TUBERCULOSIS of the RESPIRATORY ORGANS. Contents:
Primary tubercular complex 413 Tuberculosis of Intrathoracic Lymph Nodes.............. 415
Disseminated pulmonary tuberculosis................... 417
Focal pulmonary tuberculosis..... 419
Infiltrative pulmonary tuberculosis 421
Tuberculoma of a lung........ 423
Cavernous pulmonary tuberculosis. 425 Fibrous and cavernous
pulmonary tuberculosis................. 427
Cirrhotic pulmonary tuberculosis 429
Tubercular pleurisy....... 430
Tuberculosis of upper respiratory tracts, tracheas, bronchial tubes and dr...... 431
Tuberculosis of a respiratory organs combined with dust occupational diseases of lungs 433 Features of tuberculosis of a respiratory organs at its combination to other diseases............. 435
Tuberculosis of a respiratory organs (Latin tuberculum a hillock + - osis) — the disease of a respiratory organs caused by mycobacteria of tuberculosis.
A respiratory organs at tuberculosis (see) are surprised most often. The activator Thus are, as a rule, mycobacteria of tuberculosis of a human look (see Tuberculosis,
an etiology). Less often the tuberculosis of a respiratory organs caused by the mycobacteria of a bull look which are transferred to the person from suffering from tuberculosis animals meets. The damage to a respiratory organs caused by mycobacteria of a bird's look, a cut carried to tuberculosis, in a crust earlier, time is regarded by most of researchers as mikobakterioz (see Mycobacteria).
Thus can be primary, i.e. develop as a result of penetration, more often in the aerogenic way, the causative agent of the tuberculosis in a human body which is not infected with mycobacteria of tuberculosis, and secondary — developing owing to reactivation of old tuberculous focuses or, more rare, as a result of exogenous superinfection.
Primary Thus arises at children's and youthful age more often, is shown in the form of primary tubercular complex, tuberculosis intrathoracic limf, nodes, pleurisy, and also the focal, infiltratpvny and disseminated tuberculosis. In many cases at primary tuberculosis bronchial tubes, and also a pleura are surprised that leads to development of an endobronchitis of ii of pleurisy. The combination of primary tuberculosis of a respiratory organs to tubercular defeat of other bodies is possible. Progressing of primary Thus can lead to development of miliary tuberculosis, caseous pneumonia and formation of primary cavity. In a crust, time in connection with widely applied antitubercular vaccination the progressing primary Thus meets seldom.
Secondary Thus in most cases arises at mature age. At the same time the focal, infiltrative, disseminated pulmonary tuberculosis, a tuberculoma, tuberculosis intrathoracic limf, nodes and tubercular pleurisy meet. Destructive process in a lung can come to the end with formation of a cavity with development cavernous, fibrous and cavernous, and further and a cirrhotic pulmonary tuberculosis.
In modern conditions meet caseous and infiltrative and caseous pneumonia, and also miliary tuberculosis much less often that formed the basis for an exception of these forms from a wedge, classifications of tuberculosis (see Tuberculosis). Implementation of bronkhologichesky methods of a research allowed a thicket to reveal the specific damage of bronchial tubes caused by the complicated course of tuberculosis intrathoracic limf, nodes. Specific changes are most often localized in tops and subclavial zones of lungs, however in a crust.
time is quite often observed damage of average and lower parts of lungs (basal and the 6th segments), and also 4 — the 5th segments that earlier considered characteristic only of pneumonia and cancer of a lung. Recently Thus is more often, chekhm before, it is noted at persons of advanced and senile age and is much less often observed at pregnant women and women in childbirth.
Thus is often combined with other diseases — a peptic ulcer of a stomach and duodenum, a diabetes mellitus, a hypertension and other diseases of cardiovascular system, and also with occupational diseases of lungs. At patients Thus can be observed also acute and hron. pneumonia, hron. bronchitis and other nonspecific diseases of lungs, to-rye in some cases have character of metatuberculous. Quite often at Thus cancer of a lung meets, to-ry can not come to light in connection with the manifestations of active tubercular process and metatuberculous changes masking it for a long time (see Lungs).
Patients with active forms Thus allocating mycobacteria are iod observation in an antitubercular clinic in the I group of the account. In process of a zatikhaniye of an aggravation of the patient with remained a wedge, displays of a disease transfer to the II group of the account. At the same time a necessary condition is lack of growth of mycobacteria of tuberculosis within the previous two years. The persons who recovered from active Thus are transferred to the III (control) group of the account and remain under observation in an antitubercular clinic within two years (see the Clinic, Medical examination).
Thus, according to accepted in our country a wedge, classification of tuberculosis, includes primary tubercular complex, tuberculosis intrathoracic limf, nodes, the disseminated pulmonary tuberculosis, a focal pulmonary tuberculosis, an infiltrative pulmonary tuberculosis, a tuberculoma of lungs, a cavernous pulmonary tuberculosis, a fibrous and cavernous pulmonary tuberculosis, a cirrhotic pulmonary tuberculosis, tubercular pleurisy, tuberculosis of upper respiratory tracts, tracheas, bronchial tubes, etc., the tuberculosis of a respiratory organs combined with dust occupational diseases of lungs.
Primary tubercular complex is characterized by specific defeat of the site of a lung (primary affect), regional limf, a node (tubercular lymphadenitis) and limf, vessels (tubercular limfangiit). According to most of researchers, primary tubercular affect (primary center) arises in the place of implementation of the activator and develops as a result of primary infection.
To the middle of the 60th primary tubercular complex met more often other forms of primary Thus at children and made, according to different researchers, from 40 to 50%. In recent years «its frequency in structure for the first time of diagnosed Thus at children decreased approximately by 3 times. Frequency of detection of primary tubercular complex at Thus at teenagers makes 3,2 — 4,5%. Adults have primary tubercular complex, by data A. E. Rabukhina (1976), meets in 1% of cases.
Primary affect (see Affect primary) forms more often in 2 — the 5th segments of lungs under a pleura in the form of the center of a caseous bronchiolitis or an alveolitis. Around the center of a caseous necrosis there is a layer of the specific granulyatsionny fabric consisting of epithelial, lymphoid and colossal cells of Pirogov — Langkhansa (see. Colossal cells). Primary affect is usually surrounded with a wide zone of a perifocal inflammation (serous or serofibrinous). In limf, vessels, on the Crimea outflow of a lymph from primary affect to a root of a lung is carried out, inflammatory changes are found — tubercular limfangiit. Regional limf, nodes of a root of a lung are increased, condensed. Nek-rye from them are completely replaced with the mass of a caseous necrosis, others contain only the separate centers of a necrosis and tubercular granulomas (fig. 1). During the progressing of process of change are observed both in primary center, and in regional limf, nodes. Primary center at the same time increases in sizes, in it accrue exudative caseous nekrotiche-skiye changes; also the zone of a perifocal inflammation is exposed to a caseous necrosis. In granulyatsionny fabric a large number of segmentoyaderny leukocytes appears. During the involvement in process of bronchial tubes in their walls the inflammation as a caseous endo-develops, meso - and the sir bronchitis, the caseous bronchiolitis and caseous bronkholo-bulyarny pneumonia are observed. At fusion in primary center of mass of a caseous necrosis there can come their break in a gleam of adjacent bronchial tubes with formation of an acute cavity (see). Distribution of tubercular process on bronchial tubes keeps to acute bronchogenic dissimination with formation acinous or acinous lobudyarnykh the centers caseous pnev-
Fig. 1. Gistotopogramma of a lung at primary tubercular complex: 1 — the center of a caseous necrosis in pulmonary fabric in a stage of the begun otgranicheniye; 2 — a caseous necrosis of lymph nodes in the field of a root of a lung; 3 — inflammatory changes of the absorbent vessels connecting the center in a lung to lymph nodes of a root of a lung — tubercular limfangiit.
manias. In a crust, time such sharply progressing forms of primary Thus meet seldom. Restriction of primary center and a rassasyvaniye of a perifocal inflammation is more often observed. Then on the periphery of primary center the fibrous capsule is formed. After the mass of a caseous necrosis are exposed to consolidation with adjournment of salts of calcium in them (see Petrifikat). Such encapsulated calciphied center is called Ghosn's center. The inflammation in limf, vessels abates, fibrous changes develop in them. Similar processes are observed in the centers of bronchogenic or hematogenous dissimination if they took place.
Progressing of process can happen also in struck limf, nodes; it is observed in a crust, time more often than in primary center. At the same time the centers of a caseous necrosis in limf, a node increase, are involved in process next limf, nodes, to-rye merge in large conglomerates. Inflammatory changes can pass to the capsule limf, nodes, adjacent soft tissues, a mediastinum, radical departments of a lung with formation of radical infiltrate. In the last nonspecific exudative reaction prevails and form small, preferential epitet the and-oidno-giant-cell centers with a caseous necrosis in the center sometimes merging among themselves. Inflammatory changes from the capsule limf, nodes extend to walls of adjacent bronchial tubes, in to-rykh infiltration of all layers and especially mucous glands is observed. The centers of a caseous necrosis in limf, nodes can be exposed to fusion and at destruction of their capsule break in a gleam of a bronchial tube, forming bronchial fistulas (see). The massive break in a gleam of a bronchial tube of mass of a caseous necrosis usually leads to acute bronchogenic dissimination. During the healing of tuberculous focuses in limf, nodes there is a consolidation of mass of a caseous necrosis to adjournment of salts of calcium in them, a rassasyvaniye of perifocal inflammatory changes, development of fibrous fabric in the capsule limf, nodes and adjacent fabrics, in particular in the field of a root of a lung. Considerable fibrosis in a root of a lung leads to formation of bronchiectasias (see) and to a pneumosclerosis (see). Scarring of bronchial fistulas is followed by considerable deformation of a bronchial tree.
According to V. I. Puzik (1958), healing in primary tuberculous focuses happens much more stoutly, and processes of a rassasyvaniye and fibrosing are more expressed, than in limf, nodes, in to-rykh the phenomena of encapsulation prevail.
The wedge, a picture depends on expressiveness of a perifocal zone of an inflammation and prevalence of a caseous necrosis. More often a wedge, manifestations at primary tubercular complex are expressed poorly. At extensive process the disease proceeds as pneumonia (see) — with high temperature and other symptoms of intoxication (night sweats, irritability, a loss of appetite) accelerated by ROE, a leukocytosis with a deviation to the left. A characteristic sign is the lymphopenia. Over the site of defeat shortening of a pulmonary sound, weakening of breath is defined. In the presence of destructive changes, the accompanying endobronchitis and a pneumosclerosis rattles are listened. At children primary tubercular complex often proceeds behind a mask of recurrent respiratory diseases, bronchitis (see); at teenagers and adults — behind a mask of pneumonia, bronchial asthma (see) and other defeats of a respiratory organs.
The current of primary tubercular complex can be divided on uncomplicated and complicated. At an uncomplicated current, tending by a favorable outcome, are involved in process pulmonary fabric and regional limf. nodes.
Complications of primary tubercular complex are pleurisy (see), the dissemshgation, disintegration of pulmonary fabric. To rare complications the break of caseous masses from limf, nodes in a gleam of a bronchial tube treats with formation of bronchial fistulas. The diffusion inflammation of a mucous membrane of a bronchial tube is more often observed, owing to-rogo passability of the last is broken and there is an atelectasis (see) relevant department of a lung. At untimely treatment in this site the metatuberculous, and then post-tubercular pneumosclerosis can develop in the beginning.
In diagnosis the main role is played by radiological methods of a research. Rentgenol. the picture of primary complex is characterized * by four signs: emergence, is more often in 2 — the 5th segments of lungs, the large center or the site of the consolidation of pulmonary fabric of average intensity, homogeneous structure with accurate outlines located kortnkalyyu (the center of primary pneumonia); expansion and consolidation due to increase regional limf, nodes of a root of a lung on the same party; existence of the binding «path» between the center in a lung and a root of a lung caused by infiltration of pulmonary fabric around vessels and bronchial tubes; consolidation of a pleura or emergence of a plevropulmonalny tyazh at the level of the pulmonary center (fig. 2). In a phase of a rassasyvaniye on site of primary affect the centers form, to-rye are condensed and calcinated, forming the small single calcinated center (Ghosn's center) or several kroshkovidny calcine-tov; in regional limf, nodes kaltspnata are also formed — the picture of the calcinated primary complex forms. On site primary affect can be formed large, accurately outlined, with the expressed calcification (see) sites of consolidation — primary tuberculomas. Seldom during the progressing of process emergence of cavities is observed (see the Cavity); sometimes the atelectasis, pleurisy develop.
The differential diagnosis is carried out with other forms of a pulmonary tuberculosis (at children — with bronkhade-nity, the complicated atelectasis of a lung, at teenagers and adults — is more often with infiltrative tuberculosis and a tuberculoma), with damages of lungs of other etiology — pneumonia, caused by coccal flora, fungal damages to lungs — an actinomycosis (see), aspergnl-lezy lungs (see the Aspergillosis, Pneumomycoses), etc., an echinococcus of a lung (see the Echinococcosis), with cystous changes of lungs (see) during activation of inflammatory process in walls of cysts against the background of positive tuberkulinovy tests, and also with tumoral processes. During the carrying out the differential diagnosis between primary tubercular complex and nonspecific pneumonia it is necessary to consider that at acute nonspecific pneumonias consolidation of pulmonary fabric has uneven character and differs in big dynamism, increase limf, nodes is not observed; at hron. nonspecific pneumonia of change are more often localized in nizhnezadny departments of lungs with existence of the structures and bronchiectasias expressed tyazhisto-setcha-tykh. During the carrying out differential diagnosis with other listed diseases the cytologic and bacteriological research separated bronchial tubes, the material received at a bronkhoskopiya is decisive.
Treatment is begun with purpose of antituberculous remedies of 1 row (see. Antituberculous remedies), since almost always at this form of tuberculosis the causative agent of tuberculosis is sensitive to these drugs. Streptomycin, PASK and an isoniazid are used usually. Treatment of the complicated processes is carried out by these means in combination with aerosol inhalations of 2% of solution of a salyutizon or 10% of solution of an isoniazid; at the same time appoint rat anti-acrodynia factor.
At the uncomplicated course of a disease under the influence of treatment, as a rule, within the first weeks body temperature decreases, symptoms of intoxication disappear, there is an appetite, there is a gradual rassasyvaniye patol. changes in pulmonary fabric. Limf, nodes of a root of a lung decrease much more slowly. If the appointed treatment is insufficiently effective, re-
Fig. 2. The roentgenogram of a thorax at primary tubercular complex (a straight line pryktion): 1 — the site of consolidation of pulmonary fabric (the center of primary pneumonia); 2 — infiltration of perivascular and peribronchial fabric between the center in a lung and a root of a lung («path»); 3 — the expanded and condensed
root of the right lung.
shat a question of replacement of drugs: instead of streptomycin appoint Kanamycinum, instead of PASK — Etioniamidum or Ethambutolum. At early stages of treatment in the absence of contraindications use also rifampicin. The general duration of treatment makes 12 — 16 months. At the complicated primary tubercular complex for prevention of tubercular damage of bronchial tubes enter antituberculous remedies and corticosteroids in the form of aerosols. The last, possessing the expressed antiinflammatory and hyposensitizing effect, promote the best rassasyvaniye of inflammatory changes.
LFK is shown in the form of morning exercises (see Charging), the dosed walking, terrainkur (see), gymnastic exercises (see Gymnastics), outdoor games (see Games), dances, exercises of a sports and applied look, and also physical activity in the park and workshops of manual skills. And loading is raised gradually. Occupations of LFK and labor therapy (see) are carried out daily for from 1 to 3 hours with breaks. Overfatigue, overcooling, overheating, hyper insolation are contraindicated.
As a result of treatment almost full rassasyvaniye patol is reached. changes in lungs and limf, nodes even at the complicated processes. Residual changes are absent or are shown in the form of a limited tyazhistost of pulmonary fabric and small impregnations of salts of calcium. However at late revealed process, despite an intensive care, on site primary affect primary tuberculoma is formed. In such cases operational treatment — a resection of the affected lung is shown, and also caseous it is changed - nykh limf, nodes if process in them was not liquidated under the influence of antibacterial therapy. Treatment of patients with primary tubercular complex comes to the end in sanatorium.
The remote forecast favorable, a recurrence, as a rule, does not come.
Prevention includes the general a dignity. - the prof. of an action, and also specific prevention — vaccination, a revaccination, chemoprophylaxis, etc. (see Tuberculosis).
Tuberculosis of intrathoracic lymph nodes — an independent form of local tuberculosis or a component of primary tubercular complex when primary affect in lungs is absent or is very small, and defeat limf, nodes dominates. Meets preferential at children's and teenage age, but happens also at adults.
On the basis kliniko-rentgenol. data distinguish tumorous
Fig. 3. Gistotopogramma of intrathoracic lymph nodes at a tubercular bronkhadenit: 1 — the centers caseous not a
kroza in lymph nodes; 2 — a wall of a pulmonary artery.
and infiltrative tuberculosis intrathoracic limf, nodes. Also so-called small form of a bronkhadenit proceeding with slight symptomatology and insignificant increase intrathoracic limf, nodes occurs at children thanks to performing mass antitubercular vaccination.
Development of a disease in children is connected with primary infection, more often in the aerogenic way, and also as a result of penetration of mycobacteria of tuberculosis through palatine tonsils and a mucous membrane of an oral cavity. At adults the disease develops owing to reactivation of earlier postponed process in intrathoracic limf, nodes more often. In this case bronkhadenit (see) is complicated by development of bronkhozhelezisty fistula and distribution of process on pulmonary fabric. This form is known as a ferruterous and bronchogenic, ferruterous and bronchopulmonary form of tuberculosis or adenogen-ny, bronchopulmonary tuberculosis.
Nodes of an average share of the right lung, a lingular segment and upper shares of lungs are surprised preferential bronchopulmonary limf. At the same time in limf, nodes the centers of a caseous necrosis occupying sometimes all fabric limf, a node (fig. 3) form. During the progressing of process specific changes pass to surrounding fabrics, involving a wall of a bronchial tube in process, is frequent with burrowing. Processes of healing proceed with a partial rassasyvaniye and scarring of tuberculous focuses.
Klien, a picture of tuberculosis intrathoracic limf, nodes is diverse and depends on genesis of a disease, expressiveness morfol. changes and their localization. Development of a bronkhadenit, as a rule, is followed by sensitization to tuberculine (see), is frequent development of a knotty erythema (see the Erythema knotty), a fliktenulezny keratoconjunctivitis (see Conjunctivitis), scrofulodermas (see Tuberculosis extra pulmonary, a tuberculosis cutis and hypodermic cellulose), exudative pleurisy (see). Fervescence, indisposition, emergence of night sweats, deterioration in appetite, weight loss, dry cough is noted. The small form of a bron-hadenit, as a rule, proceeds is hidden, sometimes with rise in temperature, an easy indisposition that demands especially careful inspection.
Depending on reactivity of an organism of the patient (see Reactivity of an organism) and it immunol. the status the course of tuberculosis internal limf, nodes can be various. At a favorable current after acute flash there occurs decrease in temperature to subfebrpl-ny figures and the phenomena of intoxication decrease. At the same time there are rassasyvany inflammations around increased limf, nodes and reduction of their sizes. Hypersensitivity to tuberculine can remain within several years. Dynamics rentgenol. changes it is long, reduction of the sizes limf, nodes is followed by adjournment in them (preferential in their peripheral departments) the kroshkovidny, and then larger calcinated inclusions.
The complicated course of tuberculosis intrathoracic limf, nodes differs in the bigger duration and less favorable outcome. Despite a rassasyvaniye of a perifocal inflammation around limf, nodes, process in them does not calm down, and mycobacteria of tuberculosis extend in the contact or lymphogenous way to other groups limf, nodes and to other bodies.
The most frequent complication of a tubercular bronkhadenit is pleurisy (see). The symptomatology of the bronkhadenit complicated by pleurisy (a ferruterous and pleural form of primary tuberculosis) depends on localization and expressiveness of process. At the same time pains, short wind, cough are noted, at rentgenol. a research — exudate in a pleural cavity or pleural unions. At timely begun treatment the pleurisy accompanying a bronkhadenit resolves without any effects.
A frequent complication at tuberculosis intrathoracic limf, nodes is damage of bronchial tubes, conducting a wedge, a sign to-rogo is dry pristupoobrazny cough, sometimes an asthmatic state, local dry rattles. As a result of obstruction, a prelum or a spasm of a bronchial tube the atelectasis can develop, to-ry depending on caliber of the affected bronchial tube happens share, segmented, subsegmentar-ny. The atelectasis of all average share or a uvula — a so-called syndrome of an average share is rather often observed (see the Atelectasis). At gradual obstruction of a gleam of a bronchial tube because of a cicatricial stenosis or a gradual prelum of a bronchial tube from the outside increased limf, nodes the sclerosis of intersticial tissue of lung with formation of multiple small bronchiectasias and violent emphysema is possible. At obturation of a gleam of a bronchial tube the caseous masses, pus or slime the acute pulmonary heart can develop (see. A pulmonary heart) and even asphyxia (see). Due to the features of a structure of a respiratory organs and an originality of fabric reaction at tuberculosis at adults disturbance of bronchial passability is not so sharply expressed, as at children. In process of improvement of passability of bronchial tubes short wind and cough decrease, temperature is normalized, the dullness disappears, breath in a zone of the former atelectasis is normalized. In some cases after an otkhozh-deniye of the melted caseous masses the atelectasis disappears, and in limf, a node the cavity which is reported with the draining bronchial tube forms.
The course of tuberculosis intrathoracic limf, nodes can be also complicated by specific defeat of pulmonary fabric owing to bronchogenic, lymphogenous or hematogenous spread of an infection.
The diagnosis of tuberculosis intrathoracic limf, nodes is based on results of comprehensive inspection of patients. Are considered a recent bend of tuberkulinovy tests (transition of negative reaction to tuberculine to positive) and the expressed reaction to intradermal administration of tuberculine, existence of persistent intoxication, a knotty erythema, fliktenulezny keratoconjunctivitis, data of a laboratory research. In blood the neutrophylic leukocytosis, a relative lymphopenia, acceleration of ROE, a hyperglobulinemia, increase in contents a2-and 7 globulins comes to light. Mycobacteria of tuberculosis in a phlegm are found seldom, hl. obr. at development of perifocal inflammatory changes in pulmonary fabric and at break of mass of a caseous necrosis from limf, a node in a bronchial tube.
For recognition of increase limf, nodes use a row percussion auskultativnykh receptions (see Bronkhadenit), however the basic in diagnosis is rentgenol. method of a research.
At tuberculosis intrathoracic limf, nodes the expressed and malovyra-zhenny forms of defeat radiological are defined. The small expressed forms are shown by asymmetry of root shadows owing to small expansion, consolidation and camber of outside outlines of one of roots of a lung.
The tumorous form is characterized by expansion and consolidation (is more often unilateral) roots of lungs due to significant increase limf, nodes. On the same party in some cases increase tracheobronchial and peritracheal limf, nodes is noted. Outlines of roots of lungs and a mediastinum have wavy or hilly character, limf, nodes separately are not differentiated — so-called baked limf, nodes (see fig. 1, 2, 3 to the station Bronkhadenit, t. 3, Art. 392). Sometimes the expanded shadow of an upper mediastinum gets direct outlines — a symptom of «flue». At an infiltrative form deformation, expansion, increase in intensity and decrease in degree of structure of shadows of roots of lungs is noted: camber of an outline and an illegibility of their borders (see fig. 4 to the station Bronkhadenit, t. 3, p. 393). In some cases at defeat intrathoracic limf, nodes complications come to light: atelectasis, pleurisy, bronchogenic dissimination.
At patients with it is long and torpidno the current processes in increased and condensed limf, nodes chaotically located kroshkovidny or glybchaty shadows of petrifikat (see), the ring-shaped shadows formed by the calcinated capsule limf are defined. node. The prileganiye changed limf, nodes to bronchial tubes, the largest diameter of a shadow limf is characteristic, a node is located parallel to a gleam of a trachea, bronchial tube. At the level of changed limf, nodes the compression of bronchial tubes, their deformation, a stenosis can be defined. The differential diagnosis is carried out with a lymphogranulomatosis (see), a lymphosarcoma (see), a radical form of the central cancer of lung (see), a lymphoid leukosis (see Leukoses), a sarcoidosis (see). Crucial importance in most cases has a bronkhologichesky research, and also morfol. a research of the material received at a biopsy.
Treatment of TB patients intrathoracic limf, nodes shall be complex and long (at small forms — 8 — 10 months, at expressed — 12 months, at complications — 18 months). In an acute phase of a disease treatment with use not less than three antitubercular drugs at the same time, and also giposensibnlizi-ruyushchy means is shown. At different stages of a disease use of means of pathogenetic therapy for the purpose of acceleration of processes of a rassasyvaniye is reasonable (see Tuberculosis, philosophy of treatment). Classes of LFK are given in the same volume, as at primary tubercular complex. In the absence of effect of treatment by antituberculous remedies intrathoracic limf, nodes with massive caseous changes are subject to operational removal.
The forecast is more often favorable and the hl depends. obr. from character of the joined complications.
Prevention comes down to holding the general preventive actions and to specific prevention of tuberculosis (see Tuberculosis).
See also Bronkhadenit.
The disseminated pulmonary tuberculosis — a wedge, the form of tuberculosis which is characterized by formation of the multiple centers of various size emergence to-rykh is connected with dispersion of mycobacteria of tuberculosis in an organism more often hematogenous, more rare in the lymphogenous way. The disseminated tuberculosis which resulted from hematogenous distribution of contagiums (bacteremia) is called the hematogenous disseminated tuberculosis. Quite often a source of bacteremia are the caseous centers in limf, nodes or partially begun to live or becoming more active old centers in lungs, bones, generative and other organs at secondary tuberculosis. Bacteremia not always involves development of the disseminated tuberculosis. Dissimination is promoted by a hyper sensitization and decrease in reactivity of an organism because of superinfection, a hypovitaminosis, starvation, hyper insolation, flu, endocrine disturbances, a peptic ulcer, prolonged treatment by glucocorticoids, etc. At children and teenagers development of a disease can be promoted also by defects in performing vaccination of BTsZh and chemoprophylaxis of tuberculosis (see Tuberculosis).
The disseminated pulmonary tuberculosis, by data A. G. Homenko (1981), occurs at 5 — 6% for the first time of the revealed patients with active tuberculosis.
Depending on a current the disseminated pulmonary tuberculosis can be acute, subacute and chronic.
To the acute hematogenous disseminated tuberculosis the miliary tuberculosis which is characterized by a uniform rash in lungs of small prosovidny hillocks — tubercular granulomas (see the Granuloma) and generalization of process treats with defeat of many bodies and systems (serous covers, a liver, a spleen, a retina of an eye, etc.)> In a crust, time acute miliary tuberculosis meets seldom. Generally people of advanced age are ill, but the disease occurs also at children.
At acute miliary tuberculosis in lungs find symmetrically located multiple small granulomas of preferential productive, productive and exudative or exudative and necrotic character. Granulomas quite often are located in walls of small vessels (arterioles and venules), sometimes directly in their internal cover. They are formed also in other bodies, including and in a meninx that is observed at tubercular meningitis (see).
The wedge, picture of miliary tuberculosis is characterized by symptoms of the expressed intoxication. High temperature of a body, the accelerated pulse, short wind, a headache, the increasing weakness are noted. The maximum development a wedge, symptoms is noted on 7 — the 8th day of a disease. The bronchopulmonary symptomatology is expressed to a lesser extent. Patients complain of dry cough, in lungs dry and single wet small-bubbling rattles, a pleural rub are listened.
Depending on dominance of separate symptoms allocate tifoidny, pulmonary and meningeal a wedge, forms of acute miliary tuberculosis. At a tifoidny form symptoms of intoxication, disease, prevail especially in the beginning, reminds a typhoid, sepsis and other acute infectious diseases. The pulmonary form of acute miliary tuberculosis is from the very beginning shown by a bronchopulmonary syndrome: hoarse dry cough, asthma, shallow breathing, cyanosis. Temperature increases to 39 — 40 °. In lungs rigid breath, dry rattles, a pleural rub is listened, however auskultativny changes do not correspond to weight of a condition of the patient. During the progressing of a disease the acute pulmonary heart develops. The meningeal form of acute miliary tuberculosis is shown by generally meningeal symptoms (see Meningitis). Extremely seldom the most acute form of miliary tuberculosis — the tubercular sepsis (tifobatsillez Pokrovsky — Landuzi) developing at the faces which are sharply weakened by any disease, napr at a leukosis or a severe form of a diabetes mellitus meets. In lungs and in other bodies are formed small, inclined to a necrosis and purulent fusion of an ochazhka, containing a huge number of mycobacteria. The disease begins sharply, the sputa proceeds with high temperature,nnost of consciousness, nonsense, asthma, increase in a liver and spleen, tachycardia, pulmonary heart.
Unlike generalized miliary tuberculosis limited meet the acute beginning and a heavy current it is lovely pair processes in lungs with subacute and hron. current. At limited miliary tuberculosis the multiple small centers of the identical size are symmetrized in supraclavicular and subclavial zones, is preferential in cortical departments of lungs. The current is more favorable, aggravations are replaced by remissions, and sometimes — spontaneous treatment. In some cases at long, rather favorable current, limited miliary tuberculosis passes in hron. the hematogenous disseminated form.
The option of the migrating subacute miliary pulmonary tuberculosis is described, at Krom the small centers are formed from time to time, to-rye «poetazhno» extend throughout lungs. At a long current subacute process is transformed in hron. the disseminated tuberculosis.
The subacute disseminated pulmonary tuberculosis arises at distribution of the activator on circulatory and limf, to vessels, and at a specific endobronchitis — and but to bronchial tubes. The centers are localized in upper parts of lungs, characterized by the identical density and size. Existence of the centers in radical and lower parts of a lung is characteristic of lymphogenous dissimination. The subacute disseminated pulmonary tuberculosis proceeds differently. At nek-ry patients after the period of an indisposition symptoms of intoxication quickly enough accrue, temperature increases, and the disease reminds a picture acute inf. diseases (flu, typhoid, focal pneumonia). Quite often patients see a doctor with complaints to difficulty of swallowing, an osiplost of a voice, a pneumorrhagia, cough with allocation of a mucopurulent phlegm. In other cases the symptomatology of a disease erased aggravations happen short-term, and remissions last many months and years. The disease comes to light at mass fluorographic inspections of the population more often. Untimely identification and insufficient treatment lead to progressing of process, and at a number of patients — to development of the chronic disseminated pulmonary tuberculosis.
Hron. the disseminated tuberculosis is characterized by a wavy current, with immetrichny damage of both lungs. Prp it intensity of rashes is various, most expressed in upper parts of lungs and decreases in the field of basal segments. The centers differ in size, time of emergence, but the nature of cellular reactions. The productive type of an inflammation prevails. Process can be complicated by education symmetrized thin-walled (due to the lack of the expressed fibrosis in walls) cavities of rounded shape — so-called stamped cavities (see. To During the healing of the hematogenous disseminated tuberculosis fibrosis of the centers p interlobular, interalveolar partitions (fig. 4), and also the emphysema which is especially expressed in upper parts of lungs is observed.
Wedge, picture hron. the disseminated tuberculosis it is diverse and depends on a phase of process, its prevalence and prescription. Beginning of a disease gradual, often imperceptible for the patient and people around. Current wavy; at the beginning of a disease of an aggravation arise seldom. At the aggravation (flash) corresponding to formation of the fresh centers in lungs the subfebrile temperature, a loss of appetite, weakness are noted. These phenomena are expressed unsharply and short (1 — 2 week). Weak cough or tussiculation, sometimes pneumorrhagia are possible. During the period between flashes the wedge, manifestations disappear, the general state improves, for a long time subfebrile temperature sometimes can remain. In the same time there comes the partial rassasyvaniye of the centers and their consolidation. The disease can proceed and is latent for several years.
Over time the periods of aggravations are extended, intoxication becomes more expressed, gradually develops and slowly an asthma accrues. The cough arising in the period of an aggravation is followed by expectoration, in a cut mycobacteria of tuberculosis can be found, especially at disintegration and obra-
by Fig. 4. Gistotopogramma of a lung at the chronic hematogenous disseminated tuberculosis: 1 — the centers of a caseous
necrosis surrounded with the fibrous capsule; 2 — the condensed interlobular partitions.
zovaniya of a cavity; quite often arise a pneumorrhagia (see) and pulmonary bleeding (see). Characteristic for hron. the disseminated pulmonary tuberculosis discrepancy between scanty physical yielded and results rentgenol is. researches. At any stage of a disease there can be a disintegration of pulmonary fabric to formation of cavities. These changes are followed by a bronchogenic dissempna-tion, and in the absence of treatment fibrous and cavernous tuberculosis forms (see below).
Complications of the subacute and chronic disseminated pulmonary tuberculosis are tuberculosis of a throat, intestines, kidneys, generative organs (see Tuberculosis extra pulmonary), pulmonary bleedings, spontaneous pheumothorax (see), an empyema of a pleura (see Pleurisy), respiratory insufficiency (see) and a pulmonary heart (see), an amyloidosis of internals (see the Amyloidosis).
The diagnosis of the disseminated pulmonary tuberculosis is made on the basis of bacteriological, immunological, bronkhologichesky, and also microscopic examination of the material received by means of a puncture biopsy. However the leading role in recognition of this form of a pulmonary tuberculosis belongs rentgenol. to a method of a research. On the basis rentgenol. data allocate various types of the disseminated process. The acute disseminated tuberculosis is characterized by existence in lungs of the multiple centers. Depending on their sizes allocate melkoochagovy (miliary), sredneochagovy and macrofocal types of dissimination.
At melkoochagovy type of dissimination the sizes of the centers do not exceed
2 — 3 mm in the diameter, the centers have the same character, clear outlines and are evenly disseminated through both pulmonary fields. The centers form complex shadows with infiltrativ-but-condensed intersticial tkanyo; the structure of lungs at the same time gains melkosetchaty, looped character; the vascular drawing is not traced (fig. 5).
At sredneochagovy type of dissimination the centers have
the sizes 3 — 5 mm in the diameter; they are same on a forkhma, the sizes, intensity, have indistinct outlines and are located against the background of a mesh tyazhistykh of intersticial changes.
The macrofocal type of dissimination is characterized by existence of the centers with a diameter up to 12 — 15 mm. The centers have the wrong and round form, homogeneous structure; nek-ry of them are accurately outlined that testifies about their osumkovanp; the centers are inclined to merge and disintegration. In addition to
Fig. 5. The roentgenogram of a thorax at miliary tuberculosis (a direct projection): the multiple shadows in all departments of lungs formed by the small centers and infiltrative intersticial changes are visible; the vascular pulmonary drawing is not defined.
mesh also tyazhisty shadows of peribronchial intersticial consolidations are defined.
At all types of dissimination emphysema is noted, roots of lungs lose the clearness of outlines, at a number of patients comes to light bronkhadenit.
The differential diagnosis of an acute miliary pulmonary tuberculosis, especially in an onset of the illness, carry out with a typhoid (see). At tuberculosis temperature increases quickly and on 1 — the 2nd day reaches 39 — 40 °; on the 2nd week fever becomes the wrong type (see Fever), pulse speeded up, sharply expressed short wind, cyanosis, a lymphopenia without leukocytosis are noted, on 7 — the 8th day of a disease changes on the roentgenogram come to light. The research of an eyeground allows to find on it miliary hillocks. At a typhoid temperature increases gradually and forms a typical curve, relative bradycardia, a dicrotism of pulse are noted. An asthma is not expressed, the leukopenia is followed by a lymphocytosis, typhus roseolas, etc. appear. Positive reaction of Vidal is noted (see Vidal reaction) and the causative agent of a typhoid in blood is found. The roentgenogram is not changed. The tuberculinodiagnosis and bacteriological researches of a phlegm and blood often are ineffectual. Have crucial importance given to a X-ray analysis of lungs.
The differential diagnosis of the subacute and chronic disseminated tuberculosis is carried out with melkoochagovy pneumonia (see), with small abscesses of lungs, metastatic damage of lungs, a sarcoidosis (see). Pneumonia unlike tuberculosis is shown by sharply expressed bronchopulmonary syndrome. In lungs small-bubbling rattles are listened, on the roentgenogram the centers
of larger sizes in lower parts of lungs are defined, in blood the leukocytosis is expressed. Small abscesses of lungs at rentgenol. a research have looking alike tubercular defeats, however the centers at abscesses are larger, than at tuberculosis, in upper parts of lungs of pathology does not come to light, changes of blood are characteristic of a purulent infection. The disseminated pulmonary tuberculosis differentiate also with metastatic damages of lungs — a carcinomatosis, metastasises chorion-epitel of an ioma, etc. A significant amount of the metastatic centers forming dense melkopetlisty network is characteristic of the last, is preferential in lower parts of lungs, upper parts are affected less. Crucial importance has a bronkhologichesky research with the subsequent microscopic examination of scraping of a mucous membrane of bronchial tubes, gistol. a research peripheral limf, nodes, and also detection of primary center of a tumor (see Lungs, tumors; T rofoblastichesky disease). At a sarcoidosis (see) temperature is usually normal, health satisfactory, discrepancy between expressiveness of changes in lungs and a satisfactory general condition is noted; skin reaction to tuberculine negative or slabopolozhitelny; cavities do not happen; it is observed good to lay down. effect of treatment by corticosteroid drugs at inefficiency of antituberculous remedies.
In rare instances the disseminated pulmonary tuberculosis differentiate with an idiopathic hemosiderosis of lungs (see), with focal pneumonia of various etiology (see Pneumonia), ornitozny pneumonia (see the Ornithosis), diffusion adenomatosis (see Lungs, tumors), nek-ry forms of a lymphogranulomatosis (see), Hammen's syndrome — Rich (see the Boor exchange — Rich a syndrome), a system lupus erythematosus (see), a nodular periarteritis (see the Periarteritis nodular), Wegener's granulomatosis (see Wegener a granulomatosis), pneumomycoses (see), a pneumoconiosis (see) and other diseases, one of signs to-rykh are the disseminated focal changes in lungs.
Treatment of patients with the disseminated tuberculosis long (12 months and more) and complex. Major importance in achievement a wedge, treatment or permanent stabilization of process belongs to chemotherapy. At the acute miliary and subacute disseminated tuberculosis antibacterial therapy shall be very intensive. It is reasonable to appoint at the same time an isoniazid, rifampicin and streptomycin or Ethambutolum in combination with pathogenetic means, corticosteroid drugs (Prednisolonum), vitamins, etc.
At hron. the disseminated pulmonary tuberculosis appoint antituberculous remedies. The isoniazid and rifampicin combine with Ethambutolum or Etioniamidum (Prothionamidum); in 3 — 6 months of treatment pass to two drugs, and select a combination individually depending on medicinal sensitivity of mycobacteria and portability of pharmaceuticals. At formation of the cavity which is not beginning to live under the influence of chemotherapy after a rassasyvaniye of the centers and an otgranicheniye of destructive process operational treatment can be applied. At complications the corresponding treatment — haemo static therapy shall be carried out at blood spitting and bleedings (see the Pneumorrhagia, Pulmonary bleeding), drainage of a pleural cavity at spontaneous pheumothorax (see), an oxygenotherapy (see. Oxygen therapy) and cardiacs at a pulmonary heart (see. Pulmonary heart).
At the widespread disseminated pulmonary tuberculosis which is followed by disturbance of microcirculation, a pneumosclerosis and emphysema early purpose of the dosed walking and special breathing exercises directed to increase in a reserve exhalation is shown. Such form of work of LFK promotes reparative processes in lungs and improves the lung ventilation broken, as a rule, on obstructive type.
The forecast at early detection of a disease and the correct treatment favorable.
Prevention consists in full treatment of initial forms of tuberculosis.
A focal pulmonary tuberculosis — a wedge, the form of tuberculosis which is characterized by limited, preferential productive inflammatory process. The focal pulmonary tuberculosis is carried to the so-called small forms of tuberculosis which are characterized by limited inflammatory tubercular process, rather high-quality current and lack of disintegration (at a number of patients, at decrease in immunity, the disease can accept the progressing current with formation of a cavity). The focal pulmonary tuberculosis arises owing to reactivation of old tuberculous focuses or (more rare) as a result of an exogenous superpnfektspa. Under the corresponding conditions there is a transformation of persistent forms of mycobacteria in the old centers in zhiznesposob-
Riye. 6. Gistotopogramma of a lung at focal tuberculosis: 1 — the old encapsulated center of a caseous necrosis in a radical lymph node; 2 — the centers of a caseous necrosis of various size and prescription in pulmonary fabric.
the ny, breeding mycobacteria. In a crust, time reactivation of the old centers and development of focal tuberculosis is quite often observed at advanced age (the period between primary infection and developing of focal tuberculosis can make decades). This form of tuberculosis sometimes arises also at chronically current primary pulmonary tuberculosis (at hematogenous dissimination the centers arise in tops of lungs, at limfobronkhogenny planting — in average and lower parts of lungs). Often focal pulmonary tuberculosis happens an outcome of others a wedge, forms of a pulmonary tuberculosis — infiltrative, cavernous, disseminated. Practically any form of pulmonary tuberculosis in the course of involution can be transformed to a focal form.
The fresh centers (Abrikosov's centers) represent caseous of - menennye walls of intra lobular bronchial tubes with transition of process to air cells and education around the affected bronchial tube of the center of caseous pneumonia and perifocal hypostasis. Older centers called by Ashoff's centers — the Bullet, consist of the mass of a caseous necrosis which is exposed to calcification surrounded with the expressed fibrous capsule (fig. 6). Between the capsule and caseous masses there is a narrow layer of specific granulyatsionny fabric. In pulmonary fabric around the centers growths of connecting fabric are found. In limf, nodes the hyperplasia of an adenoid tissue is noted. In a phase of progressing of process of mass of a caseous necrosis in the centers are exposed to fusion, infiltration of the fibrous capsule is observed by lymphoid cells and numerous segmentoyaderny leukocytes, on the periphery the zone appears bore not a pifichesky exudative inflammation. Further specific granulyatsionny fabric and caseous nek-
roses can extend to this zone and nearby bronchial tubes, strike their wall and peribronchial fabric. The break of caseous masses in a gleam of a bronchial tube quite often leads to bronchogenic dissimination. Sometimes the aggravation of tubercular process in the center is not followed by the expressed perifocal inflammation, and is shown by infiltration of the capsule lymphoid cells and segmentoyaderny leukocytes, fusion of the capsule and a wall of an adjacent bronchial tube, break of caseous masses in a gleam of a bronchial tube with formation of an autolytic cavity.
During the healing the pernfokalny inflammation resolves, the fibrous capsule develops and fibronodular tuberculosis forms. In this case the centers are very various and represent the remains of a tubercular granuloma surrounded with fibrous fabric, is frequent with caseous inclusions of different size. The centers of defeat can be single or multiple, l to us. to 1 cm are localized more often in 1 — 2 segments of the right lung in the depth of pulmonary fabric or, more rare, under a pleura. Such pet-rifitsirovanny centers can is hidden to exist in an organism and are not shown clinically.
A wedge, displays of a focal pulmonary tuberculosis it is possible to divide into two groups: the symptoms of the general intoxication and symptoms caused by defeat of a respiratory organs. At focal tuberculosis the symptomatology is expressed, as a rule, in the period of an aggravation, in a phase of infiltration of a pla of disintegration. Only at nek-ry patients symptoms of intoxication remain is long, even in the period of a zatikhaniye of process. Patients complain of fatigue, decrease in working capacity. In the period of an aggravation of process temperature increase is noted short, within 10 — 12 days. In nek-ry cases long subfebrile condition remains also after a zatikhaniye of process. The increased perspiration, sometimes tachycardia, cough without phlegm or with allocation of a small amount of a phlegm are noted. At disintegration the pneumorrhagia can appear.
The focal pulmonary tuberculosis proceeds, as a rule, is long, wavy, with change of phases of an aggravation and zatikhaniye, but even during flash absence expressed a wedge, manifestations is characteristic. Therefore patients can not suspect about the disease and do not see a doctor. The disease at them comes to light generally at preventive fluorographic inspection, and also at the request for medical aid in other occasion.
The fibronodular tuberculosis which is easily defined at a physical research was well-known in the past and the api-cytome (apical tuberculosis) was called. However it was considered as the beginning of tubercular process in lungs. In a crust, time thanks to rentgenol. to methods of a research apical tuberculosis with fibronodular changes consider as old process with fibrous transformation — result of involution of earlier active focal tuberculosis or others a wedge, forms of a pulmonary tuberculosis.
Most of patients with fibroznoochagovy changes in upper shares of easy complaints do not show, at others only unstable subfebrile temperature is noted. At survey of the patient with fibroznoochagovy tuberculosis retraction of supraclavicular and subclavial poles, lag at breath of one half of a thorax, sharp expansion of saphenas about an awn of a shovel (Frank's symptom) often come to light. The upper edge of a trapezoid muscle on the party of defeat more flabby and thin, than on healthy, owing to dystrophy of muscles at a chronic patol. process in lungs (Pottendzher's symptom). At fibronodular processes in tops of lungs the dullness, strengthening of the breath having a bronchial shade (weakening of breath is observed only at accession of apical pleurisy) is defined, dry and wet mixed, sonorous, bitter rattles are listened. In their emergence the significant role is played by deformation of bronchial tubes in cicatricial fabric. Rattles can be listened for a long time and are not a sign of inflammatory process.
The most informative method in diagnosis of a focal pulmonary tuberculosis is rentgenol. a research, thanks to Krom it is possible to establish not only a form of a disease, but also to define localization of process, quantity of the centers, their density and character of contours. Rentgenol. the picture of a focal pulmonary tuberculosis is characterized by existence of the centers with one or on both sides, is preferential in upper parts (the 1st and 2nd segments); at bilateral defeat asymmetry of changes is noted. At fresh process the centers have the unequal size, average intensity, indistinct outlines more often; the nek-ry centers have rounded shape, homogeneous structure and accurate outlines that indicates a caseous necrosis of pulmonary fabric and its encystment. Also mesh and looped and tyazhevidny drawing owing to
Fig. 7 comes to light. The roentgenogram of a thorax at a fibronodular pulmonary tuberculosis (a direct projection): the arrow specified
various size and density (places in the form of conglomerates) the centers and fibrous changes in apical and subclavial area on the right.
intersticial changes of pulmonary fabric. Their big width, small intensity and an illegibility of outlines testifies to infiltrative character of the last. At a zatikhaniye of process the full rassasyvaniye of focal and intersticial changes can be observed or there are mesh fibrosis and the separate condensed centers.
At chronic fibronodular process the centers are usually grouped, have various size, wrong rounded shape, considerable intensity. Around the centers fibrous changes (fig. 7), wedge-shaped shadows of plevropulmonalny hems and sites of local emphysema are defined. Signs of an aggravation of process are enlargement of the centers, development of perifocal infiltrative changes around separate groups of the centers or in the field of all site of defeat, emergence of cavities of disintegration and the centers of dissimination.
In diagnosis of focal tuberculosis also detection of mycobacteria of tuberculosis in a phlegm is of great importance. In the absence of a phlegm it is necessary to resort to the inhalations of solution of sodium chloride provoking cough, and also to make a research of rinsing waters of bronchial tubes. It is necessary to investigate not less than 3 daily collected portions of a phlegm and to make 2 — 3-fold crops of material on mediums. As a rule, at patients with focal tuberculosis a bakteriovydeleniye scanty. In a phase of infiltration of a mycobacterium of tuberculosis are found at microscopic examination only in 3% of patients. However at crops of material the frequency of identification of mycobacteria at patients with an active focal pulmonary tuberculosis in a phase of infiltration (without disintegration), according to different researchers, reaches 30 — 50%.
In blood the deviation to the left, neznachitel-
acceleration of ROE is noted Nov. The quantity of leukocytes does not change more often.
Focal tuberculosis in a phase of infiltration is differentiated with the disseminated pulmonary tuberculosis. Focal tuberculosis is spoken well preferential by hemilesion, is more often 1 — the 2nd segment, irregularity of a shadow against the background of the fibrous changed tissue of a lung. The focal pulmonary tuberculosis is differentiated also with bronchial pneumonia, for a cut damage of average and lower parts of a lung, lack of the expressed pleural changes, uniformity of a shadow is characteristic. Crucial importance has bystry positive rentgenol. dynamics at treatment by nonspecific drugs.
Treatment of patients with focal tuberculosis in a phase of infiltration is carried out by antituberculous remedies, most often a combination of an isoniazid, streptomycin and PASK within 2 — 3 months. At favorable dynamics of process streptomycin is cancelled; PASK can be replaced with Ethambutolum or Etioniamidum (Prothionamidum). The general duration of chemotherapy is 6 — 9 months. At the torpid course of process and slow involution treatment in climatic resorts is shown.
At difficulties in definition of activity of the centers it is necessary to resort to treatment, preventive within 2 — 3 months, antituberculous remedies.
Forecast in most cases favorable. Correctly carried out treatment usually leads to treatment of patients with a full rassasyvaniye of the centers or formation of residual changes. At irregular treatment, and also at patients with reduced immunity, at serious associated diseases, pregnancy focal tuberculosis can progress and pass into others a wedge, forms.
Prevention consists in early detection and treatment of initial forms of tuberculosis.
Infiltrative pulmonary tuberculosis — a wedge, the form of tuberculosis which is characterized by availability of the tubercular infiltrate representing bronkhopnevmonichesky inflammatory focus in a lung with a caseous necrosis in the center.
Tubercular pulmonary infiltrate — a concept clinicoradiological. In 1924 Mr. H. Assmann one of the first described the shadow of rounded shape in a subclavial zone of a lung which received the name of early subclavial infiltrate like H. Assmann. H. Assmann and his contemporaries considered that infiltrate arises owing to exogenous superinfection. F. Redeker established that reactivation of the old centers is the reason of infiltrative changes in lungs. Researches of B. M. Khmelnytsky who found out in a phlegm of patients with early infiltrates like H. Assmann not only mycobacteria of tuberculosis, but also crystals of cholesterol, salt of calcium, calciphied elastic fibers (Ehrlich's tetrad) that demonstrated disintegration of old tuberculous focuses and pathogenetic communication of infiltrative process with the old aggravated centers became confirmation of it.
The infiltrative pulmonary tuberculosis can result also from progressing of fresh focal process. In this case infiltrate is preceded by fresh focal tuberculosis that was proved by G. R. Rubenstein and I. E. Kochnova. The infiltrative pulmonary tuberculosis can be result of limfobronkhogenny distribution of mycobacteria from @-zeozno-changed limf, nodes of a mediastinum. Quite often at such patients the endobronchitis is noted. Infiltrative process in these cases is usually localized in average and lower parts of lungs. Sources of developing of focal and infiltrative tuberculosis in essence same, but one patients have a focal form of a disease, i.e. limited preferential productive inflammatory process with hron. a current and tendency to healing, and at others — an infiltrative form, i.e. preferential exudative inflammatory process with tendency to disintegration. V. A. Ravich-Shcherbo explained development of infiltrate by existence of zones of a hyper sensitization, i.e. sites in lungs, to-rye are capable to answer with rough giperergichesky reaction to repeated implementation of mycobacteria of tuberculosis in them. Rich (A. Rich, 1944), considered that the hyper-sensitization of pulmonary fabric does not depend on anatomic or inborn features, and is the acquired property of pulmonary fabric. The hyperergy usually develops if in pulmonary fabric a large number of mycobacteria at proliferation of bacterial population accumulates.
Morfol. the picture of an infiltrative pulmonary tuberculosis is characterized by dominance of pneumonic, i.e. exudative inflammatory changes. More often in the 1st and 2nd segments consolidation to dia appears. 2 — 3 cm. In its center the small centers of a caseous necrosis decide on a wide zone of a perifocal inflammation. At the favorable course of process the perifocal inflammation resolves, the caseous center is delimited, condensed, is exposed to encapsulation and calcification. Thus, infiltrate can be transformed to focal tuberculosis or a tuberculoma. Such old encapsulated caseous centers under adverse conditions for an organism can become aggravated with formation of infiltrate again. At the same time around them there is a perifocal inflammation, and tubercular process extends contact putekhm. During the progressing of process the centers of a caseous necrosis in the center of infiltrate increase, also the zone of a perifocal inflammation extends, edges can occupy all lung lobe. Microscopically along with the sites of a caseous necrosis surrounded with epithelial, lymphoid and gagantsky cells of Pirogov — Langkhansa, it is possible to find extensive zones of a nonspecific inflammation, in to-rykh gleams of alveoluses are filled with fibrin, cells of a deskvamirovanny alveolar epithelium or acellular exudate. Fusion of mass of a caseous necrosis and their break in bronchial tubes comes to the end with formation on site of infiltrate of an acute cavity (see).
On character rentgenol. data and partly in connection with features the wedge, pictures and courses of a disease allocate a little kliniko-rentgenol. options of infiltrative tuberculosis.
The Oblakovidny infiltrate described by G. R. Rubenstein is characterized by existence of a gentle slabointensivny homogeneous shadow with indistinct, indistinct contours, bystry disintegration and formation of a fresh cavity.
Round infiltrate like H. Assmann is characterized by existence of a roundish homogeneous shadow of weak intensity with accurate contours. In this case disintegration in the form of the enlightenment defined at early stages is also possible it is preferential at a tomography.
The l is upholstered — the extensive infiltrative process taking a lung lobe. A shadow most often not homogeneous character with existence of single or multiple cavities of disintegration (sometimes the big and huge sizes).
Peristsissurit — an extensive infiltrative shadow with existence, on the one hand, accurate, with another — a diffuse edge, caused by defeat of one-two segments which are located lengthways mezhdo the left crack it is frequent with involvement in process of an interlobar pleura, accumulation of exudate and possible disintegration in pulmonary fabric.
Lobulyarny infiltrate is characterized by not homogeneous shadow representing the large ii which merged in one or several conglomerates the small centers, in the center to-rykh disintegration often comes to light.
For all kliniko-rentgenol. options existence of an infiltrative shadow is characteristic, is frequent with disintegration. At the same time as a result of bronchogenic dissimination the centers in lower parts of one or both lungs are formed.
At most of patients the wedge, a picture of a disease is characterized by temperature increase to 38 — 38,5 °, edge can stick to 5 — 10 days, and also other symptoms of intoxication — perspiration, decrease in working capacity. Cough is insignificant, but with expectoration, especially at destructive process. More often than at focal tuberculosis, the pneumorrhagia is noted. At extensive defeat, and especially in the presence of disintegration, rattles are listened, to-rye later initiation of treatment quickly disappear. At extensive infiltrates there can be a nek-swarm an obtusion of a pulmonary sound, change of breath. At a part of patients infiltrative tuberculosis proceeds asymptomatically or with scanty symptomatology.
Allocate two main options of a course of an infiltrative pulmonary tuberculosis: progressing and involute. The progressing option of a current which is characterized by extensive infiltrative changes and bystry disintegration is observed generally in the absence of treatment, decrease in immunity, associated diseases. The elevated temperature characteristic to start a disease, gradually decreases, decreases expressiveness of symptoms from a respiratory organs or they completely disappear. There occurs dissociation between a wedge, displays of a disease and dynamics morfol. changes in lungs, in to-rykh cavities of disintegration form. And V. A. Ravich-Shcherbo's bakteriovydele-niya called such improvement in a condition of the patient in the presence of destructive process imaginary recovery. In these cases after the short period the wedge, wellbeing arises new flash and the course of a disease accepts wavy character.
The involute option of a current is observed in the conditions of rational treatment. Obsolescence of all symptoms, improvement of health, the termination of allocation with a phlegm within the first 3 months of mycobacteria of tuberculosis is characteristic of it. However involution of structural changes in lungs (rassasyvany inflammations, closing of a cavity) happens more slowly.
Infiltrate can resolve completely, without leaving visible residual changes. More often on its place there are focal and fibrous changes expressed in different degree. The center of infiltrate containing the mass of a caseous necrosis can heal with formation of a hem. At minor necrotic changes the hem is so small that practically does not come to light. In that case speak about a full rassasyvaniye of infiltrate. Consolidation of infiltrate due to formation of the fibrous fabric containing the remains of specific granulyatsionny fabric is much more often observed. In the last there can be centers, capable to reactivation.
Judge firmness of healing on kliniko-rentgenol. to a picture and data of a laboratory research. In one cases the inflammatory and necrotic center is encapsulated and the tuberculoma is formed; cirrhosis of a share or segment of a lung develops in others —. Such options of involution of infiltrative tuberculosis cannot be considered as favorable. The outcome of infiltrative tuberculosis in many respects is defined both by timeliness of identification of patients, and efficiency of chemotherapy.
Special form infiltrativny tuberculosis caseous pneumonia is, at a cut in morfol. to a picture the caseous necrosis prevails. Depending on the amount of defeat distinguish acinous, lobu-lyarny and lobar caseous pneumonia. Kazeozno-izmenen-
ny segments can merge, creating the segmented, lobar centers or leading to total caseous pneumonia. At lobar caseous pneumonia the caseous necrosis takes the most part of the struck share in which center fusion of necrotic masses and formation of cavities of disintegration can be observed. Extremely heavy current with sharply expressed intoxication, high temperature (39 ° above), an adynamia, about-fuznsh then, cough, short wind, tachycardia, sometimes a pneumorrhagia or pulmonary bleeding is characteristic of caseous pneumonia. Diagnosis of caseous pneumonia is difficult, especially in the first days; sometimes she is possible only after fluidifying of caseous masses and formation of a huge cavity or multiple cavities of the small sizes that she is followed by allocation of the purulent phlegm containing a large number of mycobacteria of tuberculosis. In a crust, time such course of process meets seldom. More often infiltra-tivno-caseous pneumonia develops, at a cut there is rather small extent of sites of a caseous necrosis and preferential ex-
Fig. 8. The roentgenogram of a thorax at an infiltrative pulmonary tuberculosis (a direct projection): the arrow specified infiltrate of rounded shape,
sudatnvny type of an inflammation that defines a wedge, a picture and disease reminding pneumonia.
The diagnosis of an infiltrative pulmonary tuberculosis is made on the basis of results rentgenol. inspections, at Krom are defined limited infiltrative, and also diffuse, often extensive processes (segmented or share) depending on kliniko-rentgenol. option of a disease.
Infiltrates on roentgenograms are usually presented by the isolated focuses of rounded shape capturing group of segments, a part of a segment, the segment of a lung is more rare. They are combined with the centers and fibrous changes. The shadow of infiltrate has weak or average intensity (fig. 8), sometimes in it focal consolidations are defined. Outlines of infiltrate clear, but not such sharp, as, e.g., contours of a tuberculoma. Roundish infiltrates are inclined to a rassasyvaniye and consolidation.
Regarding cases at the progressing current the illegibility of their outlines, existence of «the taking-away path» to a root of a lung, cavity of disintegration and the fresh centers come to light. Diffuse, extensive infiltrates have the irregular triangular shape more often. Outlines their usually indistinct and uneven, intensity of a shadow average; at the expressed caseous necrosis, an atelectasis of an affected area of a pla the considerable sizes of infiltrate the shadow is very intensive. The structure of these infiltrates is often heterogeneous due to existence of more dense centers and cavities of disintegration (fig. 9. 10); the tyazhisty shadows testifying about peribronkhp-and l a no-pa r ivas to at l are usually expressed I rny am changed iya x.
Caseous pneumonia radiological is shown by formation of the multiple bronkholobulyarny focuses or consolidations taking a share or two segments of a lung, cavities of disintegration and the multiple centers of bronchogenic dissimination.
Fig. 9. The tomogram of the right lung at an infiltrative pulmonary tuberculosis (a side projection): the arrow specified infiltrate in pulmonary fabric with a cavity of disintegration.
Fig. 10. The roentgenogram of a thorax at an infiltrative pulmonary tuberculosis (a direct projection): the arrow specified infiltrate in an upper share of the right lung (lobit) with a cavity of disintegration.
In diagnosis of a pnfnltrativny pulmonary tuberculosis an important role is played by bacterial. research. With the forming or created cavity it is possible to find mycobacteria of tuberculosis in a phlegm in 96 — 97% of patients with nnfiltrativ-ny tuberculosis. It is more difficult to find mycobacteria at the patient accepting already antituberculous remedies or penicillin in a combination with streptomycin. Therefore at identification of infiltrative changes in lungs it is necessary to conduct a careful research of a phlegm prior to treatment. In the absence of a phlegm it is necessary to apply the aerosols provoking cough. If the cavity is visible only on the tomogram if it only forms pl at the patient the phase of disintegration is noted, ordinary microscopic examination allows to find mycobacteria of tuberculosis approximately in 1/3 patients, in the others 2/;> patients of a mycobacterium can be found by method of crops. In the presence of a pneumonic shadow in a lung and identification of a bakteriovydeleniye the diagnosis of infiltrative tuberculosis is reasonable. However it is not necessary to revaluate a role of a bakteriovydeleniye at diagnosis of infiltrative tuberculosis since at patients with pneumonia with the accompanying tuberculosis because of reactivation of the old centers the single or repeated bakteriovydeleniye can be also observed. The diagnosis of infiltrative tuberculosis can be made only on the basis of a complex of signs, one of to-rykh is detection of mycobacteria.
At an infiltrative pulmonary tuberculosis the picture of blood — lack of a high leukocytosis and deviation to the left is quite characteristic at the accelerated ROE. Besides, at patients with infiltrative tuberculosis the high caption of tubercular antibodies in blood comes to light. Tuberkulinovy test at them positive, however it has no great diagnostic value.
The differential diagnosis is carried out with pneumonia (see), including with a lung fever, cancer of a lung (see Lungs, cancer of a lung). More expressed pulmonary symptomatology, and also a bright stetoakustichesky picture (rattles, change of breath, etc.), existence of more rough intersticial changes in lungs and considerable dynamics rentgenol is characteristic of pneumonia. pictures. At suspicion of nonspecific pneumonia it is necessary to make crops of a phlegm on nonspecific microflora. Special value has combined bacterial. and immunol. a research at patients with the developing pneumonia against the background of metatuberculous changes, including the old centers. Differential diagnosis of infiltrative tuberculosis and pneumonia at localization of inflammatory process in an average share or a uvula of a lung is especially difficult. An important diagnostic method in this case is the bronkhoskopiya (see). The banal endobronchitis meets with a large amount of pus at pneumonia more often; the limited inflammation in bronchial tubes is more characteristic of tubercular process. Differential diagnosis between infiltra-tpvny tuberculosis and pneumonia at patients with old tuberculous focuses is difficult, to-rye often mistakenly consider an indisputable symptom of the developed infiltrative tuberculosis.
Difficulties are presented by differential diagnosis between infiltrative tuberculosis and cancer of a lung. Peripheral cancer of a lung often it is necessary to differentiate with infiltrate of rounded shape the central cancer complicated by an atelectasis — with peristsissu-rity and infiltrate with defeat of a segment. At absence in a phlegm of mycobacteria of tuberculosis and similar rentgenol. to a picture crucial importance has a bronkhologichesky research with morfol. the analysis of material of a biopsy, and also microscopic examination of material on existence of mycobacteria of tuberculosis in it and elements of a tubercular granuloma.
Infiltrative tuberculosis in a phase of disintegration should be differentiated with the abscessing pneumonia, the breaking-up cancer of a lung. The diagnosis of tuberculosis in this case is confirmed by identification of mycobacteria of tuberculosis in a phlegm and existence in it epitet ioidny and colossal cells like Pirogov — Langkhansa.
Treatment of patients with infiltrative tuberculosis long. Appoint an isoniazid and rifampicin, as the third drug within the first 3 months apply streptomycin or Etioniamidum (Prothionamidum), and also Ethambutolum. After the termination of a bakteriovydeleniye, a rassasyvaniye of infiltrative changes and closing of a cavity the chemotherapy can proceed two antituberculous remedies (usually an isoniazid and PASK or Ethambutolum). The general duration of chemotherapy is 6 — 9 months. At extensive inflammatory reaction in a lung, the slowed-down regression of the inflammatory phenomena, and also at bad portability of antituberculous remedies apply corticosteroids and other pathogenetic means (see Tuberculosis, philosophy of treatment). Treatment by corticosteroids is carried out during 3 — 6 weeks at control of clinical laboratory indicators. The stimulating therapy is recommended to patients with the slowed-down regression of a disease.
The forecast at timely begun treatment favorable even in case of destructive process. Prevention consists in early detection of early forms of tuberculosis.
A tuberculoma of a lung — a wedge,
the form of tuberculosis which is characterized by existence in a lung of roundish educations (one or several) different size. According to different researchers, this form makes apprx. 4,2 — 6,3% of others a wedge, forms Thus of. Since 50th 20 century universal increase of identification of patients with a tuberculoma of a lung is noted. Among the patients suffering from this form of tuberculosis men prevail. The tuberculoma of a lung can be found at any age, but to a thicket it is observed at persons of young and mature age.
However increase in number of patients with a tuberculoma of a lung in the senior age groups, and in a crust is in recent years noted, time of the person is more senior than 50 years make apprx. 1/4 contingents of patients with a tuberculoma of a lung.
The importance in formation of a tuberculoma of a lung is attached to a local hyper sensitization of pulmonary fabric. Disturbances of exchange processes can be the contributing factors (e.g., its thicket find in patients with a diabetes mellitus). More than at */2 patients the tuberculoma of a lung is an outcome of others a wedge, forms of a pulmonary tuberculosis. Most often it is preceded by focal tuberculosis, less often it is formed against the background of infiltrative process as a result of a rassasyvaniye of a perifocal inflammation and encystment of its caseous center, is even more rare (in 2 — 3% of cases) at obstruction of the bronchial tube draining a cavity at patients with cavernous tuberculosis.
The tuberculoma is located most often in 1 — the 2nd or 6th segments, directly under a pleura or in deeper departments of a lung, around it minor fibrous changes are observed, can be single or multiple. On a structure distinguish a solitary, layered and conglomerate tuberculoma (see). During the progressing of process the tuberculoma can increase, caseous masses in it is exposed to fusion in central or, to a thicket, a peripheral part, inflammatory infiltrate from the capsule passes to adjacent bronchial tubes, in a gleam to-rykh caseous masses is allocated, and on site tuberculomas the cavity is formed. Distribution of process on bronchial tubes can cause bronchogenic dissimination, near a tuberculoma in the beginning, and then and in more remote sites of a lung. At the same time allocation from a tuberculoma through bronchial tubes of caseous masses can promote its scarring. At stabilization of a tuberculoma or its healing the rassasyvaniye of a perifocal inflammation and cellular infiltration of the capsule, increase in the capsule of fibrosis and partial substitution of caseous masses is observed by young connecting fabric.
Wedge, a picture at a tuberculoma of a lung is defined by a phase of process. Out of an aggravation the wedge, symptoms of a disease are absent. However and at an aggravation symptoms of a disease are expressed slightly. The general condition of patients does not suffer. Thanks to the limited nature of process and a comparative rarity of damage of large bronchial tubes at physics flax inspection (survey, percussion, auscultation) patol.
signs usually do not come to light. The tuberculoma of a lung out of an aggravation is characterized by absence patol. shifts in blood and bakteriovydeleniye, and also stable rentgenol. a picture for many months and even years. Such stationary course of a disease is observed in 60 — 70% of cases, is more often at tuberculomas of the small size (to
2 cm in the diameter) at the patients who do not have serious associated diseases (a diabetes mellitus, a peptic ulcer, etc.). Long-term stability of process and absence kliniko-rentgenol. and laboratory signs of activity of process does not exclude existence of vegetans mycobacteria of tuberculosis in the caseous mass of a tuberculoma, and also morfol. signs of the kept activity of specific process in its capsule and consequently, and it is noted possibilities of reactivation of a disease, edge approximately at 10% of patients with long stabilization of process. Therefore at a stationary current of a tuberculoma of a lung even for five years and more it is necessary to speak carefully about treatment and to consider it admissible only at patients with a tuberculoma, diameter does not exceed a cut 11/2 — 2 cm.
At a number of patients (in 30 — 40% of cases) the aggravation of process is observed. At the same time allocate phases of infiltration, disintegration and dissimination, to-rye a thicket are combined one with another. Small cough with a phlegm, short subfebrile condition, unsharply expressed shifts in a picture of blood (a low leukocytosis, a deviation to the left, acceleration of ROE) is clinically noted. Phases of disintegration p dissiminations in 30 — 40% of cases are followed by a bakteriovydeleniye.
Tubercular process at a tuberculoma of a lung in a phase of an aggravation in the absence of treatment, as a rule, leads to progressing of a disease: to increase in the sizes of a tuberculoma, emergence of an enlightenment on the roentgenogram owing to emptying through the draining bronchial tube and the new centers of bronchogenic dissimination, a thicket in lower parts of lungs, and also to formation of affiliated tuberculomas in the contact way. In this case in 3 — 5 years process can pass into a fibrous and cavernous pulmonary tuberculosis. Treatment by antituberculous remedies quickly leads to desintoxication, the termination of elimination of bacilli, at 2/3 patients — to a zatikhaniye of process (the regressing option) and at 40 — 45% of patients — to treatment.
Early diagnosis of a tuberculoma of a lung in connection with asymptomatic
Fig. 11. The tomogram of the left lung at a tuberculoma (a direct projection): 1 — a tuberculoma; 2 — a cavity of disintegration; z — iy-filtrativny changes on the course of a bronkhososudisty bunch.
the course of process it is possible only at preventive fluorographic inspection, and also at systematic control of a current of other forms Thus of.
At rentgenol. a research of a tuberculoma of lungs come to light in the form of focuses of rounded shape. Tuberculomas to dia. 1,5 — 2 cm carry to small. More often tuberculomas of the average sizes — to dia come to light. 2 — 4 cm; large tuberculomas — more than 4 cm in the diameter occupy the volume of one-two segments of a lung. Intensity of their shadow considerable, structure more often heterogeneous at the expense of fibrosis, the condensed mass of a caseous necrosis, inclusions of kaltsinat, sites of disintegration. Outlines are usually accurate, uneven (scalloped). At the level of tuberculomas plevropulmonalny hems, the centers in surrounding pulmonary fabric, the expressed tyazhistost are determined by the course of a bronkhososudisty bunch.
During the progressing of process of a tuberculoma get an ellipsoidal form, indistinct outlines, in them single and multiple cavities of disintegration, wrong (semi-lunar, slit-like) the forms which are located near the mouth of the draining bronchial tube especially on the course of a bronkhososudisty bunch come to light (fig. I).
At patients with a tuberculoma of a lung in 70 — 80% of cases positive Mantoux reaction is noted (see Tuber-kulinodiagnospgik). And unlike other forms of secondary tuberculosis at a tuberculoma of a lung giperergichesky reaction to tuberculine is more often observed. At for the first time the diagnosed tuberculoma of a lung help to reveal activity of process in some cases definition of protein fractions of blood before administration of tuberculine, an indicator of damageability of neutrophils, reaction of braking of migration of leukocytes (see. Leukocytic tests), and also a blastotransformation of lymphocytes (see). The bronkhologichesky research is of great importance. At a bronkhoskopiya it is possible to find tuberculosis of mouths in 1,2 — 3,3% of patients with a tuberculoma of a lung segmented, is more rare — lobar bronchi; at a bronchography the symptom of amputation of small bronchial tubes near the capsule, their deformation, quite often small bronchiectasias comes to light. It is made also gistol. a research of the material received by means of a biopsy.
The differential diagnosis is carried out with round to a tubathe rkulezny infiltrate having similar to a tuberculoma rentgenol. a picture, with other spherical educations in lungs, is more rare — with fungal infections (see Pneumomycoses), parasitic diseases (see Lungs, parasitic diseases), a blocked pleuritis (see), etc. Infiltrative tuberculosis differs in more acute beginning with symptoms of intoxication and changes of the blood which was more expressed by dynamics rentgenol. pictures, tendency to destruction, and also positive dynamics of process (in 1,5 — 2 months after an initiation of treatment antituberculous remedies). Great difficulties arise at differential diagnosis asymptomatically of the proceeding tuberculoma with spherical formations of lungs of other etiology — with asymptomatically the proceeding peripheral cancer of a lung, the filled retentsionny bronchial cyst, and also with the benign tumors which are localized in the 1st, 2nd and 6th pulmonary segments especially the persons who had tuberculosis in the past at to-rykh have residual changes in the form of the calcinated centers in lungs and limf, nodes of a root of a lung. However, despite similarity a wedge, and rentgenol. pictures of these diseases, between them exist
ii of distinction. So, the node of peripheral cancer of lung has hilly outlines; the combination of tuberosity and radiance on contours of a shadow, increase radical limf, nodes is characteristic of it; the sizes of a node of peripheral cancer of lung increase several times within a year. The Retentsionny filled bronchial cyst of a lung its localization in the depth of a segment, on the course of an expanded bronchial tube, and also a form of a shadow with finger-shaped ledges helps to distinguish from a tuberculoma, homogeneity of structure, and at calcification — adjournment of salts of calcium on a contour of a cyst. At differential diagnosis of tuberculomas and benign tumors of lungs consider that the last are located in front departments of lungs more often, have accurate equal outlines, uniform structure. The crucial role in establishment of the diagnosis belongs to a puncture transthoracic biopsy (see Lungs, operations), a transbronchial biopsy. In some cases resort to a diagnostic thoracotomy (see). The known help in differential diagnosis can be given immunol. methods of a research (see Tuberculosis, philosophy of diagnosis).
To lay down. tactics at a tuberculoma of a lung is defined by a phase of a disease, dynamics of process, and also living conditions of the patient. In a phase of an aggravation carry out complex treatment by antituberculous remedies within 9 — 12 months. At the expressed perifocal reaction appoint corticosteroids. In process of a rassasyvaniye of a perifocal inflammation and an otgranicheniye of process and also when the disease from the very beginning proceeds without the expressed perifocal inflammation, give preference to the drugs which are well getting via the fibrous capsule (a rifamgshtsin, an isoniazid, Pyrazinamidum), and nek-ry researchers — and to Cycloserinum. In some cases the positive effect renders use of tuberculine. At damage of bronchial tubes endobronchial injections or aerosol inhalations are shown. The main criteria of efficiency of treatment are speed of disappearance pz phlegms of mycobacteria of tuberculosis, a rassasyvaniye of a perifocal inflammation and the centers of limfobronkhogenny dissimination. During the subsequent period there is a consolidation of caseous masses, an otgranicheniye of the center. However treatment by antituberculous remedies should be continued, being guided kliniko-rentgenol. and laboratory indicators of activity of process since treatment of a tuberculoma can drag on for 1V2 — 2 and even for
5 years. Such patients need seasonal courses of chemotherapy in the conditions of sanatorium.
Progressing of a disease is the absolute indication for operational treatment. Stable state and lack of the expressed effect of chemotherapy at a tuberculoma of the average and big sizes (to dia. 3 cm and more) in connection with high risk of reactivation of tubercular process are also the indication for operational treatment (see Lungs, operations) — a wedge-shaped, segmented and share pneumonectomy. Considering a wedge, data, social conditions and wishes of the patient, give preference to either operational treatment, or long chemotherapy.
Forecast, as a rule, favorable. Progressing of process with transition to a fibrous and cavernous form of a pulmonary tuberculosis is observed approximately at 3 — 5% of patients, is preferential at those, the Crimea due to various reasons rational treatment timely was not carried out. Operational treatment at a tuberculoma of a lung is a highly effective method, at Krom recovery with a bystry and complete recovery of working capacity occurs in 97% of cases.
Prevention comes down to full treatment infiltrative and other previous forms of tuberculosis.
A cavernous pulmonary tuberculosis — a wedge, the form of tuberculosis which is characterized by existence of the created cavity in the absence of the expressed perifocal inflammation, extensive bronchogenic dissimination and fibrous changes in the pulmonary fabric surrounding a cavity. The cavernous pulmonary tuberculosis can be a consequence of progressing of the infiltrative, focal, disseminated pulmonary tuberculosis, disintegration of a tuberculoma and is a buffer stage of the progressing course of destructive tuberculosis. The cavernous pulmonary tuberculosis is allocated as independent a wedge, a form at the VIII All-Union congress of phthisiatricians (1973).
Cavities can be pneumo-gene, formed on site infiltrative nnevmonichesko-go process, and bronchogenic, forming in the affected bronchial tubes. Depending on a structure of walls and expressiveness of a fibrous layer of a cavity can be elastic, easily falling down, with poorly developed fibrosis and rigid with more dense fibrous changes in walls (see the Cavity). Fibrous cavities at cavernous tuberculosis are observed seldom. In size distinguish small cavities — with a diameter up to 2 cm, average — from 2 to 4 cm, big from 4 to 6 cm and huge — is more than 6 cm. Unlike fibroznokavernozny tuberculosis existence of one cavity without the expressed fibrous changes in walls and the pulmonary fabric surrounding it is more characteristic of a cavernous pulmonary tuberculosis. Most often the cavity is located in the 1st, 3rd or 6th segments, directly under a pleura or in deeper departments of a lung. Cavities in a lung are formed at fusion of caseous masses, destruction of a wall of a nearby bronchial tube and allocation through its gleam of the melted caseous masses. At fusion of caseous masses on edge of a tuberculous focus they can separate as sequesters. Such cavity is called sequestering. The cavity has a three-layered wall. The inner caseoses-but-necrotic layer is turned into a gleam of a cavity, behind it the layer of specific granulyatsionny fabric containing epithelioid, lymphoid and colossal cells of Pirogov — Langkhansa is located, the outside fibrous layer is developed poorly and borders on surrounding pulmonary fabric. Tubercular granulyatsionny fabric from a wall of a cavity spreads also to a mucous membrane of the draining bronchial tubes. Intensity of inflammatory changes in bronchial tubes decreases in process of removal them from a gleam of a cavity, and in the field of lobar and primary bronchi only lymphocytic infiltration and egsh-bodies ioidio-giant-cell hillocks in on affairs from an isty layer are observed usually. During the healing of cavities rejection of a caseous and necrotic layer, reduction of a gleam of a cavity due to wrinkling of walls, growths of granulyatsionny fabric and fibrosis is observed. Finally on site cavities the hem of a linear or star-shaped form can be formed. Healing in a wall of a cavity is combined with clarification from the caseous mass of the draining bronchial tubes, proliferation of a bronchial epithelium, to-ry can pass from mouths of bronchial tubes to an inner surface of a cavity. In these cases the cylindrical epithelium of bronchial tubes is exposed to a metaplasia in multilayer flat (see the Metaplasia). At reduction of elasticity of a wall of a cavity its healing happens slowly (in
9 — 12 months after the beginning of chemotherapy) to formation of the center of the small sizes and fibrous changes of small extent in surrounding pulmonary fabric. In the course of healing of a cavity the gleam of the draining bronchial tubes can be obliterated, and the so-called blocked cavity — the encapsulated center of a caseous necrosis like tuberculoma is formed. Under unfavorable conditions the caseous necrosis in such center can undergo fusion with opening of a gleam of a bronchial tube and formation of a cavity again. Therefore such type of healing is defective. Rigid cavities during the healing are most often transformed to a cystiform cavity. In these cases rejection of a caseous and necrotic layer is observed, substitution of specific granulyatsionny it is woven connecting fabric. Process of transformation of a cavity in a cystiform cavity is very long. During the progressing of cavernous tuberculosis there is an increase in a caseous and necrotic layer, to-ry can extend to a layer of specific granulyatsionny fabric and fibrosis. In surrounding pulmonary fabric the perifocal inflammation is observed and the centers of caseous pneumonia can form. In lungs the centers of acute bronchogenic dissimination in the form of acinous or lobulyarny caseous pneumonia are formed.
The cavernous pulmonary tuberculosis is characterized by a wavy current. Frequency of flashes depends on features of an organism, its resilience and on efficiency and duration of chemotherapy. At successful treatment process is stabilized. At inefficiency of chemotherapy, napr, at chaotic use of antituberculous remedies, at patients the periods of flashes are extended and intervals between them are shortened. The flash is characterized by symptoms of intoxication — fervescence, the general weakness, snizhe-niyekhm appetite, and also cough with allocation of a small amount of a phlegm, sometimes the pneumorrhagia caused by aneurysmal changes of small arteries or a varicosity of bronchial tubes or destruction of the vessel located in a wall of a cavity. Symptoms of intoxication quickly enough disappear during the resuming of chemotherapy. An indicator of activity of tubercular process is the bakteriovydeleniye. Mycobacteria of tuberculosis find by means of microscopic examination and crops. At inefficiency of chemotherapy or medicinal resistance of mycobacteria of tuberculosis the constant bakteriovydeleniye even can be observed at clinical «wellbeing», testimonial of preservation of activity of process; the periodic bakteriovydeleniye also is a symptom of active tuberculosis. At nek-ry patients the syndrome of falling p raising of bacterial population, i.e. the termination of a bakteriovydeleniye and its resuming through some period can be observed that more often happens it is caused by development of medicinal resistance of mycobacteria and an exacerbation of tuberculosis. Signs of an aggravation of process are also acceleration ROE, a deviation to the left, a lymphopenia. Quite often cavernous tuberculosis
of Fig. 12. The tomogram of the left lung at cavernous tuberculosis (a direct projection): the arrow specified a thin-walled cavity on the low-changed pulmonary background,
is followed by the endobronchitis interfering healing of a cavity. The endobronchitis can become the reason of a phenomenon of inflating, or stretching of a cavity that it is observed at disturbance of passability of a bronchial tube on valve type when air, getting into a cavity of a cavity, does not come out back, and the sizes of a cavity increase, considerably exceeding the area of destruction. The phenomenon inflated, or stretched, cavities is a sign only of an elastic cavity. At treatment of an endobronchitis or suction of contents of bronchial tubes and recovery of their draining function such cavity sharply decreases in sizes.
The diagnosis of cavernous tuberculosis is made on the basis of kliniko-rents-genologicheskogo, a laboratory and bronkhologichesky research.
Rentgenol. symptoms of a cavernous pulmonary tuberculosis are limitation of specific damage of lungs limits of one-two segments and existence single created, i.e. having a wall, cavities (fig. 12) on the low-changed pulmonary background. Walls of a cavity more often thin, accurately outlined, with uneven outside outlines. In pulmonary fabric not numerous centers are defined.
The differential diagnosis is carried out with hron. abscesses of lungs (see), a wall to-rykh usually wide and rough tyazh depart from it in pulmonary fabric; with air cysts of lungs (see), more correct form, a uniform thin wall and lack of focal educations, different from a cavity.
Treatment shall be performed in the conditions of a hospital. Term its not less than 9 months. Within the first
2 — 3 months it is preferable to appoint an isoniazid and rifampicin in a combination with streptomycin. Then streptomycin is replaced with Prothionamidum or Ethambutolum and carry out treatment to closing of a cavity. At bad portability of separate drugs or detection of medicinal resistance of mycobacteria to the patient individually select a combination of antituberculous remedies. The chemotherapy allows to achieve bystry (within 3 — 6 months) closings of an elastic cavity with formation of a linear or star-shaped hem. Decrease in elasticity of pulmonary fabric around a cavity, reduction of its blood supply can slow down process of healing of a cavity. Healing of a rigid or fibrous cavity happens slowly within 9 — 12 months to gradual reduction of the sizes of a cavity, clarification of its walls and pos the aestivating granulation. Fibrous cavities of the big sizes are closed seldom. Extremely unprofitable conditions for healing are created at subpleural localization of a cavity. Subpleural cavities seldom heal even at elasticity of their walls. At effective treatment a tank - the teriovydeleniye stops in
2 — 3 months and earlier after the beginning of chemotherapy. However in some cases in a phlegm of patients at microscopic examination or crops L-forms of mycobacteria are found (see L-forms of bacteria). Existence of the causative agent of tuberculosis is confirmed also positive biol. breakdown (disease of tuberculosis lab. animals after infection with their phlegm from patients). Therefore criterion of efficiency of treatment along with the termination of a bakteriovydeleniye is also closing of a cavity in a lung. At slow reduction of the sizes of a cavity by the patient with the stopped bakteriovy-division, in addition to antituberculous remedies, appoint the means stimulating processes of healing (tuberculine, pyrogenal, prodi-gpozan, to a lidaz), and also physiotherapeutic methods — ultrasound (see. Ultrasonic therapy), an inductothermy (see). In the presence of an endobronchitis sick in addition appoint aerosols or endobron-hnalny injections.
In the absence of healing of a cavity resort to an operative measure. The question of operation is considered usually in 6 months after the beginning of chemotherapy, in some cases, napr, in the presence of a fibrous or rigid cavity, especially at the proceeding bakte-rnovydeleniye or at its subpleural arrangement, at a repeated pneumorrhagia and pulmonary bleeding, at an indiscipline of the patient and irregular reception of antituberculous remedies — in earlier terms. Operational treatment includes a segmentectomy (see), a lobectomy (see), a pneumonectomy (see), a thoracoplasty (see). After closing of a cavity further treatment can be continued in out-patient conditions and in sanatorium.
The forecast is serious since the next aggravation can lead to development hron. destructive forms of tuberculosis.
Prevention consists in early detection and treatment of the previous forms of tuberculosis.
A fibrous and cavernous pulmonary tuberculosis — the destructive form of tuberculosis which is characterized by existence in lungs of a cavity or cavities with the expressed fibrous capsule and fibrous changes in the pulmonary fabric surrounding a cavity; develops at untimely diagnosis and insufficient treatment of the disseminated, focal, infiltrative and cavernous pulmonary tuberculosis.
At a fibrous and cavernous pulmonary tuberculosis bronchiectasias, shift of bodies of a mediastinum in the struck party, bronchogenic dissimination and long wavy disease are noted also EhM-fizem of lungs. Existence on an internal wall of a cavity of necrotic masses with a large number of mycobacteria of tuberculosis causes a constant bakteriovydeleniye that represents big epide-miol. danger to people around, especially in the period of an aggravation of process. Cavities are more often localized in
the 1st, 2nd or 6th segments of one or both lungs. Cavities happen various form. In the presence of multiple cavities of disintegration they can form the reported system of cavities. The three-layered wall of a cavity has sharply expressed outside fibrous layer, the interlayer consisting of tubercular granulyatsionny fabric and an inner caseous and necrotic layer. Two last are expressed unequally and happen various thickness. Inner surface of a cavity usually uneven. Sometimes on it there are «beams» representing skeletons of the obliterated blood vessels passing through a cavity, and also belovatosery educations by the size in several millimeters (a so-called lens of Koch) representing accumulations of colonies of mycobacteria of tuberculosis. Near cavities usually there are acinous, lobulyarny or nodose centers of bronchogenic dissimination, the encapsulated pl the fresh, not having capsules. During the progressing of fibrous and cavernous tuberculosis in a wall of cavities exudative and necrotic processes prevail, bronchogenic dissimination is expressed more in lower parts of lungs. Apiko-caudal distribution of process with possible formation of new cavities of disintegration with the thin badly created walls and the expressed perifocal reaction takes place. At hron. the long course of process the phenomena of an interstitial sclerosis of pulmonary fabric accrue, emphysema, deformation of bronchial tubes, happens reorganization of vessels to the subsequent phenomena of hypertensia in a small circle of blood circulation (see Hypertensia of a small circle of blood circulation).
Klien, picture is caused various morfol. changes in lungs it is also characterized by a wavy current with change of the periods of an aggravation and zatikhaniye of process. Leaders, especially during the periods of an aggravation, symptoms of intoxication are: weakness, bystry fatigue, temperature increase, perspiration, loss of appetite, weight loss. Strengthening of cough, increase in expectoration, sometimes with impurity of blood are noted. Over an affected area of lungs against the background of bronchial, and at cavities of St. 6 cm in the diameter — amphoric breath the mixed wet and dry rattles testimonial of inflammatory changes in the pulmonary fabric surrounding a cavity are listened. During the involvement in process of the bronchial tubes draining a cavity at height of a breath the creaking rattles caused by a razlipaniye of the inflamed walls of bronchial tubes are listened.
On a wedge, to a current distinguish the limited and progressing fibrous and cavernous tuberculosis, and also fibrous and cavernous tuberculosis with complications.
The limited fibrous and cavernous pulmonary tuberculosis is rather stable and is characterized by existence of a fibrous cavity and limited fibrosis within a segment or a lung lobe. Under the influence of chemotherapy process is usually stabilized, inflammatory reaction in a wall of a cavity dies away a little, partially or completely the centers of bronchogenic dissimination resolve. Thereof there can come a nek-swarm clarification of an internal wall of a cavity from the mass of a caseous necrosis, massiveness of bacterial population decreases. Intervals between aggravations last for several months, and sometimes and years. In some cases throughout a long time the bakteriovydeleniye can otsutst-
vovat or happens periodic and scanty. At the same time at nek-ry patients of a mycobacterium of tuberculosis come to light only at microscopic examination, but do not give growth on mediums that is caused by change of their life activity and cultural properties under the influence of chemotherapy. Such course of fibrous and cavernous tuberculosis is noted by hl. obr. at patients, it is long and systematically receiving the antituberculous
remedies which are strictly observing the mode recommended by the doctor. At non-compliance with the mode, an alcohol abuse stabilization of process is replaced by its progressing.
Long aggravations and short intervals between them are characteristic of the progressing fibroznokavernozny pulmonary tuberculosis. In the period of an aggravation intoxication is sharply expressed, edges decreases at a zatikhaniye of process. Thorax pains are noted cough with a phlegm, a pneumorrhagia; further an asthma develops. These symptoms in the period of an aggravation are caused by a perifocal inflammation around a cavity, bronchogenic dissimination and an endobronchitis. In some cases the pleura with development of purulent pleurisy is surprised (see). The progressing course of fibrous and cavernous tuberculosis can lead to development of tubercular meningitis (see). At nek-ry patients the extensive infiltrative and caseous changes leading to caseous pneumonia with formation of multichamber cavities — huge cavities develop. At the progressing course of fibrous and cavernous tuberculosis, as a rule, there are a constant massive bakteriovydeleniye and medicinal stability of mycobacteria, edges interferes with stabilization of tubercular process.
The fibrous and cavernous pulmonary tuberculosis with complications is characterized by the progressing, wavy disease. Sometimes the break of a cavity in a pleural cavity is resulted by the spontaneous pheumothorax (see) which is followed by purulent pleurisy. The leading place in a wedge, a picture is occupied by symptoms of a pulmonary heart (see. Pulmonary heart). Quite often joins amploidoz internals (see the Amyloidosis), hron. a renal failure (see), repeated pulmonary bleedings (see) and a repeated pneumorrhagia are observed (see), to-rye can accept long character. The pneumorrhagia and pulmonary bleeding quite often are followed by aspiration pneumonia, and also can lead to asphyxia (see).
Also arthralgias and nonspecific polyarthritis, a generalized hyperplastic periostitis (see Bamberger — Mari a periostosis), disturbances of endocrine system belong to complications of a fibrous and cavernous pulmonary tuberculosis. The last can be shown by Itsenko's syndrome — Cushing (see Cushing a syndrome), a pituitary cachexia (see), obesity of different type (see Obesity), a hypothyroidism (see), a hyperthyroidism (see the Thyrotoxicosis), an addisonizm (see Addisonov a disease), a diabetes mellitus (see a diabetes mellitus).
Rentgenol. picture of a fibrous and cavernous pulmonary tuberculosis of a polimorfn. Process can be unilateral and bilateral; asymmetry of defeat is characteristic of bilateral process. Obligatory components of this form of tuberculosis are hron. the created cavity, the polymorphic centers in lungs, fibrosis of bronchopulmonary fabric and a pleura. Cavities can be single and multiple, the large or average sizes (fig. 13), the shadow of a cavity has the irregular ring-shaped shape with the site of an enlightenment inside. Width of a wall is usually not identical. Internal outlines of a ring-shaped shadow (a wall of a cavity) accurate, unlike indistinct and its uneven outside outlines. Existence of a shadow peribronchial perivas-kulyarnykh consolidations on the course of the draining bronchial tube, the cavity departing from an internal wall to a root of a lung (bronkhokavitarny tyazh — „path“), shadows of plevropulmonalny hems between an outside wall of cavities and a pleura (plevroka-vitarny tyazh), and also focal educations in surrounding pulmonary fabric or in the remote segments is characteristic of fibrous and cavernous tuberculosis.
Fibrous changes of pulmonary fabric are displayed in the form of mesh, mesh tyazhistykh structures and
Fig. 13. The roentgenogram of a thorax at a fibrous and cavernous pulmonary tuberculosis (a direct projection): 1 — multiple cavities in the left lung; 2 — the centers in surrounding pulmonary fabric; 3 — the centers and fibrous changes in an upper part of the right lung.
sites of consolidation pulmonary tkanp with reduction of volume of segments, shares, and sometimes and all lung. At further development of fibrosis the shift of a trachea, large bronchial tubes and vessels towards defeat, pulling up of roots of lungs up, violent educations in pulmonary fabric, pleural stratifications, shifts of a visceral (interlobar) pleura are noted. Progressing of process is shown by increase in the sizes of cavities, emergence of bukhtoobrazny protrusions, illegibilities of outside outlines of a wall and a bronkhososudisty bunch, infiltrative and focal changes in surrounding pulmonary fabric. Involution is shown by reduction of the sizes of a cavity, thinning of its wall, a rassasyvaniye of infiltrative and focal educations, sometimes scarring of a cavity. Bronkhograficheski disturbances of topography of bronchial tubes, a stenosis of bronchial tubes, bronchiectasias, as a rule, come to light.
The differential diagnosis is carried out with hron. nonspecific inflammatory diseases of lungs, at to-rykh change are more often localized in the lower and average shares of lungs, sites of defeat have rough tyazhisty structure, the phenomena of a peribronchial, perivascular sclerosis are expressed, there are bronchiectasias, and also with a polycystosis, violent formations of lungs, for to-rykh plurality and uniformity of ring-shaped shadows, lack of the centers in surrounding pulmonary fabric is characteristic.
Treatment is complex, long, it is carried out in the conditions of a hospital and sanatorium and includes antibacterial therapy taking into account medicinal sensitivity of mycobacteria, pathogenetic methods of treatment. However closing of a cavity at conservative treatment is observed seldom and does not exceed 12%. Therefore the basic at this form of tuberculosis is the operational method of treatment — a segmented resection (see the Segmentectomy), a lobectomy (see), a pneumonectomy (see), a plevropnevmon-ektomiya (see the Pleurectomy), a cavernotomy (see), a thoracoplasty (see). Operative measure is carried out, as a rule, in a phase of remission, after carrying out a course of antibacterial therapy. In some cases at patients with heavy complications of tuberculosis and associated diseases operational treatment is contraindicated.
One of methods of recovery of function of lungs at the patients who underwent operational treatment is LFK. Occupations begin from
the 2nd day after operation. At the same time use special respiratory and corrective (at disturbances of a bearing) exercises. Small loadings gradually increase; individual occupations under the leadership of the instructor replace group and independent.
The forecast depends on prevalence of process, existence of medicinal stability and the burdening associated diseases.
Prevention consists in early detection and full treatment of a pulmonary tuberculosis at earlier stages of its development.
Cirrhotic pulmonary tuberculosis — the wedge, a form of tuberculosis, for a cut are characteristic extensive growths of rough connecting fabric in lungs and a pleura with the expressed dominance of fibrous changes over specific. The cirrhotic pulmonary tuberculosis develops as a result of an insufficient rassasyvaniye of specific changes at patients with out of time revealed process. At the same time transition of a specific inflammation in nonspecific with the subsequent massive growth of connecting fabric and involvement in patol is noted. process of all structural elements of a lung. Unilateral cirrhotic tuberculosis is an outcome of fibrous and cavernous tuberculosis of a lung, can be created as a result of involution of extensive infiltrative process like lobit, on site an atelectasis of a segment or a lung lobe at primary and secondary tuberculosis (in the presence in kollabirovanny pulmonary fabric of tubercular changes), and also at patients with is long the proceeding exudative tubercular pleurisy and a pneumopleuritis (the pleurisy which arose at spontaneous or medical pheumothorax) in the presence in a lung of tubercular changes (pleurogenic cirrhosis, plevropnevmotsirroz). Bilateral cirrhotic tuberculosis is a consequence is long proceeding hron. the disseminated pulmonary tuberculosis.
The cirrhotic pulmonary tuberculosis is characterized by development in pulmonary fabric of a rough sclerosis (cirrhosis) and not cavernous cavities (bronchiectasias, cysts, emphysematous bulls) or cavities without signs of progressing. Between hems tuberculous focuses (fig. 14) can be defined the different size and a structure. Cirrhotically the changed lung is sharply deformed, reduced in volume, condensed. At a plevropnevmotsirroza the pleura is thickened, sometimes considerably, reminds the armor covering all lung, may contain the centers of calcification and ossification. Due to the existence massive fibrous tyazhy lightness of pulmonary fabric is sharply reduced, on a section the sites of an atelectasis alternating with uchast-
Fig. 14 are visible. Gistotopogramma of a lung at cirrhotic tuberculosis: 1 — cirrhotically the deformed tissue of a lung; 2 — bronchiectasias; 3 — the calciphied center of a caseous necrosis.
Kami of emphysema. The bronchial tree is sharply deformed, bronchiectasias various the forms and the sizes are had. Reorganization of blood vessels is followed by change of their gleams, emergence of vessels of the closing type and a multiple arteriovenous anastomosis. In the walls found sometimes among fibrous fabric of cavities the outside fibrous layer with its distribution on surrounding pulmonary fabric and a pleura prevails. The layer of specific granulyatsionny fabric is rich with blood vessels, the caseous and necrotic layer is usually expressed unevenly, sometimes is absent. In walls of expanded bronchial tubes, bronkhoektatichesky cavities and the cleared cavities the nonspecific inflammation usually is noted.
The wedge, a picture depends on prevalence morfol. changes, compensatory opportunities of an organism, extent of functional frustration, phase of development of specific and nonspecific inflammatory process, its duration.
The cirrhotic pulmonary tuberculosis can proceed is long with the small expressed symptomatology. Gradually an asthma and the general weakness accrue, cough with a phlegm is noted, appear the tachycardia amplifying at an exercise stress, nagging pains in a thorax, the pneumorrhagia connected with hypertensia in a small circle of blood circulation and a rupture of angiectasias in the deformed walls of bronchial tubes. Fervescence, acceleration ROE, a moderate leukocytosis and hypochromia anemia are more often caused by an exacerbation of pneumonia or inflammatory process in lungs and bronchial tubes at bronchiectasias. At the same time
signs of activity of tuberculosis can be noted: intoxication, a slope
a nost to aggravations, the periodic scanty allocation of mycobacteria of tuberculosis which is quickly stopping after purpose of antituberculous remedies.
At survey of patients with unilateral cirrhotic tuberculosis the atrophy of muscles of a shoulder girdle, reduction of volume of a thorax, retraction of fabric in supraclavicular and subclavial zones, narrowing of intercostal spaces and space between a backbone and an inner edge of a shovel, a vtya-nutost of intercostal spaces are noted omission of a shoulder on the party of defeat, at a breath, the shift of a trachea, borders of a cardiovascular bunch and apical beat of heart towards defeat. Owing to emphysema the lower bounds of lungs on the party of cirrhosis are displaced up, and on the opposite side — down. The percussion sound over cirrhotically the changed site of a lung is shortened, on other extent has a bandbox shade. The breath weakened or bronchial, over other departments of lungs — rigid. Dry and wet creaking rattles are listened; their quantity depends on a phase of inflammatory process.
At dvusto early tsirrot iches a lump the tuberculosis developing on the soil hron. hematogenous disseminiro - bathing tuberculosis, the thorax is symmetric. The expressed retraction of fabric in supraclavicular and subclavial zones and flattening of upper parts of a thorax with expansion of the lower intercostal spaces owing to vicarious emphysema is noted. Aggravations of tubercular process at cirrhotic tuberculosis arise rather seldom, proceed with unsharply expressed symptoms of intoxication and short-term allocation of mycobacteria of tuberculosis.
The current and an outcome of cirrhotic tuberculosis depend on how dysfunctions of breath and blood circulation quickly progress. Substitution of a part of a pulmonary parenchyma cicatricial fabric, gives development of emphysema of lungs to worsenniya of alveolar gas exchange, to development of an alveolar hypoxia, an arterial anoxemia, hypercapnia, increase in minute volume of heart, and also to a sclerosis of branches of pulmonary arteries, narrowing and a partial obliteration of their gleam, build-up of pressure in system of a pulmonary artery and a right ventricle and to gradual development of a pulmonary heart (see). Respiratory insufficiency (see) at cirrhotic tuberculosis wears a restrictive uniform. Decrease in vital capacity and maximal ventilation of lungs is observed at patients with widespread tsirro-tpchesky tuberculosis and massive pleural changes.
Carry also profuse pulmonary bleeding from erozirovanny vessels of a wall of a broi-hoektatichesky cavity or a fibrous cavity caused by hypertensia in a small circle of blood circulation or owing to development of consecutive infection to complications of a tsirrotnchesky pulmonary tuberculosis. At a number of patients repeated pulmonary bleedings are noted (see. Pulmonary bleeding) and an amyloidosis (see) internals owing to hron. purulent process in bronchial tubes.
The diagnosis is based on data rentgenol. researches: sites of consolidation of pulmonary fabric of various extent are defined. Changes can be unilateral, bilateral, sometimes extend to all lung (a picture of a fibrothorax). In the latter case intensive blackout of the corresponding half of a thorax, reduction of its volume is defined. In the field of cirrhosis the calcinated centers, bronchiectasias can come to light. At unilateral cirrhosis of a lung the shadow of heart, large vessels and a trachea are displaced towards defeat. The opposite lung is usually increased in volume, in it the centers of consolidation can be defined. At bilateral cirrhotic process the shadow of heart is narrowed and extended, roots of lungs are tightened up, vessels are located vertically and remind branches of a weeping willow. At defeat of upper shares of lungs they completely can be projected in the field of tops. Roots of lungs are sharply tightened up, the vascular drawing has an appearance of «the falling rain» that demonstrates reduction of volume of upper shares and increase in volume of other departments of lungs, in to-rykh along with a sclerosis and emphysema the centers of consolidation come to light (rps. 15). Diaphragm
of Fig. 15. The roentgenogram of a thorax at a cirrhotic pulmonary tuberculosis (a direct projection): the upper share of the right lung is reduced in volume, condensed; the dense centers in upper parts of lungs (are specified by shooters).
it is located low, flattened, amplitude of its movements is reduced. The bronchiectasias and the cleared cavities hidden by cirrhotic changes can be revealed on tomograms, and also by means of a bronchography. During the carrying out the last specific bronchitis, deformation and a stenosis of bronchial tubes come to light.
The differential diagnosis is carried out with a pneumosclerosis (see) not tubercular etiology, developed after pneumonia, abscesses, against the background of bronchiectasias, atelectases and pleurisy, for to-rogo resistant absence in a phlegm of mycobacteria of tuberculosis in the presence of wet rattles, absence in lungs of the condensed and calciphied centers, localization of process preferential in average, lower shares and a uvula of a lung, low sensitivity of patients to tuberculine is characteristic. With the differential and diagnostic purpose preventive treatment by antibacterial agents taking into account sensitivity to them of microflora and an exception of antituberculous remedies during the first 10 days can be carried out. It is necessary to distinguish rather favorable changes, residual without signs of activity, after a wedge from a tsirrotnchesky pulmonary tuberculosis, treatment of tuberculosis.
Treatment of patients with a cirrhotic pulmonary tuberculosis is carried out according to the principles of complex treatment of TB patients (see), a cut includes use of antituberculous remedies (at an aggravation of tuberculous focuses in a zone of cirrhosis), nonspecific antibacterial therapy at an aggravation of nonspecific inflammatory process, and also pathogenetic and symptomatic therapy by cardiovascular means, vitamins, oxygen, etc. Operational treatment is shown to patients with unilateral cirrhotic tuberculosis, the expressed bronchiectasias, tendency to a repeated pneumorrhagia and aggravations of specific and nonspecific inflammatory processes at satisfactory indicators of a functional condition of a respiratory organs, blood circulation and kidneys (see the Lobectomy, the Pneumonectomy). For the purpose of prevention of pulmonary bleedings it is necessary to avoid physical and emotional overworks, to control the ABP level.
At cirrhotic tuberculosis without cavities or with debrided residual cavities are shown to lay down. gymnastics, special breathing exercises and the dosed walking. The choice of rational exercises, the initial position, volume and intensity of loading are defined with degree of respiratory insufficiency and existence hron. pulmonary heart. Independent occupations repeated during the day special exercises are obligatory. The disturbance of drainage function of bronchial tubes arising at a cirrhotic pulmonary tuberculosis demands daily active expectoration at the corresponding postural drainage. Dignity. - hens. treatment is carried out in the sanatoria located in areas with a warm and arid climate — in a steppe zone or on the Southern coast of the Crimea. Stay in mountain resorts is contraindicated.
Forecast adverse. Complications of tuberculosis — pulmonary bleeding, an amyloid and lipoid nephrosis, hron are a cause of death. pulmonary heart, thromboembolism of a pulmonary artery, etc.
Prevention of a tsirrotnchesky pulmonary tuberculosis consists in early detection and the correct etiopatogenetichesky treatment of the previous forms of tuberculosis. At the same time special attention shall be paid on timely diagnosis and topical treatment of specific changes in bronchial tubes. At aggravations, even in case of lack of signs of active specific process it is recommended to conduct seasonal courses of chemoprophylaxis (see Tuberculosis, prevention).
Tubercular pleurisy — a wedge, the form of a pulmonary tuberculosis which is shown an inflammation of a pleura and accumulation of exudate in a pleural cavity. It is more often observed at the focal, disseminated, infiltrative pulmonary tuberculosis, tuberculosis intrathoracic limf, nodes, as a rule, at persons of young age. Tubercular pleurisy can be one of early displays of primary tuberculosis.
Inflammatory reaction of a pleura is caused by the mycobacteria of tuberculosis getting into it in the lymphogenous or hematogenous way. At the same time the hyper sensitization of a pleura is of great importance. On genesis distinguish allergic, perifocal pleurisy and tuberculosis of a pleura; depending on localization — kostalny, apical, is more rare — paramediastinal, epiphrenic, interlobar pleurisy.
Depending on character of exudate (see) distinguish serous, serofibrinous, serous and purulent, purulent, hemorrhagic, chyle, cholesteric pleurisy (see). On cellular structure exudate can be lymphocytic, eosinophilic, neutrophylic. At dominance in exudate of neutrophilic leukocytes it becomes serous and purulent or purulent that demonstrates extensive kaze-ozno-necrotic changes and is observed at tuberculosis of a pleura. At this form of pleurisy in exudate it is possible to find also tubercular mycobacteria. Tubercular pleurisy with purulent exudate is called an empyema of a pleura.
Klien, a picture is various and depends on age of the patient, a condition of its organism, degree of a sensitization, character morfol. changes, localization and form of pleurisy (allergic, perifocal pleurisy or tuberculosis of a pleura).
On character of a course of process distinguish acute, subacute and chronic pleurisy. Acute and subacute pleurisy are characterized by temperature increase to 38 — 39 °, stitches, dry cough, tachycardia, gradual increase of an asthma. In an initial stage of kostalny pleurisy the pleural rub can be listened, to-ry disappears in process of accumulation of exudate. The dullness with the upper bound in the form of a parabolic curve (Ellis's line — Damuazo — Sokolova) and other symptoms is noted (see Pleurisy). Hron. the course of pleurisy differs in a stertost a wedge, pictures, is frequent lack of temperature reaction, gradual increase of symptomatology.
The diagnosis is made on the basis of data fiznkalny and rentgenol. researches. The nature of a disease solving in recognition the pleurocentesis is (see) with the subsequent cytologic research of the received liquid.
The differential diagnosis is carried out with pleurisy of other etiology.
Treatment can be conservative and operational. Conservative therapy is carried out by antituberculous remedies — an isoniazid, streptomycin and PASK. In the presence of tubercular changes in lungs appoint also rifampicin, and at plentiful exudate — Prednisolonum. Duration of chemotherapy three drugs of the 1st row makes not less than 2 — 3 months. Further streptomycin and PASK replace with Ethambutolum or Prothionamidum. The general duration of chemotherapy — 6 — 9 months. At considerable accumulation of exudate against the background of antibacterial therapy make repeated aspiration of exudate. Carrying out at tubercular pleurisy of LFK promotes a rassasyvaniye of exudate and pleural imposings, interferes with development of disturbances of lung ventilation and atrophy of muscles of a thorax on the party of pleurisy. At the beginning rassasyvaniye of exudate and before elimination of residual displays of the postponed pleurisy the special exercises strengthening respiratory excursions of a thorax on the party of defeat are necessary. At hron. purulent pleurisy resort to operational treatment — a pleurectomy (see).
Forecast, as a rule, favorable.
Prevention consists in the prevention of primary tuberculosis (see Tuberculosis), and also in timely and correct treatment such its wedge, forms, to-rye can be the reason of pleurisy.
In detail pathological anatomy, a clinical picture, the diagnosis and treatment — see Pleurisy.
Tuberculosis of upper respiratory tracts, tracheas, bronchial tubes, etc. includes also tuberculosis of an oral cavity, a uvula, palatine tonsils, handles and a throat.
Tuberculosis of an oral cavity, upper respiratory tracts and a throat consider as secondary display of tuberculosis at destructive forms of a disease. Thanks to preventive actions, early identification of patients and successful treatment of tuberculosis the frequency of specific damages of upper airways and a throat sharply decreased. By data And. N. Voznesensky (1975), tuberculosis of a nose, oral cavity, throat and throat is observed at 0,1 — 0,5% of patients with active forms of tuberculosis.
Four main possible ways of local damage of a mucous membrane of upper respiratory tracts and a throat are known: sputogen-ny (through a phlegm), lymphogenous, hematogenous and contact. Distinguish two forms of tubercular damage of mucous membranes of a nose, a mouth, a throat and a throat — infiltrate and an ulcer. Infiltrate can be limited and diffusion, seldom tumorous. The mucous membrane of pink, red or gray color is thickened, soft in case of dominance of an exudative component of an inflammation, and dense at productive inflammatory process. The tubercular ulcer usually has irregular shape, superficial, deckle-edged. The bottom of an ulcer is covered with granulyatsionny fabric and a fabric detritis. Depending on a phase of inflammatory process distinguish infiltration, disintegration, planting, and also consolidation, calcification and a rassasyvaniye.
Tuberculosis of a nose at various active forms of a pulmonary tuberculosis meets seldom — in 0,1% of cases. It is explained with the fact that the phlegm does not get on a mucous membrane of a nose, and also alleged active bactericidal effect of nasal slime on a mycobacterium of tuberculosis.
The wedge, a picture is not pathognomonic — nose/disturbance of nasal breath, department of the crusts painted by blood are noted dryness in a nose, «mortgaging». More often the nasal partition (see the Nose) that it can lead to perforation of a cartilage and deformation of a nose (is surprised at a tubercular lupus in a combination with damage of an outside nose). In diagnosis an important role is played by these rinoskopiya (see), morfol. and bacterial. researches. The differential diagnosis is carried out with banal rhinitis (see), eczema (see), tumoral processes and other diseases of a nose.
Tuberculosis of an oral cavity is observed also quite seldom at patients with the progressing forms of a destructive pulmonary tuberculosis. Proceeds in the form of a tubercular lupus (see Tuberculosis extra pulmonary, a tuberculosis cutis and hypodermic cellulose), quite often has an asymptomatic current. The diagnosis is established with the help morfol. and bacterial. methods of a research. The differential diagnosis is carried out with stomatitis (see), fungal infections of an oral cavity, syphilis (see), red flat it is deprived (see. Deprive red flat) and other diseases.
Tuberculosis of a throat, uvula, palatine tonsils and handles is more often combined with tuberculosis of an oral cavity and throat at patients with a fibroznokavernozny pulmonary tuberculosis at its neuzhlonny progressing and massive allocation of mycobacteria of tuberculosis. Acute and subacute forms of tuberculosis of a throat (see) meet seldom. For a wedge, pictures hron. forms pains during the swallowing are characteristic, feeling of a sadneniye and burning, i.e. the symptoms inherent to many nonspecific diseases of a nasopharynx (a nasal part of a throat, T.) and stomatopharynxes (oral part of a throat, T.). The asymptomatic current is characteristic of a tubercular lupus. The diagnosis is established on the basis of results morfol. and bacterial. researches. The differential diagnosis is carried out with Simanovsky's quinsy — Plau-ta — Vincent (see Quinsy), a lymphogranulomatosis (see), a leukosis (see), cancer, syphilis of a throat (see the Drink).
Tuberculosis of a throat occurs less than in 0,5% of cases at the adults sick with the active and progressing destructive pulmonary tuberculosis. Frequency of defeat of various departments of a throat (see), by data A. N. Voznesensky (1959), is various: most often phonatory bands, then an interchondral part of a glottis (interarytenoid space), then ventricles of a throat (blinking - you are ventricles), a linking of a threshold, subcopular space are surprised (a nodgolo-sovy cavity, T.), an epiglottis, it is black fishing and dny cartilages.
Wedge, symptomatology of specific damage of a throat is defined by character of a course of process, a cut happens acute, subacute and chronic. Patients show complaints to irritation, burning, dryness, a pharyngalgia, hoarseness of a voice up to a full aphonia. At the same time distinguish a dysphonia of the I degree (the alternating hoarseness),
the II degrees (resistant hoarseness) and
the III degrees (aphonia). Depending on expressiveness of a pain syndrome define a dysphagy of the I degree (pain non-constant — at a proglatyvaniye of food), the II degrees (pains the constants amplifying during the swallowing, cough, a conversation) and a dysphagy of the III degree (pain constant, painful, irradiating in ears). Infiltration, hypostasis of outside and internal departments of a throat cause the complicated stenotic breath. Cough and a pneumorrhagia are not characteristic of tuberculosis of a throat.
The diagnosis is made on the basis of data of a laringoskopiya (see), at a cut find infiltrate or an ulcer of a throat. Infiltrate takes a part of a throat, spreads to all body less often. In an acute exudative phase of an inflammation infiltrate has bright red coloring, in a productive phase — pale. Tubercular ulcers (superficial ii deep) have uneven corroded edges. During the healing of process in a throat small hems are formed. In cases of difficulty in diagnosis the biopsy is shown. The differential diagnosis is carried out with nonspecific laryngitis (see), tumors, syphilis of a throat (see), a scleroma (see) and damages of a throat at leukoses (see).
Acute nonspecific laryngitis is characterized by diffusion damage, hypostasis of a throat, a total hyperemia, inflammatory changes in a pharynx and palatine tonsils. Benign tumors of a throat (fibroma, a lymphangioma, an angioma) do not present great difficulties for diagnosis since are located, as a rule, on the limited site and have a characteristic appearance. Diagnostic difficulties can cause papillomas since a productive phase of tubercular vospatthe eniya is also followed quite often papillomatozny-mn by growths. At throat cancer broad infiltration of the struck parts of body, density and rigidity of surrounding elements of a throat, the congestive vascular drawing is noted, increase regional limf, nodes is frequent.
Treatment of tuberculosis of an oral cavity, upper respiratory tracts and a throat carry out by streptomycin, an isoniazid and other antituberculous remedies. Apply oil inhalations, instillations in a nose, and also rinsings to removal of a pain syndrome solutions of the anesthetizing substances. In the presence of ulcers 5 — 20% solution of silver nitrate make their cauterization. To the patient appoint a sparing diet.
The forecast favorable, local process calms down within 1 month.
Prevention comes down to the prevention and timely treatment of various forms of a pulmonary tuberculosis.
Tuberculosis of a trachea and bronchial tubes develops for the second time at active tubercular process in easy and intrathoracic limf, nodes. At children the most often specific damage of bronchial tubes comes to light at primary tuberculosis. Thanks to broad preventive actions and effective treatment of a pulmonary tuberculosis the frequency of specific damage of a trachea and bronchial tubes considerably decreased. Considerably the frequency of damages of bronchial tubes decreased and at all forms of a secondary pulmonary tuberculosis. In a crust, time the fibrous and cavernous pulmonary tuberculosis is complicated by specific damages of large bronchial tubes in 13 — 20% of cases, cavernous tuberculosis — in 8 — 10% of cases, disseminated — in 9 — 12%, infiltrative — in 4 — 12%, focal — in 4 — 6% of cases. Active tuberculosis of bronchial tubes at the vaccinated children and teenagers, according to M. I. Bugaeva (1974), develops in 2,4 times less than at not vaccinated.
Ways of infection at tuberculosis of a trachea and bronchial tubes are various and hl are defined. obr. character and activity of basic process. There is their infection with contents of a cavity or center of destruction more often. At a sputogenny way of distribution the causative agent of tuberculosis gets through crypts of mucous glands into a submucosal layer of a wall of a trachea or bronchial tube and causes a specific inflammation. The contact way of transfer is characterized by infection of a trachea and bronchial tubes in connection with distribution of specific tubercular process of the main center (limf, a node, a cavity). More often it is observed at primary tuberculosis with defeat intrathoracic limf, nodes. A. I. Abrikosov (1904) for the first time paid attention to damage of bronchial tubes at TB patients intrathoracic limf, nodes due to distribution of tubercular granulyatsionny fabric to a wall of bronchial tubes from struck intrathoracic limf, nodes. Also lymphogenous way of infection of a trachea and bronchial tubes is probable, to-ry meets both at primary, and at secondary tuberculosis. Hematogenous infection of a trachea and bronchial tubes long time was disputed from TB patients. A. Huzly in 1962 established its opportunity, and M. V. Shesterina (1976) experimentally proved hematogenous specific damage of a trachea and bronchial tubes.
The pathoanatomical picture of tuberculosis of bronchial tubes is characterized by preferential productive inflammatory reaction. Infiltrates, as a rule, limited, plotnovaty, flat, light pink color; in case of dominance of exudative reaction they are edematous, larger, red color (tsvetn. tab. of Art. 400, fig. 20). The canker of a trachea and bronchial tubes at wide use of antituberculous remedies is observed approximately at 9 — 10% of patients with an active pulmonary tuberculosis. At a canker limfobronkhialny fistulas are quite often formed (tsvetn. the tab. of Art. 400, fig. 21) as result of transition of specific process with limf, a node on a wall of a bronchial tube. Ulcers are more often single, small, sometimes crateriform. At primary tuberculosis the canker of bronchial tubes prevails over infiltrative. At the same time ulcers or limfobronkhialny fistulas represent microperforations; at most of patients the productive inflammation is noted.
The wedge, a picture of tuberculosis of bronchial tubes in most cases develops gradually. Often tuberculosis of bronchial tubes proceeds asymptomatically. The symptomatology depends on reactivity of an organism, a phase of process, a wedge, forms and features of a course of a pulmonary tuberculosis. The most characteristic symptoms of tuberculosis of bronchial tubes are cough, sometimes with a stethalgia, the expressed asthma, the atelectasis of a part or all lung, existence blocked, the inflated cavities. However these symptoms can be absent even at ulcer tuberculosis of bronchial tubes. At children the acute forms of specific process caused by break in bronchial tubes of caseous masses from limf, nodes are possible. Klien, a picture at the same time can remind the symptom complex developing at hit in a bronchial tube of foreign bodys (see). At tuberculosis of bronchial tubes the atelectases of segments or a lung lobe testimonial of disturbance of bronchial passability are found in children. After a wedge, treatment of tuberculosis of bronchial tubes are often observed residual a-ism -
Fig. 16. Bronkhogramma at a concentric stenosis of the left primary bronchus:
the arrow specified the site of a stenosis.
neniya: scars, hems, deforma
of a tion, stenoses, etc. (tsvetn. tab., Art. 400, fig. 22). Character and extent of residual changes depend on timely diagnosis of bronchial defeat, duration of the directed therapy and expressiveness of tubercular bronchopulmonary process.
L. K. Bogush et al. (1967) distinguish a concentric cicatricial stenosis (fig. 16), a pristenochny stenosis with defeat of one wall of a bronchial tube and a stenosis of a bronchial tube owing to a full atrophy of walls (a so-called atrofichny bronchial tube).
Sometimes, at reactivation of tuberculosis intrathoracic limf, nodes, in a gleam large (main or share) and smaller (segmented or subsegmented) a bronchial tube the broncholith representing the sequester of the calcinated part limf, a node or the calcinated caseous masses which got into a bronchial tube through bronchial fistula is formed. Distinguish an endobronchial broncholith, at Krom kal-tsinat there is completely in a gleam of a bronchial tube, a transmural broncholith which is characterized by a partial exit of a kaltsinat in a gleam of a bronchial tube, and an intramural broncholith, at Krom kaltsinat is in more thickly walls of a bronchial tube. The wedge, a picture at formation of a broncholith is characterized by various symptomatology and can remind bronchitis, pneumonia, a tumor, etc. (see the Broncholithiasis).
The diagnosis of tuberculosis of a trachea and bronchial tubes establish at a bronkhoskopiya (see) with a biopsy and bakte-riol. a research of the received material. At rentgenol. a research it is necessary to consider direct and indirect signs of defeat. Direct signs of damage of a trachea, the primary and lobar bronchi are their deformation and narrowing up to full closing of gleams, local thickenings of walls; in the field of a prileganiye to a wall of the bronchial tubes condensed limf, nodes, sometimes from kaltsinata, protrusion of walls of bronchial tubes is noted. Various ventilating disturbances belong to indirect signs: atelectasis, hypoventilation, sites of emphysema, various on volume.
The differential diagnosis is carried out first of all with acute and hron. nonspecific endobronchitis. As the main criterion at the same time serves prevalence of damage of a mucous membrane: limited — at tuberculosis and diffusion, bilateral — at nonspecific process. Tuberculosis of bronchial tubes is differentiated with benign tumors (see Bronchial tubes), bronchogenic cancer, coming from an epithelium of large bronchial tubes in an initial stage of its development, with a sarcoidosis (see) a respiratory organs, to-ry, according to a number of researchers, in 12% of cases is followed by emergence in a mucous membrane of large bronchial tubes of proliferative changes in a type of the plaques and hillocks similar with tubercular, and in some cases — with a lymphogranulomatosis (see), syphilis (see), a xanthomatosis (see).
Treatment of tuberculosis of a trachea and bronchial tubes complex taking into account portability the patient of medicines, and also resistance of mycobacteria of tuberculosis to them. Specific damage of a trachea and bronchial tubes testifies to the complicated course of pulmonary process. Therefore there is a need of strengthening of therapeutic impact on an organism in general. At the same time terms of treatment are extended depending on a form of basic process. Use combinations of various antituberculous remedies (not less than 3 — 4) in combination with pathogenetic. One of drugs is entered endobronkhialno the syringe or in the form of an aerosol taking into account individual portability of this or that way of introduction. At widespread damage of a mucous membrane of bronchial tubes aerosol therapy is shown, at the localized process — endobronchial administration of medicines. Contraindication to local therapy is tendency of the patient to allergic reactions, and also procedures arising later a bronchospasm and severe ongoing cough.
For inhalation of pharmaceuticals use domestic inhalers of AI-1, PAI-2, etc., and also the ultrasonic aerosol devices UZI-Z released in GDR, etc. Inhalations of pharmaceuticals should be carried out
1 — 2 time a day, duration of the procedure does not exceed 15 — 20 min. The term of treatment is established individually taking into account dynamics of process; on average it proceeds from 2 to 6 months. Before performing inhalations of antituberculous remedies within 5 — 7 days appoint mix of the means possessing anti-spastic action. As aerosols use streptomycin, streptosalyuzid, a tuba z ides, Kanamycinum, solyutizon, a florimi-tsina sulfate, etc. At treatment of the tuberculosis of bronchial tubes complicated by limfobronkhialny fistulas it is necessary to carry out bronchoscopic sanitation with removal of slime, caseous masses, sometimes granulyatsionny fabric. Use in treatment of rifampicin and Ethambutolum gives the chance to increase considerably (from 2 weeks to 1V2 — 2 of month) intervals between to lay down. bronkhoskopiya. In treatment of tuberculosis of bronchial tubes use also corticosteroids (on 20 — 25 mg of a hydrocortisone within
20 days) for the purpose of reduction of infiltration, hypostasis and a hyperemia of a mucous membrane. At accession of nonspecific complications in a complex to lay down. actions include streptocides and antibiotics of a broad spectrum of activity. At cicatricial stenoses of II and III degrees large (main, share) bronchial tubes operational treatment is shown: plastics of a bronchial tube (on condition of preservation of a part or all lung), a resection of a part of a lung or a pneumonectomy (in the presence of destructive specific and nonspecific changes in a lung).
Forecast favorable. In most cases there comes treatment. At limited forms of a pulmonary tuberculosis the wedge, the treatment of tuberculosis of bronchial tubes which is followed by the minimum residual changes can be reached in all cases.
Prevention consists in the prevention and timely rational treatment of a pulmonary tuberculosis.
The tuberculosis of a respiratory organs combined with dust occupational diseases of lungs. Thus can be combined with dust occupational diseases of lungs — a pneumoconiosis (see), is more often with the most widespread of them — a silicosis (see). Incidence of tuberculosis of the persons which are affected by the dust containing free silicon dioxide, above than at other population. Especially often tuberculosis is noted at nodular and nodal forms of a silicosis, and also at patients with the heavy course of this disease.
Distinguish a silicosis with the subsequent accession of tuberculosis, tuberculosis with accession of a silicosis, and also a tuberculosilicosis, at Krom it is not possible to establish the nature of primary defeat. Though tubercular changes are more often localized in upper parts of lungs, and snliko-tichesky — in average and lower, such differentiation is not always accurately expressed.
The pathogeny of a tuberculosilicosis
is completely not found out. As a rule, tuberculosis at a silicosis is secondary. The old centers localized in apical and cortical departments of a lung or in limf, nodes of a root of a lung are a source of tubercular process. Distribution of process happens lymphogenous and bronchogenic, more rare in the hematogenous way. Assume that the originality of distribution of tubercular process at a silicosis consists in selective defeat limf, systems.
The Silikotuberkulezny centers have a peculiar structure. Their periphery represents a belt hyalinized poor in connective tissue cells, and the center — the site of a necrosis. In the centers find particles of silicon dioxide, and sometimes — tubercular mycobacteria. Tubercular process at a silicosis is characterized by a combination of a necrosis to the expressed fibrosis, development around the centers of a necrosis of cicatricial fabric. Progressing of a tuberculosilicosis leads to education in lungs of large cavities of disintegration with dense fibrous walls. Usually are involved in process also intrathoracic limf, nodes, in to-rykh against the background of a silicosis and sharp fibrosis are defined tuberculous focuses and granulomas.
Thanks to considerable compensatory opportunities of an organism a tuberculosilicosis the long time clinically is not shown. After a certain period body temperature increases, there is cough, weight loss is noted. In process of progressing of a disease the symptomatology becomes more diverse; it depends on degree patomorfol. changes, reactivity of an organism, existence of associated diseases. The general state worsens, intoxication amplifies, function of breath and blood circulation is broken. However at a tuberculosilicosis intoxication is less expressed, than at the similar forms of a pulmonary tuberculosis which are not combined with a silicosis, and the bakteriovydeleniye even at far come tubercular process is absent. Seldom or never at hematogenous distribution of process the tuberculosilicosis can be complicated by tubercular meningitis, tuberculosis of intestines, throat, trachea.
There is no standard classification of a tuberculosilicosis. In practice use classification of a silicosis and tuberculosis. At rather poor development of silikotichesky fibrosis it is easy to establish a form of tubercular process radiological. Most often at a tuberculosilicosis the focal form of tuberculosis meets; defeat quite often bilateral with the polymorphic centers to 1,5 cm in the diameter which are localized, as a rule, in subclavial zones and upper parts of lungs. The diagnosis of focal tuberculosis against the background of the expressed silicosis is difficult since it is difficult to distinguish tuberculous focuses from the merged silikotichesky small knots. Infiltrative tuberculosis at a silicosis can be presented by lobulyar-ny, roundish infiltrate, pe-ristsissurity, a labitome, seldom caseous pneumonia with preferential localization in
the 2nd, 3rd and 4th segments of lungs. Rassasyvaniya of infiltrate is almost not observed, most often there is its consolidation and turning into the large fibrous nodes called by silikotuber-kulema. At the disseminated tuberculosis in combination with a silicosis tuberculous focuses of a polimorfna, are located preferential in upper parts of lungs. At hron. the disseminated tuberculosis the centers of various density, pleural changes, sometimes symptoms of cirrhosis of lungs are defined. At a fibrous and cavernous tuberculosilicosis from both or on the one hand against the background of asymmetrically located massive sites of fibrosis large cavities of the wrong, often bobovid-shy form are defined, it is frequent with a fluid level. In the remote sites easy against the background of silikotichesky fibrosis and emphysema the centers of bronchogenic dissimination come to light. At all forms of a tuberculosilicosis the changes of roots of lungs caused by increase, consolidation, sometimes calcification limf, nodes, a pneumosclerosis and the phenomena of hypertensia in a small circle of blood circulation are observed. Classification of tuberculosis in some cases is insolvent in connection with an originality of a course of tuberculosis at a silicosis. Therefore it is offered kliniko-rentgenol. classification, in a cut four basic groups of atypical forms of a tuberculosilicosis are allocated: 1) silikotuberkulezny bronkhadenit with preferential localization of tubercular process in intrathoracic limf, nodes, characterized by expansion and consolidation of root shadows, on-litsiklichnostyyu their outlines; in some cases calcification as an egg shell; 2) a melkouzelkovy form of a tuberculosilicosis with formation of separate blackouts with a diameter up to 3 cm, in to-rykh it is impossible to differentiate elements of tubercular and silikotichesky process; 3) a macronodular tuberculosilicosis with single or multiple blackouts with a diameter from 3 to 8 cm of rounded shape — silikotuberkulemam; 4) the massive tuberculosilicosis corresponding radiological to the III stage of a silicosis at Krom a wedge, a form of tubercular process cannot be specified.
In differential diagnosis of the merged silikotichesky small knots with tuberculous focuses the tomography is important (see), with the help the cut is possible to reveal the cavities of disintegration invisible in survey pictures.
An essential role for establishment of the diagnosis of a tuberculosilicosis is played by the bronkhoskopiya (see) allowing to establish changes in bronchial tubes, specific to tuberculosis, limfobronkhialny fistulas. The most reliable sign of specific process is detection of mycobacteria of tuberculosis and existence of the created cavity. At a tuberculosilicosis changes in blood are observed: the accelerated ROE, shift of a formula to the left, a lymphopenia, a monocytosis. A certain diagnostic value has positive effect of treatment by antituberculous remedies. In cases, difficult for diagnosis, make a biopsy deep cervical limf, nodes (Daniels's method) and a mediastinoskopiya (see).
Other pneumoconiosis is less often combined with tuberculosis. Such types of an anthracotic tuberculosis as antrakotuberkulez, siderosili-kotuberkulez, the combination of tuberculosis to a pneumoconiosis of welders, a siderosis (see), asbestosis (see Sealy-katozy), is rare with a berylliosis meet (see Beryllium).
Manifestations of an anthracotic tuberculosis differ in big variety; current its rather high-quality.
Diagnosis of tuberculosis against the background of this pneumoconiosis is difficult. Along with clinical and datas of laboratory in recognition of tubercular changes at pnevmokonpo-za plays an important role rentgenol. method of a research. However and its
diagnostic opportunities are limited and the diagnosis of tuberculosis can be established by means of this method only in the presence of shadows of tubercular changes and signs of inflammatory process in the struck departments of a lung.
Treatment of patients with a tuberculosilicosis and other types of an anthracotic tuberculosis is carried out by the same principles, as treatment of TB patients. It is based on prolonged use of a combination of antituberculous remedies (from 10 — 12 to 18 months and more). Duration of treatment is defined by prescription and expressiveness of tubercular process and efficiency of drugs. At patients with fresh infnltrativny forms of a tuberculosilicosis and other types of an anthracotic tuberculosis glucocorticoids in combination with antibacterial agents have favorable effect. However results of chemotherapy at a tuberculosilicosis it is worse, than at the corresponding forms of the tuberculosis which is not combined with a silicosis and depend not only on a form of tuberculosis, but also on weight of a silicosis.
Operative measures at a tuberculosilicosis are applied seldom. Indications to them are defined by extent of development of fibrosis, a condition of function of breath and blood circulation, prevalence of tubercular changes.
The forecast depends on prevalence of process, and also on holding preventive and medical actions. The great value is attached to chemoprophylaxis at patients with a pneumoconiosis and, first of all, a silicosis, especially predisposed to a disease of tuberculosis. Daily appoint once daily dose of an izonia-zpd continuously within 3 — 4 months in a year (in autumn and winter time) within 3 years in a row. Chemoprophylaxis shall be performed in a complex about a dignity. - a gigabyte. and medical actions for fight against tuberculosis (see) and a pneumoconiosis (see) on this production.
Features of tuberculosis of a respiratory organs at its combination to other diseases. One of the main lines of a pathomorphism of a pulmonary tuberculosis in modern conditions — increase in frequency of its combination to various diseases.
The combination of tuberculosis and cancer of a lung tends to growth in connection with increase in incidence of the population of lung cancer and extension of life of TB patients. Frequency of bronchogenic cancer at suffering from tuberculosis lungs, according to D. D. Yablokov and A. I. Galibina (1976), averages 0,4%, and the frequency of tuberculosis at patients with cancer of a lung — apprx. 9,5%. The combination of these diseases occurs preferential at men 50 years are more senior. On observations of different researchers, cancer of a lung meets against the background of inactive residual focal and sclerous changes more often, and also at hron. fibrous and cavernous and cirrhotic tuberculosis. Patomorfol. the substrate promoting development of tumoral process are chronic inflammatory and dystrophic changes in a parenchyma of a lung various, including tubercular, the nature; a metaplasia (see) cylindrical an epithelium of bronchial tubes in multilayer flat; the centers in lungs and in intrathoracic limf, nodes from kaltsinata and crystals of cholesterol; fibrous walls of old cavities and hems on a mucous membrane of bronchial tubes. In a zone of such hems there can be so-called cicatricial cancer, in particular apical cancer like Pankost (see Lungs, tumors). During the progressing of tumoral process tuberculosis can also gain the progressing character. Tuberculosis does not influence significantly the course of bronchogenic cancer of lung, but the last can promote an exacerbation of a pulmonary tuberculosis owing to decrease in body resistance, intoxication or involvement in the region of growth of a tumor of old tuberculous focuses.
Klien, a picture of such combined damage of lungs is various depending on a stage and a form of cancer and tuberculosis. Strengthening of dry cough, asthma, stethalgias, emergence of a persistent pneumorrhagia, fever of the wrong type, sharp weight loss, fast changing of an auskultativny picture is noted.
Timely cancer detection of a lung at its combination to tuberculosis is connected with great difficulties in view of similar symptomatology of these diseases. Besides, cancer and tuberculosis quite often proceed under masks hron. nespetsp-fichesky diseases of lungs. Most often it is necessary to differentiate peripheral cancer of a lung with a tuberculoma. The differential diagnosis of a pnevmoniyepodobny form of cancer of slight and infiltrative tuberculosis, a miliary carcinomatosis and the disseminated tuberculosis, a band form of cancer of slight and cavernous tuberculosis or abscess of slight, apical cancer of Pankost and infiltrative tuberculosis is exclusively difficult. Only by means of comprehensive examination of the patient, including kliniko-rentgenologiche-skiye, tool, laboratory, immunol. methods of a research, it is possible to make the diagnosis timely.
The greatest diagnostic value have detection of tumor cells in a phlegm, expressed patol. shifts in biochemical indicators (increase in level of fibrinogen of blood, etc.)> the repeating pneumorrhagia, and also data rentgenol. and bronkhologichesky research. Allocate 4 main types rentgenol. changes at the combined damage of lungs tuberculosis and cancer: 1) emergence in a zone of the stationary or regressing tubercular changes of the new single isolated macrofocal shadow or focus of the irregular rounded shape with wavy contours and homogeneous structure; 2) emergence against the background of active tubercular changes or out of their new shadow similar described above, edges despite carrying out specific chemotherapy, increases in sizes at regression of tubercular changes; 3) emergence against the background of residual changes or active tuberculosis of signs of hypoventilation, emphysema, pneumonitis, an atelectasis of a segment, share or all lung; the peribronchial, intersticial or located on the course of an interlobar pleura consolidations accruing, coming from a root of a lung; unilateral уве^ treatments and consolidations of a root laid down: whom at the expense of intrathoracic limf, nodes; 4) emergence of an asymmetric thickening of a wall of an old tubercular cavity with polipoobrazny hilly growths in a gleam or around it in the absence of a perifocal inflammation and the centers of bronchogenic dissimination.
Possibilities of modern thoracic surgery, chemotherapy and radiation therapy changed the forecast at the bronchogenic cancer which is combined with a pulmonary tuberculosis. In cases of early recognition of the combined pathology the issue
of operational treatment is resolved. At an operative measure in to - and the postoperative period, and also at treatment carry out by tsitostatpchesky means and ionizing radiation for the prevention of reactivation of tuberculosis long tuberculostatic therapy.
Tuberculosis of a respiratory organs comes to light at patients with a diabetes mellitus by 3 — 5 times more often than among other population. Persons with a severe form of a diabetes mellitus (see a diabetes mellitus) get sick with tuberculosis more often than from easy. The risk of a disease of tuberculosis at men is more expressed 50 years sick with a diabetes mellitus are more senior. At a combination of these diseases infiltrative and fibrous and cavernous forms of tuberculosis, the progressing tuberculomas with preferential localization of process in the lower shares of lungs prevail. More frequent development of tuberculosis in patients with a diabetes mellitus is promoted by the strengthened disintegration of proteins, the lowered maintenance of a glycogen in a liver and its fatty infiltration, the expressed acidosis, disturbance of lipidic exchange, dysfunction of sympathoadrenal and pituitary and adrenal systems, dehydration and exhaustion of an organism. Feature of the combined pathology is, as a rule, the oligosymptomatic beginning of tuberculosis.
The current of the last is defined by weight of a diabetes mellitus. So, at a severe form of a diabetes mellitus in a tubercular inflammation exudative and necrotic reaction prevails, processes of healing and fibrosing are expressed poorly. At the same time at the compensated diabetes mellitus and effective complex treatment of tuberculosis regression of a specific inflammation and healing of destructive changes are observed.
The wedge, a picture of a pulmonary tuberculosis and a diabetes mellitus at their combination depends on weight of exchange disturbances and process in lungs, age of patients and on the sequence of development of diseases. The diabetes mellitus which joined tuberculosis usually makes heavier its current.
For identification of the hidden disturbances of carbohydrate metabolism at TB patients use test of tolerance to glucose (see a diabetes mellitus). It is applied at inspection of the persons cured of tuberculosis and having big residual changes in the lungs sick hron. forms of tuberculosis, with medicinal intolerance, symptoms of a diabetes mellitus and the heredity burdened by it. Patients with for the first time the diagnosed tuberculosis need also to be inspected by means of glucose loading since the hidden diabetes mellitus quite often provokes tuberculosis, and the last promotes transition of a latent diabetes mellitus to explicit.
Treatment would be carried out in specialized department tubercular antitubercular (see. Antituberculous remedies), pathogenetic and antidiabetic means (diet, insulin, etc.) - It is necessary to appoint antitubercular drugs with care in view of frequent emergence at patients with a diabetes mellitus of side reactions. Frequency of side reactions increases during the progressing of a diabetic mik-roangiopatiya and tuberculosis. The Etioniamidum tempting the dispeptic phenomena, lowering appetite and breaking absorbability in intestines against the background of an insulin therapy can promote a hypoglycemia therefore it is replaced better with Prothionamidum transferred by patients. Ethambutolum is contraindicated at a diabetic retinopathy (see), in this case preference is given to Ftivazidum and metazid (but not to an isoniazid having the expressed sympathicotrope effect). Processes of healing at patients with a diabetes mellitus proceed more slowly therefore duration of antitubercular therapy at the combined pathology shall exceed twice that at those я^е the forms of tuberculosis which are not complicated by a diabetes mellitus. It is necessary to apply the pathogenetic means improving microcirculation and raising immunol to prevention of side effect of pharmaceuticals and normalization of exchange disturbances. reactivity. It is necessary to liquidate a ketosis, epistatic immunity and reducing activity of antituberculous remedies. The cavity is available the patient with difficult compensated and complicated diabetes mellitus at bad portability of antitubercular drugs, at to-rykh and the bakteriovydeleniye remains, artificial pheumothorax is shown short-term (duration till 1 year) (see). According to indications during stabilization of both diseases carry out operational treatment.
The forecast at the diabetes mellitus which is combined with a pulmonary tuberculosis in a crust, time favorable. Patients manage to be cured of tuberculosis and to return them working capacity on condition of timely diagnosis of tuberculosis and rational treatment of a diabetes mellitus.
Patients with a diabetes mellitus are group of the increased risk of a disease of tuberculosis therefore prevention of tuberculosis (see) in this group shall be performed by systematic X-ray fluorographic surveys, isolation from bakteriovydelitel, a revaccination of BTsZh which are not infected, chemical ioprof silt the act ik and infected and persons with big residual post-tubercular changes in lungs, treatments of a diabetes mellitus (see a diabetes mellitus). At deterioration in a current of the last, decrease in efficiency of an insulin therapy, emergence of symptoms, suspicious on tuberculosis, it is necessary detailed kliniko-rentgenol. inspection of the patient.
A peptic ulcer of a stomach and duodenum (see. The peptic ulcer), according to D. D. Yablo-kov and A. I. Galibina (1976), comes to light at suffering from tuberculosis lungs in 2,6 — 6,3% of cases that exceeds incidence of other population. Frequency of a pulmonary tuberculosis at the persons who transferred a gastrectomy (see), above than among neoperi-rovanny. This combined pathology prevails at men at the age of 30 — 50 years. The peptic ulcer in most cases precedes tuberculosis. More often it is combined with fibrous and cavernous and infiltrative its forms. The exacerbation of tuberculosis at patients with a peptic ulcer, especially after a resection of a stomach, can be connected with decrease in body resistance under the influence of neurovegetative and dispeptic frustration, etc.
Klin, the picture at a combination of these diseases is defined by the sequence of their development. The peptic ulcer arising against the background of tuberculosis proceeds with insignificant a wedge, manifestations; tuberculosis thus has the progressing character more often. More favorably the tuberculosis which joined a peptic ulcer proceeds. At the combined pathology symptoms of both diseases are observed. However weakness, a hyporexia, weight loss, vegetative and exchange disturbances, involvement in patol. process of other bodies went. - kish. a path heartburn, nausea and vomiting — are noted more often, and less than at the peptic ulcer which is not combined with tuberculosis. At localization of an ulcer in a duodenum at patients tuberkulezokhm the hyperoxemia is defined more often, but level is lower than it, than at persons only with a peptic ulcer. Recognition of a peptic ulcer at TB patients is complicated in connection with scarcity of its symptomatology and also because dispeptic frustration are quite often regarded as manifestations of side effect of antituberculous remedies. Therefore at emergence in suffering from tuberculosis dispeptic disturbances the careful research is necessary went. - kish. path.
Treatment of a pulmonary tuberculosis at patients with a peptic ulcer in a stage of an aggravation is complicated by bad portability of pharmaceuticals, emergence of dispeptic frustration, abdominal pains, etc. In these cases prefer to refuse their appointment inside and to enter intravenously, kapelno, intramusculary, rektalno and intratrakhealno. In process of a zatikhaniye of an aggravation of a peptic ulcer use of a number of drugs inside against the background of antiulcerous therapy is possible. Patients with the accompanying peptic ulcer well transfer to stages of remission, especially at discontinuous treatment, Ethambutolum, an isoniazid, Cycloserinum, it is worse — rifampicin and Prothionamidum. Oral administration of Etioniamidum, PASK, thioacetazone, Pyrazinamidum is excluded. Operational treatment both diseases carry out to the period of remission. The persons with a peptic ulcer who especially transferred a gastrectomy are carried to group of the increased risk of a disease of tuberculosis. At an aggravation any of two diseases hospitalization of patients in specialized department of tubercular hospital is necessary. Patients with the combined pathology shall be a long time under dispensary observation; in this group of patients carry out a complex to lay down. - the prof. of actions, including courses of proti-voretsidivny therapy of a peptic ulcer. The forecast depends on weight of each of diseases.
In recent years increase of a combination of a pulmonary tuberculosis to nonspecific diseases of a respiratory organs is noted (emphysema, hron. bronchitis, bronchiectasias, acute and hron. pneumonia). It is connected with growth of number of the persons cured of tuberculosis, but having the expressed residual changes in lungs and also with increase among this contingent of people of advanced age. Fibrous changes of tissue of lungs, deformation and disturbance of passability of bronchial tubes, disturbance of ventilation form a basis for development of nonspecific diseases at tubercular process. With post-tubercular changes nonspecific diseases of lungs diagnose for persons by
2 — 3 times more often than among other population. They can develop as at active tuberculosis (more often at a fibrous kavernoznokhm), and against the background of inactive specific changes. The nonspecific infection quite often precedes tuberculosis, masking its manifestations and making heavier a current. Nonspecific diseases of lungs meet at persons with a long tuber-kuleznsh process more often that confirms their metatuberculous genesis. They interfere with reparative processes, complicate treatment of tuberculosis, accelerate development of a pulmonary heart that causes a high lethality in this group of patients.
The diagnosis of the accompanying nonspecific disease of lungs is made on the basis of the anamnesis, data of the clinicoradiological, laboratory and bronkhologichesky researches conducted in dynamics against the background of trial therapy by antibiotics of a broad spectrum of activity.
Treatment of patients with the nonspecific diseases of lungs accompanying tuberculosis shall be complex, directed to suppression of life activity of specific and nonspecific microflora, recovery of function of self-cleaning of bronchial tubes. At the combined pulmonary pathology intensive antibacterial care with use of the rifampicin possessing a broad spectrum of activity and other antibiotics is shown. Possibilities of operational treatment of such patients are limited because of prevalence of process.
The forecast is defined by prevalence of process both tubercular, and nonspecific, and also a condition of drainage function of bronchial tubes, existence of bronchiectasias. Patients with nonspecific diseases of lungs make group of the increased risk concerning a disease of tuberculosis. Therefore early detection of these diseases and their full treatment is necessary.
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See also bibliogr. to St. Tuberculosis. A. G. Homenko; A. V. Alexandrova (rents.), I. I. Vorobyova (to lay down. physical.), I. P. Zhingel (tuberculoma of a lung), K. Ya. Keleberda (tuberculosis intrathoracic limf, nodes), JI. V. Lebedeva (primary tubercular complex),
A. S. Mamolat (the disseminated pulmonary tuberculosis), T. F. Smurova (a cirrhotic pulmonary tuberculosis), V. A. Solovyov (prof.), O. A. Uvarov (a stalemate. An.),
B. V. Utkin (features of tuberculosis at its combination to other diseases), V. P. Filippov (tuberculosis of an oral cavity, upper respiratory tracts, throats,
tracheas, bronchial tubes, etc.).