SECONDARY TUBERCULOSIS

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SECONDARY TUBERCULOSIS

• LECTURE
• doc. Kravchenko N.S.

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DISSEMINATED TUBERCULOSIS - APPERARS DURING
LYMPHOHEMATOGENOUS DISSEMINATION OF THE INFECTION
AND IS CHARACTERISED BY BILATERAL SYMETRIC FOCAL
LESION, WHICH IS LOCALISED IN SUPERIOR AND
CORTICAL PARTS OF LUNGS. THERE IS ACUTE,
SUBACUTE AND CHRONIC DISSEMINATED TUBERCULOSIS
OF LUNGS. THIS FORM OF TUBERCULOSIS AFFECTS
BONES, KIDNEYS, GENITAL ORGANS , LARYNX, PLEURA,
MORE FREQUENTLY.
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PPATHOGENESIS PPATHOGENIC FACTORS ARE 1.   -
Presence of tuberculous infection in the
organism. 2.   - Bacteriemia. 3.   -
Hypersensibilization and hyperpermeability of
pulmonary vessels. More frequently mycobacteries
appear in blood from affected intrathoracic
lymthatic nodes. Through thoracic duct
subvclavian vein in right ventricle and futher in
pulmonary bifurcation and lungs.
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Ways of MBT spreading. 1 haematogenous 2
lymphogenous 3 - bronchogenous
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Miliary tuberculosis
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TABLE 1. Organ
Involvement in Miliary Tuberculosis at Necropsy
Organ ( involved)
Spleen 86
Liver 91
Lungs 100
Bone marrow 24
Kidneys 62
Adrenals 14
Eye
Thyroid 19
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AS TO CLINICAL PROGRESS MILIARY TUBERCULOSIS IS
CONDITIONALLY DIVIDED INTO
-   LUNG - 
TYPHOID
- MENINGEAL
- SEPTIC
FORMS.
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FIGURE 1. Chest radiograph of a patient with
miliary tuberculosis. Note the extensive,
symmetrical distribution of 2- to 3-mm lesions
throughout both lungs.
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FIGURE 2. Close-up view of the chest radiograph
in Figure 1. Note the uniform distribution of
nodules throughout the lung parenchyma.
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Subacute disseminated tuberculosis
This form of the tuberculosis develops during
decreased resistance of the organism, in senile
age, during immunodepression therapy.
Pathologic anatomy. Subacute disseminated
tuberculosis appears during affection of
intralobular veins and intralobular branches of
pulmonary artery. It results formulation of
great simetric focuses (5-10 mm) in the superior
parts of pulmonary fields.
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Clinical picture. The start of
disseminated tuberculosis can be acute or
gradual. In case of gradual start there are such
symptoms fatiquabiliti, general weakness, poor
apetite, dry couph, then pus-mucus couph, blood
sputum, chest pain, dyspnea. General state
of the patient changes for the worse, develops
circulatory insufficiency, caused by overload of
right heart chambers. In some cases onset
signs can be larynx lesion (painful swallowing,
hoarse voice) or kidneys affection. Objective
investigation is characterized by symmetric dull
sound under upper and middle pulmonary parts,
auscultation - of harsh or vesicular-bronchial
breathing, moist fine bubbling rales.
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Laboratory investigation. Hypochromic
anemia, leucocytosis (12-17x109), neutrophils
elevation (10-15), lymphopenia, monocytosis,
elevation of the erythrocyte sedimentation rate
are observed in blood picture. During distruction
process mycobacterium in sputum can be observed.
Mantus test is positive. Negative unergic
process appears during progressive of the
process. X-ray examination. It is
characterized by large symmetric focal shadows
with uneven outlines, total or subtotal
affection. These X-ray changes are typical
and imitate the picture of dropping snow. Then
appear lightings with irregular shape situated
symmetrically in the upper lung segments.
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Disseminated lung tuberculosis (subacute)
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Disseminated lung tuberculosis (subacute)
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Stamped cavern in the apper part of the right
lung
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Chronic disseminated tuberculosis of lungs.
Appears in case of not entirely effective
therapy of the subacute disseminated
tuberculosis, its observed more frequently as
independent form. Characterized by presence of
temporary remission of a disease and acute
condition, which is caused by bacteriemia,
dissemination and infiltrating changes in lungs.
Pathologic anatomy. The process has
apica-caudal dissemination calcific focuses are
situated in the upper segments of lungs, but
there are lower fresh focuses. Symmetric cavities
are formed in the upper segments, emphysema
prevails in lower segments.
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Chronic disseminated lung tuberculosis
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X-ray examination. During hematogenic
dissemination on the X-ray we can observe
symmetrically situated focal shadows with weak
intensity and unclear outlines of shadows.
Typical X-ray picture of chronic disseminated
tuberculosis formulates during long course
multishaped focal shadows, with different
intensity in superior and median segments of
lungs, deformation of the lung picture. In the
inferior segments we observe particulary clear
lung field and poor lung picture, wich is caused
by emphysema. Old focuses are situated in the
superior segments, they are more intensive with
well contured outlines. Fresh focuses are in the
inferior segments, characterized by low
intencity. Deformation of the roots of lungs with
superior disposition ("sign of willow branches")
is observed.
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Chronic disseminated lung tuberculosis
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Differential diagnosis. More frequently
differential diagnosis carries out with -
bilateral focal pneumonia, - carcinomatosis
-silicosis - sarcoidosis -pulmonary congestion
For the comfirmation of diagnosis of
the tuberculosis it is neccessary to pay
attention on contact with affected persons,
enduring of primary tuberculosis, pleuritis,
focuses in the superior and cortical segments.
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Bilateral nidus pneumonia
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Sarcoidosis of the lungs and intrathorasic limph.
nodes
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Sarcoidosis of the lungs and intrathorasic
limph. nodes
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Carcinomatosis
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Lung stagnation phenomena
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Lung stagnation phenomena.
Left-side transsudate
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Focal ( Nidus) lung tuberculosis (FLT)
In this form of tuberculosis, foci of specific
inflammation are formed in the lungs with a size
up to 1cm, single or multiple, 1-side or 2-side,
localized not more 1-2 segment.

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FLT is divided into 1- Soft focal (acute) with
fresh foci of exudative or productive character
2 - Fibrouse focal (chronic) at which foci are
surrounded with a connective tissue capsule,
sometimes with elements of calcination but
places of active inflammative process could be
found. Lung tissue is sclerotized there is
possible bronchial deformation, and pleural
layers. Fibrous-focal tuberculosis may be the
next stage of development of soft-focal
tuberculosis or involution of other forms.
   
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• fig. 1 Focal lung tuberculosis

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fig.2 Roentgenogram. Focal lung tuberculosis
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Determination of activity of
tuberculosis process Active are such
tuberculosis change at which specific process is
not finished and may progress or regress. It must
be treated. For determination of process activity
these criteria are used. .

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The most informative criteria of activity of
tuberculosis process - Finding of
MBT - X-ray criteria -
Involution of the process under the test
treatment.
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Infiltrative lung tuberculosis (ILT)
ILT is a zone of specific inflammation mostly of
exudative character, with size more than 1 cm,
with ability to progressing and destruction.
 

     
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variants of infiltrate
fig. 5. Cloudlike infiltrate
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fig. 6. Round shaped infiltrate
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Fig. 7. Lobitis.
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X-ray examination. 1. On X-ray theres seen a
shadow, with diameter more than 1 cm that in
tuberculosis has some specialties. 2.
Localization in 1, 2, 6 segments (on anterior
lower X-ray-above, under the clavicle and
parahillary). 3. Non-homogenic structure due
to more intensitive foci conditioned by old
fibrosis formations around which infiltrate
developed or by caseoua foci. Areas of lighting
also condition non-homogenic of infiltrate during
formation of destruction cavities. 4. Focal
shadows with unclear borders around the inlitrate
and in other parts of this or that lung as a
result of lympha- or bronchogenoc dissemination
5. Road to the root often as double stripe
of infiltrated walls of bronchus is revealed
often at tuberculosis infiltrate in destruction
phase.

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Infiltrative tuberculosis
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fig.3 Roentgenogram. Infiltrative lung
tuberculosis ?6 left lung with decay
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fig.4 Roentgenogram. Cloudlike infiltrate of
left lung.
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Differential diagnosis at infiltrative
tuberculosis
(table)
Main signs Infiltrative tuberculosis Pneumonia Infarct of lung Eosinophilic infiltrate Cancer of lung
ANAMNESIS Sometimes contact with tb patients, previous tb Caught a cold, catharrh of upper respiratory ways, angina Operation, trauma, trombophlebitis, heart diseases Allergic diseases, helminths Patients are men after 40, smoking
COURSE Beginning often is gradual, acute. At tuberculostatic therapy regress is slow The beginning is acute, fast regress after antibiotics The beginning is acute The beginning is not visible, rare acute Gradual beginning, progressive worse condition
SYMPTOMS Moderate toxication, fever, sweating, cough. Few ausculatative changes High temperature, dyspnea, cough. Full ausculataive picture (wet and dry rhonchi) Pain in chest, dyspnea. Above the infiltrate zone, there is dullness, bronchial breathing None complains, sometimes cough, impermanent dry or wet rhonchi Pain in chest, dyspnea, cough, a big tumor or complicated with atelectasis dullness, sometimes dry rhonchi above infiltrate
ROENTGENO-LOGIC PICTURE Not homogenic infiltrate in1, 2 or 6 segment. Road to root, injured places on the background and around infiltrate Shadow in most cases is homogenic Triangle homogeny shadow, apex towards the root. Rare shadow is round or oval. High state of diaphragm Shadow with unclear margins like cotton tampon, often homogeny. Rapid appearance and disappearance of infiltrate. At peripheral cancer the shadow is homogenic and tuberose. At central one the shadow goes out of root
OTHER METHODS OF INVESTIGATION Positive Mantu test. At bronchoscopy there is a specific endobronchitis At bronchiscopy there is unspecific endobronchitis On ECG there are signs of overloading of right heart Positive skin tests with specific allergen Direct and indirect signs of tumor at bronchoscopy
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fig.8 Roentgenogram. Pneumonia of inferior part
of left lung.
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fig.9 Roentgenogram. Eosinophilic pneumonia.
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fig.10 Roentgenogram. Central cancer of left
lung.
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fig.11 Tomogram of right lung. Infarct of lung
.
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Caseous pneumonia Caseous pneumonia is a
clinical form of tuberculosos with massive
caseous changes in lungs and severe, progressive
clinical course.

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fig. 12 Lobar caseous pneumonia.
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X-ray investigation determines massive uneven
darkness of entire lung lobe during caseuos
pneumonia, there can be separate intensive foci
on the background of it. While next progressing
of process shadow becomes almost homogenic, than
on its background lightening of cavity
destruction appears or gigantic caverns form.
Lower lobar shadow in other regions of either
lungs broncho-dissemination processes
appear. During lobular caseous pneumonia big
processes with irregular margins are defined (if
lobular caseous pneumonia appears on the
background of disseminative tuberculosis, they
are localized symmetrically in both lungs).
During the progressing of disease in pneumonic
foci appears multiple lightening of cavity
destruction, in other lungs there are new
bronchogenic injured places, which are united
rapidly and destruct.
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fig.13 Caseous pneumonia of left
lung. Bronchogenic dissemination of right lung.
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Caseous pneumonia
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Staphylococcal pneumonia
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LUNG TUBERCULOMALung tuberculoma is a distinct
by genesis encapsulated caseous formation
exceeding 1 cm in diametre and having a chronic
torpid course.
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Homogenous tuberculoma
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Layer-by-layer tuberculoma
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Conglomerate tuberculoma
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Tuberculoma of the cerebellum
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Tuberculoma
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FIBROUS-CAVERNOUS LUNG TUBERCULOSIS   Fibrous-cave
rnous lung tuberculosis is a chronic destructive
process, characterized by the presence of an old
fibrous cavern, expressed fibrosis and nidi of
bronchogenic dissemination in lung tissue,
surrounding the cavern, or in other parts of the
lungs protracted undulant course with
aggravations and remissions periods, constant or
periodic bacterial secretion. In the social
aspect fibrous-cavernous lung tuberculosis
patients are invalids, predominantly of the 2-nd
group.
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Fibrous-cavernous lung tuberculosis


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Fibrous-cavernous lung tuberculosis
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Stages of destructive process in lungs.

• Fresh elastic
  cavity fibrous cavity
• disintegration    

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elastic cavity
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Fibrous-cavernous lung tuberculosis
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fibrous-cavernous lung tuberculosis
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Possible ways of cicatrization of cavities.

• 1. scar      
• 2. hearths      
• 3. blocked cavity      
• 4. pseudocysts.

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chronic abscess
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CIRRHOTIC LUNG TUBERCULOSIS   Cirrhotic lung
tuberculosis is a clinical form, that is
characterized by the development of connective
tissue in lungs and pleura as a result of
involution of various clinical forms of lung
tuberculosis or specific pleurisy, with the
preservation of signs of tuberculous process
activity, inclination to periodic aggravations
and meagre mycobacterial secretion, but without
the presence of an active cavern. In patients
with firstly diagnosed lung tuberculosis
cirrhotic tuberculosis is observed very rarely,
somewhat more frequently among the contingents of
antitu-berculous dispensaries (up to 1 ).
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Cirrhotic lung tuberculosis
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Cirrhotic lung tuberculosis
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Cirrhotic tuberculosis
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Pleurogenic cirrhosis of the left lung