring. Now are causes of death of an eye at tuberculosis: an atrophy of an eyeglobe, secondary glaucoma, scarring patholologically the changed fabrics.
Clinical forms of tuberculosis of eyes. Carry to metastatic forms of tuberculosis of eyes horiore-tinit (see the Retinitis, the Choroiditis), front uvent (iridocyclitis), a keratitis (see), a sclerite (see) and tuberculosis of appendages of an eye (a conjunctiva a century, slezoprovodyashchy ways, etc.).
Carry a fliktenulezny keratoconjunctivitis, conjunctivitis to tubercular and allergic diseases (see) and a keratitis, an episcleritis (see the Sclerite), an iridocyclitis (see), or a front tubercular and allergic uveitis. The acute beginning, a short current (from several days to 1 — 1,5 month), tendency to a recurrence is characteristic of all tubercular and allergic damages of eyes. Both eyes, sometimes in different terms are surprised always, and inflammatory process can alternate, striking one, other eye.
Tubercular x about r and a shouting e t and N and t. Distinguish the pair, focal and disseminated tubercular chorioretinitis is lovely.
The miliary tubercular chorioretinitis develops at the phenomena of violently progressing general mi-lparny tuberculosis. On an eyeground of both eyes multiple small yellowish roundish ochazhka with indistinct borders appear. They can completely resolve or leave after accurately limited sites of an atrophy of a choriocapillary layer of a horioidea.
A focal tubercular chorioretinitis — the most often found form of metastatic tuberculosis of eyes. It is characterized by emergence in horioidy the single large (konglobirovanny) center of an inflammation — a tubercle, to-ry quickly extends on adjacent to horioidy a retina; the picture of a chorioretinitis develops. The patient complains of floating opacities and a spot before an eye, decrease in sight (depending on localization of the center to horioidy). Occasionally on the aching dull ache in the depth of an eye.
D issy in irovanny in t at Burke at l e z-ny the chorioretinitis is characterized by existence in the horioidy several centers of a specific inflammation. At an oftalmoskopiya (see) on an eyeground the chorioretinal centers of different prescription are found (tsvetn. the tab., Art. 400, fig. 14) not inclined to merge which are localized more often in its central part (tsvetn. the tab. to St. Eyeground, t. 6, Art. 96 — 97, fig. 50 — 51).
The tubercular chorioretinitis can proceed with aggravations, to-rye, especially at localization of the centers in the central region of an eyeground, quite often are followed by an allergic inflammation of a retina. At the same time hemorrhages are observed, the exudation and hypostasis of a retina causing secondary dystrophic changes of a retina and masking the main chorioretinal center amplify. In the outcome of an inflammation on site of such central center there is a rough pro-mining hem, falloff of visual acuity is observed. On site the paracentral and peripheral chorioretinal centers, process in to-rykh proceeds, as a rule, without allergic stratifications, there are atrophic centers of yellowish or white color with a pigment around them.
At localization of the chorioretinal centers at edge of an optic disk the neuroretinitis or a yukstapapillyarny chorioretinitis develops (see the Retinitis, a tubercular retinitis). Since the optic disk is involved in process (see. Congestive nipple, Optic nerve), in an early stage a wedge, manifestations of a neuroretinitis are similar to those at neuritis or a congestive optic papilla (tsvetn. tab., Art. 400, fig. 15). In process of reduction of hypostasis of a retina around an optic disk the chorioretinal centers begin to come to light.
An outcome of a neuroretinitis is the partial atrophy of an optic nerve with the atrophic chorioretinal centers surrounded with a pigment (tsvetn. tab., Art. 400, fig. 16).
The front tubercular uveitis (both r and d about c and C and r) clinically proceeds in the form of serous, plastic (serofibrinous) or focal process.
The serous tubercular front uveitis can sharply proceed or has a sluggish chronic current with periodic aggravations, in time to-rykh poorly expressed pericorneal injection, the rare poorly pigmented precipitated calcium superphosphates is noted; single small back synechias, a cellular suspension in a vitreous.
The plastic front uveitis, as a rule, begins sharply, but can accept and sluggish hron. current. Emergence of the fat (grease) precipitated calcium superphosphates which were earlier considered characteristic of a tubercular uveitis is observed seldom, more often precipitated calcium superphosphates do not differ from precipitated calcium superphosphates at uveites of other etiology. Formation of the powerful, strong back synechias which are badly giving in to a rassasyvaniye is characteristic. At an acute current of a uveitis «flying» jellylike small knots in the field of a pupil (an ochazhka to Keppa) or on a surface of an iris can appear (ochazhka the Bouza to and). A current of uveites long, recurrent, in nek-ry cases sluggish with formation of synechias. After a zatikhaniye of an inflammation there are always intensive back synechias and gonio-synechias that in some cases can lead to secondary glaucoma (see).
At focal front tubercular twine the small multiple centers of grayish color can be located in a pupillary part of an iris, at a root of an iris the large single centers — tubercles develop more often (tsvetn. tab., Art. 400, fig. 17). Process can inertly proceed, without the expressed signs of an inflammation, in nek-ry cases the inflammation can begin with an acute diffusion iridocyclitis (see), and in process of a zatikhaniye of the acute phenomena the center «born» from depth of a stroma of an iris — a tubercle becomes visible. Rassasyvaniye of a tubercle goes slowly, precipitated calcium superphosphates periodically appear, according to localization of a tubercle stromal back synechias develop. Process can be followed by the increase in intraocular pressure caused by disturbance of outflow of intraocular liquid (watery moisture, T.) through a corner of an anterior chamber as a result of formation of goniosinekhiya, deposits of a pigment or closing of a part of a corner with a tubercle. In the outcome of a focal uveitis the tubercle resolves, leaving behind thinning of an iris. or cicatrizes (tsvetn. tab., Art. 400, fig. 18).
The tubercular keratitis results for the second time from transfer of mycobacteria of tuberculosis from the centers which are localized in adjacent structures: a ciliary body, a root of an iris (see tsvetn. the tab. to St. Keratitis, t. 10, Art. 256 — 257, fig. 9). As a rule, the phenomena of an iridocyclitis join an inflammation in a cornea and the picture of a keratouveit develops (see the Keratitis).
Tubercular with to l of ER and t develops at distribution of inflammatory process of a horioidea or a ciliary body (see the Sclerite). At defeat of a sclera in the field of a limb the cornea is involved in process and the wedge, a picture of a sclerokeratitis or a skle-rokeratouveit develops. After a rassasyvaniye of the scleral center there is a site of the thinned atrofichny sclera. At localization of such site at a limb its stretching and formation of a staphyloma is possible (see). In the outcome of the recurrent sclerites which are localized at a limb there is regional opacification of a cornea (see the Cataract), its stretching and scleras leading to formation of a hydrophthalmia (see). The current is recurrent, chronic.
Tuberculosis a conjunct and in y meets very seldom. Emergence of the ulcerating tubercular granuloma in the field of a conjunctiva of a cartilage of an upper eyelid is characteristic of it. A current chronic with bent to a recurrence (see. To an onjyunktiv).
Tuberculosis of slezootvodyashchy ways. Feature is preservation of passability of the lacrimal ways, despite development of a dacryocystitis (see). At a X-ray analysis of slezootvodyashchy ways with filling with their contrast agent it is possible to see sometimes irregularity of a relief of a mucous membrane of a dacryocyst. On skin in the field of a dacryocyst openings of the fistular courses can be visible. In crops of contents from fistula and rinsing waters of slezoprovodyashchy ways mycobacteria of tuberculosis can be found.
Fliktenulezny damages of eyes (a conjunct of willows and t, a keratitis) are characterized by emergence in surface layers of a conjunctiva of an eyeglobe, a limb or a cornea of gray roundish small knots, so-called phlyctenas, to the Crimea bunches of conjunctival vessels approach. Small knots can be small (miliary) multiple or large, single (solitary). Phlyctenas can resolve or ulcerate extremely seldom up to a perforation of a cornea with formation of the cataract soldered to an iris (see the Keratitis, Conjunctivitis).
At a heavy fliktenulezny keratitis signs of an iridocyclitis join. Especially hard the fliktenulezny ulcers of a cornea complicated by a purulent infection proceed. After a rassasyvaniye of phlyctenas in a cornea remain various extent and size of opacification (from a cloudlet to a cataract).
A tubercle zno-and l of l e r-gichesky e and and with to l of e r and the t is characterized by formation of an episkleralny node more often near a limb.
At giperergichesky character patol. process the disease proceeds with sharply expressed signs of an inflammation of an episclera and an adjacent conjunctiva, on a convex part of an episkleralny node there is abscess with bystry fusion of fabrics on its surface (tsvetn. the tab., Art. 400, fig. 19) then involution of an episkleralny node begins, to-ry resolves sometimes completely (see the Sclerite).
Tuberculosis but - and l of l e r-@ and h e with to and y front at in e-and t (irites and iridocyclites). At this form of tuberculosis of eyes the active tuberculous chorioretinal focus can sometimes be a source of a sensitization of a front piece of a uveal path. For the purpose of identification of this center careful inspection of an eyeground both a sore eye, and eye is necessary, in to-rokhm there are no signs of a uveitis.
At tubercular and allergic front twine a wedge, manifestations (a pericorneal injection, a hyperemia of an iris, formation of synechias, etc.) have nonspecific character and are observed at all uveites of an allergic origin.
Tubercular defeats of vessels of a retina (a tubercular periphlebitis and a periarteritis) result from development in a vascular wall of the specific center or have allergic character (see the Retinitis, a tubercular retinitis). At an oftalmoskopiya on vessels «couplings» or exudative deposits are defined (tsvetn. the tab. to St. Eyeground, t. 6, Art. 96 — 97, fig. 54).
Complications of tuberculosis of eyes are: secondary amotio of a retina (see), secondary glaucoma (see), the complicated cataract (see), the cataract soldered to an iris (see the Cataract), a subatrophy of an eye.
Diagnosis. Diagnosis of tuberculosis of eyes is difficult because of polymorphism klinich. manifestations, their looking alike a wedge, a picture of diseases of eyes of other etiology, impossibility to allocate mycobacteria of tuberculosis from fabrics of an eyeglobe. The diagnosis is based on data of comprehensive examination of the patient, from to-rykh leaders at metastatic tuberculosis results of focal reaction to administration of tuberculine are, and at tubercular and allergic defeats — identification of the active center of extra eyes - ache localizations.
Comprehensive examination includes the collecting the anamnesis and survey of the patient directed to identification of possible communication of a disease of eyes with a tuberculosis infection. Ophthalmolum is carried out careful. inspection of the patient (see Inspection of the patient, ophthalmologic inspection).
Besides, special methods of a research are applied: radiological, a tomography, a bronkhoskopiya, a puncture and a biopsy increased peripheral limf, nodes, a research of urine; phlegms, rinsing waters of a stomach and bronchial tubes on a mycobacterium of tuberculosis (see the Phlegm), etc., directed to identification of tuberculous focuses of extra eye localization, and also a wedge, blood tests and urine.
Immunol. the research on tuberculosis is based on identification of humoral and cellular antibodys to mycobacteria of tuberculosis and products of their life activity, e.g.
cellular antibodies, by means of reaction of a blastotransformation of lymphocytes (see), to-ruyu will see to a Mantoux test.
A tuberculinodiagnosis (see) carry out after complex (Ophthalmolum., immunol. hematologic) inspections of the patient. In 2 hours after statement of Mantoux reaction about 2 THOSE standard tuberculine (PPD-L) at a kampimetrichesky research can be observed: increase in the sizes of a blind spot, increase in intraocular pressure, reduction of number of eosinophils of blood. In 24, 48, 72 and 96 hours after statement of Mantoux reaction check local general and focal reactions. Process in an eye is regarded as tubercular if on Mantoux reactions positive local and focal reactions or negative local and positive focal reaction are received.
In case of the expressed local reaction to Mantoux reaction at negative focal reaction to the patient appoint Koch's test, since 10 THOSE (then 20 — 50 THOSE) standard tuberculine before receiving focal reaction. If there is no focal reaction at active inflammatory process in an eye, its tubercular etiology is rejected.
At tubercular and allergic damages of eyes focal reaction does not matter, in this case pay attention to expressiveness of local reaction to tuberculine and the general reaction (temperature increase, an indisposition, changes of a gemogramma, protein fractions of blood, etc.). At positive local reaction or positive mestnokh! and the general reactions to Mantoux reaction to the patient conduct the additional researches (a tomography, a bronkhoskopiya, etc.) directed to identification of an active tuberculous focus of extra eye localization.
At expressed local and general reactions to Mantoux reaction and lack of an active tuberculous focus of extra eye localization to the patient carry out 2 — 3-month specific trial antibacterial treatment and if local and general reactions to Mantoux reaction fade, aggravations of allergic process change the character (become more rare, shorter or stop), make to the patient the diagnosis of tubercular and allergic damage of eyes with an undetected active tuberculous focus of extra eye localization and continue specific treatment at an oftalmoftiziatr.
Apply as well other methods a tubercle inodiagnostik and: administration
of tuberculine of the increasing concentration through eyelids of a sore eye by method of an electrophoresis across Burginyo - well before receiving focal reaction; administration of tuberculine by method of an electrophoresis according to Bourguignon through skin of an inner surface of a forearm; test of STsABO — administration of tuberculine under a conjunctiva of a healthy eye — and modified test of STsABO (a method eksgkhress-dpag-nostiki) — administration of tuberculine under a conjunctiva of a sore eye (at bilateral process — the worst eye on sight); tuberkulinovy test of the Kiev scientific research institute of tuberculosis, to-ruyu begin with the graduated Grpnchar's test — Karpi-lovsky, and then in case of lack of focal reaction and depending on expressiveness of local reaction carry out Mantoux reaction with various cultivations of tuberculine to receiving focal reaction, etc.
For the purpose of differential diagnosis make Wassermann reaction, blood analyses on a toxoplasmosis, immunol. researches on viruses (e.g., herpes). If necessary exclude hron. tonsillitis, rheumatism, hold consultations of the gynecologist and urologist.
Treatment consists in performing causal antibacterial and pathogenetic treatment according to the general principles of antitubercular treatment (see Tuberculosis).
Antibacterial therapy of tuberculosis of eyes has nek-ry features. In eye practice, as a rule, do not apply Ethambutolum, to-ry possesses selective toxic effect on a retina and an optic nerve. Due to the need of the prevention of processes of scarring streptomycin is appointed a short course (20 — 30 days) at the beginning of a basic course of treatment and the patient with acute exudative processes.
For more gentle scarring on the 3rd month of treatment appoint chymotrypsin, a lidaza, papain or lecozimum, since small doses, to-rye gradually bring to therapeutic. In later terms under control of a condition of inflammatory process in an eye FIBS, a vitreous are shown.
Surely include the hyposensibilizing means in complex treatment of tuberculosis of eyes (calcium chloride, Suprastinum, etc.). The general treatment by corticosteroids is shown only at the acute progressing exudative inflammation which is not stopped by means of the complex therapy which is carried out within 1 — 1V2 months, and drugs are appointed small doses, a short course (no more than 1 month) and it is obligatory under protection of antibacterial agents.
The patient with recurrent central horioretpnita, coup about in about dayushch to them is I to ro in about from l iya N of an iya-ma, for the purpose of specific desensitization and bolnsh with the slow persistent tubercular processes (front uveites and horioretinitakhm) which are not giving in to chemotherapy for increase in specific reactivity of an organism carry out a tuberculinotherapy. Tuberculine can be entered as subcutaneously, and by means of an electrophoresis through eyelids.
Along with the general treatment surely appoint local therapy. At a tubercular allergi-cheskikh damages of eyes topical treatment generally consists in purpose of the symptomatic and hyposensibilizing means (vitamins, midriatik, miotik, corticosteroids, Dicynonum, etc.). At patients with metastatic tuberculosis of eyes, except symptomatic, locally surely apply antituberculous remedies (Tubazidum, PASK, Saluzidum, streptomycin, Pasomycinum, streptosalyuzid). The method of introduction depends on localization patol. process: at defeat
of a conjunctiva and cornea pharmaceuticals are appointed in drops and ointments, at defeat of a front piece of a uveal path — in drops and podkonjyunktivalno, at defeat of a back piece of an eye — parabulbarno, retrobulbarno. At all types of localization medicinal environmentsstvo enter also by method of an electrophoresis (see) or a fo-noforeza (see. Ultrasonic therapy). Topical treatment is carried out it is long, alternating different methods of introduction, changing antibacterial agents in order to avoid development of a medicinal allergy.
Duration of a basic course of specific treatment at for the first time the revealed patients and at a recurrence of a disease of 10 — 12 months. Treatment stage: 3 — 4 months — in a hospital,
3 — 4 months — in specialized sanatorium, then are out-patient at an oftalmoftiziatr of a tubercular clinic. After the termination of a basic course of treatment patients for 3 years 2 times a year receive seasonal antibacterial treatment 2 — 3 months, including and a dignity. - hens. treatment. In the absence of aggravations patients are observed 1 more year at an oftalmoftiziatr, then strike them off the register and translate under observation of the doctor of the general network. Patients with big residual changes or the recurrent course of a disease remain under observation of an oftalmoftiziatr.
Operational treatment of complications of tuberculosis of eyes (the complicated cataract, secondary glaucoma, etc.) is carried out surely against the background of the general antitubercular therapy in order to avoid an aggravation of inflammatory process. Depending on a degree of activity of an inflammation in an eye before operation to the patient appoint 2 — a 8 weeks course of antibacterial therapy and 4 — a 8 weeks course after an operative measure. In case of a section rough shvart upon termination of operation on the operating table together with Dexasonum, Dicynonum under a conjunctiva enter streptomycin (in total no more than 1 ml). Maintaining the postoperative period usual (see. Postoperative period).
At treatment of the complicated cataract the best results are yielded by intrakapsulyarny extraction of a cataract (see).
Antiglaukomatozny operations for secondary glaucoma (see) are possible in any stage of activity of a specific inflammation against the background of antibacterial therapy. In the presence of moderate goniosine-hiya make a sinusotrabekuloek-tomiya (see the Sinusotomy, Trabekul-ektomiya)', in the presence of the multiple rough lobbies and back goniosinekhiya which are almost completely closing a corner, combine a sinusotomy and a trabekulektomiya with iri-denkleyzisy (see).
At the permanent opacification of a cornea leading to decrease in sight the layer-by-layer or through keratoplasty is shown (see).
Besides, to an otgranicheniye and removal of the active chorioretinal center and coagulation of the vessels possessing a hyperpermeability use the laser (a method of a laser burning out) against the background of a basic course of antibacterial treatment (see the Laser).
Suffering from tuberculosis eyes consider on five groups of the dispensary account (see the Clinic, an antitubercular clinic). In all city, regional and regional tubercular clinics there is a doctor oftalmoftiziatr, a task to-rogo is diagnosis, treatment, dispensary observation and rehabilitation of suffering from tuberculosis eyes (performing recovery and resorptional therapy, operational treatment of complications of tuberculosis of eyes).
The forecast at tuberculosis of eyes concerning functions of eyes is always serious and depends on localization, weight and prevalence of process. So, at localization of the chorioretinal center in the field of a macula lutea even at a permanent cure visual acuity sharply decreases. However at early diagnosis and full treatment in most cases there comes the wedge, recovery and patients are returned to work.
Prevention consists in timely vaccination and a revaccination of the population, early identification and full treatment of TB patients (see Tuberculosis).
The TUBERCULOSIS CUTIS AND HYPODERMIC CELLULOSE
the Tuberculosis cutis and hypodermic cellulose arises at hematogenous or lymphogenous distribution of mycobacteria of tuberculosis from the tuberculous focuses which are localized in other bodies is preferential in limf, nodes.
Skin is surprised at suffering from tuberculosis other bodies seldom that explain with absence in skin of conditions, favorable for the causative agent of tuberculosis. The question of the factors promoting developing of a tuberculosis cutis finally is not solved. According to I. B. Veynerov (1970), in most cases the tuberculosis cutis in a crust, time is connected with activation of old, is long the centers of tuberculosis which were in stable state, from to-rykh contagiums get into skin in the hematogenous way. In a papillary layer thanks to features of microcirculation there can be initial tubercular ochazhka from where process extends to other layers of skin. At the same time the combination of specific inflammatory reaction (tubercular granulomas or the centers) to the phenomena of a nonspecific inflammation is characteristic. Play a role and nonspecific factors: neyroen
dokrinny frustration, acute infections, and also injuries.
Clinical forms of a tuberculosis cutis. Distinguish the localized and disseminated forms of a tuberculosis cutis. Carry primary tuberculosis cutis (a tubercular chancre), a tubercular lupus, a kollikva-tivny, warty tuberculosis cutis, a miliary and ulcer tuberculosis cutis to the localized forms; to disseminated — acute the pair tuberculosis cutis, the disseminated miliary tuberculosis of the person, a rozatseopodobny tubercle of ides, a papulonecrotic tuberculosis cutis, the condensed erythema is lovely and deprive of scrofulous.
In typical cases to all a wedge, to forms of a tuberculosis cutis are inherent slow development, hron. a current, lack of the acute inflammatory phenomena and the expressed morbidity; they are inclined to a wavy current, remissions and a recurrence during the spring and autumn period.
Primary tuberculosis cutis (tuberculosis cutis primaria; a synonym a tubercular chancre) — the rare damage of skin described by hl. obr. at babies, but can occur also at adults. On skin there are pustules, erosion or ulcers with a little condensed bases. Process on skin is followed by increase regional limf, nodes, to-rye are condensed, accustomed to drinking among themselves, abscess, opened with formation of a hem. In separated ulcers and suppurated limf, nodes find mycobacteria of tuberculosis. At full treatment of a recurrence it is not observed. Primary tuberculosis cutis differs in lack of infiltrate in the basis from a hard ulcer, and also negative takes serol. reactions to syphilis (see).
Tubercular lupus (lupus vulgaris, tuberculosis cutis luposa; the synonym a lyupozny tuberculosis cutis) is characterized by localization patol. process preferential on a face (tsvetn. the tab., Art. 400, fig. 5), a long current, the deformation of fabrics resulting from scarring of infiltrate and leading to a disfiguration. Primary element of a tubercular lupus is the hillock, or the lyupoma located most often in upper and average layers of a derma, having the size 2 — 3 mm, pink coloring, a clear boundary. During the pressing on lyupy a slide plate (see Dermoskopiya) against the background of the skin which turned pale from a prelum of vessels the infiltrate lying in it in the form of small flat formation of yellowish color — a phenomenon of «apple jelly» is visible. Lyupoma is usually soft. During the pressing on it the bellied probe in it there is a deepening remaining during nek-ry time (the «phenomenon of the probe» described in 1896. And. I. Pospelov). Along with it also diffusion forms meet, at to-rykh lymphocytic infiltration with accumulation of epithelioid and colossal cells like Pirogov — Langkhansa extends to all layers of a derma.
Tubercular hillocks can be exposed to fibrosing further. At the same time collagenic and elastic fibers of skin collapse. At the exudative nature of process infiltration of the centers by segmentoyaderny leukocytes, fusion of a lyuioma in the center is observed. Under the influence of various factors, first of all an injury, the centers of a tubercular lupus can ulcerate (tsvetn. tab., Art. 400, fig. 6). Ulcers are usually superficial, with soft uneven edges and easily bleeding bottom. The changes which are observed in circulatory and limf, vessels in the field of lupoid process have usually nonspecific character.
Appendages of skin in the centers of defeat are exposed to destruction and sometimes in lyupozny infiltrate find the remains of hair follicles, sweat glands and their output channels. The epithelium of follicles can proliferate, as well as a cover epithelium. Nerve fibrils long time remain in sites of damage of skin in this connection its sensitivity and morbidity remain.
Big variability morfol. changes at a tubercular lupus its wedge, manifestations causes variety. Owing to tendency lyupy to the peripheral growth and merge flat surface infiltrates — a flat lupus are formed (tsvetn. tab., Art. 400, fig. 7). Quite often elements of a tubercular lupus considerably tower over the level of skin, there are hypertrophic and even tumorous forms of a tubercular lupus. At stratification of scales on the surface of infiltrate forms exfoliative, in the presence of plentiful growths of an epithelium in the form of outgrowths and warts — a warty form.
Patol. process at a tubercular lupus always comes to an end with scarring, and the superficial gentle cicatricial atrophy is characteristic of a flat lupus; skin gathers in folds like tissue paper (tsvetn. tab., Art. 400, fig. 8). The centers of a tumorous ulcer lupus can leave the rough spoiling hems deforming the soft tissues of a nose, lips leading to a cicatricial ectropion a century. Transition of a tubercular lupus to a mucous membrane of a nose, a mouth, throat, throat, and also emergence to them of the isolated defeat is possible. Lyupozny infiltrate can lead to destruction of wings of a nose, a webby and cartilaginous part of a nasal partition. Seldom on the periphery of lupoid defeats or on hems cancer — a so-called lyupus-carcinoma develops (tsvetn. tab., Art. 400, fig. 9). The differential diagnosis is carried out with syphilis (see). Unlike dense syphilitic hillocks of a lyu-poma have a soft consistence, hems after grumous syphilis unlike hems after a tubercular lupus dense, uneven, scalloped, do not gather pleated. Serological tests on syphilis at a tubercular lupus negative.
To about l of l and to in and t and in N y y a tuberculosis cutis (tuberculosis cutis colliquativa; synonym: the scrofuloderma, scrofulous gummas, tubercular gummas) can be primary (at a hematogenous drift of contagiums) and secondary. Originally in deep layers of a derma there is
a node of 1 in size — 3 cm, plotnovaty, low-painful, consisting preferential of epithelial, lymphoid and colossal cells like Pirogov — Langkhansa. The node increases in sizes, sometimes melts, forming cold abscess, and is opened with one or several openings with formation of fistulas, from to-rykh the bloody discharge containing grains of necrotic masses is allocated. At the same time several nodes can be formed. Further ulcers with the soft upper subdug cuts form, to-rye sometimes connect among themselves the fistular courses. Healing of ulcers happens to formation of usually uneven hems sometimes having at the edges nipples or tyazh as a result of epithelization of the subdug edges and the fistular courses.
The secondary kollikvativny tuberculosis cutis arises usually owing to transition of tubercular process from limf, nodes, joints in hypodermic cellulose and skin, and ulcers and hems deeper, than at primary kollikvativny tuberculosis (tsvetn. tab., Art. 400, fig. 10).
Sometimes kollikvativny tuberculosis has looking alike an actinomycosis (see), a hydradenitis (see), cancer (see Skin, tumors), hron. a piokokkovy ulcer (see the Pyoderma). Tell positive tuberkulinovy reactions about existence of kollikvativny tuberculosis (see Tuberkulinodiagno-stpik), a combination patol. process on skin with tuberculosis limf, nodes.
The warty tuberculosis cutis (tuberculosis cutis verrucosa) results more often from superinfection, napr, batsil-lovydelitel at constant contact of skin with the infected phlegm or at prosectors and veterinarians at damage have skin of hands, napr, at necropsy of the suffering from tuberculosis person or an animal (a cadaveric hillock, an anatomic hillock). Process begins with emergence of the plotnovaty small painless small knot of pinkish and cyanotic coloring formed by tubercular granulyatsionny fabric and surrounded with the expressed perifocal inflammatory infiltrates. The small knot increases in sizes with the subsequent formation of three zones: an inflammatory rim on the periphery, then an infiltrirovanny nimbus of cyanochroic coloring and in the center — keratosic warty growths of epidermis. Such typical type of a tubercular small knot distinguishes it from ordinary warts. Detection of tuberculous focuses in other bodies helps to exclude deep mycoses (see Zymonematoses, the Sporotrichosis).
The m silt of couples but - an ulcer tuberculosis cutis (tuberculosis miliaris ulcerosa cutis) develops is exogenous at batsillovyde-litel owing to autoinfection. Most often process is localized on skin around natural foramens (nasal, a mouth, an anus and an outside opening of an urethra), and also on a mucous membrane of a mouth. Clinically the disease is characterized by emergence of small yellowish-red small knots, to-rye quickly ulcerate, merge among themselves and form the superficial very erethistic ulcers which are easily bleeding, sometimes covered with the small yellow small knots (Trel's grain) representing small abscesses. Ulcers are usually very painful and are sometimes the first manifestation of tubercular process. In a phlegm, urine and Calais depending on localization of process find mycobacteria of tuberculosis. At localization miliary yaz-vennogo tuberculosis in genitals it should be distinguished from inflammatory erosive processes on the basis of characteristic a wedge, pictures, allocations of mycobacteria of tuberculosis and hypersensitivity to tuberculine.
The acute miliary tuberculosis cutis represents displays of the general miliary tuberculosis. Process is characterized by an enanthesis of a trunk and extremities of papules of Roseau-vato-cyanochroic coloring, in the center to-rykh sometimes there are superficial sores covered with a bloody crust. Local necroses of a derma and an epithelium without inflammatory reaction can form. From elements of rash allocate mycobacteria of tuberculosis.
The disseminated miliary tuberculosis of l and - c of a (tuberculosis miliaris disseminata faciei, lupus miliaris disseminatus faciei; a synonym the disseminated miliary lupus of the person) — the rare form of a tuberculosis cutis described in 1878 by Fox (W. T. Fox). Process is characterized by emergence on face skin, sometimes necks, separate soft painless small knots of pinkish or brown coloring, to-rye can resolve without trace, and in case of an ulceration the scar forms. The differential diagnosis is carried out with vulgar and red eels. Process differs from eels in lack of pustules isocies and the expressed inflammatory phenomena. In doubtful cases the issue is resolved on the basis gistol. researches.
Rozatseopodobny to a tuba r to at l and d, described in 1916 by F. Lewandowsky, represents a wedge, the form of a tuberculosis cutis similar to the disseminated miliary tuberculosis of the person. Against the background of rozatseopodob-ache redness and teleangiectasias pinkish-brown papules, sometimes with the pustules in the center which are drying up in a crust are located. After rejection of crusts there are scars. The rozatseopodobny tuberculid differs from pink eels in existence of the expressed reaction to administration of tuberculine, characteristic of tuberculosis morfol. signs.
The papulonecrotic tuberculosis cutis (tuberculosis cutis papulonecrotica) is described in 1891 Mr. Barthélemy (R. T. by Vag-thelemy) under the name «acnitis». In 1930 to Zh. Darya called this form papulonecrotic tuberculosis and included a tubercle of id in group. Rashes are symmetrized on face skin, a thorax, extensor surfaces of top and bottom extremities, represent soft roundish papules of 2 in size —
3 mm, cyanochroic buroi colourings, almost painless. The papule consists from epitet ioidny, lymphoid and colossal cells like Pirogov — Langkhansa. It can be localized in all layers of skin and hypodermic cellulose. In the center of an element there is a peculiar pustule containing nekrotichesKia the masses which is drying up in a crust. The necrosis in the centers arises initially with the subsequent development around it specific granulyatsionny fabric and nonspecific inflammatory infiltrate. Epidermis is also exposed to a necrosis. In it bubbles and intraepithelial pustules are quite often formed. In vessels inflammatory changes with the phenomena of an obliterating vasculitis, sometimes with specific composition of infiltrate are observed. After rejection of crusts there are small superficial depigmented «stamped» scars, sometimes papules are resolved without hem (tsvetn. tab., Art. 400, fig. 11). The main sign at a differentiation of process with papulonecrotic (nodular and necrotic) type of an allergic arteriolit P unter (see. In askulit skin) high tuberkulinovy sensitivity at patients with papulonecrotic tuberculosis is.
The condensed erythema (erythema induratum; synonym: the indurative tuberculosis cutis, Bazena a disease) is the most common form of a tuberculosis cutis in a crust, time. It is described in 1855 by A. Bazen. Process is localized preferential in shins where moderately painful dermo-hypodermal node plotnoelastichesky a horse of an istention
to dia forms. 1 — 3 cm (tsvetn. tab., Art. 400, fig. 12). In process of increase in a node skin over it becomes pinkish and cyanochroic. Further in some cases the centers are softened, opened with formation of inertly current erethistic ulcers — an ulcer form of Getchinson (tsvetn. tab., Art. 400, fig. 13). Generally central part of a node, edge of an infiltrirovana, plotnovata melts. Ulcer forms always leave hems. Nek-ry patients on site of nodes have «retraction» of skin and hypodermic cellulose. In the absence of a softening nodes often are completely resolved, sometimes there is a dense small knot, on site to-rogo afterwards there can be a recurrence. In initial stages of development morfol. structures can be presented only by vascular changes and nonspecific limfogistiotsitarny infiltrates. In some cases a tubercle about and dny changes do not come to light also during later periods that complicates gistol. diagnosis. For gistol. researches fabric from elements should be taken not earlier than through 1V2 month after their emergence.
The differential diagnosis of the condensed erythema is carried out with the migrating thrombophlebitis (see), a knotty erythema (see the Erythema knotty).
At the migrating thrombophlebitis rather bystry development of process, the expressed morbidity of nodes, their arrangement in the course of veins of shins, lack of sensitivity to tuberculine is observed. The knotty erythema differs in bystry emergence, acute inflammatory character and the expressed morbidity of nodes in shins. Elements do not ulcerate. In case of a tubercular etiology reaction to tuberculine reeko positive.
(lichen scrofulosorum, tuberculosis cutis lichenoides; the synonym a lichenoid tuberculosis cutis) is characterized by emergence of the papular rash which is located on skin of a trunk, extensor surfaces of extremities. Process is most often localized in top coats of skin, under epidermis. Sometimes elements are located around hair follicles. Primary element of an eypa is the painless soft small small knot (papule) roundish, oval, sometimes a polygonal form with a scale on a surface. Color of papules — yellowish, quite often coloring does not differ from color of normal skin. Rashes are inclined to grouping. Histologically process is characterized by a combination of tubercular and nonspecific elements of an inflammation. Process is allowed usually without trace. The disease should be distinguished from seborrheal eczema (see), hair depriving (see Keratoza) and a miliary syphilide. Along with characteristic localization and tendency of elements to grouping at herpes scrofulous the expressed nature of skin tuberkulinovy reactions, and also existence of other displays of tuberculosis in an organism, negative serol is noted. reactions to syphilis.
Diagnosis. Diagnoses of a tuberculosis cutis are the cornerstone characteristic a wedge, and morfol. changes in skin and hypodermic cellulose. Also careful collecting the anamnesis is necessary. Studying of data kliniko-rentgenol is of great importance. inspections of patients taking into account both active specific changes, and the postponed diseases (a kaltsinata in roots of lungs, hems after fistular forms of tubercular lymphadenitis, etc.). Methods bacterial. diagnoses matter only at inspection of patients with ulcer forms of a kollikvativny tuberculosis cutis (scrofuloderma) and a tubercular lupus. At clarification of sensitivity to tuberculine by means of Mantoux reaction it is necessary to remember that at herpes scrofulous and papulonecrotic tuberculosis the positive take is observed also at statement of less sensitive scarifying graduated Grinchar's test — Karpilovsky (see the Tuberculinodiagnosis). At assessment gistol. data it is necessary to consider that tubercular changes constantly are found in the centers of a tubercular lupus, a warty tuberculosis cutis, the disseminated miliary tuberculosis of the person. At the same time in the centers of the condensed erythema and papulonecrotic tuberculosis both specific structures, and nonspecific changes (limfogistiotsitarny infiltrates, changes of vessels) come to light. In not clear cases resort to trial treatment. According to M. I. Shapoval (1978), the research at TB patients of skin of a gistaminopek-sichesky index before intradermal administration of tuberculine is a reliable diagnostic method of this disease (see Gis-taminopeksiya). Lowering of the level of a gistaminopeksiya in comparison with initial indicates existence of an active tuberculosis cutis.
Early diagnosis of a tuberculosis cutis is carried out in the course of survey for the first time of the revealed patients with tuberculosis of other bodies, and also children with displays of tubercular intoxication. All patients with for the first time the established diagnosis of a tuberculosis cutis or with suspicion shall be directed to it to a ftiziodermatolog of a regional, regional or republican antitubercular clinic for specification of the diagnosis.
Treatment is carried out according to the modern principles of treatment of TB patients (see); it shall be continuous, long, and (see) it is necessary to appoint antituberculous remedies in a complex in sufficient daily and course doses. In the course of treatment it is necessary to consider a form of a disease, expressiveness and character a wedge, manifestations, individual portability of treatment, medicinal sensitivity of microflora.
At the localized forms in cases of the single centers sometimes carry out an obkalyvaniye of elements by streptomycin. At accession of consecutive infection or emergence around ulcerated elements of eczema symptomatic local therapy is applied (disinfecting solutions, ointments, etc.). At a combination of a kollikvativny tuberculosis cutis to tuberculosis peripheral limf, nodes opening of «cold» abscesses, removal kazeozno changed limf, nodes is sometimes shown.
In complex treatment of the disseminated forms of a tuberculosis cutis, especially papulonecrotic tuberculosis, include ginosensibiliziruyushchy means, and in nek-ry cases corticosteroids, delagil. There are data on effective use of a fonoforez from 10% solution of sodium thiosulphate on the centers of the condensed erythema.
Obtaining favorable and resistant results requires carrying out a basic course of treatment (10 — 12 months), 4 or 6 preventive courses (3 months 2 times a year in sanatorium conditions) and further active observation within 5 years. After this person, had a tuberculosis cutis, can be struck off the register if on the nature of an associated disease they are not subject to observation in TB facilities.
In the presence of the disfiguring hems in a face after removal of the patient from the account perhaps operational elimination of cosmetic defects, a cut is carried out against the background of preventive antitubercular treatment.
The forecast at timely diagnosis and correctly organized treatment generally favorable. Growth of the material standard of living and culture of the population, broad holding recreational and special antitubercular events yielded positive takes: indicators
of incidence and morbidity of a tuberculosis cutis decreased, the number of patients with a tubercular lupus decreased, favorable shifts during this disease are noted (the spoiling forms meet seldom and are always a consequence of late diagnosis, process proceeds generally in the form of a flat lupus and will well respond to treatment). Especially favorable changes occurred during a tuberculosis cutis at children. If during the pre-war period the tuberculosis cutis was considered a disease of children's age since among patients with a tubercular lupus of 60% children made, then by 1975 this indicator decreased to 3,9%.
Prevention includes planned immunization and a revaccination of the population and full treatment of a pulmonary tuberculosis and extra pulmonary tuberculosis.
TUBERCULOSIS of INTESTINES, the PERITONEUM AND MESENTERIC LYMPH NODES
are included In the concept «abdominal tuberculosis» tubercular defeat of bodies of the alimentary system (a gullet, a stomach, intestines), peritoneums, limf, nodes of a mesentery and limf, nodes of retroperitoneal space, and also extremely seldom found tubercular damage of a liver and spleen, pancreas.
Lack at the same time of pathognomonic symptoms, quite often a stertost the wedge, pictures of a disease cause considerable difficulties at diagnosis that explains discrepancy of statistical data on the frequency of abdominal tuberculosis at certain authors.
By data A. M. Barenboim and with - apprx. 90% of patients, the Crimea the diagnosis of a tubercular mesadenitis was made to a bus (1971), it was necessary to strike off the register since the diagnosis was not confirmed. At the same time, on a nek-eye to data, at operative measures concerning not tubercular diseases quite often find abdominal tuberculosis.
In the USSR abdominal tuberculosis, according to data of the dispensary account, makes less than 2 — 3% of number of all sick T. century. The most widespread is tuberculosis mesenteric limf, nodes and limf, nodes of retroperitoneal space (apprx. 70% of all cases of abdominal tuberculosis), tuberculosis of digestive organs (apprx. 18%) and peritoneums meets less often (apprx. 12%). If still in recent times abdominal tuberculosis was revealed by hl. obr. at children, in a crust, time, as well as at other localizations of T. century, among patients adults prevail.
Development of abdominal tuberculosis is connected by hl. obr. with lymphogenous distribution of contagiums from limf, nodes of a mediastinum, a backbone, genitalias, etc. To an alimentary way of infection to a crust, time the modest place is allowed; it is connected, first of all, with consumption of raw milk from suffering from tuberculosis animals. Cases of development of tuberculosis of intestines owing to swallowing a bacillar phlegm by the patient are extremely rare. The Nespetspfichesky diseases of a mucous membrane of intestines reducing local resistance promote development of tuberculosis of intestines.
Bystry involvement in inflammatory process regional limf is characteristic of abdominal tuberculosis, nodes and limf, nodes of a root of a mesentery, defeat to-rykh in most cases gains the leading value during a disease.
Tuberculosis of digestive organs differs in big polymorphism a wedge, pictures. Rather seldom tuberculosis of a gullet and stomach meets. In a gullet (see) tubercular process is generally localized at the level of bifurcation of a trachea, is more rare — in its proximal department. Allocate the ulcer, miliary and stenosing forms of tuberculosis of a gullet. Tuberculosis of a gullet is shown by pains behind a breast and yavleniyakhlsh dysphagies. At an ezofagoskopiya find multiple superficial ulcerations, hl. obr. in an upper third of a gullet. As a result of their scarring stenoses can develop.
Distinguish the following forms of tuberculosis of a stomach: ulcer, hypertrophic or tumorous, fibrous and sclerous and mixed, or ulcer and hypertrophic (see the Stomach). R. Lerish and A. Ponce along with ulcer and tumorous forms allocate inflammatory and miliary forms. In a stomach specific tubercular ulcers are located on big curvature more often.
Tuberculosis of a stomach in early stages of a disease is followed by dull ache, an eructation air, nausea, feeling of weight in epigastric area, a loss of appetite. Gastric acidity is usually reduced. Eventually the pylorostenosis can develop (see).
In intestines (see) tubercular process it is most often localized in ileocecal department (ileal and blind guts). In a small bowel tuberculosis proceeds in ulcer, hypertrophic, or stenosing, and ulcer and hypertrophic forms. The disease begins with defeat limf, the device of a wall of a gut. Then during the progressing of tubercular process on site struck single and group limf, follicles ulcers are formed (see tsvetn. the tab. to St. Intestines, t. 10, Art. 400 — 401, fig. 3), to-rye quite often have circular character. Specific inflammatory process quickly extends to nearby limf, nodes. On a serous cover in the field of a projection of an ulcer tubercular granulomas are formed. 'Develop local peritonitis (see) and commissural process (see Commissures). In cases of perforation of an ulcer diffuse peritonitis can develop, and at extensive commissural process — the sacculated abscess. During the scarring of ulcers deformations of intestinal loops, their stenozirova-ny are observed.
At tuberculosis the terminal department of an ileal gut and a caecum — a tubercular ileotyphlitis is surprised more often. Usually initially the caecum is surprised. The long time process proceeds asymptomatically or is shown by symptoms hron. appendicitis (see), a coloenteritis (see). Больны^ show complaints to colicy pains in a stomach, often non-local, dysfunction of intestines — ponosa, locks. Disease wavy. In process of distribution of process on area of the bauginiyevy gate and terminal departments of an ileal gut of pain accept the localized character, symptoms of partial intestinal obstruction appear. During this period weight loss, subfebrile temperature are observed. At a palpation blind and ileal guts are condensed, hilly, slow-moving, morbidity moderate, tension of a wall of a stomach is absent or is not expressed that quite often conducts to the wrong diagnosis. Complications: intestinal
impassability, development of commissures between loops of guts, perforation of an ulcer with development of tubercular peritonitis. The diagnosis is made on the basis of existence in the anamnesis of a disease of tuberculosis, contact with the TB patient, positive reaction to tuberculine. Quite often at the same time use Koch's test for a call of focal reaction (see the Tuberculinodiagnosis). At rentgenol. a research of intestines reveal functional and morfol. signs of defeat.
Tuberculosis of a worm-shaped shoot is described. Other departments of a large intestine are surprised extremely seldom. The wedge, a picture corresponds observed at hron. appendicitis (see Appendicitis). The diagnosis is established by hl. obr. after a gi-table, researches of a remote shoot. At localization of tubercular process in a rectum and an anus patients complain of pain and unpleasant feelings in the field, purulent discharges from svshtsy. Ulcers and fistulas differ in exclusively persistent current. The disease can be complicated by paiillomatozny growths in the field of an anus, to-rye maligni-zirutsya in some cases.
Tuberculosis mesenteric limf, nodes (see the Mesadenitis) and limf, nodes of zabryushinyy space can be observed both at primary, and at secondary tuberculosis. At defeat limf, nodes distinguish ginerplastichesky, fibrocaseous and fibrous forms. At a hyperplastic form against the background of increased giperplazirovanny limf, nodes formation of tuberculous focuses of various type is observed. The fibrocaseous form is characterized by merge of the separate centers and their fusion (kazeifnkation) or formation of the large centers of a caseous necrosis surrounded with the fibrous capsule. Healing of the centers usually is followed by development fibrous shopping mallAnia in the form of hems and tyazhisty growths on site tubercular changes. At a caseous necrosis limf, nodes in the subsequent adjournment of salts of calcium can be observed. Such calciphied limf, nodes can be a source of distribution of process in an abdominal cavity and contact damage of ovaries, a uterus and its appendages or other bodies. Tuberculosis mesenteric limf, nodes and limf, the nodes located zabryu-shinno (a tubercular mesadenitis), is the most frequent localization of abdominal tuberculosis. A current, as a rule, chronic, with remissions and aggravations. Complaints to an abdominal pain, swelling of intestines, locks which sometimes are replaced by ponosa, a febricula, a loss of appetite, a pokhudanpa. Pain has uncertain character, by data A. G. Sycheva (1972), is more often localized in epigastric, ileocecal areas or about a navel. At a palpation of a stomach in cases of sharp increase limf, nodes sometimes it is possible to probe them. Typical painful points — in the right ileal area, several knutra from Mac-Berney's point, are closer to a navel, about a navel, at the left and slightly higher from a navel (across Shternberg). However in most cases tuberculosis of adbominalny localization proceeds or asymptomatically, or the available symptoms of a nespetspfichna for this pathology.
The peritoneum is involved in tubercular process for the second time, most often at tuberculosis of intestines and limf, nodes. Distinguish serous (exudative), adhesive (adhesive), or dry, knotty and tumorous and caseous and ulcer forms of tuberculosis of a peritoneum. At perforation of a tubercular ulcer limited or diffuse peritonitis (a serous form) develops. On a surface of a peritoneum at the same time there are tubercular granulomas, to-rye sometimes form in a peritoneum complexes or forkhmirut the different size the caseous centers (a knotty and tumorous form). At a rassasyvaniye of inflammatory changes there can be commissures, between to-rymi tuberculous focuses (an adhesive form) remain. At break in a peritoneum of a tubercular ulcer of intestines there can be a caseous and ulcer form of tuberculosis of a peritoneum. At tuberculosis of a peritoneum patients complain of an abdominal pain, stupid or skhvatkoobrazny, the dispeptic phenomena (tendency to a diarrhea is noted), fatigue, weight loss. Subfebrile temperature is sometimes observed. At a serous form in an abdominal cavity find free liquid. The stomach is increased in volume, perkutorno note obtusion, borders to-rogo change depending on position of the patient. In cases of adhesive or knotty and tumorous tuberculosis of a peritoneum during the early periods the wedge, symptoms are not expressed, only in later stages of a disease at a palpation it is possible to define tumorous educations in an abdominal cavity. The productive peritonitis often is complicated by commissural impassability of intestines, quite often life-threatening the patient and demanding the emergency conservative or operational treatment.
The liver at tuberculosis is surprised in the hematogenous way. At miliary tuberculosis, naira., in a liver the typical tubercular granulomas similar on a structure to hillocks in easy and other bodies form (see the Liver). Less often in a liver the large caseous centers like tuberculomas form (see). At specific treatment tubercular granulomas resolve. Sometimes on their place there are small scars. The large caseous centers are encapsulated and obyzvestvlyatsya. Similar changes can be observed in a spleen (see) where tubercular granulomas and tuberculomas at hematogenous and lymphogenous spread of tuberculosis form.
Tuberculosis of a liver arises and is diagnosed rather seldom. Jaundice, increase in a liver, a splenomegaly is noted. However clinically it is also shown seldom that testifies to resistance of a liver to a tuberculosis infection. There is an opinion that tuberculosis of a liver meets more often than it is diagnosed; it proceeds behind a mask of its nonspecific defeats, especially in the presence of tuberculosis of other localizations.
Tuberculosis of a spleen is followed scanty a wedge, symptomatology. Subfebrile temperature, ascites is most often observed to force-nomegaliya. At rentgenol. a research of abdominal organs in a spleen petrifikata can be found.
Tuberculosis of a pancreas (see) meets seldom and it is found, as a rule, on section. Arises in the hematogenous, lymphogenous or contact way. In literature single observations are described; symptoms, typical for tuberculosis, are not revealed. The disease as chronic pancreatitis proceeds (see). The course of a disease is defined generally by weight of defeat of easy and other bodies.
The diagnosis of abdominal tuberculosis is made by hl. obr. on the basis of results of a bacteriological or histologic research. In addition to collecting the anamnesis directed to identification of communication of a disease with a tuberculosis infection all existing ways of inspection of abdominal organs shall be applied: survey, a palpation,
roentgenoscopy and a X-ray analysis, a research of contents of a stomach and intestines for the purpose of allocation of mycobacteria of tuberculosis, a tuberculinodiagnosis (see), tool, including a laparoscopy (see Peritoneoskopiya), and operational methods of a research.
The authentic diagnosis of abdominal tuberculosis can be established only at a laparotomy (see), including trial, with gistol. and bacterial. research of biopsy material. Have important diagnostic value a X-ray analysis of abdominal organs for the purpose of identification calciphied limf, nodes at tubercular lymphadenitis and contrast researches went. - kish. path. At tubercular damage of intestines note disturbances of a passage of contents on intestines, deformation, stenoses, ulcers (fig. 10), smoothing gaustr a colon, etc. Great diagnostic value has Shtirlin's (losses) symptom — detection at a contrast research of intestines of the site blank by barium of the ascending colon at the expressed contrasting above - and underlying departments. Spo-
Fig. 10. The roentgenogram of area of ileocecal department of intestines at its tubercular defeat: the terminal department (1) of an ileal gut has an uneven gleam, contours its uneven, lips
of the bauginiyevy gate are thickened (2).
purposeful detection of defect of its filling with the dosed pressure upon ileocecal area can be itself early radiodiagnosis of tuberculosis of an ileal gut. A valuable diagnostic method of abdominal tuberculosis is identification of mycobacteria of tuberculosis in contents of a stomach and intestines, however at the same time all other possible sources of their receipt shall be excluded in went. - kish. path.
The differential diagnosis is carried out with hron. dysentery (see Dysentery), appendicitis (see), an ileitis (see Krone a disease), hron. colitis (see), cancer of a caecum, an adhesive desease, intestinal impassability (see Impassability of intestines), a mesadenitis of not tubercular etiology (see the Mesadenitis), cysts and tumors of female generative organs, a lymphogranulomatosis (see).
Treatment of abdominal tuberculosis is carried out according to the general principles of treatment of tuberculosis (see Tuberculosis). The chemotherapy which is the main method of treatment shall be perhaps earlier, complex and long (10 — 12 months). At purpose of specific chemotherapy avoid such drugs as Etioniamidum, Ethambutolum aggravating the dispeptic phenomena which are available at abdominal tuberculosis and possessing a hepatotoxic action.
At the same time with specific antibacterial treatment appoint a full-fledged diet with enough proteins, fats, carbohydrates, vitamins A, groups B, ascorbic to - you, exclude not easily assimilable foodstuff. Considering the dispeptic disturbances accompanying abdominal tuberculosis, appoint pathogenetic and symptomatic means (festal, panzinorm, drugs of a kolibakterin, etc.). Operational treatment is carried out by hl. obr. at complications of abdominal tuberculosis (ulcers, stenoses, perforation, impassability of intestines, etc.). The positive take is yielded by removal mesenteric limf, nodes, at a tubercular mesadenitis if it is possible to make it without considerable traumatization of a mesentery and intestines. At tuberculosis of a peritoneum (especially to its exudative form) aspiration of ascitic liquid at its accumulation in a large number is shown.
Dignity. - hens. treatment of patients with abdominal tuberculosis is carried out both in local sanatoria, and in the conventional resort areas, by hl. obr. in specialized sanatoria for sick T. century.
The forecast depends on timely diagnosis and treatment.
Prevention of abdominal tuberculosis consists in full treatment of primary forms of tuberculosis. Also the dignity is carried out. - a gleam. the work directed to the prevention of the use by the population in food of the products infected with mycobacteria of tuberculosis (boiling of milk, etc.).
MENINGEAL TUBERCULOSIS AND CENTRAL NERVOUS SYSTEM
Tuberculosis of c. the N of page includes a meningeal tuberculosis (tubercular meningitis), a tuberculoma of a brain, and also damage of a spinal cord at a tubercular spondylitis.
Before implementation in a wedge, practice of antibiotics tubercular meningitis made approximately V3 of all forms of tuberculosis and was preferential a disease of children's age. A lethality from tuberculosis of c. reached N of page 20% of an over-all mortality of tuberculosis, and the lethality from tubercular meningitis made 100%. As a result of preventive which are widely carried out to the USSR and to lay down. actions frequency of tuberculosis of c. N of page, especially tubercular meningitis at children, sharply decreased, and recovery from the last at timely begun treatment reaches 100%.
Tubercular meningitis — preferential secondary tubercular defeat (inflammation) of covers of a brain (soft, web less often firm) arising at patients with various is more often active and widespread, forms of tuberculosis. Is the most severe form of tuberculosis.
Pathogeny. In most cases mycobacteria of tuberculosis get into c. N page and a meninx in the hematogenous way at the disseminated pulmonary tuberculosis, tuberculosis intrathoracic limf, nodes and primary tubercular complex. Also lymphogenous way of infection of a meninx at tuberculosis is possible intrathoracic limf, nodes. "At a tubercular spondylitis, specific damage of bones of a skull, inner ear transfer of contagiums happens in the likvo-rogenny and contact way. A meninx can be infected also from the tuberculous focuses (tuberculomas) which were earlier existing in a brain as a result of an aggravation patol. process. However primary center of tubercular defeat sometimes does not manage to be found, and meningitis appears the only manifestation of specific process.
Pathological anatomy. Tubercular meningitis is a kind of meningitis (see). It can be preferential exudative or productive. At exudative tubercular meningitis the soft cover of a brain in the field of its basis bulked up, dim, with a set of friable commissures, is impregnated a gelatinous look with the exudate containing fibrin and necrotic masses. Originally patol. changes develop in vessels of a meninx and vascular textures of cerebral cavities in the form of a vasculitis with the fibrinoid swelling of vascular walls and thrombosis leading to disturbance of a vascular barrier. As a result of it mycobacteria of tuberculosis get through the changed vascular walls, lead to their specific defeat, and then infect cerebrospinal liquid and a soft cover of a brain, hl. obr. bases of a brain (basal meningitis). In perivascular fabric epithelioid and epithelioid and giant-cell tubercular granulomas, including with a caseous necrosis in the center, with the lymphocytic infiltration expressed perifokalyyuy are disseminated. During the progressing of process on the surface of a brain the tubercular granulyatsionny fabric consisting from forms epitet io and dny and lymphoid cells, sometimes with colossal cells of Pirogov — Langkhansa between them. Inflammatory changes on the basis of a brain, a varoliyeva of the bridge are especially expressed (the bridge of a brain, T.), the basis of frontal lobes around a visual ps-rekrest, olfactory paths, in lateral (silviyevy) furrows (see tsvetn. the tab. to St. Meningitis, t. 15, Art. 32, fig. 5). Exudate can get into the cerebellar and brain tank. At timely treatment exudate resolves, inflammatory changes disappear, the structure of a meninx is completely recovered. At late begun treatment there comes fibrosis of tubercular granulomas and centers, a soft meninx, especially in the field of the basis of a brain that leads to blockade of outflow tracts of cerebrospinal liquid p to development in some cases of hydrocephaly. Cerebral cavities at the same time are expanded. It is noted ependimatit, followed by a rash of tubercular granulomas on a surface of an ependyma. Inflammatory changes in area of vascular textures are shown by hypostasis, loss of fibrin, formation of tubercular granulomas (fig. 11).
From a soft cover of a brain Eospalitelny changes pass to substance of a brain (encephalomeningitis), on the course of blood vessels to-rogo lymphocytic infiltration is observed. There is pericellular and perivascular hypostasis of tissue of brain (fig. 12). Defeat of blood vessels, especially on the course of an average brain artery, can lead to formation of the centers of a softening in the relevant departments of a brain (see tsvetn. the tab. to St. Meningitis, t. 15, Art. 64, fig. 6).
At use of specific treatment the expressed exudative forms of tubercular meningitis meet less often. The phenomena of encephalitis are less expressed, the large centers of an encephalomalacia, hemorrhagic heart attacks in connection with much more rare vasculites of large brain arteries are not formed.
At productive tubercular meningitis of the phenomenon of hypostasis of a meninx are expressed less; on the basis of a brain millet-shaped granulomas epithelioid gi-gantokletochnogo structures with the phenomena of fibrosis form.
Sometimes tubercular process is localized preferential on the verkhnelateralny surface of a brain and in the field of furrows (korgveks an italny encephalomeningitis) where the rash of tubercular granulomas of various structure is noted.
Along with covers of a brain at distribution of process also the soft cover of a spinal cord can be surprised.
Clinical cards and N and. The course of tubercular meningitis in a crust, time sharply changed under the influence of treatment protivotuberku-
Fig. 11. Microdrug vascular to a spla of a teniye of a brain at tubercular meningitis: 1 — tubercular hillocks;
2 — colossal cells; 3 — a blood vessel, coloring hematoxylin-eosine;
Fig. 12. Microdrug of a brain and the site of a soft meninx in the field of a silviyevy furrow at a tubercular encephalomeningitis: 1 — hypostasis and
infiltration of a soft meninx; 2 — lymphocytic infiltration and hypostasis of substance of a brain; 3 — colossal cell in substance of a brain; coloring hematoxylin-eosine; X 250.
forest means. Its wedge, a picture became more diverse, duration of a disease increased, the forecast changed.
At all variety a wedge, displays of tubercular meningitis on the basis of features a wedge, pictures and depending on preferential localization patol. process distinguish three most typical clinical forms of tuberculosis with defeat of covers and substances of a brain: basal (basilar) tubercular meningitis, tubercular encephalomeningitis and tubercular meningoentsefalomiye-litas (cerebrospinal leptopakhi-meningitis). During the progressing of process transition of one form to another — basal in me-ningoentsefalitichesky or cerebrospinal is possible. Nek-ry clinical physicians allocate a konveksitalny form of a tubercular encephalomeningitis, at a cut process is localized preferential on covers of an upper lateral surface of a brain, especially in the field of furrows. More rare atypical forms of tubercular meningitis are described.
Basal tubercular meningitis is the most often found form. It is observed in rather early stage of a disease. Inflammatory process to a lokalizuatsya it is preferential on
covers of the basis of a brain.
The wedge, a picture is characterized expressed brain (disturbances of mentality, vegetovascular frustration, etc.), meningeal (a headache, vomiting, a stiff neck)
by symptoms, disturbances a skull -
but - a brain innervation and
chilly vein reflexes, the phenomena of hydrocephaly and changes of composition of cerebrospinal liquid (protein to 1,5 — 2 °/00, a pleocytosis from 50 to 700 cells lymphocytic neytro-filnogo character in 1 mkll the sugar content is lowered to 0,45 — 0,3 g! л). Mycobacteria of tuberculosis in cerebrospinal liquid find in 30 — 40% of patients. Disease, as a rule, without aggravations, occasionally long, an outcome favorable. Improvement of the general state and disappearance of brain symptoms, decrease in temperature is noted during
3 — 4 weeks. Disappearance of meningeal symptoms happens in 2 — 3 months, and sanitation of cerebrospinal liquid — in 4 — 5 months. At a part of convalescents unsharply expressed frustration of a craniocereberal innervation in the form of a smoothness of a nasolabial fold, an anisocoria, squint, and also increase or oppression of tendon jerks can be noted.
A tubercular encephalomeningitis — the most severe form of tubercular meningitis, edge to p r a name-day and I am an ant because to t of e r news agency of l of a na x
means, came to an end, as a rule, letalno. In addition to the expressed brain and meningeal manifestations, at a tubercular encephalomeningitis focal symptoms — motive disturbances (paresis, paralyzes of extremities, gn-perkineza, spasms), disturbances of a craniocereberal innervation, sometimes endocrine frustration, the expressed hydrocephaly are noted. Changes of cerebrospinal liquid are more considerable, than at basal meningitis.
Disease is heavy, sometimes long, with aggravations. Recovery — with the expressed residual changes (hydrocephaly, decrease in intelligence, disturbance of the emotional sphere, paralyzes or paresis of extremities, endocrine frustration) caused by disturbance of outflow of cerebrospinal liquid owing to commissural process and also changes in substance of a brain.
Uberkulezny meshshgoentsefa-lomiyelit t meets rather seldom. The gradual small imptomny beginning is characteristic that causes quite often late diagnosis. Further the expressed meningeal syndrome is noted, often radicular pains, brain symptoms and disturbances of a craniocereberal innervation are expressed moderately. Changes of cerebrospinal liquid are most considerable.
The disease proceeds usually less hard, than mennngoentsefalit, but with slow sanitation of cerebrospinal liquid (from 5 to 15 months). Seldom in cases of transition of inflammatory process from a meninx to substance of a spinal cord, at a strong prelum its commissures, heavy complications are possible: paralyzes, paresis, development of the full block of outflow tracts of cerebrospinal liquid, hydrocephaly.
Diagnosis. At diagnosis of tubercular meningitis consider a wedge, manifestations: gradual development, meningeal symptoms, defeat craniocereberal (cranial, T.) nerves (see Meningitis).
At suspicion of tubercular meningitis of the patient it is necessary to inspect in a complex for the purpose of identification of primary localization of tuberculosis. At inspection carry out a X-ray analysis of a thorax, and at children, besides, and a tomography, Mantoux reaction (see the Tuberculinodiagnosis). Consultations of the phthisiatrician, the oculist, the neuropathologist and other specialists are necessary. The differential diagnosis is carried out with somatopathies, at to-rykh the phenomena of a meningism (see), and also meningitis of various etiology can be observed (see Meningitis, the table, t. 20, additional materials). The research of cerebrospinal liquid is defining in diagnosis (see).
JI echen and e. Patients are subject to urgent hospitalization in specialized departments where pim appoint antituberculous, fortifying and symptomatic pharmaceuticals (see Meningitis), the corresponding diet.
In the course of chemotherapy make control spinal punctures (see) for a research of cerebrospinal liquid. Further the patients who had tubercular meningitis are observed in an antitubercular clinic (see). In the first 2 — 3 years after an extract preventive courses of treatment by an isoniazid in combination with etambutolokhm or to protshsh-a ido in m 2 times a year 2 —-21/2 months, as a rule, in the conditions of sanatorium are conducted. Persons with the residual phenomena of the postponed meningitis, in addition to a clinic, are observed and treated at neuropathologists, oculists, psychiatrists. The issue of working capacity is resolved individually VKK. Duration of chemotherapy is defined by character of a course of meningitis and the basic tubercular process, but there have to be not less than 6 months from the moment of normalization of composition of cerebrospinal liquid. The general duration of treatment makes 12 months and more since a wedge, recovery considerably advances recovery of anatomical structures, and also ^вследствие combinations of meningitis to the tuberculosis of internals demanding prolonged treatment.
At late diagnosis of meningitis and its heavy current, and also at impossibility to take medicine through a mouth (difficulty of swallowing, persistent vomiting) intravenous drop administration of an isoniazid before noticeable improvement of a state is shown. Corticosteroid hormones are appointed inside or intravenously, and at disturbance of circulation of cerebrospinal liquid — endolyumbalno. It is reasonable to appoint rifampicin since the beginning of a course of treatment, especially at a severe disease.
Patients with tubercular meningitis children shall be on a bed rest before normalization of composition of cerebrospinal liquid, adults — before disappearance of meningeal symptoms and considerable improvement of composition of cerebrospinal liquid.
The forecast for life in most cases favorable.
The tuberculoma of a brain is one of forms of tuberculosis of c. by N of page it is also connected with hematogenous dissimination of contagiums from primary tuberculous focus. Macro - and microscopically the tuberculoma of a brain is similar to a tuberculoma of a lung and represents usually roundish center of the encapsulated caseous necrosis to dia. 1 — 4 cm. The mass of a caseous necrosis in a tuberculoma (see) can be condensed and calcinated. Specific granulyatsionny fabric is transformed in fibrous, accurately delimiting the center from tissue of a brain. Solitary tuberculomas meet more often, however their number can be various. In cases of progressing of process and at an arrangement of a tuberculoma near the surface of a brain the inflammatory phenomena can pass to a soft meninx of a brain.
Two types of disease meet (see the Brain, infectious granulomas). For one of them the acute beginning with rise in temperature, bystry development of the symptoms of damage of a brain depending on localization of process with the subsequent wavy current and long subfebrile condition is inherent. At the same time meningitis is often diagnosed, mennngoentsefalit. The second type is characterized by slow development, with remissions.
Diagnosis by a tubercle of a brain is difficult. At the same time consider the anamnesis, a wedge, symptomatology, data of kliniko-neurologic inspection, and also rentgenol. researches, an angiography, an electroencephalography, an ekhoentsefalografiya and the computer tomography allowing to establish localization and the sizes of a tuberculoma. The differential diagnosis should be carried out with tumors of a brain, gummas (see Syphilis), other neuroinfections.
Treatment is operational, the tuberculoma is deleted completely, «enucleating» it within healthy fabric. Operational treatment of tuberculomas is combined with konservativnsh (antituberculous, diuretic remedies, fortifying and the subsequent a dignity. - hens. treatment). The forecast is serious; in far come cases of change from a nervous system are irreversible.
Damage of a spinal cord at a tubercular spondylitis is observed during the progressing of tubercular process in a backbone. Owing to destruction and the shift of vertebrae, development of granulyatsionny fabric and formation of cold abscess, from to-rogo caseous masses extend under a back longitudinal ligament of a backbone (see the Spondylitis), there can be a prelum of a spinal cord and the vessels feeding a spinal cord. At the same time circulatory disturbances, endophlebites, fibrinferments, and also the specific vasculitis causing hypostasis of a spinal cord and a compression myelitis develop. The firm cover of a spinal cord interferes with distribution of tubercular process on tissue of a spinal cord. Its direct transition to a firm cover and development of a pachymeningitis is only seldom or never possible (see).
In a wedge, a picture prevail nevrol. frustration (local and radicular pains, disturbances of sensitivity, motive frustration, paresis and paralyzes).
The paralyzes arising at the height of a disease call early. At timely elimination of abscess the forecast favorable. Late paralyzes develop in several years from the beginning of a spondylitis. Them is the reason it is long the abscess existing in cicatricial fabric, a prelum of a brain the destroyed vertebrae and fibro the changed firm cover, degenerative changes of a spinal cord. Forecast their adverse. In addition to extent of damage of vertebras, prevalence of process and its prescription, a wedge, a picture nevrol. frustration depends p on localization of process.
Detection of the active or postponed pulmonary tuberculosis, limf is of great importance for diagnosis, nodes and other bodies, and children have also positive tuberkulinovy reactions, existence of contact with the TB patient.
Treatment of a tubercular spondylitis includes an immobilization in a plaster bed, wide use of antituberculous remedies and an operative measure, a cut it is especially important in the presence nevrol. complications. Main types of operations are the necretomy and an abstsessektomiya, to-rye allow to eliminate a prelum of a spinal cord. Efficiency of operation the greatest in an early stage of paralyzes — in the first 6 — 12 months of their emergence. During this period treatment of almost all patients, in 2 years — half of patients is observed, and after 3 years of recovery it is not observed.
See also Spondylitis.
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See also bibliogr. to St. Tuberculosis. I. N. Petrov, N. S. Gontuar (oft.), V. F. Elufimova (not BP.), to G. A. Zedgenid-za, Yu. V. Pikuleva (spina ventosa),
O. V. Litovchenko (dermas.), T. P. Mochalova (Urals.), O. A. Uvarova (stalemate. An.).