The term lung tuberculoma unites aetiologically various capsulated caseous focuses more than 1 cm in diameter cavities. Tuberculoma can be single or multiple. Distinguished small tuberculoma (up to 2 cm in diameter), average (2 — 4 cm) and large (more than 4 cm in a diameter). Three clinical variants of tuberculoma course are allocated:
- progressing, described by occurrence at any stage of illness of disintegration, perifocal inflammation around tuberculoma, bronchogenic dissemination in surrounded lung tissue;
- stable — absence of tuberculoma rentgenological changes or rare aggravations without signs of tuberculoma progressing;
- regressing tuberculoma is characterized, by slow reduction in its size with the subsequent focus or group of focuses formation on its place, and of the field of indurations or combination of these changes.
The proportion tuberculoma among all forms of lung tuberculosis make 6 — 10 %. It is explained that large infiltrative pneumonic processes under influence of treatment and the increase of a host resistance becoming limited, are condensed, losing the aggravated course. Process recovers not completely, the precisely outlined dense formations remain in the places of infiltrations.
Clinical signs.
As tuberculoma in itself is a parameter of high body resistance, frequently patients with this form of lung tuberculosis easy reveal casually, at fluorography examinations, routine examinations, at presence of other diseases. Practically the patients do not show complaints. At tuberculoma usually symptoms of intoxication, peculiar to tuberculosis: weakness, weight loss, sweating, cough, raise of temperature are absent. There are periods of expectoration of a big amount of sputum with inclusion of caseous grains.
At physical examination of the patient any pathological signs in lungs often usually are not presented. The crackles are listened only at massive inflammation with widespread infiltrative changes around tuberculoma or it’s disintegration.
Radiographic image of tuberculoma looks like rounded shadow with precise contours. Inside of the shadow circle form of enlightenment, boundary localized could be observed due to disintegration. Sometimes there are perifocal inflammation and small amount of bronchogenic focuses, and also calcification sites. Calcinated lymphatic nodes could be revealed In lungs roots.
The picture of blood without peculiarities, sometimes at acute stages moderate acceleration of ESR observed. Mycobacterium tuberculosis is not found in sputum at stable course of tuberculoma, but at presence of disintegration bacilli expectoration meets if there is connection with drainage bronchus.
The tuberculin tests.
The patients with lung tuberculoma in most cases react positively on tuberculin — of test Mantoux usually is sharply positive.
Treatment.
At the background of chemotherapy the tuberculoma is regressing or proceeding chronically without any aggravations among the 80% of patients. If in tuberculoma the disintegration is long kept and the patient continues to expectorate MBT, and prolong therapy does not give desirable results, the surgery intervention is recommended.
Surgical treatment.
Usually operation is made with the minimal removal of lung tissue — segmenal resection. The surgical treatment is shown also in cases, when there is no certainty that the patient ill with tuberculosis and it is difficult to distinguish tubercular tuberculoma from other lung diseases.
Differential diagnostics.
Rentgenological picture of tuberculosis lung tuberculoma — isolated rounded focus in lung fields — is characteristic for many diseases. Practically more often the patients have lung cancer, benign tumors, abscess pneumonia, parasite lung diseases. To distinguish one disease from another, it is necessary to collect detailed anamnesis, carefully to examine all organs and systems of the patient.
It is especially important the x-ray examination. Very important to investigate sputum for MBT content, atypical cells or fungi. In some cases lung biopsy is recommended. The highest development has received brocnhological examination with catheter biopsy, and puncture of bifurcation lymph nodes. Anti-tuberculosis treatment ex juvantibus is useful and if the focus in lungs under the influence of specific treatment decreases, it testifies its tubercular origin.
Complex application of rentgenological, tool palette and laboratory methods of investigations allow to establish the correct diagnosis.