4.2.2 Tuberculosis of intrathoracic lymphatic nodes


Bronchoadenitis — disease of lymph nodes of the lung root and mediastinum. At this form of primary tuberculosis mediastinum lymphatic nodes are mainly involved in the process of inflammation. Anatomic structure of the lung lymphatic nodes system belongs to regional lympho-vascular system of the lungs and lymphatic nodes of lungs roots serves as collectors, through which lymph passes. During pathological process in the lungs roots react to inflammatory process. At the same time in the root and in mediastinum lymph nodes, the pathological processes arise irrespective of disease in the lungs.

Clinical signs of tubercular bronchoadenitis.

The course of tubercular bronchoadenitis, as a rule, it begins with signs of acute intoxication with specific clinical symptoms: subfebrile temperature, deterioration of a general condition, and loss of appetite, weight loss, adynamical changes by excitation of nervous system. Sometimes, there is marked sweating. In progression, and especially in small children, occurs bitonal cough (cough of two tones). It causes by compression on the bronchus with increased volume of caseouse necrosis in the lymph nodes. In the adult, in connection with loss of elasticity of a wall of the bronchus, compression is observed very seldom and that only in patients with long term of the diseases, when lymph nodes are massive, dense, containing caseous masses with calcified elements. Among adults, attacks of dry, “hoarse” tickling cough is observed. It is caused by irritation of the mucous of bronchus or perforation of bronchus damaged by tuberculosis. As a result of damage of the nervous plexuses, which are taking place in the zone of tubercular changes, can give rise to bronchial spasm. In small children, the bifurcating groups of the lymph nodes rapidly grows in volume, quickly accrues, and as a result, of accumulation in them of liquefied caseouse masses and extensive perifocal reaction can causes the symptoms of asphyxia. These dangerous symptoms of asphyxia, cyanosis, are accompanied by cyanosis, breath faltering, inflating of wings of the nose and narrowing of the intercostal space. Turning the child to the position on to his abdomen relieves the condition of the child owing to moving forward of the damaged lymphatic nodes.

The analyses of blood — without any features in comparison with hemogram of tuberculosis patient with other localization of the tuberculosis. However at disintegration of the caseouse mass of the lymph nodes and at its rupture into bronchus ESR gives a little higher quantity of leucocytosis to achieve 13000 — 15000.

Detection of MBT.
In flushed water of a stomach, it is possible to find out MBT, usually part of it is present in the sputum and in flushed waters of the bronchus during the rupture of the caseouse mass into the bronchus.

X-ray examination of bronchoadenitis.
The x-ray examination serves good performance for the establishment of the diagnosis of bronchoadenitis. Clinical and X-ray course of bronchoadenitis have two different varieties: infiltrative form and tumour like form.

Infiltrative form meets more often. After a phase of infiltration, at correct treatment rather quickly develops resolution. Lymph nodes are condensed, around them fibrous capsule is formed, on roentgenogram, the calcifications are visibly notify. If the treatment is begun in time, calcification cannot be formed, and on the place of the damaged lymph nodes, condensed scars remain.

Tumourous form is observed in small children, infected with big amount of MBT. Quite often, tumourous bronchoadenitis goes together with tuberculosis of eye, bones, and skin. During the disease, the damage of the lymph nodes undergoes changes, typical to that of tuberculosis. The reversible development of tumourous bronchoadenitis goes more slowly Resolution happens inside the capsule, the caseouse mass gets calcified. Calcinations are formed in big quantity, than at infiltrative form, and on roentgenogram, non-uniform shadows of round or oval form could be revealed. The sites of condensations go together with less dense shadows. Capsule is turned to hyalinosis. The foci reminds of a mulberry or raspberry.

Complications of tubercular bronchoadenitis.
At the complicated course of tumourous bronchoadenitis: massive fibrosis of the root; extensive non-uniformly petrificated lymph nodes, containing remnants of caseouse necrosis with presence of MBT. In this situation the opportunity of tuberculosis reactivation is very high. At favorable course and complete resolution of the infiltrative processes, bronchoadenitis is documented with minute calcifications and higher densities in the lung roots.

Complications of tuberculosis of intrathoracic lymphatic nodes.

In bronchoadenitis, there are possibilities of the damage of bronchus with the formation of fistula between the bronchus and the lymph nodes. At complete infringement of the bronchial passage owing to the blocking of the bronchus by the caseouse mass or compression by its massive lymph nodes, damage by tuberculosis ( tumour like bronchoadenitis) can give rise to pulmonary atelectasis. Complications such as pleurisy, in particular interlobar could be very often. Even after it resolution, the pleura remains condensed of both lobes, producing adhesion. Subsequently adhesion subsides, but such remnants of survived from pleurisy remains for the whole life. In rare cases, when there is a connection of damaged lymph nodes with drainage bronchus, caseous mass comes out, a cavity develops in this place. In chronically course of bronchoadenitis lymphahematogenic disseminations are observed, it is found in both lungs – mainly in the upper lobes. Bronchoadenitis can be a source of hematogenic dissemination.

Treatment of tubercular bronchoadenitis.

Treatment of patients with tubercular bronchoadenitis must be combined, with application of antibacterial drugs and vitamins on a background of sanitary-hygienic regime. The patient can return to his professional work after period of fading and can continue treatment by outpatient method. Early beginning of treatment of tubercular bronchoadenitis in children and in adults and its pedantic realization during long term guarantees recovery of the patient and prevent the complicated course of illness. Intensive specific and pathogenetic treatment quickly brings good results.

Differential diagnosis.
During the establishment of the diagnosis of tubercular bronchoadenitis, it is necessary to differentiate it with bronchoadenitis of another etiology. It is necessary to study well the anamnesis, presence of contact with bacillary patient, results character of the tuberculin tests, transferred diseases, which can be connected with tubercular intoxication or with small displays of primary tuberculosis. Several diseases of the interthoracic lymph nodes have some similarity with tubercular bronchoadenitis.

Lymphogranulamatosis — the widespread damage of the lymph nodes. The character of the damage of the lymph nodes in lympogranulomatosis sharply differs from the damage during tuberculosis. In lympogranulomatosis lymphatic glands get damaged symmetrically and often damaged all groups of the peripheral glands. They are sharply increased, dense, and are not connected with the surrounding tissues. The tuberculin tests are either negative or weakly positive. The wavy increase of temperature is characteristic with its rise and fall, pain in the chest, in extremities and joints. The changes of blood are not similar to the changes in tuberculosis. Anemia, leucocytosis, neutrophylesis and lym[hapeny most often are revealed. Treatment with antibiotic therapy does not give any result. The diagnosis of lymphagranulomatosis should be confirmed by cytological investigation of biopsy material of lymphatic node.

Sarcoidosis — disease of uncertain etiology having signs of infiltrative changes in the intrathoracic lymph nodes. Mainly meets at the age of 20-40 years, more often among females. Sometimes it is difficult to diagnose, as the general condition, despite of duration of disease, remains good, tuberculin probes are negative. Antibacterial therapy does not give effect. In more detail about sarcoidosis is submitted in section of sarcoidosis.

In the adults, the tubercular bronchoadenitis is necessary to be differentiating with the central cancer and lymphasarcoma. At differential diagnosis between tubercular bronchoadenitis and a root form of central lung cancer it is useful to pay attention on the following. The cancer id developing, as a rule, among males of older age. A heavy cough takes place, dispnea, chest pain, signs of large vessels pressure. Enlargement of subclavian lymphatic nodes (Virhov’s glands) are revealed at metastasis of a cancer. Tuberculin tests could be negative. The diagnosis is confirmed at bronchological investigation when elements of the tumor are revealed in biopsy material of bronchi mucous.

On chest X-rays an intensive, of irregular form shadow is revealed at peribronchial development of the central cancer. Tomography can reveal shadow of tumor in lumen of large bronchus, narrowing of its inner diameter, enlargement of intrathoracic lymphatic nodes.
At endobronchial enlargement the tumor quickly can cause obstruction of a bronchi, development of cancer pneumonitis and atelectasis. The hemogram is characterized by left shift in leukocyte formula, ESR (40-60 mm/h).

Lymphasarcoma causes different clinical symptoms to compare with tubercular bronchoadenitis, which it is necessary to differentiate. Patients complain on fever, weakness, sweating, fatigue develops quickly. The patients with lymphosarcoma to compare with patients with tubercular adenitis more often suffer from painful cough, dispnea and chest pains. The hemogram is characterized by prominent lymphapeny, and sharply ESR. Tuberculin tests are negative. In the process of malignancy all groups of lymphatic nodes are involved. Peripheral lymphatic nodes are enlarged and comprise big packets they are dense and painless.

X-ray picture differ at lymphosarcoma differ from tubercular bronchoadenitis by the fact that lymphatic nodes prominently enlarged, massive, having quick enlarged (symptom of smoke tube). Cyto-hystological examination of lymphatic node usually reveals big quantity of lymphoid elements (90-98%), which have enlarge nuclei, surrounded.

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