CLINICALCLASSIFICATION

OF TUBERCULOSIS.

PRIMARY TUBERCULOSIS

Respiratory tuberculosis

Pulmonary tuberculosis: Primary tuberculosis complex Disseminated pulmonary tuberculosis Nodulary pulmonary tuberculosis Infiltrative pulmonary tuberculosis Fibrous-cavernous pulmonary

tuberculosis Tracheobronchial tuberculosis

Respiratory tuberculosis

Extrapulmonary tuberculosis: Pleural tuberculosis Tuberculosis of intrathoracic lymph

nodes Other forms of upper airway

tuberculosis

Extrarespiratory tuberculosis Tuberculosis of central nervous system Skeletal tuberculosis (bone and joint) Intestinal tuberculosis, tuberculous

peritonitis, Lymph node tuberculosis Genitourinary tuberculosis Cutaneous tuberculosis

Confirmation of the diagnosis by

direct microscopy of samples cultures histopathological examination clinic-radiological examination

Characteristics of tuberculous process:

Localization and extension: in the lungs: limited (1, 2 segments) and

extended (3 and more segments) in other organs

Phase

progressing (infiltration, destruction,dissemination)

regressing (desorption, consolidation) stationary (without roentgenological

dynamics) stabilization (recovery)

Complications

haemoptysis spontaneous pneumothorax respiratory failure pulmonary heart atelectasis amyloidosis fistula insufficiency of affected organs

Primary TuberculosisPrimary tuberculosis complex.

Background Tuberculosis (TB) is increasing among

adults in many areas TB is major cause of childhood morbidity

and mortality worldwide Limited information on epidemiology of TB

in children

Features of primary tuberculosis

Primary tuberculosis develops after thechild's first contact with theMycobacterium tuberculosis

It is mainly in children and adolescents With conversion of tuberculin test Develop delayed-type hypersensibility, so

appear hyperergical tuberculin tests

Features of primary tuberculosis

Paraspecifical reactions arecharacteristic :

erythema nodosum phlyctenular conjunctivitis poliarticular syndrome (Poncet’s

rheumatism is an “allergic” type of jointswelling which may disappear in two tothree weeks, and does not indicate thepresence of tubercle bacilli in the jointspace)

Features of primary tuberculosis

In the pathologic process is involved lymphaticsystem

Tuberculosis in infants and children younger than3 years old is much more likely haematogenousdissemination of the organisms occurs andspreads the organisms throughout the body,leading to acute disseminated TB (milliary TB)and tuberculosis meningitis, a very dangerousforms of the disease

Features of primary tuberculosis

In most cases, tuberculosis in children is amild disease and may heal on its ownwithout treatment

The record multidrogresistent primaryM.tuberculosis to antituberculosis drugs

The diagnosis can be establishedon the following considerations

history of contact with case ofpulmonary tuberculosis

significant reaction to the tuberculin skintest

absence of elevated white cell count inthe blood

absence of clinical and/or radiologicalimprovement after treatment with abroad-spectrum antibiotics

PRIMARY TUBERCULOSIS COMPLEX

is a form of primary tuberculosis inchildren and adolescents withmorphological substrate - specificinflammation of lung parenchyma(primary focus), involved in theprocess of lymphatic routes(lymphangitis) and mediastinallymphadenopathy

Lesions associated with primary tuberculosis

Initial infection with Mycobacterium tuberculosisin an immunocompetent individual usuallyoccurs in an upper region of the lung producinga sub-pleural lesion called a Ghon focus

Granulomatous involvement of peribronchialand/or hilar lymph nodes is frequent in primarytuberculosis due to lymphangitic spread fromthe Ghon focus

Lesions associated with primary tuberculosis

The early Ghon focus together with thelymph node lesion constitutes the Ghoncomplex

These lesions undergo healing and overtime usually evolve to fibrocalcific nodules

The combination of late fibrocalcific lesionsof the lung and lymph node which evolvedfrom the Ghon complex is referred to asthe Ranke complex

Clinical manifestationsof intoxication syndrome

the central nervous system - generalweakness, asthenia, excitability, headaches,sleep disturbances, feverish, night sweats

endocrine system - the growing disorderchildren, the dysfunction of the thyroid gland inthe age of puberty (hyperplasia of gr. II-III,hyperfunction), the disorder of the ovarianfunction (primary or secondary irregular of themenstrual cycle), decreased of the functionadrenal glands (adynamy, hypotonia)

Clinical manifestationsof intoxication syndrome

immune system - children are frail, oftenrespiratory tract infection (influenza,recurrent bronchitis and pneumonia),reactivation of chronic infections (sinusitis,tonsillitis, pyelonephritis etc.)

the heart – toxico-allergic myocarditis(tachycardia, cardiac tone I reduced,apical systolic functional murmur)

digestive system – diminished appetiteand progressive weight loss, subacidgastritis

Pulmonary syndrome

Cough - is most frequently, usually moremarked in the morning and is commonlyproductive

Chest pain – may result frominvolvement of the pleura

Dyspnoea – due to consolidation,cavitation, fibrosis and pleural affection

Haemoptysis - appears in complicatedcases with primary cavity, most commonin adolescents

Mucocutaneous manifestations

Erythema nodosum appears in theform of bluish red tender subcutaneousnodules several millimeters to severalcentimeters in diameter on the shins,sometimes on the backs of the armsand rarely on the front, in two to threebursts

They are painful, raised lesions that mayturn purple and take on the appearanceof a bruise

Mucocutaneous manifestations

Phlyctenular conjunctivitis begins withgeneralized pain and irritation in one eyeaccompanied by watering and photophobia

On examination, grey or yellow lesions can beobserved where the cornea joins the white of theeye; a number of blood vessels enter the lesions,giving an appearance of vascular engorgement ofthe conjunctiva

Each lesion persists for about a week, and thendisappears, to be replaced by others

In severe cases the cornea may ulcerate

Local symptoms

Often the chest physical examination -normal, with radiological discrepancy

Notice any limitation of movements onthe affected part

Dullness Harsh vesicular breathing and many

diffuse rales of small caliber

Radiographic picture of a primarytuberculosis complex

The primary complex has four stages ofdevelopment. There are four stages ofprimary complex development :

1. I stage – pneumonic2. II stage - resorption3. III stage - condensation4. IV stage - calcination

Pneumonic stage consists of a small area of

infiltration at any location in thelung parenchyma, accompanied byunilateral mediastinallymphadenopathy

The infiltration forms when thebacilli are first inhaled (as adefence reaction around thelocation at which the bacilli firstdeposit); it is characteristicallysmall (3 to 10mm in diameter)

This nodular shadow is sometimessurrounded by a lighter, less denseshadow with irregular edges

On lateral X-ray, mediastinallymphadenopathy appears as arounded or oval latero-tracheal orhilar shadow

Pneumonic stage On X-ray general view three

components of a complex arevisible:1) the focus in lung tissue bythe size 2-4 cm. in diameter ormore, of oval or irregular form,various intensity (more often -average and even high), with anindistinct, obscure contour;

2) the flow out to a root -lymphangitis, which is definedas linear tension bars from focusto the hilum;

3) in a hilum - enlargedinfiltrated lymphatic nodes.The hilum is represented to beextended, it’s structure) is blurry,the intensity is increased. Thecontours outlining lymphaticnodes, or are dim, or moreprecisely depict the increasednodes.

Stage of resorption

The radiologicalpicture is that of aprimary focus in thelung withaccompanyingmediastinal lymphnodes enlargementunited by an opaquetape (lymphangitis –the draininglymphatics becomebeaded bytubercles, distendedand tortuous)

Stage of resorption The size of the focus

in lung tissuedecreases, itsintensity raises, thecontours becomeprecise

The flow out to ahilum and infiltrationof lymphatic nodesdecreases

Stage of condensation On a place of focus area

remains with the size up to1 cm, inside of it inclusionsof calcinations appear asfine spots of sharpintensity

Same spots of calcinationsare noticeable and inlymphatic nodes of thelung hilum

Thin tension bars aredetermined between thefocus and the hilum

Stage of condensation

Calcination-stage The focus in lung tissue

becomes even smaller, moredensely, of high intensity, withdistinct contour, frequentlyrugged and rough

Calcinations are intensifiedalso in hilum lymphatic nodes

Calcinations in certain casesare represented by solid,dense formations, in others -they have less intensiveshadows of inclusions, whichtestify about incompletecalcifications of the focus andpreservation of caseousregions in it

Outcome of primary tuberculosis

At favorable course of primary tuberculouscomplex with time calcification increases up toossification at the place of former caseosislocated in peripheral parts of lungs. This isGohn's focus

When primary complex is revealed in time andthe patient receives valuable treatment,frequently could be achieved complete dissolutionof pathological changes in lung tissue and in root,with complete restoration of their initial structure

Gohn's focus

The lesion is small andusually cannot be detectedduring its active stage;not until calcium salts aredeposited in the healedlesion can its presence bedetected

In a large majority ofinstances healing takesplace with fibrosis andcalcification (Gohn's focuspointed be arrow)

The tuberculin skin test

in most cases is hyperergical andcoincides with a tuberculin conversion

Bacteriologic diagnosis Sputum can rarely be collected from

children Can try sputum induction in older children Bronchoalveolar lavage is invasive,

expensive and should be reserved forsituations where the diagnosis is in question

Gastric aspirates• people swallow mucus in their sleep• collect gastric contents before the stomach empties

TUBERCULOSISOF INTRATORACICLYMPHATIC NODES

Definition is a primary form of

extrapulmonary tuberculosis withspecific inflammation ofintratoracic lymphatic nodes, inchildren and adolescents

It affects mostly lymph nodes afterSuchenicov - Esipov scheme(paratracheal, tracheo-bronchial,interbronchial, bronho-pulmonarylymph nodes) and Engel (para-aorticlymph nodes)

Clinical-radiological forms

Infiltrative

Tumor-like (pseudotumor)

Traheobronchiallymphadenopathyof small volume

Infiltrative form

morphologically characterized by partiallymph nodes necrosis, predominateexudative inflammation type involvingadjacent tissue

In clinical picture prevails intoxicationsyndrome

Tumor-like (pseudotumor) form

is characterized by morphological totalcaseation of lymph nodes

In clinical picture predominatesbronchopulmonary syndrome withcompression bronchus (bitonalspasmodic cough), dyspnoea expiratory

Traheobronchial lymphadenopathyof small volume

is a variant of pseudotumor form and meet and youngadults

Clinical manifestations are moderate, or even missing This form should be suspected in children and

adolescents from foci of tuberculosis with syndrome ofintoxication, with conversion of tuberculin test ortuberculin tests hypererergical

Groups of affected lymph nodes has diameter up to 1 cmand are hidden in the shadows of mediastinum andheart, invisible on X-ray standard

To detect them is required chest x-ray in profile,mediastinal tomography, and computerized tomography

Infiltrative form• On chest x-ray the

shadow of the lunghilum is extended onthe damaged part, theoutside contour isunclear, the structure isheterogeneous andintensity is increased

• Shadows of enlargedlymphatic nodes areclearly come to light onx-ray tomogram

Infiltrative form

The pseudotumor form

The shadow of the hilum lookssame, as an infiltrative form,but its exterior contour is clear,regular or polycyclic. Theshadow of the upper part ofmediastinum is expanded at adefeat of para-tracheal andtracheo-bronchial lymphaticnodes

The defeat of bifurcationlymphatic nodes is revealedusually on the chest x-ray ortomograms

Pseudotumor form

Traheobronchial lymphadenopathyof small volume

Groups affected lymphnodes with diameter up to 1cm are hidden in theshadows of mediastinumand heart, invisible on X-raystandard

For detect them is requireda lateral chest radiograph,mediastinal tomography,computerized tomography.

Local complications of primary tuberculosis

Fistulation of the lymph node into thebronchi: the lymph node swells anderodes into the bronchus (usually betweenthe 4th and 7th month of development)

This can be a serious event for smallinfants, where the caseous material cancreate acute bronchial obstruction; inolder children it usually causes cough

Local complications of primary tuberculosis

The formation of a primarytuberculous cavity at the site ofinfiltration is a more unusual complication

Delayed local complications

Bronchiectasis may develop in thepoorly ventilated area of the lung,creating bronchial superinfections andrepeated episodes of haemoptysis.

The most characteristic feature of thistype of sequelae is “hilar disease” or“right middle lobe syndrome”:

Atelectasis hilar calcification recurrent haemoptysis.

Atelectasis

Differential diagnosis

sarcoidosis, st. I lymphogranulomatosis lymphosarcoma leukemiaadenopathy nonspecific

Infants may have acquired TB

• by trans placental spread through theumbilical vein to the fetal liver

• by aspiration or ingestion of infectedamniotic fluid

• via airborne inoculation from closecontacts (family members or nurserypersonnel)

• About 50% of children born to motherswith active pulmonary TB develop thedisease during first year of life ifchemoprophylaxis or BCG vaccine isnot given

Neonatal TB

The clinical presentation nonspecific Multiple organ involvement Usually fever, lethargy, respiratory

distress, hepatosplenomegaly, or failure tothrive may indicate TB in an infant with ahistory of TB exposure

For diagnosis: culture and smear oftracheal aspirates, urine, gastric washingsfor acid-fast bacilli, chest x-ray (milliaryinfiltrates)

Biopsy of the liver, lymph nodes, or lungand pleura may be needed

Skin test results may be negative

Cerebrospinal fluid analysis in TB meningitis

CSF is clear or opalescent, pressure is elevated CSF pleocytosis with lymphocytic

predominance: presence of more than 50 white cells/mm³on microscopic examination of the CSF, with morelymphocytes than polymorphonuclear cells

Decreased CSF glucose: value of CSF glucose 50% orless than simultaneous serum glucose determination.

Increased CSF protein: value of CSF protein more thanthe upper limit of normal of the performing laboratory'sreference values, i.e. > 0.45 mg/dl.

Abnormal CSF: presence of all 3 of the above CSF findings(CSF pleocytosis with lymphocytic predominance +decreased CSF glucose + increased CSF protein.

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