Focal tuberculosis of the upper lobe. Focal pulmonary tuberculosis

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General description

Infiltrative tuberculosis is usually considered as the next stage in the progression of miliary pulmonary tuberculosis, where the leading symptom is already infiltration, represented by an exudative-pneumonic focus with caseous decay in the center and an intense inflammatory reaction along the periphery.

Women are less susceptible to tuberculosis infection: they get sick three times less often than men. In addition, the trend towards a higher increase in incidence among men continues. Tuberculosis occurs more often in men aged 20-39 years.

Acid-fast bacteria of the genus Mycobacterium are considered responsible for the development of tuberculosis. There are 74 species of such bacteria and they are found everywhere in the human environment. But the cause of tuberculosis in humans is not all of them, but the so-called human and bovine species of mycobacteria. Mycobacteria are extremely pathogenic and are characterized by high resistance in the external environment. Although the pathogenicity can vary significantly under the influence of environmental factors and the state of the defenses of the human body that has been infected. The bovine type of pathogen is isolated in cases of illness in rural residents, where infection occurs through the nutritional route. People with immunodeficiency conditions are susceptible to avian tuberculosis. The overwhelming majority of primary human infections with tuberculosis occur through the airborne route. Alternative ways of introducing infection into the body are also known: nutritional, contact and transplacental, but they are very rare.

Symptoms of pulmonary tuberculosis (infiltrative and focal)

Low-grade body temperature.
Heavy sweats.
Cough with gray sputum.
When coughing, blood may be released or blood may appear from the lungs.
Pain in the chest is possible.
The respiratory rate is more than 20 per minute.
Feeling of weakness, fatigue, emotional lability.
Poor appetite.

Diagnostics

Complete blood count: slight leukocytosis with a neutrophilic shift to the left, a slight increase in the erythrocyte sedimentation rate.
Analysis of sputum and bronchial washings: in 70% of cases, Mycobacterium tuberculosis is detected.
X-ray of the lungs: infiltrates are most often localized in the 1st, 2nd and 6th segments of the lung. From them to the root of the lung there is a so-called path, which is a consequence of peribronchial and perivascular inflammatory changes.
Computed tomography of the lungs: allows you to obtain the most reliable information about the structure of the infiltrate or cavity.

Treatment of pulmonary tuberculosis (infiltrative and focal)

Tuberculosis must be treated in a specialized medical institution. Treatment is carried out with special first-line tuberculostatic drugs. Therapy ends only after complete regression of infiltrative changes in the lungs; this usually requires at least nine months, or even several years. Further anti-relapse treatment with appropriate drugs can be carried out under clinical observation conditions. In the absence of a long-term effect, the persistence of destructive changes, the formation of foci in the lungs, collapse therapy (artificial pneumothorax) or surgical intervention are sometimes possible.

Essential drugs

There are contraindications. Specialist consultation is required.

(Tubazid) - antituberculosis, antibacterial, bactericidal agent. Dosage regimen: the average daily dose for an adult is 0.6-0.9 g, it is the main anti-tuberculosis drug. The drug is produced in the form of tablets, powder for the preparation of sterile solutions and a ready-made 10% solution in ampoules. Isoniazid is used throughout the entire treatment period. If the drug is intolerant, ftivazid is prescribed, a chemotherapy drug from the same group.
(semisynthetic broad-spectrum antibiotic). Dosage regimen: taken orally, on an empty stomach, 30 minutes before meals. The daily dose for an adult is 600 mg. For the treatment of tuberculosis, it is combined with one anti-tuberculosis drug (isoniazid, pyrazinamide, ethambutol, streptomycin).
(a broad-spectrum antibiotic used in the treatment of tuberculosis). Dosage regimen: the drug is used in a daily dose of 1 ml at the beginning of treatment for 2-3 months. or more daily or 2 times a week intramuscularly or in the form of aerosols. When treating tuberculosis, the daily dose is administered in 1 dose, in case of poor tolerance - in 2 doses, the duration of treatment is 3 months. and more. Intratracheal, adults - 0.5-1 g 2-3 times a week.
(anti-tuberculosis bacteriostatic antibiotic). Dosage regimen: taken orally, 1 time per day (after breakfast). It is prescribed in a daily dose of 25 mg per 1 kg of body weight. It is used orally daily or 2 times a week in the second stage of treatment.
Ethionamide (synthetic anti-tuberculosis drug). Dosage regimen: prescribed orally 30 minutes after meals, 0.25 g 3 times a day, if the drug is well tolerated and the body weight is more than 60 kg - 0.25 g 4 times a day. The drug is used daily.

What to do if you suspect a disease

1. Blood test for tumor markers or PCR diagnosis of infections
4. Analysis for CEA or General blood test

Blood test for tumor markers
In tuberculosis, the concentration of CEA is within 10 ng/ml.
PCR diagnostics of infections
A positive result of PCR diagnostics for the presence of the causative agent of tuberculosis with a high degree of accuracy indicates the presence of this infection.
Biochemical blood test
In tuberculosis, increased levels of C-reactive protein may occur.
Biochemical examination of urine
Tuberculosis is characterized by a decrease in the concentration of phosphorus in the urine.
Analysis for CEA
In tuberculosis, the level of CEA (carcinoembryonic antigen) is increased (70%).
General blood test
In tuberculosis, the number of platelets (Plt) is increased (thrombocytosis), relative lymphocytosis (Lymph) (more than 35%), monocytosis (Mono) is more than 0.8 × 109 /l.
Fluorography
The location of focal shadows (foci) in the image (shadows up to 1 cm in size) in the upper parts of the lungs, the presence of calcifications (round-shaped shadows, comparable in density to bone tissue) is typical for tuberculosis. If there are a lot of calcifications, then it is likely that the person had fairly close contact with a patient with tuberculosis, but the disease did not develop. Signs of fibrosis and pleuroapical layers in the image may indicate previous tuberculosis.
General sputum analysis
During a tuberculous process in the lung, accompanied by tissue disintegration, especially in the presence of a cavity communicating with the bronchus, a lot of sputum can be released. Bloody sputum, consisting of almost pure blood, is most often observed with pulmonary tuberculosis. In pulmonary tuberculosis with cheesy disintegration, the sputum is rusty or brown in color. Fibrinous clots consisting of mucus and fibrin may be detected in the sputum; rice-shaped bodies (lentils, Koch lenses); eosinophils; elastic fibers; Kurschmann spirals. An increase in the content of lymphocytes in sputum is possible with pulmonary tuberculosis. Determination of protein in sputum can be helpful in the differential diagnosis between chronic bronchitis and tuberculosis: with chronic bronchitis, traces of protein are detected in the sputum, while with pulmonary tuberculosis the protein content in the sputum is higher and can be determined quantitatively (up to 100-120 g /l).
Rheumatoid factor test
The rheumatoid factor level is higher than normal.

Which doctors should you contact if you have focal pulmonary tuberculosis?

What is Focal pulmonary tuberculosis

Focal pulmonary tuberculosis classified as post-primary (secondary), which arose in the body with primary tuberculosis foci that were previously cured.

Focal pulmonary tuberculosis accounts for about 50% of all newly diagnosed tuberculosis diseases. It can occur without subjective sensations and is detected only during a mass fluorographic examination. But upon additional examination, it is often established that patients did not attach importance to a number of symptoms of tuberculosis intoxication for a long time.

Clinically and radiographically there are two forms of focal tuberculosis: fresh soft-focal and chronic fibrous-focal. During the healing process of various forms of tuberculosis, focal changes are formed. These lesions are replaced by fibrous tissue, encapsulated, and are considered fibrotic residual lesions.

What causes focal pulmonary tuberculosis

Pathogens of tuberculosis are mycobacteria - acid-fast bacteria of the genus Mycobacterium. A total of 74 species of such mycobacteria are known. They are widely distributed in soil, water, people and animals. However, tuberculosis in humans is caused by a conditionally isolated M. tuberculosis complex, which includes Mycobacterium tuberculosis(human species), Mycobacterium bovis (bovine species), Mycobacterium africanum, Mycobacterium bovis BCG (BCG strain), Mycobacterium microti, Mycobacterium canetti. Recently, it has included Mycobacterium pinnipedii, Mycobacterium caprae, which are phylogenetically related to Mycobacterium microti and Mycobacterium bovis. The main species characteristic of Mycobacterium tuberculosis (MBT) is pathogenicity, which manifests itself in virulence. Virulence can vary significantly depending on environmental factors and manifest differently depending on the state of the microorganism that is subject to bacterial aggression.

Tuberculosis in humans most often occurs when infected with human and bovine species of the pathogen. Isolation of M. bovis is observed mainly in residents of rural areas, where the route of transmission is mainly nutritional. Avian tuberculosis is also noted, which occurs mainly in immunodeficient carriers.

MBTs are prokaryotes (their cytoplasm does not contain highly organized organelles of the Golgi apparatus, lysosomes). There are also no plasmids characteristic of some prokaryotes that provide genome dynamics for microorganisms.

Shape - slightly curved or straight rod 1-10 microns * 0.2-0.6 microns. The ends are slightly rounded. They are usually long and thin, but bovine pathogens are thicker and shorter.

MBT are immobile and do not form microspores or capsules.
Differentiates in a bacterial cell:
- microcapsule - a wall of 3-4 layers 200-250 nm thick, firmly connected to the cell wall, consists of polysaccharides, protects mycobacterium from the external environment, does not have antigenic properties, but exhibits serological activity;
- cell wall - limits the mycobacterium from the outside, ensures stability of cell size and shape, mechanical, osmotic and chemical protection, includes virulence factors - lipids, the phosphatide fraction of which is associated with the virulence of mycobacteria;
- homogeneous bacterial cytoplasm;
- cytoplasmic membrane - includes lipoprotein complexes, enzyme systems, forms an intracytoplasmic membrane system (mesosome);
- nuclear substance - includes chromosomes and plasmids.

Proteins (tuberculoproteins) are the main carriers of the antigenic properties of MBT and exhibit specificity in delayed-type hypersensitivity reactions. These proteins include tuberculin. The detection of antibodies in the blood serum of tuberculosis patients is associated with polysaccharides. Lipid fractions contribute to the resistance of mycobacteria to acids and alkalis.

Mycobacterium tuberculosis is an aerobe, Mycobacterium bovis and Mycobacterium africanum are aerophiles.

In organs affected by tuberculosis (lungs, lymph nodes, skin, bones, kidneys, intestines, etc.), a specific “cold” tuberculous inflammation develops, which is predominantly granulomatous in nature and leads to the formation of multiple tubercles with a tendency to decay.

Pathogenesis (what happens?) during Focal pulmonary tuberculosis

Pathogenesis of focal tuberculosis different, diverse and complex. This form may be a manifestation of the primary or, more often, secondary period of tuberculosis.

Secondary focal forms arise in adults under the influence of exogenous superinfection or endogenous spread of MVT from latent, previously formed foci. Such lesions contain caseation and MVT and are located in the lymph nodes or in any organ.

During the period of exacerbation of the process, MVT from the foci spreads along the lymphatic tract and small bronchi. Most often, fresh lesions appear in the apices of the lungs. First, endobronchitis develops, then the lesion covers all the small branches of the bronchi in this zone. A cheesy necrosis of the walls of the altered bronchi occurs, followed by a transition to the lung tissue, mainly in the apical region. A small focus such as caseous, acinous or lobular pneumonia is formed.

The lymphatic network is involved in the pathological process only around the lesion. Regional lymph nodes usually do not respond to lesions in the lungs. Exudative phenomena are small and quickly give way to a productive reaction.

Hematogenous spread is characterized by a symmetrical arrangement of foci, the remains of which are located in the apical regions of the lungs.

Symptoms of focal pulmonary tuberculosis

Some patients identified using fluorography actually do not have any clinical symptoms. However, most of them react to the occurrence of low-spread focal pulmonary tuberculosis with weakness, sweating, decreased ability to work and decreased appetite. Patients complain of heat in the cheeks and palms, short-term chills and low-grade fever during the day. Sometimes there is an intermittent cough, dry or with a scant amount of sputum, and pain in the side.

Diagnosis of focal pulmonary tuberculosis

When examining the patient, slight pain in the muscles of the shoulder girdle on the affected side is noted. Lymph nodes are not changed. In the lungs, there may be a shortening of the percussion sound only when the lesions merge. In the fresh phases of development of focal tuberculosis in the presence of infiltrative changes, when coughing, hard breathing and small, moist single wheezes are heard.
Tuberculin tests are usually moderately expressed.

There is nothing characteristic of this form of the disease in the blood, and changes in the blood depend on the phase of the disease. In mild, fresh forms, blood counts are normal, in the infiltration phase, the ESR is somewhat accelerated, the left shift of the formula reaches 12-15% of band forms, and slight lymphopenia.

In the chronic course of the process of focal tuberculosis, the so-called productive form is observed. Foci of small and medium size (3-6 mm), round or irregular in shape, clearly defined, of medium and sharp intensity are identified.

The radiograph reveals lesions up to 1 cm in diameter, round or irregular in shape. Their contours can be clear or blurred, the intensity is weak or medium. The lesions are single and multiple, most often located in one lung, mainly in the upper sections: in segments I, II and VI; often merge with each other. Wide linear interlacing shadows are visible around the lesions - lymphangitis.

With progression, an increase in the number of fresh lesions is determined, lymphangitis intensifies, and decay cavities appear.

Treatment of focal pulmonary tuberculosis

With modern antibacterial treatment, fresh tuberculosis lesions and lymphangitis usually resolve within 12 months. On the x-ray, you can see complete restoration of the pulmonary pattern or residual slight heaviness and small outlined lesions. Less often, after full treatment, fresh lesions do not resolve, but are encapsulated, and gross fibrosis develops at the site of lymphangitis.

Prevention of focal pulmonary tuberculosis

Tuberculosis is one of the so-called social diseases, the occurrence of which is associated with the living conditions of the population. The reasons for the epidemiological problem with tuberculosis in our country are the deterioration of socio-economic conditions, a decrease in the living standards of the population, an increase in the number of people without a fixed place of residence and occupation, and the intensification of migration processes.

Men in all regions suffer from tuberculosis 3.2 times more often than women, while the growth rate of incidence in men is 2.5 times higher than in women. The most affected are persons aged 20 - 29 and 30 - 39 years.

The morbidity rate of contingents serving sentences in penal institutions of the Ministry of Internal Affairs of Russia is 42 times higher than the Russian average.

For the purpose of prevention, the following measures are necessary:
- carrying out preventive and anti-epidemic measures adequate to the current extremely unfavorable epidemiological situation regarding tuberculosis.
- early identification of patients and allocation of funds for drug provision. This measure will also be able to reduce the incidence of illness among people who come into contact with sick people in outbreaks.
- carrying out mandatory preliminary and periodic examinations upon entry to work on livestock farms affected by bovine tuberculosis.
- increasing the allocated isolated living space for patients suffering from active tuberculosis and living in crowded apartments and dormitories.
- more timely implementation (up to 30 days of life) of primary vaccination for newborn children.

Focal pulmonary tuberculosis is a secondary form of the disease. Develops on the basis of previously treated primary lesions. Almost half of the cases of pathology are detected in patients again. The disease is sometimes asymptomatic. Often the disease is detected during a planned diagnosis. Fluorography can show that those manifestations to which no attention was paid for a long period are symptoms of the disease. There are two forms of the disease: fibrous-focal chronic and soft-focal fresh. During the healing of lesions, zones with fibrous tissue form.

Focal pulmonary tuberculosis is a pathology that occurs in areas with unfavorable indicators and a low level of preventive control methods. The causes are poor diet and lifestyle.

With low social well-being of residents, lack of a balanced diet, increased migration, the presence of a large number of people without a permanent place of registration, lack of proper medical services, the number of cases of tuberculosis increases significantly.

The disease only rarely develops as a primary process. Most often, pathology occurs in the presence of pre-existing immunity to tuberculosis. It is a secondary infection.

Disease progression occurs for a number of reasons:

reactivation of the source of infection present in the human body;
with secondary penetration of mycobacteria into the body from the environment.

Weakened immunity causes reversion of Koch's bacillus.

Conditions in humans that contribute to this include:

chronic diseases: ulcers, diabetes, pathologies of the respiratory system;
bad habits: alcoholism, smoking, drug addiction;
prolonged contact with a patient who has an open form of the disease;
wrong way of life.

The prognosis of therapy depends on the stage of the pathology.

Today, focal pulmonary tuberculosis is divided into several forms:

Fibrous-focal. It is characterized by the formation of scars and dense lesions. Inflammation is almost completely absent. During the deposition of calcifications, the tissues become very hard.
Fresh soft-focal. Focal tuberculosis in the infiltration phase is a fresh form. Characterized by the formation of cavities. When therapy is carried out in a timely manner, the inflammatory processes disappear almost completely. Small areas of compaction may form. The remaining disintegrated tissues are eliminated by the draining bronchioles and lungs. However, the decay cavity remains in their place.

Acute focal tuberculosis occurs in different ways.

Most often, secondary symptoms develop on the basis of existing complications or pathologies. The lesions are localized in the lungs. However, some of them are present in other organs. For this reason, making a diagnosis is sometimes difficult.

In the stage of exacerbation of the disease, from a few foci, MBT disperse throughout the body through the lymphatic system and bronchi. New lesions appear primarily in the upper lobe of the lung. Endobronchitis develops, and only then cheesy necrosis forms. It subsequently spreads to the entire lung tissue. This stage is characterized by the formation of a focus that has common features with pneumonia.

Various tissues and lymph nodes are gradually involved in the progression of the disease. The productive reaction is changed by minor exudative phenomena. The focus of tuberculosis is symmetrical.

The main consequences of the pathology are:

favorable course with timely treatment and detection of the disease;
the disease disappears, but residual fibrosis and calcifications may be observed;
When the pathology passes into a severe stage, the prognosis is unfavorable.

The clinical picture of the pathology completely depends on the patient’s body. Tuberculosis of the upper lobe of the left lung may be in the phase of disintegration and compaction, infiltration.

At various stages of development, the disease has certain symptoms. The initial phase has no symptoms. But due to the penetration of a small amount of toxins into the blood, a slight negative effect on the organs can be observed.

Focal pulmonary tuberculosis is characterized by wave-like symptoms.

Almost all signs of pathology are absent during the quiescent period. During exacerbation, symptoms are also minor.

The main signs of the disease that you should pay attention to:

slight increase in temperature throughout the week;
irritability;
lack of appetite;
weight loss;
heat in the palms and cheeks;
pain in the side;
dry cough with little sputum production;
severe sweating during night sleep, tachycardia;
increased weakness;
When lung tissue collapses, hemoptysis is observed.

After the end of the acute period, symptoms become mild. However, sometimes signs of intoxication persist for some time.

Observed:

hard breathing;
wet rales;
percussion sound is dull.

Diagnostics and therapy

To diagnose a patient, a specialist performs an examination, x-ray diagnostics and laboratory tests. The focal form is easiest to detect using x-rays.

Upon examination, the doctor may detect slight soreness in the muscles of the patient’s shoulders and arms. When the lesions merge, a percussion sound is noted. At the initial stage, many patients are characterized by the presence of moist rales in the lungs.

The Mantoux test gives an insignificant reaction. Depending on the phase of the disease, biochemical test indicators may show different data. The initial stage is characterized by results within the normal range. As soon as an infiltrate occurs, an acceleration of ESR and a slight decrease in the number of lymphocytes are observed.

X-ray is one of the most informative methods. Without it, it is difficult to establish a correct diagnosis.

The examination allows you to detect lesions up to 1.1 cm of various shapes. They can be either multiple or few. More often they are found only in one lung, in its upper part. In some cases, signs of lymphangitis are found. If there is no correct therapy, then the progression of the pathology is revealed on the x-ray. It is manifested by an increase in the number of fresh lesions, worsening lymphangitis, and the appearance of decay cavities.

Sputum examination also occupies a central place in diagnostic activities. In the absence of sputum, specialists induce it using certain inhalations that cause coughing attacks. In it, specialists often detect mycobacteria in small quantities, which is not a threat to others, but is significant when making a diagnosis. If Koch's bacilli are present in the sputum, we can confidently speak about the development of tuberculosis. This diagnostic method is ineffective if there are dense lesions on the x-ray. In these patients, biochemical and other diagnostic methods are used.

If focal tuberculosis is diagnosed, treatment with antibiotics can eliminate the infection within a year. After therapy, a control x-ray is taken. If the result is positive, it shows a restored pulmonary pattern, absence or a small number of lesions. In some cases, fibrosis still develops after treatment, and the lesions do not disappear.

Focal pulmonary tuberculosis should be treated only comprehensively. Antibacterial therapy is mandatory.

In addition, medications are prescribed to help maintain immunity at a high level. If the disease progresses while taking medications, then specialists replace the ineffective drug with another.

In the hospital, the disease is treated in the infiltration phase. The patient receives first-line drugs. Treatment is completed only after absolute regression of changes in the lungs. Most often, the course lasts 9 months. The dispensary provides anti-relapse treatment. In the absence of positive dynamics, surgical intervention or artificial pneumothorax is performed.

Anti-tuberculosis drugs:

Tubazid;
Isoniazid;
Rifampicin;
Streptomycin;
Ethambutol;
Ethionamide.

When tuberculosis is diagnosed, therapy should be started immediately, regardless of whether the patient is contagious or not at that time. Timely measures taken will prevent the development of the disease and give a favorable prognosis.

Preventive measures

Focal tuberculosis is a social disease, the occurrence of which directly depends on living conditions.

It is for this reason that prevention shows positive results.

The main reasons for the development of pathology are:

low standard of living;
poor quality diet;
weak immunity.

The incidence rate depends on the level of migration processes in the region, the standard of living of people, and the number of people without permanent residence.

According to statistics, men suffer from this pathological condition in most cases.

The incidence among the stronger sex is several times higher than among women.

The age group is divided into age periods from 20 to 29 and from 30 to 39 years.

The most effective preventive measures to avoid infection with tuberculosis, experts include:

Anti-epidemiological timely measures that would fully respond to the current situation in a certain territory.
Informing residents of the region, carrying out medical examinations that would make it possible to identify pathology at the earliest stage of its development and begin proper therapy.
Timely and complete provision of patients with medications, providing them with favorable conditions for treating the disease.
Completely limiting the contact of sick people with healthy people. Therapy should be carried out in special hospitals staffed by highly qualified medical workers.
Mandatory timely medical examinations for certain groups of people. These include food workers, shops, livestock and agricultural workers.
Vaccination of newborn children.

What is focal tuberculosis and how dangerous is it for the patient’s life?

Experts say that this pathology accounts for half of all detected cases of infection with the disease.

The course of the disease passes without specific symptoms. It is often detected during fluorography. However, often, after examination by a doctor, it turns out that the person simply did not attach much importance to the visible symptoms of intoxication for a fairly long period. For this reason, the main condition for a quick recovery is timely diagnosis.

Focal pulmonary tuberculosis refers to minor forms of tuberculosis, which in most cases are benign. This form of tuberculosis is currently the most common both among newly identified patients and among those registered. Among newly identified patients with pulmonary tuberculosis, focal tuberculosis is observed in 60%, and among those registered in anti-tuberculosis dispensaries - in 50%.

The relative frequency of focal tuberculosis among patients with tuberculosis is determined by the organization of the entire system of preventive anti-tuberculosis measures and in recent years has increased even more only thanks to the timely detection and effective treatment of tuberculosis.

Focal tuberculosis includes processes of various origins and duration, limited extent, with a focus size of no more than 1 cm in diameter. As can be seen from this definition, focal tuberculosis is a collective concept, therefore, two main forms of focal tuberculosis are distinguished: soft-focal and fibrous-focal tuberculosis. The need to isolate these forms is due to their different genesis, different pathomorphological picture and potential activity, and unequal tendency to reverse development.

Soft focal tuberculosis is the beginning of secondary tuberculosis, which determines the significance of this most important form of the process for the development of subsequent forms.

In the pathogenesis of the development of focal tuberculosis, it is important to correctly understand the role of exo- and endogenous infection. A. I. Abrikosov attached decisive importance in the development of secondary tuberculosis to the repeated entry into the lungs of Mycobacterium tuberculosis from the environment. The importance of exogenous infection is confirmed by the more frequent incidence of tuberculosis in persons who have had contact with tuberculosis patients. Although the incidence of “contacts” (persons in contact with patients with active tuberculosis) has now significantly decreased, it is still 3-4 times higher than the general incidence of the population.

The endogenous development of tuberculosis is also of undoubted importance, which is confirmed by the almost constant detection in the zone of fresh tuberculosis foci of older ones, which were apparently the source of exacerbation of the process. Old encapsulated and calcified lesions in the lungs and lymph nodes are detected in 80% of patients with focal tuberculosis. The importance of endogenous infection is also indicated by the more frequent disease of active tuberculosis in previously infected individuals, especially those who are X-ray positive, i.e., those who have traces of a previous tuberculosis infection in their lungs.

The tendency to exacerbation of old lesions depends on the nature and duration of residual changes and the state of reactivity of the body. Live, virulent Mycobacterium tuberculosis can persist for a long time in the body (directly in the foci and in the lymph nodes). Mycobacterium tuberculosis is usually not found in scar tissue.

Currently, TB specialists recognize the importance of both endogenous and exogenous infection. Exogenous superinfection sensitizes the body and can contribute to the exacerbation of endogenous infection. The entire system of anti-tuberculosis measures is built on a correct understanding of the role of endogenous and exogenous infection: vaccination, early diagnosis and treatment of primary and secondary tuberculosis, as well as tuberculosis prevention.

In the pathogenesis of focal tuberculosis, as well as other clinical forms of the process, unfavorable factors that reduce the body’s resistance are also important: concomitant diseases, occupational hazards, unfavorable climatic and living conditions, excessive sun exposure, mental trauma, etc.

Thus, the pathogenesis of focal tuberculosis of the secondary period is different. Focal tuberculosis can develop as a result of exogenous superinfection or endogenous spread of Mycobacterium tuberculosis from latent tuberculosis foci in the lymph nodes, bones, kidneys, and more often from aggravated old encapsulated or calcified foci in the lungs. By their origin, these pathological changes either relate to the period of primary infection, or are residual changes after infiltrative processes, hematogenous disseminations or small cavities.

The initial pathological changes in secondary tuberculosis consist of the development of endoperibronchitis of the intralobular apical bronchus [Abrikosov A. I., 1904]. This is followed by cheesy necrosis of the inflammatory walls of the bronchus. Panbronchitis develops, sometimes with blockage of the bronchial lumen by caseous masses, then a specific process spreads to the adjacent pulmonary alveoli. This is how a focus of specific caseous bronchopneumonia arises - the Abrikosov focus. The combination of such foci with a diameter of up to 1 cm creates a pathomorphological picture of soft-focal tuberculosis.

With tuberculous inflammation, the exudative stage is gradually replaced by the proliferative stage. Fresh lesions are therefore often replaced by connective tissue and turn into scars. A capsule is formed around the caseous foci. Such lesions are called Aschoff-Bullet lesions. Morphologically, alterative and proliferative foci are distinguished, but their combination is more often observed. Based on size, lesions are divided into small - up to 3 mm, medium - up to 6 mm and large - 10 mm in diameter.

It has been established that certain physicochemical changes are observed in the lung during the formation of foci. In the area where Mycobacterium tuberculosis settles, the pH of the environment shifts to the acidic side, which stimulates the activity of the connective tissue involved in delimiting the inflammatory area of the lung.

The formation of limited focal changes in a person suffering from tuberculosis, and not an extensive infiltrative-pneumonic process, is possible only under conditions of a certain state of reactivity of the body, which is characterized by the absence of increased sensitivity of the body to tuberculin and the preservation, although somewhat reduced, of relative immunity. This is evidenced by the normergic reactions to tuberculin detected in patients with focal tuberculosis and the data of biochemical studies. Patients with focal tuberculosis do not have such a sharp increase in the level of histamine in the blood as with infiltrative-pneumonic tuberculosis, when pronounced sensitization of the body is observed.

The clinical picture of soft-focal tuberculosis is characterized by low symptoms for a certain period. However, for soft-focal tuberculosis the predominance of general mild functional disorders of some internal organs and systems always remains typical.

Some patients experience low-grade fever, increased sweating, sleep and appetite disturbances, and decreased ability to work.

The appearance of patients with focal tuberculosis does not allow one to suspect an incipient tuberculosis process: they look healthy. However, an objective examination of the chest organs clearly reveals symptoms of reflex sparing of the affected areas: a lag in the act of breathing on the affected side of the chest, tension and soreness of the muscles over the affected area, weakening of inspiration. There may be a shortening of the percussion tone and, during auscultation, increased exhalation over the affected segment, the degree of which depends on the number of foci, their fusion and involvement of the pleura in the process.

The leukocyte form and ESR remain normal in a significant proportion of patients with focal tuberculosis. In a number of patients, minimal changes are detected in the form of a slight shift in the leukocyte count to the left, a moderate increase in ESR. Lymphocytic leukocytosis or its combination with monocytic leukocytosis is often observed. An increase in the absolute content of monocytes and lymphocytes in the peripheral blood indicates functional stress on the part of the hematopoietic system involved in anti-tuberculosis immunity, and more often this accompanies the benign course of the disease.

The detectability of Mycobacterium tuberculosis depends on the phase of the process and the research methodology. In focal tuberculosis, Mycobacterium tuberculosis is found mainly in the phase of decay of lung tissue.

It is necessary to use the entire complex of microbiological studies: bacterioscopy (using enrichment methods, in particular flotation), fluorescent microscopy, cultural and biological methods. It is the latter two methods for focal tuberculosis that more often make it possible to detect Mycobacterium tuberculosis. To determine Mycobacterium tuberculosis, bronchial or gastric lavage water is usually examined, since patients produce a small amount of sputum.

Repeated cultures almost double the detection rate of Mycobacterium tuberculosis in the focal form.

The integrated use of laboratory methods not only increases the reliability of determining the frequency of isolation of mycobacterium tuberculosis, but also makes it possible to judge the nature of bacilli isolation: viability, virulence and drug sensitivity of microbacteria tuberculosis, their type, which is of great importance for chemotherapy.

The X-ray picture of focal tuberculosis depends on the phase, genesis and duration of the process. Fresh lesions that have re-emerged in the intact lung are visible on the radiograph as round, spotty shadow formations of low intensity with vague contours, usually located in groups, often in a limited area.

The nature of radiological changes is better revealed by tomography. The greatest role of X-ray tomography is in the diagnosis of destruction, since in this form small decay cavities are observed (up to 1 cm in diameter), which can rarely be detected during survey or even targeted radiography. Up to 80% of such decay cavities in focal pulmonary tuberculosis are detected only using a tomographic research method, therefore, for all newly diagnosed patients with focal pulmonary tuberculosis, X-ray tomography is mandatory. Otherwise, most small decay cavities remain undiagnosed, treatment is ineffective and the process progresses.

Patients with focal tuberculosis are identified mainly during mass fluorographic examinations, as well as during the examination of people visiting the clinic for catarrh of the upper respiratory tract, asthenic conditions, vegetative neurosis and other diseases, under the “masks” of which focal tuberculosis can occur.

Differential diagnosis of focal tuberculosis should be carried out with its “masks”: influenza condition, thyrotoxicosis, vegetoneurosis and diseases in which focal-like shadows are radiologically detected in the lungs - focal eosinophilic pneumonia, limited pneumosclerosis.

In differential diagnosis, it is necessary to conduct a timely x-ray examination, which will confirm or exclude the presence of focal changes in the lungs. In addition, it is necessary to take into account the history and characteristics of the clinical course of the disease.

With eosinophilic focal pneumonia, an increase in the number of eosinophils in the peripheral blood is detected, eosinophils are also found in the sputum. Noteworthy is the rapid disappearance of clinical and radiological signs of eosinophilic focal pneumonia. Eosinophilic foci of pneumonia often develop with ascariasis, since ascaris larvae undergo a development cycle in the lungs and sensitize the lung tissue.

When diagnosing focal tuberculosis, it is important not only to establish the origin of the lesions, but also to determine the degree of their activity.

If, when using the entire complex of clinical and radiological research methods, it is difficult to resolve the issue of the degree of activity of focal tuberculosis in a newly diagnosed or long-term treated patient, subcutaneous injection of tuberculin (Koch test) and sometimes diagnostic therapy are used.

The response to subcutaneous injection of tuberculin is assessed by the size of the infiltrate. A reaction with an infiltrate diameter of at least 10 mm is considered positive. The general reaction is judged by changes in the patient’s well-being (the appearance of symptoms of intoxication) - an increase in body temperature, changes in the leukocyte formula and ESR, and biochemical changes in the blood serum. In case of a focal reaction, which is very rarely detected radiologically, catarrhal phenomena may occur in the lung and Mycobacterium tuberculosis may be detected in the sputum or lavage waters of the stomach and bronchi.

To carry out the above tests, the temperature is measured every 3 hours for 3 days before using the Koch test (excluding night time), and a general blood test is performed the day before the test. On the day of the test, the blood serum is examined for the content of hyaluronidase, histamine, and protein fractions. This analysis is repeated after 48 hours, a general blood test - after 24 and 48 hours. At the same time, sputum or washings of the stomach and bronchi are examined for Mycobacterium tuberculosis by culture.

An active process is characterized by an increase in the number of leukocytes, the appearance of a shift in the leukocyte formula to the left, an increase in the number of lymphocytes, monocytes in the peripheral blood and a decrease in the number of eosinophils, and sometimes lymphocytes. In the blood serum there is a shift towards coarse protein fractions - a- and y-globulins. Particularly characteristic is an increase in the level of hyaluronidase, histamine, serotonin and catecholamines during an active process.

In the absence of reliable data indicating the activity of the tuberculosis process, the issue is resolved negatively. In case of doubtful data, a 3-month diagnostic course of treatment with three main tuberculostatic drugs is advisable. In 90-95% of patients, this period is sufficient to resolve the issue of the activity of the tuberculosis process.

The course of focal tuberculosis is determined by the potential activity of the process and the method of treating patients. Soft focal tuberculosis is characterized by pronounced activity, which requires great attention to the treatment of patients suffering from this form.

Treatment of patients with active focal pulmonary tuberculosis must begin in a hospital setting with three main tuberculostatic drugs against the background of a rational general hygienic regimen, as well as diet therapy. All this is carried out until there is significant clinical and radiological improvement. In the future, treatment is possible in sanatorium and outpatient settings using two drugs. The duration of treatment should be at least 12 months, during which intermittent chemotherapy can be performed.

In case of protracted course of focal tuberculosis, pathogenetic agents can be recommended: pyrogenal, tuberculin. With the exudative nature of inflammation, a pronounced infiltration phase, with allergic symptoms caused by anti-tuberculosis drugs, with concomitant diseases of an allergic nature, the use of corticosteroid hormones is indicated.

The outcomes of focal tuberculosis depend on the nature of changes in the lungs at the start of treatment and the method of treating patients. With the integrated use of modern methods of therapy, cure occurs in 95-98% of patients. Complete resorption is observed only with fresh lesions (in 3-5% of patients). In most patients, in parallel with resorption, delimitation of foci occurs with the formation of local pneumosclerosis. This is due to the body’s sufficient resistance to tuberculosis infection and the predominance of the intermediate phase of inflammation from the very first days of the development of the disease.

In 2-7% of patients with focal tuberculosis, with the confluence of a number of unfavorable factors, the disease may progress with the development of the following forms of secondary tuberculosis: infiltrates, tuberculosis, limited fibrous-cavernous pulmonary tuberculosis. In these cases, there may be indications for surgical treatment - economical lung resection.

The pathogenesis of fibrous-focal tuberculosis is in connection with the reverse development of all forms of pulmonary tuberculosis: primary tuberculosis complex, disseminated tuberculosis, soft-focal tuberculosis, infiltrative, tuberculoma, cavernous tuberculosis.

Pathomorphologically and clinically, fibrous focal tuberculosis is characterized by great polymorphism, depending on the prevalence and duration of the forms of the previous tuberculosis process.

Patients with fibrous focal tuberculosis may complain of weakness, increased fatigue and other functional disorders.

Complaints of cough with sputum, sometimes hemoptysis, chest pain can be explained by specific pneumosclerosis in the affected area.

An objective examination above the affected area reveals a shortening of the percussion tone, and upon auscultation, dry rales are heard.

Changes in blood and sputum depend on the degree of activity of both specific and nonspecific inflammatory processes in the focal area. During the compaction phase in the blood, lymphocytic leukocytosis is possible. Mycobacterium tuberculosis is found very rarely in sputum.

X-ray examination of fibrous-focal tuberculosis clearly reveals the intensity, clarity of boundaries and polymorphism of foci, pronounced fibrosis and pleural changes (Fig. 28).

In the diagnosis of fibrous-focal tuberculosis, the greatest difficulties are in determining the degree of activity of the process, as well as the reasons for the exacerbation of the inflammatory process in the area of tuberculous pneumosclerosis. To answer this question, a comprehensive examination of the patient is necessary. There may be indications for diagnostic chemotherapy.

The course of fibrous focal tuberculosis depends on the number and condition of the lesions, the method of previous therapy, as well as the living and working conditions of the patient.

Indications for specific therapy for patients with fibrous focal tuberculosis are determined by the phase of the process. Persons with fibrous focal tuberculosis in the thickening phase do not require specific antibacterial therapy. Preventive treatment with GINK drugs. and PAS is indicated for them under complicating circumstances: when climatic conditions change, after intercurrent diseases or surgical interventions.

Patients with fibrous-focal tuberculosis in the infiltration phase need treatment with chemotherapy, first in a hospital or sanatorium, and then on an outpatient basis.

For newly diagnosed fibrous focal tuberculosis of questionable activity, it is necessary to carry out therapy with three main drugs for 3-4 months, and if it is effective, continue therapy on an outpatient basis.

The criterion for clinical cure of focal tuberculosis is the absence of clinical, functional and radiological data on lung disease observed within 2 years after the end of an effective course of treatment.

LECTURE ON TUBERCULOSIS.

TOPIC: FOCAL TUBERCULOSIS. INFILTRATIVE TUBERCULOSIS. CASEUS PNEUMONIA. CLINIC AND PATHOGENESIS.

Focal tuberculosis - this is a form of the disease that is characterized by a limited extent of the inflammatory process in the lungs with a predominance of the productive nature of inflammation in the body. The length is usually determined by 1-2 segments. If we take radiological signs, then usually the spatial field is taken not lower than the 2nd rib, that is, when focal changes in the lungs are in the upper segments. If focal changes have spread below the second rib, then this process is called disseminated tuberculosis.

The focus is a pathomorphological concept. There are two variants in the inflammatory process during tuberculosis: focus and infiltrate.

A lesion is a focus of inflammation that does not exceed 10 mm in size. Pathologists divide them into small (within 3-5 mm), medium (5-8 mm), large (10 mm). In focal tuberculosis, these foci cannot be more than 10 mm, because in this process the nature of inflammation is productive. There are tuberculous tubercles, which contain a large number of epithelioid cells, delimiting caseous, small foci containing Mycobacterium tuberculosis. Considering that these changes are located in a limited space, these foci are limited in volume, and accordingly, the clinical symptoms of focal tuberculosis are very, very scarce. The patient, as a rule, complains only of intoxication syndrome, which is usually accompanied by the appearance of only low-grade fever in the evening. Less often, the patient complains of symptoms of vegetative-vascular dystonia, which are a consequence of the same intoxication syndrome. Complaints of night sweats, headaches, fatigue, etc. But usually, against the background of good health and good performance, in the evening such a patient develops a low-grade fever. This form, with such meager symptoms, can drag on for years in the patient, and if he does not see a doctor, then the diagnosis is not made. At a certain time, the patient feels quite well - his low-grade fever disappears, there are no complaints, but in the spring or autumn a deterioration in health suddenly begins to appear, time passes and the condition improves again. And only with fluorography or radiography is a patient diagnosed with focal pulmonary tuberculosis. In the 50-60s, we had a lot of focal tuberculosis - focal tuberculosis was detected in the range of 40-50%. Over the years, due to the use of mass fluorography, timely detection of tuberculosis, and changes in the immune background, the proportion of focal tuberculosis has been falling, despite the high incidence of tuberculosis in our country (5%, in some areas up to 8%).

Pathogenesis of focal tuberculosis: to date, there is no clear hypothesis regarding focal tuberculosis. Some believe that this is a consequence of exogenous infection (or exogenous superinfection in a previously infected person, while the entry of a fresh portion of Mycobacterium tuberculosis, which usually enters the upper lobe, develops limited inflammation, because the person in this case is previously infected or in childhood, a person who has had some form of primary tuberculosis is infected with a weakly virulent strain against the background of good reactivity of the body. A number of experts believe that this is a consequence of retrograde flow of lymph in persons who had tuberculosis in the lymph nodes in childhood, in which residual changes remained after suffering tuberculosis in the form. petrificates, and at some stage, when the body's reactivity decreases (stressful situations, respiratory diseases - influenza and herpes), which leads to the release of mycobacterium tuberculosis from petrificates and is carried into the upper segments of the lungs with the lymph flow. According to the first hypothesis, focal tuberculosis is the result. exogenous infection, the second - endogenous infection.

The nature of the course of focal tuberculosis is, in principle, favorable. But its peculiarity is that it is prone to wavy flow. This form of tuberculosis can develop for years, and the patient does not see a doctor. These patients, as a rule, do not excrete bacteria, that is, they are not dangerous to others, because, as a rule, there are no destructive changes in the lesion. The lesions are quite dense, and Mycobacterium tuberculosis does not have the opportunity to escape. In general, among patients, bacteria excretors are a maximum of 3%. Even with the disintegration of foci, bacterial excretion is also minimal - within a maximum of 7-10%.

Progression of focal tuberculosis is rare. This form of tuberculosis usually responds well to chemotherapy - three anti-tuberculosis drugs; with sufficient discipline and a healthy lifestyle of the patient, it is treated quickly.

If the patient’s complaints are scanty and limited to low-grade fever in the evening, and less often to symptoms of vascular dystonia, then it is natural that the physical signs of this form of tuberculosis are almost always absent, which is generally understandable logically - such small lesions are 5-8 mm. If only the picture of endobronchitis develops, then scant dry rales can be heard above the apexes. If there are small decay cavities, you can hear scanty, moist rales. Even without treatment, these wheezes disappear. A reliable diagnosis of focal tuberculosis is made only after an X-ray examination.

Peripheral blood: as a rule, unchanged. Red blood is almost always normal, leukocytes are also within normal limits. Sometimes you may notice some lymphopenia, and a slight increase in the number of monocytes.

Routine collection of sputum for microscopic examination usually reveals nothing. In such patients, mycobacteria are detected using additional research methods - bronchial lavages; during bronchoscopy they try to take swabs if they see a picture of endobronchitis - in this case, scanty bacterial excretion is sometimes found. Sometimes phthisiatricians in the focal form of tuberculosis distinguish 2 options:

soft-focal form

fibrofocal form (may be a consequence of previous infiltrative tuberculosis)

These are, in general, pathological diagnoses.

Diagnosis: focal tuberculosis S 1 -S 2 of the right lung in the phase of infiltration, decay, scarring, calcification, etc.

Infiltrative tuberculosis.

If focal tuberculosis is characterized by limited spread in the lung, scant symptoms and a fairly favorable course, but prone to chronicity, then infiltrative tuberculosis is not limited to any one area of the lung tissue - it can be small infiltrates, infiltrates that involve an entire segment, a lobe, or the entire lung and both lungs. Naturally, the manifestation of clinical symptoms depends on the volume of lung damage.

Infiltrate is a focus of inflammation in which the exudative phase of inflammation predominates. And since exudation predominates, then infiltration grows rapidly - that is, around this focus of inflammation there is an influx of lymphocytes and leukocytes. Phthisiatricians identify several forms of such infiltrates - they can be:

rounded (usually subclavian infiltrates). Asmann described it in the 1920s. A rounded infiltrate is detected in the subclavian region, but unlike focal tuberculosis, it is always more than 10 mm (usually within 15-25 mm). The infiltrate has a round shape, without clear boundaries - which indicates a fresh inflammatory process.

cloud-shaped - inhomogeneous, involving 1 or 2 segments.

They can occupy an entire lobe of the lung - lobitis

located in one or two segments of the lungs, but along the intertissue gap (that is, limited to the border of the pleura) - perifissuritis.

In contrast to focal tuberculosis, the dependence of the clinical picture on the volume of infiltrate is clearly visible. Since there is infiltration here, the clinic is usually characterized by a clinic of pneumonia. Unlike nonspecific pneumonia, all symptoms depend on the size of the infiltrate. This form of tuberculosis is often called infiltrative-pneumonic, and until 1973 this form was classified. Often, clinical manifestations begin acutely; within 1-2 days the patient’s temperature rises to 39 degrees. The patient is in bed, lying down, limited in activity, and the condition is sometimes serious. This form of tuberculosis, unlike focal tuberculosis, undergoes destruction very quickly - decay of the lung tissue is formed very quickly in these infiltrates, and a cavity with decay is formed. With this form of tuberculosis, the state of the body is hyperergic - the patient is highly hypersensitized to this infection, therefore the exudative phase predominates in the process. The cells phagocytose mycobacteria and are destroyed, releasing large amounts of proteolytic enzymes that lyse caseous masses. Caseous masses liquefy, and these foci are drained by 1-3 bronchi, and the patient coughs up these liquid masses and a cavity is formed in this place. Such patients are massive bacteria excretors. These patients are dangerous to others.

Especially if infiltrative tuberculosis is detected in the form of lobita, where there is a large number of caseous masses, lysis of these caseous masses occurs and patients cough these masses into another lung (bronchogenic spread) - both lungs are seeded very quickly. And in this case, if adequate therapy is not taken, such a patient can quickly be lost.

Infiltrative tuberculosis has its own approach to treatment. First of all, it is necessary to prescribe desensitizing therapy - 15-20 mg of prednisolone is prescribed. For cloudy infiltrate, 30 mg of prednisolone can be prescribed. 3-4 anti-tuberculosis drugs are also prescribed. If 4 drugs are prescribed, then 2 of them parenterally - isoniazid, streptomycin and 2 orally. Or 1 orally, 2 parenterally, 1 in the form of inhalation.

Parenteral administration is extremely beneficial. For lobita, infusion therapy up to 1 liter (since there is dehydration), protein hydrolyzate. It is better to install an anti-tuberculosis catheter.

Outcomes of infiltrative tuberculosis: cure (most often). Subclavian round infiltrates resolve without a trace with the therapy performed. A fibrous patchy area may remain (rarely).

Cloud-shaped (1-2 segments + destructive changes are involved) - after treatment, extensive fibrous-focal fields with deformation of the lung tissue remain (they are registered with the 7th group for life).

Lobitis (extensive caseous changes) - giant decay cavities are formed, as a rule, they become chronic, since this cavity cannot be closed. If such a patient is not promptly referred for surgical treatment, then chronicization occurs first into the cavernous form (even with treatment), then into the fibrous-cavernous form (the most dangerous for others).