4.2.3 Disseminated lung tuberculosis


To disseminated forms of tuberculosis refer all disseminated processes in lungs of hematogenic, lymphogenic and bronchogenic origin. According to clinical classification, hematogenic disseminated forms are divided into three basic groups:

  1. Acute disseminated (miliary) tuberculosis;
  2. Subacute disseminated lung tuberculosis;
  3. Chronic disseminated tuberculosis of lungs.

1. The acute military lung tuberculosis

At hematogenicaly disseminated lung tuberculosis diverse pathophysiological disorders and clinical symptoms appeare. The clinic of not advanced miliary tuberculosis is characterized common, not acute functional frustration. They are expressed as loss of appetite, weakness and subfebrile temperature. The patients have a dry cough. In anamnesis there is an indication on contact with bacillary patients, on transferred earlier exudative pleurisy, lymphadenitis. At the acute onset of the disease, rise of temperature till 39-40 C, dyspnea, dry cough, sometimes with expectoration of small amount of sputum take place. At the examination of the patients, marked cyanosis revealed (lip, finger-tips). In percussion the lung sound with tympanic character sound could be revealed. In auscultation the hard or weakened breath, in small amount dry or fine damp rattles is listened, especially in paravertebral regions.

Spleen and liver are moderately enlarged. Marked labile pulse and tachycardia could be revealed. Tuberculin test usually false negative (negative anergy).

The changes in blood are characterized by leucocytosis, monocytosis, eosinopenia, and neutrophils shift to the left, increased ESR. In urine proteins is determined. Radiographic picture of miliary tuberculosis in the first days of disease is expressed by diffused downturn of the lung fields transparency with dullness of vessel picture, appearance of tiny loops as consequences of indurative inflammation. Only for 7-th day of illness, on general view radiograph it is possible to see multiple, rounded, well outlined focuses, located by a chain, by the size of millet. Total dissemination of lung fields is symmetric in both lungs fine equal size focuses. If the process progresses, pleura and meninges could be damaged.

At improvement of the miliary tuberculosis the focuses can completely dissolve and calcified. The quantity of calcified focuses is less, than in the dissemination period, as part of the focuses dissolve. The patients with unrecognized of generalized tuberculosis can die at the phenomena heavy tubercular intoxication, hypoxemia and hypoxia.

Differential diagnostics.
Miliary, subacute disseminated tuberculosis of lungs often should be differentiated with abdominal typhus. At miliary tuberculosis, as well as at typhus there are acute headaches, high temperature, delirium blacked out consciousness. However correct analysis of symptoms, contradicting to typhus, will help to put the correct diagnosis. The typhus begins with gradually developing of weakness and increase of temperature. At typhus observe bradycardia, at miliary tuberculosis — tachycardia. The following points are in support of tuberculosis and against typhus: such symptoms as breathlessness, cyanosis, tachycardia, irregular type fever, absence of dyspeptic disturbances. picture of blood also different at these two diseases: typhus is characteristic leucopenia and lymphocytosis, for tuberculosis, leucocytes within the limits of norm or leucocytosis up to 15 000-18 000, lymphopenia, monocytosis. To the moment, when the Widal’s reaction can solve doubts, it will be positive result only at abdominal typhus. Roentgenograms confirm suspicions on miliary lung tuberculosis. At early diagnostics of miliary tuberculosis it is important to examine fundus of eye, where tubercles could be found out at early stages of the disease.

2. Subacute hematogenicaly disseminated tuberculosis

The signs of this clinical form of tuberculosis are diverse. The functional frustration remind a picture of acute infectious disease, abdominal typhus. The disease can proceed under a mask of an influenza, focus pneumonia. Often hemoptysis is the reason of the patients to seek help from a doctor. The patients address to the doctor also in connection with a tubercular lesions of other organs, for example larynx, when occur voice hoarseness, pain in a throat at swallowing. The course of subacute hematogenic process can be asymptomatic. It could be revealed at preventive fluorographic screenings. The patients complain of small cough with sputum expectoration, high temperature. Physical examination of lungs reveals weak shortening of percussion sound. At auscultation, small quantity of fine bubbly sounds in inter scapular space, pleural rub are listened. At formation of a cavity, as a rule, fine and middle bubbly sounds are listened. Mycobacterium tuberculosis reveal in sputum. Tuberculin tests have hyperergic reaction.

The changes in blood characterized by leucocytosis (12000-15000), increase stub neutrophiles, increase ESR (20-30 mm / h). At X-ray examination numerous symmetrically dispersed fine or large focuses are found out in both lungs, they settle down mainly in the upper parts of lungs. Interstitial lung tissue is represented as condensed fine alveolus net.

X-ray appearance of blood spread origin of subacute pulmonary tuberculosis:

  1. blood spread of TB from the primary lesion (invisible) to form small lesions at the apex of both lungs. Higher oxygen in this part of the lungs encourages the growth of the bacilli;
  2. lesions have become confluent (run together);
  3. cavities has developed in the places of infiltrations. Disease can spread to the middle zone of each lung.

The subacute hematogenic disseminated tuberculosis develops in deferent ways. If the process progresses, the intoxication increases, the focuses merge in pneumonic infiltrations or conglomerates. Hematogenic metastasis appear in other organs. At progressing of miliary tuberculosis, owing to trophic changes in lungs, the disintegration of lung tissue develop characteristic thin-walled cavities. Usually the cavities are multiple, rounded, of identical form and sizes. They are named “stamped”. Sometimes they are located lineally, quite often is symmetric in both lungs. Cavities of disintegration single or multiple of various sizes are formed.

In an origin of cavities plays a role damage of blood vessels, their thrombosis and obliteration. The blood supply of the lung’s damaged sites are broken and in these places destruction is formed. X-ray examination at subacute disseminated tuberculosis is characterized by together multiple fine focuses, confluent focuses in both lungs are determined. Cavities are thin-walled, “stamped”.
Under influence of the chemotherapy temperature reduce, cough and amount of sputum expectoration decrease.

The functional frustration is eliminated; hemogram, ESR and protein fraction of white blood are normalized; mycobacterium expectoration stop. Partial dissolution of focuses takes place. The positive results at treatment could be reached during 9-12 mo.

3. Chronic disseminated tuberculosis of lungs.

Chronic disseminated lung tuberculosis develops at chronically prolongation of the disease and inefficient treatment. The weakness, adinamia, fever (subfebrile temperature) is accompanied by the complaints of the patients on cough with sputum, dyspnea, reinforcing at physical load. Often precursor of chronic hematogenic disseminated lung tuberculosis aggravation is tubercular exudative pleurisy. Precede or accompany it tuberculosis of kidneys, костей or other organs. At the physical examination in lungs, the dispersed dry rattles, fine damp rattles, noise of friction pleural rib are listened , in paravertebral space. The following clinical signs accompany chronic disseminated tuberculosis such as the disturbance of nervous system and cerebral cortex disturbance: psychic lability, irritability, reduction of work capacity, loss of sleep, neurotic reactions are observed. The disturbances of endocrine system: hyper or hypothyroidism.

The patients may have hemoptysis and lung hemorrhage, attacks of asthmatic bronchitis. The signs of lung-heart insufficiency appear, such as cyanosis, tachycardia, dyspnea, hypostatic phenomena in lungs, liver, kidneys, edema of lower extremities. On hemogram neutrophil nuclear shift to the left, lymphopenia, monocytosis, acceleration of the ESR take place. Patients become sputum positive.

On X-ray condensation of lung connective tissue, non-uniform net like and rough bound linear shadows appear. On this background, mainly in the lung upper parts, there are dispersed focuses, of various form, sizes and density. Attributes of emphysema are marked in distal and lower parts of lungs. At progression of chronic hematogenic-disseminated tuberculosis the increase of dyspnea, increase of sputum amount and hemoptysis appear. At lung auscultation above caverns the widespread middle bubbled rattles are listened. The specific damage of the upper respiratory ways, intestines, serous membranes and other organs joins to previously described signs. Under treatment (chemotherapy, pathogenetic treatment) the cough decreases, MBT expectoration stops, fresh focuses and disseminations dissolve.

The lymphogenic forms of disseminated tuberculosis.

The clinical picture of the lymphagenic disseminated tuberculosis proceeds torpid, poorly symptomatic. The clinical symptoms are subfebrile temperature, vegetative frustration, pains in chest, which are connected to pleura damage. The dry cough is marked, occasionally can be limited hemoptysis. The changes in hemogram are characterized by moderate leucocytosis, monocytosis, and shift neutrophiles to the left, acceleration of ESR. MBT find out in the sputum. Tuberculin tests are positive, sometimes are hyperergic.

At physical examination in lungs fine and middle bubble, damp rattles are listened. At X-ray examination of various size, forms and intensity focuses revealed in the upper, middle and near lung roots parts of the lungs. At bilateral process, the focuses are located asymmetrically. Characteristic for the lymphagenic-disseminated tuberculosis is the deformation of lung picture, more often in near lung roots zones caused by lymphangitis. The downturn of the lung field’s transparency occurs for the account of lymphostasis and pleural lays.

The bronchogenic forms of disseminated lung tuberculosis.

For the bronchogenic forms of disseminated lung tuberculosis it is characteristic the presence of the initial focus in lung or in intrathoracic lymphatic nodes at absence of infiltrative focus with disintegration or cavernous lung tuberculosis. At infiltrative process with disintegration or cavernous tuberculosis the bronchogenic dissemination will be a phase progression of the process.

The course of bronchogenic form of disseminated lung tuberculosis is chronic, focuses larger, than at lymphogenic processes, located asymmetrically, the walls of visible bronchi are thicken. For this form is characteristic multistage formation of the focuses and presence of the initial center. Clinical and radiographic picture of the various forms of disseminated tuberculosis reminds a number of diseases, for which is characteristic focus dissemination in lungs. These are infective inflammative diseases, bacterial, virus, fungal lesions of the of lungs, reticulosis, collagenosis and lung tumour.

Differential diagnosis.
The lagest group of lung diseases, to which it is necessary to compare disseminated forms of tuberculosis, make lobular bronchial pneumonia of different etiology (after measles, flu, septic etc.).

Acute miliary tuberculosis could be cured even with meningitis. The treatment should be complex, taking into account all pathophysiological disorders. As a result of treatment comes complete dissolution of the focuses with restoration of normal physiological functions of organism. In some cases the focuses are dissolved partially and becoming indurate and calcified.

The treatment of the patients with disseminated forms of tuberculosis should be complex. The major importance has chemotherapy, in a sharp phase of process it is necessary intravenous introduction of antibacterial drugs. Is shown Long chemotherapy is indicated, up to complete dissolution or condensation of the fresh focuses in lungs. Among pathogenic means of treatment in the sharp period the therapy use of corticosteroids is indicated (prednisone, prednisolone). At the patients with subacute and chronic hematogenic disseminated lung tuberculosis, at presence of disintegration, collapse therapy is indicated – imposing of pneumoperitoneum. If during treatment the cavities in lung are remain surgical methods of treatment could be applied.

Treatment of subacute and chronic disseminated forms of tuberculosis extremely difficult and long-term task. To fulfill this task it is necessary to use complex of all possible medical measures which are carried out in conditions of specialized phthisiatric service.

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