Pulmonary fibrosis: what it is and how to treat it. Development of the fibrous-cavernous form of tuberculosis Video: Surgical treatment of fibrous-cavernous tuberculosis - pleurectomy

Multicomponent antibiotic regimens can effectively cure tuberculosis by destroying mycobacteria, both during reproduction and during the dormant period. This provides a favorable prognosis after long-term treatment. The exception is advanced forms, when the growth of cavities is chronic and there are extensive foci of contamination. With insufficient therapy, fibrous-cavernous pulmonary tuberculosis is a stage preceding the cirrhotic type, in which the lesions are irreversible.

Etiology

Initially, the cause of the development of pathology is infection with a pathogen that belongs to the class of prokaryotes. It is an acid-fast, virulent pathogen that is protected by a three-layer cell wall. The membrane is based on polysaccharides. It is not capable of producing antigenic bodies, but has serological properties. Thanks to the protein compound tuberculin, the pathogen exhibits high resistance, which makes treatment difficult.

Fibrous-cavernous tuberculosis develops due to a previous form, usually infiltrative. There may be several reasons for this:

Deformation processes occur due to the proliferation of connective tissue when scarring is absent or delayed.
Presence of open cavities with a large strain population.
The time period for the development of previous forms of tuberculosis ranges from one and a half to three years.

Pathogenesis

If the cavity formed as a result of infiltrative manifestations does not heal, connective tissue begins to grow around it. Among such areas there are vast zones with a large area of infestation. As a rule, the initial penetration of mycobacteria into the lungs does not manifest any special symptoms. Early detection of the pathogen is quickly stopped, treatment of the disease is successful, the process has no complications.

If the progression of the pathology is prolonged, it develops into fibrous-cavernous pulmonary tuberculosis with characteristic damage to muscle fibers and the formation of tubercles on the bronchial mucous membranes. As a result, caseous necrosis is formed with narrowing and obliteration of the lumens and the occurrence of bronchiectasis. Further development of the disease leads to the formation of huge cavities, which often occupy both lungs.

The cavities consist of several walls covered with a network of capillaries and vessels with signs of an aneurysm. Often, damaged arteries cause bleeding that is difficult to stop. Massive fibrosis does not allow complete scarring; all parts of the pleural tissue are involved in the process. They develop inflammation, areas of fusion, which distinguish fibrous-cavernous tuberculosis. Because of this, mobility is limited, stretching increases and healing is inhibited.

In open caverns, a constant process of division and reproduction of the strain occurs, and the population of mycobacteria rapidly increases. Therefore, an inflammatory process with necrotic signs is maintained in the walls, which is difficult to stop. With each new exacerbation, the following areas are involved in the process, which entails the formation of new disseminated zones. These lesions eventually merge into larger areas, and as a result of destruction, more and more cavities appear.

The cavernous membranes consist of three layers. The caseous part is characterized by melting of tissues and structures. The breakdown and rejection of tissue is accompanied by the formation of cavities through which the organs are filled with air. The granulation part consists of giant epithelial cells. When purulent masses are cleared, a fibrous layer is formed. As drainage functions deteriorate, release becomes impossible. With infiltrative changes, the cavities are not able to close, therefore fibrous-cavernous tuberculosis is accompanied by the formation of replacement tissues. The classification of the pathogenesis of the disease is based on the following factors:

Progressive cavities with blurred boundaries in the decay phase in the presence of infiltrates.
Cavities lined with a granulation layer.
Three-layer encapsulated formations.
The predominance of fibrous walls and necrosis is characteristic of a long-term progressive process.
Residual changes, cleared of granulation masses with partially preserved walls as a result of treatment.

Due to extensive epithelial growths, fibrous-cavernous pulmonary tuberculosis is accompanied by bleeding, which is difficult to stop with a conservative method. Due to the violation of integrity, the vessels do not collapse; the cavities are covered with purulent exudate, which serves as a breeding ground for the proliferation of mycobacteria and other pathogens. As this form progresses, complications often develop - cardiac and respiratory failure, pneumothorax, amyloid dystrophy.

Clinical picture

Pathology can occur in several ways. The first is a limited option, due to successful treatment of the preliminary form, which is characterized by the absence of significant symptoms. The progressive type is characterized by frequent relapses and wave-like manifestations. Periods of remission are followed by moments of attenuation. Despite the serious destructive process, a patient diagnosed with fibrous-cavernous pulmonary tuberculosis may feel satisfactorily for a long time. It is customary to distinguish 3 clinical forms of the disease:

The stable process is accompanied by rare outbreaks, the spread of mycobacteria is insignificant. The interval between exacerbations can drag on for several months or even years. Subject to compliance with the regimen and regular chemotherapy, there are no signs, patients have no complaints.
Progression can be short or long. During outbreaks, the patient suffers from severe intoxication, shortness of breath is accompanied by a cough with sputum. Bloody clots may appear in the discharge. During the inflammatory process, pleurisy develops, there is a lack of appetite, tachycardia, and chest deformation. Next, hypoxemia and pulmonary hypertension appear, and the endocrine and nervous systems are involved in the process.
Complicated pathology is a severe degree of development with decompensated stages, circulatory disorders, and muscle dystrophy. The patient begins to have amyloidosis and multiple pulmonary hemorrhages. This is the most dangerous form of the disease, as the risk of death is very high. In addition, cachexia, arthralgia, and periostitis are often diagnosed.

Diagnostics

The basic principle of identifying this form of pathology lies in an x-ray examination. If light areas are found against the background of darkened areas, this indicates that fibrous-cavernous pulmonary tuberculosis has begun to develop. But the cavities are visible in the image when the melting of the tissues began and air entered the cavity. The shadow has the appearance of a ring with clearly defined solid boundaries. Also signs of the development of fibrosis are the following indicators:

Accumulation of fluid within the lungs
Sclerotic and infiltrative formations in the bronchi, converging towards the caverns
Large, locally fused foci of dissemination with vague contours
Alternating fibrous and emphysema zones
Compaction and deformation of the root and pleural areas
The presence of ectasis with varying degrees of severity and prevalence
Displacement of organs towards the affected side.

Reactions to tuberculin in such patients are moderate. At the time of remission, sensitivity is positive, with progression - negative. Mycobacteria in sputum are constantly sown, but can change. In most cases, they show resistance to the antibiotics used in the treatment process. Therefore, the phthisiatrician often replaces medications.

Biochemical analysis shows an increase in leukocyte and neutrophil elements, while lemphocyte and eosinophil compounds increase. When pneumonia is associated, anemia is observed due to bleeding. Patients are characterized by dysfunction of the pituitary gland, immune and digestive systems.

Since most patients already have a history of tuberculosis, diagnosis of this form is carried out quickly. The only difficulty is differentiation from a lung abscess. Both pathologies have similar symptoms; their distinguishing feature is bleeding. But fibrous-cavernous tuberculosis is usually accompanied by low-grade fever, and with an abscess the patient always suffers from fever. On x-ray, purulent inflammation has no foci, differs in the nature of scarring and the shape of the cavity walls. In addition, the abscess responds well to treatment, and the patient recovers quickly.

Principles of therapy

Previously, before the creation of combination regimens using anti-tuberculosis drugs, a patient with this form of tuberculosis could live no more than 3 years. It should be borne in mind that the healing process of cavities is very slow. If one lung has undergone destruction, it is advisable to perform resection. There are several methods for this, the most effective of which are the following:

Pneumolysis

Surgical intervention involves detachment of damaged pleural and pulmonary tissues by injecting a nitrogenous mixture into the cavity. But such an operation turned out to have low results, so it was decided to perform paraffin sealing. The procedure is carried out through preliminary resection of part of the rib. To prevent fluid and blood clots from accumulating at the site of detachment, regular punctures with additional injection of air are necessary. The formed bubble helps maintain the pneumothorax process in the desired state.

If the operation proceeds without complications, the patient is transferred to outpatient treatment under the supervision of a phthisiatrician. The created air cavity lasts about one and a half years. Thanks to pneumolysis, further growth of fibrous tissue stops and decay stops.

Thoracoplasty

The principle of the technique is that the parameters of the chest decrease, as a result of which elasticity decreases. This creates conditions for compression and reduction of cavities. The fact is that against the background of clinical therapy, cavities rarely heal without consequences. More often, there are no scars, no closure is observed, and a narrow lumen lined with epithelial tissue forms in place of the cavity. Inside it there are granulation formations with traces of necrosis. Such a gap can turn into metastasis during outbreaks of pathology.

Thoracoplasty is indicated when resection of part of the lung is impossible; the patient can be operated on only with stable stabilization. Fresh lesions and infiltrates are extinguished by antibacterial therapy. For limited processes, large-scale surgical intervention is not advisable. For weakened patients with extensive organ damage, the procedure is carried out in several stages. As a result, the condition of patients, even with bilateral intervention, remains satisfactory.

Resection

In the presence of tuberculomas, chemotherapy is ineffective in most cases. Surgery is indicated for all signs of progressive development, symptoms of intoxication, and massive release of mycobacteria. Currently, it is advisable to carry out local resections when cavities are formed within one or two fields, but provided that there is no contamination. The operations are well tolerated by young and middle-aged patients, much worse by older people.

The results of surgical intervention are favorable, mortality is no more than 1%. Recurrent processes and exacerbations are extremely rare. For any operation, preliminary and subsequent antibiotic therapy is required for 6 months to a year. Treatment is carried out in a specialized hospital and involves the use of 3-4-5-component regimens with first- or second-line drugs. The following medications are used for this:

The antituberculosis drug Pyrazinamide remains active in an acidic environment and may exhibit bactericidal or bacteriostatic properties, depending on the concentration. The active substance quickly penetrates into the lesions, where they destroy the cell membranes of the pathogen. Used in combination with other compounds. The dosage is 1-2 g per day, taken in the morning, after meals, with water.
A derivative of isonicotinic acid, isoniazid, has been used to treat tuberculosis for many years. Intra- and extracellular microorganisms are exposed to it, but it exhibits the highest activity against dividing pathogens. It is able to suppress the synthesis of mycolic acid, necessary for the construction of bacterial structures. Dosage – 15-40 mg/kg 2-3 times a week, depending on the age and condition of the patient.
Another antibiotic, Rifampicin, is effective in combination with other drugs. Suppresses the production of polymerase compounds, thereby stopping the reproduction and growth of the pathogen. It is recommended to take it half an hour before meals, on an empty stomach at a dosage of 10 mg/kg once a day.

Prognosis and prevention

The only way to prevent the development of this form of pathology is timely diagnosis and complete treatment of the previous disease. In order to prevent destructive damage to organs, it is necessary to strictly adhere to the doctor’s instructions; it is forbidden to interrupt the therapeutic course. It is necessary to follow a diet, stop drinking alcohol and smoking.

The prognosis is favorable after the operation. But in some cases, intervention is fraught with complications. The most dangerous of them are cirrhotic lung disease, cancer, spontaneous pneumothorax, pleural empyema. In addition, there is a risk of death due to bleeding.

Cavernous pulmonary tuberculosis refers to a chronic form of an infectious disease in which cavities are formed in the lungs, framed by a thin-walled membrane. It is the appearance of cavities that signals the transition of the disease to a complicated chronic stage. In the future, it is possible for nearby tissues to degenerate into fibrous tissue, which is diagnosed as the fibrotic stage.

To identify fibrous cavernous pulmonary tuberculosis, standard examination methods are used in the form of tuberculin tests, x-rays and detection of mycobacteria in the patient’s sputum. Treatment involves hospitalization, long-term chemotherapy, and patient compliance with behavioral recommendations. In some cases, surgical tactics are required as the only way to avoid more serious complications. Detailed information about the clinical picture and methods of infection and treatment of the disease will help you understand the features of the development of fibrous cavernous tuberculosis.

General characteristics

Cavernous pulmonary tuberculosis refers to a separate stage of the development of the disease associated with damage by mycobacteria. A distinctive feature of this form is the formation of light cavities with thin walls in the tissues.

Most often, this type of tuberculosis occurs in groups of adult patients. When diagnosing tuberculosis in children with intrathoracic lymph nodes or primary pulmonary tuberculosis, the risk of cavities is sufficiently minimized.

Cavernous pulmonary tuberculosis becomes a logical continuation of infiltrative, focal or disseminated tuberculosis.

In the absence of adequate therapy, the process of formation of cavities in the affected lungs does not end with the cavernous form. Quite often, fibrous tissue enters into genesis, which is inherently designed to prevent the proliferation of necrosis.

The walls of the cavity are covered with fibrous tissue. Moreover, this also applies to single large cavities or numerous lesions.

The share of fibrous cavernous pulmonary tuberculosis in the total number of diseases is no more than 6%. The consequence of an untreated disease is the development of the final stage in the form of cirrhotic tuberculosis, in which the lungs shrink against the background of significant tissue degeneration.

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Main causes of the disease

The impetus for the development of the destructive process can be various provoking factors. The formation of pathological cavities in the lungs most often occurs in patients with tuberculoma, infiltrative,

In the background:

massive activation of mycobacteria;
reduction of the body's immune defense;
addition of other infectious diseases;
increased sensitization;
exacerbation of chronic diseases;
bad habits and antisocial lifestyle.

Before the formation of cavities in the form of empty cavities, the disease goes through a stage of disintegration, at which areas filled with necrotic substance in the form of caseous masses appear in places of inflammation. Over time, such masses become liquid and are removed from the lungs through the draining bronchi. In the vacated places, empty spaces remain - cavities.

Most often, such voids are filled simply with air. If the drainage system does not fulfill its functions, the cavity fills with liquid.

The formed cavity is covered with a wall formed by the main 3 layers:

The pyogenic layer is the inner shell of caseous mass.
Granular membrane - the middle layer consisting of epithelioid and giant cells.
Elastic capsule - the top layer of connective tissue.

Important ! The diagnosis of cavernous pulmonary tuberculosis is made when single cavities are detected without the presence of fibrous formations and in the absence of significant inflammation.

If multiple cavitary inseminations and the presence of fibrous membranes and changes in the lungs are detected, the next stage of the disease is recorded in the form of fibrous-cavernous pulmonary tuberculosis.

Basic classification of cavernous form of tuberculosis

Chronic tuberculosis of the cavernous type is classified according to the presence of basic morphological changes in the lungs.

In medical practice, several stages and, accordingly, types of disease of this form are considered:

fresh decaying - at this phase of decay, foci are formed in the form of cavities that do not have defined boundaries;

elastic fresh - the next phase of decomposition, in which cavities appear, limited by two main layers: pyogenic and granulation in nature;
encapsulated - this stage is the direct cavernous form, in which three layers of the membrane covering the cavity are formed;
fibrous - the existing membranes of the cavity are covered with fibrous tissue, which is defined as fibrous tuberculosis;
sanitized - occurs when the cavities are completely cleansed of caseous and granulation masses, which corresponds to signs of remission or cure.

There is also a separate classification based on the size of the cavities formed:

with a diameter of less than 2 cm, small cavities are determined;
with a diameter of 2 to 5 cm, I diagnose the average value;
when the size is more than 5 cm, the presence of large cavities is noted.

Based on this classification, doctors determine the degree of irreversible damage to the lung and choose the only correct treatment tactics.

Symptoms of cavernous tuberculosis

Cavernous pulmonary tuberculosis is most often concentrated on one side. This outcome is caused by lack of or inadequate treatment. And after 3–4 months of the course of the disease of other forms, cavities begin to form.

We can talk about a clear, vivid clinical picture only at the stage of decay, when the cough is accompanied by copious discharge of sputum and blood. When listening, wet wheezing is detected in the area of cavities.

When the cavity is fully formed, the symptoms lose their specificity and become scarce.

Patients may complain of:

poor appetite;
weight loss;
breathing problems;
periodic increase in temperature;
constant fatigue.

Such patients are a direct threat to the health of others, since the disease occurs in an open form, and the infection is constantly released with sputum.

It is the presence of mycobacteria in the sputum that allows the open form.

With a latent course, a characteristic sign of lung destruction is bleeding that occurs for no apparent reason in an absolutely healthy person. Pulmonary hemorrhage occurs if the location of the cavities coincides with the location of the pulmonary arteries.

Complications can arise when cavities break through into the pleural cavities, which gives rise to the formation of pleural empyema and bronchopleural fistulas.

The duration of development of cavernous tuberculosis in some cases reaches 2 years. If the outcome is positive, scars and sanitized cavities form in place of the cavities. The disease can follow the path of development of tuberculomas, single tuberculosis foci. Otherwise, when a fibrous membrane begins to appear, they speak of the development of fibrous-cavernous pulmonary tuberculosis.

Adequate diagnostic methods

For patients with tuberculosis, the diagnosis of cavernous type is not primary. Typically, such patients have been treated by a TB doctor for a long time or have had tuberculosis in the past.

It is quite rare to encounter such advanced forms during initial diagnosis or after a preventive fluorographic examination.

Physical examination methods are not very informative. Already formed caverns do not “speak” of their presence when listening, which gave rise to calling them “silent”.

There are no significant abnormalities in blood tests other than lymphocytopenia, increased ESR and increased neutrophil granulocytes.

X-ray photographs show ring-shaped shadows, giving round and oval shapes in the periphery. It is these signs that provide the basis for further examination and clarification of the diagnosis.

Differentiation is carried out with diseases similar in X-ray signs, first of all, suspicions of cancer or lung abscess, limited pneumothorax are removed.

For this purpose, additional laboratory and endoscopic examinations are carried out.

A huge number of mycobacteria are found in sputum.

Bronchoscopy is performed if it is not possible to obtain sputum naturally in a volume sufficient for examination. In addition, bronchoscopy allows you to identify inflammatory processes in the bronchi, which do not allow the cavities to close.

The same examination methods are acceptable for detecting fibrous cavernous pulmonary tuberculosis.

How is the treatment carried out?

Since patients with cavernous type tuberculosis are too contagious, all anti-tuberculosis measures are carried out in a hospital setting.

To obtain a therapeutic effect, such patients require an increased anti-infectious attack. Therefore, 3–4 medications are prescribed simultaneously. Moreover, along with oral administration and intravenous administration, insemination of the bronchi and administration of drugs directly into the cavities is carried out. Antibiotics are commonly used Isoniazid, Ethambutol, Rifampicin, Streptomycin.

In addition to chemotherapy, the patient is prescribed therapeutic exercises, physiotherapy in the form of ultrasound, laser therapy and inductothermy.

If bacterial resistance to the drugs used is suspected, fluoroquinolones and kanamycins are added to the treatment regimen.

If the treatment is chosen correctly, then after 4–6 months you can expect improvement. At a minimum, bacterial production and cavity size should decrease. If the course is favorable, the cavities close and scar.

When conservative treatment does not produce positive results, resection of the affected part of the lung is performed.

After therapy in a hospital, the patient requires continuation of therapy, but at home or in a sanatorium. In the future, the tuberculosis patient remains under observation with periodic medical examinations and outpatient treatment.

Usually the prognosis for cavernous tuberculosis is favorable. Small cavities can completely close and even scar under the influence of therapy. In the presence of walls that are disloyal to therapy, periodic filling of the cavities with masses of caseous origin is possible. Against the background of such relapses, false tuberculomas are formed.

An unfavorable prognosis is rare and is associated with suppuration and progression of tuberculous processes.

Fibrous-cavernous pulmonary tuberculosis is a chronic disease that manifests itself in the form of the formation of hollow cavities on the surface of the organ. This pathology is diagnosed in 7% of patients with diagnosed tuberculosis and is quite dangerous. This is due to the fact that when cavities form, a large volume of the organ is affected, resulting in difficulty breathing.

Fibrous-cavernous pulmonary tuberculosis develops against the background of penetration into the body of bacteria that are resistant to an acidic environment. They can be found not only in soil or water, but also in living organisms. The disease begins to develop as a result of a decrease in protective forces.

Pathology is characterized by the presence of pathogenicity, which manifests itself in the ability to be transmitted. When making a diagnosis, many patients are interested in whether this form of tuberculosis is contagious or not? It is this property that poses a great danger to others.

The disease can also change shape depending on environmental factors. Once an infection enters the body, inflammation begins and spreads. In this case, the disease takes on a necrosing form.

The cavernous form of pulmonary tuberculosis is the next stage of the disease. An infiltrative type begins to develop, which is not contagious. It is the result of the spread of pathogenic microorganisms against the background of the penetration of a primary infection.

It is worth considering that a small number of pathogenic microorganisms are present in the body of every person. With fibrous-cavernous pulmonary tuberculosis, the following occurs:

Fibrous sclerosis.
Increased airiness.
Rejection of dead tissue.

The pathology is characterized by a wave-like course, when periods of remission and exacerbation replace each other. Many patients at the initial stages of development do not notice the symptoms that have arisen; the pathology is mild.

In medicine, two forms of fibrous-cavernous pulmonary tuberculosis are known:

Limited. The pathology has a stable course. Treatment is carried out with chemotherapy, which gives positive results. But the period of exacerbation occurs after several years.
Progressive. The disease develops rapidly and is accompanied by pronounced symptoms. Patients complain of fever, dry cough and bleeding. It is also possible that a secondary infection may occur due to decreased immunity.

With a progressive form, dry skin, muscle atrophy and sudden weight loss are also noted. Patients develop bruises under their eyes. Outbreaks of fibrocavernous pulmonary tuberculosis are characterized by pulmonary insufficiency, and the skin becomes sallow in color and the liver enlarges.

Clinical picture

Cavernous pulmonary tuberculosis, depending on the nature of the course, can manifest itself in the form of shortness of breath, constant weakness and the release of large amounts of sputum.

The patient's condition is often assessed as satisfactory. But with extensive damage to the lung tissue, it is characterized as moderate.

Patients experience a slight increase in body temperature. Indicators can increase to 37 degrees. Also, when diagnosing, the doctor pays special attention to the presence of the following symptoms, since treatment directly depends on the clinical picture:

Weakness and rapid weight loss. The skin becomes moist and acrocyanosis occurs.
With the prolonged development of pathology, conditions that are dangerous to life and health, such as cachexia, can develop. It is characterized by exhaustion of the body.
The chest area takes on the shape of a barrel.
On the side affected by the pathological process, a temporary or permanent retraction of the cavities of the subclavian or supraclavicular type is established.

In addition, cavernous pulmonary tuberculosis is determined by the lag of the infected area of the chest during respiratory function.

Over time, the disease is characterized by an undulating course. At the same time, foci of inflammation and cavities begin to form on the surface of the lungs. A dangerous sign is the constant production of sputum, which contains pathogenic microorganisms. They negatively affect body functions, including respiratory.

As the inflammatory process spreads, the patient’s general condition worsens, and the risk of complications such as respiratory failure and the appearance of blood clots in the sputum increases.

Diagnostics

Cavernous pulmonary tuberculosis is diagnosed based on clinical manifestations and external examination. To confirm the diagnosis and establish the nature of the course of the disease, the following are prescribed:

Bacterioscopic examination of sputum. Necessary to identify the type and number of bacteria.
Urine and blood tests and tuberculin test.
Radiography.
Tomography.

X-ray examination helps to determine the presence of specific signs. The type of tuberculosis is determined based on the images obtained. An indirect manifestation of the disease includes a horizontal shadow that is located inside the cavity. The image also shows the draining bronchi, which represent two shadows.

Treatment

Timely therapy and the use of modern drugs make it possible to achieve resorption of the fluid located in the cavities. But in cases where a large amount of it is established, surgical intervention is performed.

When diagnosing fibrous-cavernous pulmonary tuberculosis, patients are advised to take Streptomycin. The antibiotic is used only as prescribed by a doctor in the indicated dosages. Prednisolone and Phtivazid may also be prescribed.

The course of therapy is three weeks. During this period, the patient must be under the supervision of a doctor in a hospital. Experts recommend stopping smoking and drinking alcohol. This will help increase the likelihood of recovery and eliminate the development of complications.

Cavernous pulmonary tuberculosis, when treatment was started in the later stages, also has the ability to be cured. The main condition is complete, continuous and comprehensive treatment.

But the healing process of cavities is quite long. If indicated, surgical intervention is performed. This involves excision of part of the lung.

The prognosis for life after therapy is favorable. Patients manage to return to normal life even after surgery.

Fibrous-cavernous pulmonary tuberculosis is also a serious disease that, if left untreated, can cause respiratory failure. In case of timely treatment, it is possible to stop the pathological process and significantly increase the patient’s life expectancy.

Even at the beginning of the last century, tuberculosis (consumption - obsolete) was almost 100% fatal. Modern medicine has the means to treat patients with tuberculosis, but poor social conditions or inattention to one’s health still leaves a significant number of patients with severe forms of the disease.

What is fibrocavernous tuberculosis

The fibrous-cavernous form is one of the last stages of tuberculosis. The destructive process in the lungs occurs chronically, as a result of which cavities (cavities) of a specific structure are formed in the lung tissue. In the fibrous-cavernous form, the cavities are enclosed in a fibrous capsule. The fibrous form is characterized by a three-layer structure of the cavity walls:

The internal one is caseous, contains melted necrotic tissue.
Granulation – altered tissue with a granular structure.
Fibrous - connective tissue, clearly demarcated wall of the outer wall of the cavity.

Connective tissue changes are also observed in nearby lung tissues.

In the caverns there are tissue decay products that are expelled (sputum). With the development of the destructive process, nearby blood vessels are involved in necrosis. The walls of the vessels are perforated, and therefore blood is present in the sputum (hemoptysis).

Deeper ulceration of the vessel can lead to bleeding, which in turn is fraught with aspiration pneumonia. General bleeding leads to death - drowning in one's own blood.

Features of the disease

The disease is characterized by an undulating course: periods of remission are followed by relapse. The patient's condition during the period of improvement is assessed as satisfactory, during the period of exacerbation - moderate-severe.

Cavernous tuberculosis as a step towards the development of fibrous-cavernous pathology

Cavernous capsules are formed due to necrosis of the affected areas of the lung. Next, the causative masses are liquefied and removed outward by the draining bronchi. A void filled with fluid, pus or air forms at the site of the lesion. As a result of the progression of the disease, this cavernous stage becomes fibrous-cavernous: the capsule is overgrown with fibrous tissue, acquiring a more rigid shell.

Fibrous changes also occur in the nearby lung parenchyma. It is worth noting that any form of tuberculosis can lead to the cavernous form (in the absence of treatment or inadequate therapy): infiltrative, dissimilated, etc.

Symptoms of the disease

The undulating course of the process is characterized by seasonality: periods of relief for patients in summer and winter, deterioration of the condition in spring and autumn. During the period of remission, the symptoms of the disease are much weaker:

Weakness;
Cough with phlegm;
Low-grade fever;
Shortness of breath (heart failure).

As destruction progresses, blood appears in the sputum. Further, there is an increase in symptoms in a negative direction, loss of appetite and, accordingly, body weight - up to dystrophy or cachexia. In addition, complications appear - damage to nearby organs and systems, giving symptoms characteristic of their pathology.

Causes of the disease

The fibrocavernous form is more often diagnosed in adults. The destructive process progresses:

Due to massive desemination (contamination) by pathogenic microorganisms.
Incorrect treatment (or lack thereof) of the previous stage of the disease.
Low immunity.
Weakening of the body due to bad habits (smoking), unfavorable environmental conditions.

The appearance of new cavities and the further development of tuberculosis is facilitated by bronchogenic contamination: the caseous contents of the cavity (sputum) contain a large number of bacteria, which spread through the bronchi draining the cavity (the mouth of the bronchus is part of the cavity capsule) to other parts of the lung. In this case, the lesions are located in the upper lobes, forming infiltrates and microperforations of the bronchi near the bronchial lumen.

In addition, the infection can spread:

Hematogenously - through the bloodstream;
Lymphogenic – through the lymphatic system.

Through these routes, seeding of organs and tissues remote from the source occurs, such as kidneys, bones, eyes, etc.

Main phases of the disease

The fibrocavernous form is diagnosed if a cavena with a formed fibrous membrane is present. Depending on the size of the lesion, the number of cavities, and associated complications, several clinical forms are distinguished:

Stable shape with a single fibrous capsule. Characterized by rare short outbreaks and a long period of calm.
Slowly progressive form - prolonged and/or frequent exacerbations with short periods of calm.
Progression of destruction with involvement of neighboring organs of the bloodstream and complications in the form of hemoptysis and periodic bleeding. The clinic presents with aspiration pneumonia and bronchiectasis changes.
Severe destructive changes in the form of a huge cavity formed by the fusion of several extensive fibrous lesions, as a result of which the lung is deformed. The extreme form is characterized by bone deformations (barrel chest), displacement of nearby organs, and cachexia.

Note: The clinical form with periodic bleeding was previously diagnosed as hemophthisis (blood consumption).

Frequent complications

The fibrous-cavernous form is dangerous in epidemiological terms, since the patient’s sputum contains a large number of pathogens. This moment is dangerous for the patient himself: with bronchogenic and hematogenous turbidity, mycobacteria infect an increasingly larger area of the organ, and the disease also affects other human systems:

Brain;
Intestines;
Osteoarticular apparatus;
Kidneys, etc.

Damage to organs and systems gives rise to specific symptoms inherent in the pathology of the corresponding organs: tuberculosis of the meninges, tuberculosis of the bones, etc. Purulent necrolysis of newly formed foci results in massive intoxication, inflammation, and complications in the form of purulent foci (pleurisy, empyema). Displacement of the mediastinal organs and tissue deformation further aggravate the symptoms and course.

Diagnostic methods

The diagnosis is made based on:

The patient's complaints are cough with sputum, fever, weakness, shortness of breath, sweating.
Examination - pallor of the skin, thinness, circles under the eyes, deformation of the chest (barrel-shaped), recession of the sub- and supraclavicular fossae.
Auscultation - wet and dry rales are heard. Above the giant caverns there are sharp and piercing sounds arising from the calcification of the walls.
Percussion - tapping produces a dull, shortened sound over the affected areas.

More often, the fibrous-cavernous form at the initial diagnosis is found in patients with a history of social disadvantage - in the initial stages and during the period of remission, the patient’s condition is satisfactory and he does not (does not have the opportunity to consult) a doctor.

The complex of additional examination and diagnostics includes:

Bacteriological analysis of sputum - to confirm the diagnosis of tuberculosis and determine the type of mycobacterium.
Complete blood count – increased ESR, leukocytes, lymphopenia. Anemia is present if bleeding has occurred.
Urinalysis - increased protein levels may be observed.
X-ray of the lungs - the images show cavities, their size, quantity, shape, fibrous cords are visible, the presence of fluid in the cavities in the form of horizontal lines.
Tomography - complements the picture of tissue damage, allows you to see deformations that are invisible on the R-image due to the abundance of fibrous inclusions and new foci of necrosis.

Based on the obtained picture of the disease, treatment tactics are chosen.

Principles of therapy

Treatment of the fibrous-cavernous stage is long-term. Closure of cavities during drug therapy occurs in 19% of cases (according to some authors, even less - 8 - 12%). In advanced cases and with the presence of complications (empyema), surgical and complex treatment is required.

Carrying out chemotherapy

Another goal of drug treatment (in addition to recovery) is abacillation - to stop further destruction, dissemination, and prevent the epidemiological danger of the patient.
There are several chemotherapy strategies: short-term (6–8 months) and long-term. Taking anti-tuberculosis drugs should be combined with measures to increase the body's defenses:

diet;
improvement of living conditions;
giving up bad habits (alcohol, smoking, drugs).

Important! Due to the lack of discipline of patients - the contingent does not have social responsibility - drug-resistant strains of bacteria arise. If the formula for taking the drug is not followed, mycobacteria become resistant to it.

If a drug-resistant form of tuberculosis is diagnosed, chemotherapy is supplemented with surgical interventions.

Surgery

Excision of a single cavity gives a positive result. But more often, due to the massive presence of mycobacteria in the cavity of the cavity, the destructive process is extensive. In this case, only removal of the foci does not produce results; the probability of death is high with extensive resections.

For the treatment of fibrocavernous tuberculosis, complicated by a drug-resistant form and concomitant pathologies, surgery is combined with various procedures according to individual schemes:

Preoperative chemotherapy + aerosol therapy + intravenous laser irradiation of blood (BJIOK) + laser treatment of cavity walls using a videoscope (BJIO) + resection surgery.
LEP (local extrapleural pneumolysis) + cavernotomy + laser treatment of the walls of the cavern, draining bronchi + final operation.

The choice of regimen and methods is selected taking into account all the nuances of the disease.

Disease prognosis

Mortality is quite high for the last stages of the disease. However, if you follow all the doctor’s recommendations, sleep and diet, giving up addictions allows you to count on a successful outcome.

Preventive measures

To protect yourself from a disease that claims lives even in the 21st century, you must comply with the following conditions:

Do not neglect primary vaccination of children;
Lead a healthy lifestyle that promotes strong immunity;
Follow sanitary rules when living with a patient with active tuberculosis;
Attentive attitude to your health, timely access to a medical institution;
Nationwide - mandatory medical preventive examination upon hiring, annual medical examination at enterprises;

Providing tuberculosis patients with adequate treatment, sanatorium-resort recreation, and separate housing (while living in a densely populated area) will help avoid epidemiological situations.

Fibrous-cavernous tuberculosis is a deadly disease (including for others). Only modern techniques, coupled with close cooperation between doctor and patient, and careful execution of prescriptions, provide not only hope, but a complete cure.

Pathogenesis of the development of fibrous-cavernous tuberculosis
How is fibrocavernous tuberculosis diagnosed?
Treatment of fibrous-cavernous tuberculosis

Fibrous-cavernous is a chronic form of the disease, accompanied by the appearance of cavities surrounded by tissue of fibrous origin, as well as degenerative changes in the surrounding surfaces of the lungs. Among other types of tuberculosis, the fibrous-cavernous form occurs in approximately 5-10% of cases. Cavities, which are the main indicator of the transition of the disease to a chronic form, are formed as a result of the necrotic process occurring in the lungs under the influence of pathogenic mycobacteria.

Fibrous tissue is a consequence of the body's attempts to prevent the process of proliferation of the area of necrosis. It is worth noting that fibrocavernous is not an independent form, but develops against the background of another type of this disease. Most often, the fibrous-cavernous form occurs against the background of infiltrating pulmonary tuberculosis. Fibrous cavernous pulmonary tuberculosis is dangerous because it can turn into cirrhotic, accompanied by significant replacement of healthy tissue and cause a decrease in lung volume and pulmonary failure.

Fibrous-cavernous tuberculosis can develop as a result of the progression of any other form of this disease. After Mycobacterium tuberculosis enters the lungs, as a rule, minor tissue changes are observed as the disease progresses, but if adequate measures have not been taken to relieve symptoms and eliminate pathogenic microflora, the disease may be complicated by the appearance of cavities and fibrous tissue. During the normal course of the disease, cavities usually do not scar, so they do not cause significant damage to the lungs.

However, in the case of fibrocavernous tuberculosis, everything is different, since the caverns have a tendency to scar, which provokes an uncontrolled proliferation of connective tissue. Over time, the processes of proliferation of fibrous tissue lead to deformation of the cavities themselves. This process in medical practice is known as cavity aging, since it is extremely time-consuming and takes about 1.5-3 years. Thus, fibrocavernous tuberculosis is diagnosed when several cavities are found in one or both parts of the lungs, surrounded by a significant ring of fibrous tissue that has replaced normally functioning pulmonary tissue. The wall of the old cavern has a three-layer structure, including:

caseous layer;
granulation layer;
fibrous layer.

Despite the complex structure, it must be taken into account that in fibrous-cavernous tuberculosis, fibrous tissue still predominates, due to which the walls of the cavernous formation have a density similar to cartilage. In addition, around the neoplasm there are always areas of proliferation of fibrous tissue, spreading to the bronchi and blood vessels, which contributes to severe deformation of healthy cells. The shape of cavernous formations can be:

rounded;
slit-like;
geometrically incorrect.

In rare cases, cavities can be represented by a complex system of cavities and be complicated by damage to the bronchi that drain them.

A detailed examination of the cavity reveals that the caseous layer in this form of the disease does not resolve, as is often the case with other variations of pulmonary tuberculosis.

In this case, the cavity is not cleaned and continues its destructive effect on healthy lung cells. The greatest danger is the erosive effect of the neoplasm on the blood vessels that permeate the lungs, since if one of them is damaged, there is a high risk of developing severe pulmonary hemorrhage and asphyxia as a result.

If a complication such as pulmonary hemorrhage develops against the background of fibrocavernous lesions, in most cases immediate surgical intervention is required, since conservative methods of treatment are usually ineffective. Fibrous-cavernous pulmonary tuberculosis develops over a long period of time, so it may subsequently be accompanied by disseminated areas of small foci of caseous tissue that are located outside the cavern, as well as epithelioid cell granulomas and infiltrates that do not have clear boundaries. It is these tissue changes, observed in the final stages of the disease, that cause a strong decrease in the area of healthy lung tissue and the development of respiratory failure.

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Symptomatic manifestations of fibrocavernous tuberculosis

The main symptoms accompanying fibrous cavernous pulmonary tuberculosis do not differ from those that occur with other forms of this disease. Most patients complain of:

severe cough;
shortness of breath;
general weakness;
release of a large amount of sputum.

In addition, low-grade fever may be present for a long time. However, despite the seriousness of lung damage, the condition of most patients with fibrocavernous tuberculosis remains stable and satisfactory for a long time. The progressive stage of the disease is always accompanied by:

severe weakness;
loss of body weight;
increased skin moisture;
acrocyanosis.

If the progressive process has been going on for a long time, cachexia may develop. The chest changes its shape to barrel-shaped. If one lung is affected, then on its side the subclavian and supraclavicular cavities may sink, and in addition, there may be a lag in the rise of the chest during breathing.

Breathing in most people suffering from fibrocavernous tuberculosis is bronchial with obvious moist rales. At later stages of lung damage, the following may be observed:

chest pain;
rapid heartbeat;
hemoptysis;
profuse pulmonary bleeding;
muscle atrophy due to lack of oxygen;
sagging skin;
dry skin;
muscle weakness;
premature appearance of wrinkles.

The disease can occur in 2 main types. In some cases, after therapy, stable remission is achieved, and the disease may stop progressing for many years. In other cases, it is not possible to achieve long-term remission with the help of drug therapy, so the disease constantly manifests itself in strong and long periods of exacerbation. With this variant of the course of the disease, the life of patients is significantly shortened.