Destructive forms of tuberculosis lecture for students by Prof. Kopylov. Destructive pulmonary tuberculosis

Symptoms

Diagnostics

Types of destructive tuberculosis

Methods of combating destructive tuberculosis

Cavity formation mechanism:

continuation

X-ray signs

Laboratory sign

MBT with simple microscopy

Difficulties in diagnosing cavities

Types of involution of the decay cavity

Chronic destructive forms of tuberculosis

Cavernous tuberculosis

Fibrous-cavernous tuberculosis

Clinic

Objective data

continuation

Laboratory data

Radiological signs of FCTL

Other types of examination

Epidemic danger

Treatment and outcomes

Complications of FCT

Conclusion on the FCT

Cirrhotic tuberculosis

the right lung is shadowed and reduced in volume due to fibrosis and massive pleural layers; calcifications are detected in the costal pleura (

Symptoms of pathology

Features of pathology treatment

Other

Considering the fact that tuberculosis often occurs without visible clinical manifestations, it is most often possible to detect it only during a routine chest X-ray examination. This disease is characterized by the presence of many forms, which differ from each other not only in the X-ray picture, but also in treatment tactics with further prognosis. As a rule, destructive forms of tuberculosis can arise from any other form without the necessary treatment, even in a short period of time (within a year).

Destructive pulmonary tuberculosis develops against the background of progression of other forms of tuberculosis, most often infiltrative. As a result of this transformation, cavities are formed - decay cavities without signs of inflammatory foci.

This formation is enclosed in a capsule consisting of three layers:

The upper one is caseous.
Medium – granulation (contains a large number of cells).
The lower one is fibrous.

Cavities can occur in different sizes, depending on the area of the damaged tissue, its elasticity and the condition of the draining bronchus.

The mechanism of cavity formation against the background of infiltrative tuberculosis is as follows: with the death of the protective cells that surrounded the infiltrative focus of inflammation, proteolytic enzymes are released, the lung tissue is destroyed, which leads to the release of the caseous mass through the draining bronchus.

All this characterizes the disintegration phase, during which the inflammatory focus around the formed cavity remains. As the lesion disappears and the surrounding lung tissue becomes fibrotic, we can speak of a cavity having formed. A factor predisposing to decay may be the presence of superinfection in the body and its reduced resistance.

This destruction of lung tissue leads to a deterioration in the patient’s condition, complicates healing at the site of the lesion and worsens the prognosis of the disease.

Usually the lesion affects only one side of the lung. Destructive tuberculosis during its development has a complex of clinical manifestations that are characteristic specifically for the decay phase. At this time, the patient begins to be bothered by a strong cough with sputum discharge, and episodes of hemoptysis are possible. When examined by the attending physician, the patient is often able to detect the presence of medium and large-caliber moist rales at the site of the lesion.

When the cavity has already formed, the above symptoms disappear, and the patient’s general well-being worsens due to:

Severe general weakness and decreased performance.
Lack of appetite, severe weight loss.
A continued rise in general body temperature to subfebrile levels (up to 37.8).

These signs often do not alert the patient himself regarding his condition, which explains the delay in seeking specialized medical care.

The standard method for detecting tuberculosis today is an X-ray examination. An X-ray of the lungs is characterized by the appearance of a clearing zone in the form of a circle with a clear boundary. Very rarely it is visualized against the background of unchanged lung tissue, since the site of occurrence is closely related to the previous form of the tuberculous process. It is usually possible to see contamination around the lesion, the presence of a fluid level, as well as the lumen of the draining bronchi.

Since a patient with cavernous tuberculosis produces infected sputum, it is imperative that it be tested for the presence of Mycobacterium tuberculosis.

Sometimes the attending physician may encounter certain diagnostic difficulties when making a diagnosis, most often this is due to the absence of signs of decay on the x-ray, and in the clinic - a characteristic auscultation picture. In such a situation, a CT scan is indicated for the patient.

Destructive processes in the lungs become chronic and occur in several forms:

The cavernous type is an isolated lesion of the lung tissue, which is characterized by the presence of a cavern in the absence of changes in the surrounding lung tissue. The upper layer of its capsule is weakly expressed, the lower (fibrous) layer is completely absent, and the main part of the cavity is occupied by the middle (granulation) layer. Clinically, the picture of this form of tuberculosis is poor, and cure is achieved only through surgery.
The fibrous-cavernous type of the disease is significantly different from the previous one. It is characterized by the formation of cavities together with the presence of fibrous changes in the structure of the lung tissue.
In the cavity capsule, the fibrous layer prevails over the rest, and next to it there are multiple foci that are perforated by the bronchi. These lesions are clearly demarcated from healthy lung tissue. The symptoms of the disease are characterized by a long, undulating course, with periods of exacerbation and remission. During an exacerbation, the clinical picture of pulmonary damage is pronounced, and intoxication syndrome is often associated. The radiograph shows a round lesion with a thick wall, the lung tissue is reduced in volume. It is important to know that people suffering from this form of tuberculosis are very strong bacteria excretors. The disease is poorly treatable and has an extremely unfavorable prognosis.
The cirrhotic form is represented by widespread sclerotic damage to the lung tissue with preservation of foci of tuberculous lesions. Clinically, the period of exacerbations occurs extremely rarely, and the symptoms are barely noticeable. X-ray signs of this form are clearly expressed: the volume of the affected lung is reduced, its airiness is reduced, and a sharp deformation of the bronchi is noted.

The healing process usually occurs only in the cavernous form and proceeds according to the type of scarring with the formation of false tuberculoma or cyst. Other forms have an unfavorable prognosis. With them, complications most often occur in the form of empyema of the pleural cavity and bronchopleural fistula, as well as caseous pneumonia and hematogenous contamination, which most often leads to death.

To undergo the necessary course of treatment, the patient must be hospitalized in a hospital. The main direction of therapy is the prescription of anti-tuberculosis drugs. In addition to them, for greater effectiveness, therapeutic exercises are often prescribed.

If there is a high risk of the pathogen developing resistance to specific therapy drugs, antibacterial agents from the fluoroquinolone group are added to treatment.

The effectiveness of therapy for the cavernous form of tuberculosis is confirmed by the absence of mycobacterium tuberculosis in the patient’s sputum six months after the start of therapy. Otherwise, the patient is prescribed a surgical treatment method.

It is important to remember that only timely detection (in the early stages) and timely treatment can lead to a complete recovery. To do this, every person needs to undergo a fluorographic examination of the chest organs on a scheduled basis once a year.

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LECTURE: Chronic forms of pulmonary tuberculosis: cavernous, fibrous-cavernous, cirrhotic.

Plan:

1. Reasons for the development of chronic destructive forms of tuberculosis

2. Pathogenesis of chronic destructive forms of tuberculosis

3. Cavernous pulmonary tuberculosis

4. Fibrous-cavernous pulmonary tuberculosis

5. Cirrhotic pulmonary tuberculosis.

Reasons for the development of chronic destructive forms of tuberculosis:

Violation of the rules of antimicrobial therapy (monotherapy, low doses of anti-inflammatory drugs, unreasonably short courses, frequent, long breaks in treatment)

Patient's lack of adherence to treatment

Intolerance to a number of anti-TB drugs in patients
The patient has severe concomitant diseases

Cavernous pulmonary tuberculosis- a clinical form of tuberculosis, which is characterized by the formation in the lung of an isolated, often single cavity, with thin walls (no more than 4 mm), without pronounced changes in the surrounding lung tissue. It is an intermediate stage (between the decay phase of one or another clinical form of tuberculosis and FCTL) during the destructive tuberculosis process.

Clinical forms of tuberculosis preceding the development of CT:

ITL in the decay phase, against the background of 3-4 months of chemotherapy

Focal pulmonary tuberculosis in the decay phase

Disseminated tuberculosis in the decay phase (rare)

Diagnosed in 0.4% of newly diagnosed patients. In the contingent, PTD is approximately 1%. The decay phase of any clinical form of pulmonary tuberculosis is the beginning of the destructive process. The destructive process occurs due to the presence of caseosis or caseous necrosis in the lesion. Under the influence of proteolytic enzymes, caseosis is liquefied. If there is a connection with the bronchus, it is gradually rejected, forming a decay cavity.

Types of caverns: proteolytic: melting of caseous masses begins from the center of the pneumonic focus and gradually spreads to the periphery;

Sequestering: melting of caseous masses begins in the marginal areas, moving towards the center of the caseous focus;

Atheromatous: melting of caseous masses in encapsulated lesions;

Alternative: disruption of microcirculation and tissue nutrition around old foci of tuberculous inflammation, followed by their necrosis and melting.

Pathomorphology: the decay cavity is represented by 2 layers:

Layer of caseous-necrotic masses

Layer of specific granulations (transitioning into the zone of perifocal inflammation)

Under the influence of PTT, perifocal inflammation resolves, and a third, outer connective tissue layer, is formed near the decay cavity. The cavity turns into a cavity.

Clinic: the low-symptomatic course is due to the development of the process against the background of chemotherapy of various forms of tuberculosis.

Mild symptoms of intoxication (increased fatigue, decreased appetite, unstable mood)

Symptoms of bronchopulmonary damage of varying degrees of severity (cough with sputum, hemoptysis, shortening of the pulmonary sound during percussion, auscultation - single wet and dry rales, more often “silent” cavities)

Changes in the hemogram are associated with an exacerbation of the process and are an indicator of an active process (moderate acceleration of ESR, moderate leukocytosis, lymphopenia)

Bacterial excretion is scant (usually by culture - if the process is treated), but there is always some, maybe. permanent with inadequate chemotherapy or drug resistance

M.b. syndrome of “fall and rise of the bacterial population”, because bacterial excretion ceases, and after 4-6-8 months chemotherapy resumes (this is an unfavorable sign indicating the development of drug resistance)

The emergence of the phenomenon of “hidden drug resistance” (in sputum, MBT strains sensitive to PTP are detected, and drug-resistant MBT grow in the cavity wall)

Unidentified LN is the cause of non-healing of cavities.

Features of CT treatment:

Etiotropic therapy

Endobronchial administration of PTP

Detoxification therapy

Vitamins

Hepatoprotectors

Collapse therapy

If treatment is ineffective - lung resection (lobectomy)

Outcomes cavernous tuberculosis:

Focus-scar, linear scar

Star scar

Filled cavity (pseudotuberculoma)

Cyst formation

As the process progresses, the formation of fibrous-cavernous tuberculosis

Sanitized cavity

Fibrous-cavernous pulmonary tuberculosis.

Epidemiology. In newly diagnosed patients – 3% (official data),

In the PTD contingent – 8-10%,

Represents the greatest epidemiological danger, since there is constant bacterial excretion,

Patients more often isolate MBT with MDR, XDR.

Fibrous-cavernous tuberculosis is a clinical form of tuberculosis, which is characterized by the presence of:

cavities with thick fibrous walls (wall thickness more than 4 mm, possibly irregular in shape)

Pronounced fibrous changes in the surrounding lung tissue and

foci of bronchogenic contamination.

With a long course, the volume of the affected area of the lung decreases, and there is a displacement of the mediastinal organs towards the lesion.

Fibrous-cavernous tuberculosis is the final stage in the progressive course of the destructive tuberculosis process.

Flow options (Khomenko A.G.):

Limited and relatively stable fibro-cavernous process. It is characterized by limited damage and a stable course of the process, rare outbreaks, bacterial excretion during the period of exacerbation.

Slowly progressing fibrous-cavernous tuberculosis.

Rapidly progressing fibrous-cavernous tuberculosis (may result in the development of caseous pneumonia).

Fibrous-cavernous tuberculosis with the presence of various complications and a progressive course.

Clinical picture characterized by two main phases:

1. Infiltrative outbreak phase

2. Stabilization phase

Intoxication syndrome from mild to severe symptoms of intoxication - febrile body temperature, lack of appetite, weight loss to the point of exhaustion, sweating.

Bronchopulmonary syndrome of varying severity: cough with sputum, hemoptysis, chest pain.

Respiratory syndrome, and later LSN: increasing shortness of breath, cyanosis, tachycardia, pain in the heart, swelling.

Bacterial excretion is always during the period of exacerbation, LU.

Tuberculin tests from positive to negative.

In the hemogram: anemia, accelerated ESR, leukocytosis with a shift to the left, lymphopenia.

Complications:

Pulmonary heart failure, cor pulmonale (shortness of breath, circulatory disorders, arrhythmia, hypertension in the pulmonary circulation)

Amyloidosis of internal organs, including the kidneys with the development of renal failure, chronic uremia; liver; intestines; hearts (less often)

Multiple pulmonary hemorrhages. Repeated pulmonary hemorrhages and hemoptysis are called “hemophthisis” (blood consumption). With extensive pulmonary hemorrhage, death may occur from asphyxia (drowning in one’s own blood), or due to the development of aspiration pneumonia, progression of the process (terminal caseous pneumonia)

Fibrous-cavernous tuberculosis (treatment features):

Combined chemotherapy, individualized regimen, taking into account DR and patient tolerability

Detoxification therapy

Vitamins

Hepatoprotectors

Antioxidants

Surgical treatment: collapse-surgical methods – thoracoplasty,
with a limited process - lung resection (lobectomy, pneumonectomy)

FCTL outcomes:

Favorable: with radical surgery; less favorable - with transformation into cirrhotic tuberculosis.

Unfavorable: death with progression and development of complications.

Cirrhotic pulmonary tuberculosis- this is a clinical form that is characterized by the development of pronounced fibrotic changes in the lungs, disruption of tissue architecture in the affected part, the presence of emphysema and bronchiectasis while maintaining clinical and radiological manifestations of the active tuberculosis process.

Cirrhotic pulmonary tuberculosis is the outcome of all previous forms of tuberculosis.

There are cirrhotic tuberculosis and post-tuberculous cirrhosis (they differ in that with cirrhotic tuberculosis the activity of the tuberculous process remains active, and with cirrhosis the process is inactive, the result of clinical cure)

Forms of tuberculosis, of which cirrhotic tuberculosis or post-tuberculous cirrhosis most often develops:

PTC and TVLU, complicated course (with the development of specific bronchial lesions and impaired bronchial obstruction)

Common infiltrative pulmonary tuberculosis with multiple decay cavities

Caseous pneumonia

Disseminated tuberculosis

Exudative pleurisy (encystation, “armored” pleurisy)

Fibrous-cavernous pulmonary tuberculosis

Cirrhotic pulmonary tuberculosis (pathogenesis). According to pathogenesis, the following types of cirrhosis are distinguished:

Bronchogenic

Pneumoniogenic

Pleurogenic

Cirrhotic pulmonary tuberculosis (morphological changes) of a specific nature:

Lesions (polymorphic, encapsulated, caseous)

Small tuberculomas

Caverns (retain their fibrous wall, cleared of a layer of specific granulations, necrotic changes, irregular shape)

Non-specific:

Part of the lung parenchyma becomes empty and coarse connective tissue grows

The remaining lung tissue undergoes emphysematous swelling and bullae form

In the interstitium, proliferation of connective tissue, deformation of blood vessels

Some of the bronchi also become empty, become deformed, become stenotic, and develop bronchiectasis (cylindrical)

Innervation is disrupted

Metatuberculosis syndrome: changes in blood vessels lead to the development of pulmonary hemoptysis and bleeding,

Impaired perfusion leads to the development of DN, followed by the formation of cor pulmonale,

Bronchiectasis – the addition of a secondary infection – metatuberculous bronchitis,

Long-term specific and nonspecific intoxication - metabolic disorders - acidosis - dysfunction of other organs (gastrointestinal tract, central nervous system, etc.)

Cirrhotic pulmonary tuberculosis (active process). Bacterial excretion in 75% of cases.

To resolve the issue of process activity:

Multiple sputum examination for MBT (5-10 times)

Bronchoscopy

X-ray examination in dynamics.

In a one-way process:

Decrease in lung volume or lobe

Emphysema in the lower regions

High intensity shadow, non-homogeneous, due to areas of enlightenment

The root of the lung is expanded, deformed and pulled towards the affected side

The trachea and mediastinal shadow are shifted towards the affected side

The diaphragm is elevated, the dome is deformed, and the costal pleura is thickened.

Cirrhotic pulmonary tuberculosis (x-ray diagnostics) For bilateral lesions:

At the apices there is intense homogeneous darkening, thickening of the apical pleura

There may be focal shadows of high intensity in the upper, middle parts of the lungs

Strengthening and deformation of the pulmonary pattern

Development of emphysema in the lower sections (increased transparency)

The root is expanded, deformed, pulled upward (symptom of “weeping willow”)

The middle shadow is a “drip” heart

The dome of the diaphragm is deformed, tightened, fusion and adhesions of varying severity

Diagnosis of cirrhotic pulmonary tuberculosis:

From the anamnesis it becomes clear when and what form of pulmonary tuberculosis the patient suffered from.

Positive Mantoux reaction.

Bacteriological examination of sputum during an exacerbation period reveals highly virulent Mycobacterium tuberculosis and their L forms.

X-ray:

Limited cirrhotic pulmonary tuberculosis: the process is one-sided, the area of cirrhosis is reduced in volume. The root of the lung and mediastinum are shifted towards the lesion. The vascular pattern of the lower lobe is pronounced (the “weeping willow” symptom).

Diffuse cirrhotic pulmonary tuberculosis: a bilateral process, multiple linear shadows with clear contours. The mediastinal shadow is pulled up, deformed, the dome of the diaphragm is flattened.

Differential diagnosis of cirrhotic pulmonary tuberculosis:

tuberculosis,

atelectasis,

lung cancer,

postpneumonic cirrhosis,

sarcoidosis,

fibrosing alveolitis,

aplasia of a lobe, segment,

bronchiectasis,

fibrous-cavernous tuberculosis,

caseous pneumonia.

Features of treatment:

Etiotropic therapy: individualized chemotherapy regimen - during an outbreak

Detoxification therapy

Hepatoprotectors

Antioxidants

Broncho-mucolytics

Drugs for the treatment of CHF, oxygen therapy

If the process is limited and functional reserves are preserved, lung resection is performed.

Outcomes:

Favorable – with a limited process after surgery.

Unfavorable – in case of common processes – development of CHL, CHF, other complications – death.

Called destructive
tuberculosis accompanied
decay phase.
Frequency among first timers
identified patients
tuberculosis - about 50%
(mainly in adults and
teenagers).

Caseous masses liquefy under
action of enzymes
the wall of the draining bronchus is destroyed,
expectoration of caseosis
fresh destruction is formed - 2 layers
(pyogenic and granulation)
formation of a fibrous wall transformation into a true cavity.

The decay phase occurs at any
clinical form of tuberculosis.
It occurs rarely in primary tuberculosis,
focal, not often with tuberculoma.
Often accompanied by a decay phase:
infiltrative tuberculosis (70%),
disseminated (70%).
Always, in 100% of cases, cavities are present when
cavernous and fibrous-cavernous TB.

Cavern sizes:
* small – up to 2 cm in diameter;
* average – 2-4 cm;
* large - 4 – 6 cm;
* giant - > 6 cm.

Decay phase syndrome (cavities)
includes clinical and
radiological signs
Clinical signs:
cough with phlegm;
pulmonary hemorrhage;
wet medium and coarse bubbles
wheezing (localized)

Direct
- clearing against a darkened background or ring-shaped
shadow with closed contours, defined by
two types of x-ray examination.
- lack of pulmonary pattern in the area
enlightenment.
- incongruity of contours.
Indirect
- seeding around
- liquid level
- lumen of the draining bronchus

Massive
bacterial excretion.

Absence of wheezing (“mute”
Caverns";
no signs of decay
plain radiograph.
We need a tomography, CT scan.

Formation of a linear scar.
Star scar.
False tuberculoma.
Post-tuberculosis cyst
(sanitized cavern).

Cavernous.
Fibrous-cavernous.
Cirrhotic

Thin-walled decay cavity without
pronounced infiltration and
fibrotic changes in the environment
lung tissue.
The clinic is poor.
MBT +.
Treatment is predominantly
operational.

Characterized by several, less often one
cavity with thick fibrous walls
and pronounced fibrous changes
in the surrounding lung tissue.
Varieties by prevalence:
limited process - no more than a share;
widespread – more than a fraction.

Histotopographically
th section of the lung at
fibrocavernous
tuberculosis: 1 -
chronic
caverns; 2 -
pneumocirrhosis; 3 -
thickening and sclerosis
pleura; coloring
hematoxylin and
eosin.

FCT frequency
Among the newly identified patients –
2,5%.
Among all contingents of patients -
17%.
Reasons for the formation of the FCT:
- late identification of the process;
- refusal of patients from enough
long-term treatment.

The course is long with exacerbations and
remissions.
Intoxication syndrome, increasing with
exacerbations.
DN syndrome, later LSN.
Pulmonary symptoms: cough with sputum,
often painful, annoying (due to
bronchial lesions TB). Hemoptysis and
pulmonary hemorrhage, possible pain in
chest.

General condition from satisfactory to
moderate and severe;
- Habitus phtisicus – asthenic build,
decreased nutrition, depression over and
subclavian spaces, pale skin, often
with acrocyanosis, muscle wasting;
- affected half of the chest (or more
affected) is delayed in breathing;

-
-
percussion - dullness due to rough
fibrosis; in unaffected sections -
boxed sound (compensatory
emphysema);
Auscultation - hard breathing,
bronchial, sometimes amphoric,
wet medium to coarse bubbles
wheezing, sometimes localized dry
wheezing.

Massive bacterial excretion;
often multi-drug
resistance (MDR);
significantly increased ESR;
lymphopenia;
hypochromic anemia is possible;
pathology in urine analysis is possible (due to
toxic nephropathy, amyloidosis).

Ring shadow with
thick walls,
defined in 2
projections against the background
inhomogeneous darkening.
Volume reduction
lung tissue due to
replacing it with fibrous
cords.
Presence of bronchogenic
contamination in the same or
another lung.

X-ray
chest organs
cells at
fibrocavernous
pulmonary tuberculosis:
right pulmonary field
narrowed, mediastinum
shifted to the right, in
apex of right
lung is determined
giant cavern with
thick dense
walls (indicated
arrow), in the middle
and lower sections
left lung -
multiple
merging
shading areas
(foci of dropouts).

Upper lobe of the right lung
reduced in volume, small interlobar
pleura at the level of p.o. 2 ribs. In S1-S2
right lung against the background of local
severe pneumofibrosis is determined
cavity 2.5*3.5cm irregular
shapes, with different wall thicknesses (0.5 –
1.5 cm), with uneven inner
contour and the presence of a “path” to
root (drainage bronchus); around
multiple polymorphic foci
different sizes. In S1-2 of the left lung
and S9 of the right lung lesions with indistinct
contours, small and medium
intensity, prone to fusion.
The right external sinus is homogeneous
shaded to the level of the diaphragm dome with
clear upper contour.
Pleuroapical layers on the right.
The roots of the lungs are not expanded,
low-structured, right –
deformed and pulled up.
The trachea is slightly displaced to the right.
Conclusion: Fibrous-cavernous
tuberculosis of the upper lobe of the right
lung with contamination S1-2 left
lung and S9 of the right lung,
complicated by exudative pleurisy
right.

Tomogram of organs
straight chest
projections of the patient
fibrous-cavernous
tuberculosis of the right
lung and left side
caseous pneumonia:
left lung is reduced in size
volume, diffuse
shaded, in the upper parts
departments are determined
multiple cavities
decay (1); right lung
increased in volume, in
its middle departments
dropout areas are identified
(2), at the second level
intercostal space
- cavern (3); shadow
mediastinum is displaced
to the left.

Reaction to tuberculin Mantoux test -
normergic;
FBS-N or signs of specific
bronchial lesions;
FVD – DN;
ECG – possible signs of CHL.

Due to the constant massive
bacterial excretion and frequent MDR
patients with fibrocavernous
represent tuberculosis
the greatest epidemic
danger.

Chemotherapy (CT) is not very effective. At
limited forms - surgical
treatment.
Possible transition to cirrhotic
tuberculosis against the background of chemotherapy.
More often the prognosis is unfavorable.
The causes of death are
complications.

Specific
caseous pneumonia
hematogenous
seeding
TB of the bronchi, trachea,
language
pleurisy, empyema,
pneumothorax
Nonspecific
DN
HLS
pulmonary hemorrhage
amyloidosis
abscessation of the cavity
DIC syndrome

Leads to death
mainly
progression of the process in the form
specific complications.
Most often like this
complications are:
caseous pneumonia (70%),
hematogenous contamination (20%).

Fibrous-cavernous TB – chronically ongoing
destructive process that develops in
as a result of progression of other forms
tuberculosis.
This process is difficult to treat and
is the leading cause of death
for tuberculosis.
Leading directions for preventing this
forms of tuberculosis: timely detection and
adequate treatment of its other forms.

Overgrowth of rough connective tissue in the lungs and pleura
while maintaining the activity of the process: lesions, tuberculomas,
cavity formations (bronchiectasis, bullae and
sanitized cavities), emphysema
Clinic
Tuberculosis intoxication, moderate;
picture of nonspecific inflammation (CNPL);
recurrent hemoptysis;
LSN (shortness of breath, CHL, NC);
the course is wavy with rare or frequent
exacerbations.

the right lung is shadowed and reduced in volume due to fibrosis and massive
pleural layers, calcifications are detected in the costal pleura (1),
at the level of the clavicle in the right lung a chronic cavity is visible (2),
the pulmonary pattern is sharply deformed on both sides, in the left lung
there are scattered high-intensity shadows of old lesions (3), shadow
the trachea is shifted to the right, the median shadow is deformed.

Destructive pulmonary tuberculosis is a disease, the main difference of which is the presence of an isolated decay cavity in the lung tissue. The clinical picture of this form of the disease usually does not cause the appearance of a large number of symptoms and the patient complains only of increased fatigue, loss of appetite and the rare appearance of cough with sputum. In addition, the occurrence of causeless hemoptysis or bleeding may indicate the progression of such a disease in the human body. Diagnosis of the cavernous form of tuberculosis is carried out using X-ray diagnostics and tuberculin diagnostics, also by identifying mycobacteria in the patient’s secretions.

The main cause of development of the destructive form of pathology is infiltrative tuberculosis. At the very beginning of the development of the disease, the infiltrate includes the focus of inflammation and necrotic lung tissue is observed in its very center. If there is a perifocal infiltrate, an increased concentration of lymphocytes, leukocytes and macrophages is detected.

After the death of such cells, a large concentration of proteases is formed, which manages to melt the caseosis without any problems. The result of this is the leakage of caseosis through the draining bronchus, which causes the appearance of a decay cavity. During diagnosis, the patient is diagnosed with infiltrative tuberculosis, which is in the stage of decay. If effective drug therapy is not carried out, the perifocal infiltration around the site of decay occurs. As a result, a cavity remains, around which elements of inflammation are always present, transforming into caseous tissue.

Another reason for the development of a destructive form of pathology is the transformation of tuberculosis into a cavity.

In a situation where a cavity occurs, this significantly aggravates the characteristics of tuberculosis disease and increases the risk of an unfavorable outcome. This is explained by the fact that ideal conditions arise for infected secretions from the cavity to enter healthy lung tissue. The healing process of the cavity becomes too difficult, since inflammation of the organ tissue creates obstacles to its healing.

Medical practice shows that a feature of the destructive form of the disease is its one-sided localization. Most often, the pathology begins to develop approximately 3-4 months after the start of ineffective drug therapy for other forms of tuberculosis. The clinical picture reaches particular brightness precisely during the period of decay and the appearance of a strong cough with sputum is noted. In addition, during listening, moist rales are detected, the location of which becomes the decay cavity. After the process of cavity formation ends, the signs of the disease noticeably decrease and become less pronounced.

During this phase, this form of tuberculosis is characterized by the appearance of the following symptoms:

constant feeling of weakness and fatigue;
loss of appetite or its complete absence;
severe weight loss of the patient;
development of asthenia;
periodic low-grade fever.

In fact, patients with cavernous tuberculosis are considered a source of infection and a spreader of mycobacteria. If such a disease becomes latent, this may be indicated by bleeding from the lungs, which can occur without any reason in an apparently healthy person.

When the destructive form of the disease transitions to a complicated one, a breakthrough of the cavity into the pleural cavity is possible, and the development of the following pathologies:

pleural empyema;
bronchopleural fistula.

Depending on the size of the cavity, experts distinguish cavities of small, medium and large sizes. Typically, the course of the cavernous form of tuberculosis is about two years, after which healing of the caverns occurs. Most often, this process occurs in the form of tissue scarring, the formation of tuberculoma and a tuberculosis focus.

Number of observations

12 months and more

Minimal destructive tuberculosis

Limited destructive tuberculosis:
with one cavity 2-4 cm

with two caverns 2-4 cm.

Common destructive tuberculosis with a cavity system of 2-4 cm

with large caverns (5-11 cm)

Diagnosis of cavernous tuberculosis is carried out using bacteriological methods and clinical and radiological studies. Patients with cavernous tuberculosis require placement in an inpatient tuberculosis dispensary. This is due to the fact that such patients are a source of active release of bacteria, which poses a serious danger to others.

When a cavernous process is initially detected, drug treatment is prescribed using the following anti-tuberculosis drugs:

Rifamycin.
Streptomycin.
Ethambutol.
Isoniazid.

In order to achieve a high concentration of such chemotherapeutic drugs, intravenous and intrabronchial administration of them into the patient’s body, as well as into the vein cavity, is prescribed. Drug therapy using drugs is complemented by therapeutic exercises for the respiratory system and tuberculin therapy.

In addition, the following physiotherapeutic procedures are prescribed:

laser treatment;
ultrasound;
inductothermy.

In the uncomplicated course of the destructive form of the disease, after 5-6 months the patient experiences positive treatment results. The patient stops secreting mycobacteria, the cavity decreases, and even its complete closure occurs. If after a certain time it is not possible to achieve healing of the cavity, then specialists decide to perform surgical intervention. Doctors perform such types of surgery as resection of lung tissue and artificial pneumothorax.

In fact, the cavernous form of tuberculosis responds quite successfully to drug treatment. When diagnosing small cavities in a patient, anti-tuberculosis treatment can achieve their closure and scarring of the tissue.

The caverns are gradually filled again with caseous masses, and the result is the appearance of pseudotuberculoma.

In some cases, various complications may develop, but this is diagnosed extremely rarely. In some patients, despite drug therapy, suppuration of the lung tissue and further progression of the tuberculosis process are observed.

By the beginning of the 90s, an unfavorable epidemic situation regarding tuberculosis had developed in the world. This applies to both developed and developing countries. Tuberculosis is recognized by WHO as a global problem causing enormous economic and biological damage. In 1993, the World Health Organization declared that tuberculosis was out of control and “in a critical situation worldwide.”

In Russia, this was due to the intervention of three powerful destabilizing factors in the epidemic process of tuberculosis: the socio-economic crisis, a decrease in the activity of anti-tuberculosis measures and the spread of HIV infection. In subsequent years, negative trends began to increase - preventive examinations decreased to 63-65% and against this background the proportion of destructive forms of tuberculosis increased.

According to R.Sh. Valieva (1987) among patients registered for newly diagnosed tuberculosis, destruction of lung tissue was found in 35.8%, bacterial excretion in 67.1%.

Over a ten-year period, the incidence of destructive forms of tuberculosis increased almost 2-2.5 times - from 12.3 per 100 thousand population in 1992 to 35.2 in 2004 and the incidence of bacterially excreted tuberculosis from 14.0 in 1992 to 35.2 per 100 thousand population in 2004.

The effectiveness of treatment of newly diagnosed patients according to the criterion of closing decay cavities in 1998 was 63.4%, according to the criterion of stopping bacterial excretion - 73.2%, which is 15% lower than the values in 1992.

The decrease in these indicators is due to a whole group of factors, both objective and subjective, ranging from a shortage of drugs to a change in the social composition of patients towards the predominance of unemployed people, their negative attitude towards treatment, an increase in the number of patients with acutely progressive forms of tuberculosis, caseous pneumonia with abundant bacterial excretion .

The initial massiveness of bacterial excretion creates serious difficulties in curing tuberculous changes, since it fully reflects the prevalence of pulmonary tuberculosis with multiple destructions and slow involution of a specific process. The insufficient effectiveness of treatment for patients with various forms of destructive pulmonary tuberculosis is directly related to impaired immunity due to various endogenous and exogenous factors and the lack of their positive dynamics during chemotherapy, as well as drug resistance of Mycobacterium tuberculosis (MBT).

On the problem of destructive pulmonary tuberculosis.

The epidemiological situation of tuberculosis in any region depends on the reservoir of tuberculosis infection circulating in the environment surrounding a person and environmental factors. The reservoir of infection is associated with the number of patients secreting tuberculous mycobacteria, i.e. sick, primarily with destructive forms of pulmonary tuberculosis. The possibility of reducing the reservoir of infection depends on the cure of such patients. Therefore, studying the epidemiology of destructive pulmonary tuberculosis, its clinical course depending on the immunological and psychological state of the body, drug resistance of Mycobacterium tuberculosis (MBT), as well as environmental and geochemical factors influencing them in modern socio-economic conditions and improving methods of its treatment seems relevant the task of phthisiology.

For the purpose of differentiated treatment, pulmonary tuberculosis, according to qualitative characteristics, has long been divided into small forms without decay, widespread without decay and destructive.

All destructive pulmonary tuberculosis with such a division of processes according to qualitative characteristics is assigned to one category and, accordingly, a uniform method of treatment is recommended. Meanwhile, destructive processes in the lungs are extremely heterogeneous. The existing literature does not provide criteria for delimiting the described categories of processes, or the criteria are very heterogeneous and without appropriate justification; sometimes not so much the number and size of cavities are taken into account, but the prevalence of infiltrative and focal changes.

Thus, the question of dividing destructive pulmonary tuberculosis into groups according to qualitative and quantitative characteristics before the start of its study by the staff of our department was only at the stage of problem formulation. Meanwhile, this is important not only for differentiated treatment, but also for comparative assessment of the effectiveness of various complex therapy regimens proposed by different authors for implementation from the point of view of evidence-based medicine. However, a detailed analysis of the literature of that time did not allow us to evaluate them comparatively and identify the most effective among them.

Destruction of lung tissue is not just a complication of the disease, it is an indicator of a qualitatively different form of the tuberculosis process, the occurrence and course of which is apparently determined by primary immunodeficiency. The implementation of the latter in the disease of tuberculosis depends on various reasons, known as risk factors. Non-destructive forms of the disease, once established, rarely progress and are detected during preventive fluorographic examinations of the population. Destructive tuberculosis forms in a short time during the period between two fluorographic examinations, manifesting itself with symptoms. It is more often diagnosed in clinics when visiting a doctor. Among the destructive forms, there are variants that differ in the rate of progression. Therefore, the concepts of minor and initial (early) tuberculosis are not identical. The incidence rate of destructive pulmonary tuberculosis per 100,000 population, as well as the number of patients who died within a year after the onset of the disease, and the number of patients who became ill again with bacteriologically positive tuberculosis are the main ones for assessing the epidemiological situation of tuberculosis. The indicator of the general incidence of tuberculosis in the population should be regarded as additional, and not primary.

The analysis showed that the frequency of detection of destructive tuberculosis with a fluorographic examination once a year, for example, was in 1994. - 33.1%, gradually decreased and amounted to in 1998. - 32.2%. This suggests that even with regular annual examinations of the population, destructive tuberculosis is detected in every third case, i.e. This is not the neglect of the case, as was previously believed, but the uniqueness of the course of tuberculosis. When assessing the passage of fluorography among patients identified by referral, it was found that among those whose last fluorographic examination was less than 1 year, the frequency of detection of destructive tuberculosis was 41.1% -53.4%, which once again confirms the possibility of the formation of destruction in a short time time period. At the same time, among those who were not examined for more than 5 years or did not undergo fluorographic examination, the frequency of destruction was 66.7% -73.8%. The results of our data formed the basis of regulatory documents for determining the frequency of preventive examinations for tuberculosis depending on risk factors and professional affiliation, approved by Decree of the Government of the Russian Federation No. 892 of December 25, 2001.

The conducted studies suggest that the use of the incidence rate of destructive pulmonary tuberculosis per 100 thousand population helped to objectify data on the epidemiological situation of tuberculosis both in the Republic of Tatarstan and Russia, because since 2005 it is included in the official statistics of the Ministry of Health and Social Development of the Russian Federation.

We tried to divide destructive pulmonary tuberculosis into groups based on the main feature - the timing of healing of decay cavities with conventional chemotherapy and some other treatment regimens. Then the remaining signs of the clinical course of the disease were assessed, which confirmed the existence of qualitative differences in the groups identified by the main sign (Table 1).

Table 1

Terms of closure of decay cavities as a percentage for various types of destructive pulmonary tuberculosis

In parentheses - intensive complex treatment

A detailed analysis of the treatment results made it possible to identify the following variants of destructive pulmonary tuberculosis, which clearly differed in terms of the timing of healing of decay cavities:

1. Pulmonary tuberculosis with minimal destruction (MDT). This includes cases where the decay phase was diagnosed by indirect signs (47 observations) and cases where there were decay cavities less than 2 cm (usually up to 1.5 cm), single (135 observations) or multiple (73 observations). The analysis showed that the timing of closure of decay cavities, including multiple ones, in all these cases, is approximately the same and differs sharply from the healing time of larger cavities. After only 2 months of treatment, the decay cavities were no longer detectable in a third of the patients, and after 4 months - in two thirds of the patients. In most cases, where the cavities were no longer detectable, at a later date it was possible to establish that in the areas of infiltration of the lung tissue there were caseous foci with their partial melting, on which the slow dynamics depended. Some of these patients developed typical tuberculomas during treatment.

2. Limited destructive pulmonary tuberculosis (LDT). Initially, we included here only processes with single decay cavities of medium size (2-4 cm). It turned out that cavities with a diameter of 2 cm occupy an intermediate position in terms of closure between cavities up to 1.5 cm and cavities 3-4 cm in size, which are closer to the latter in location. Therefore, we classified processes with such cavities as limited destructive pulmonary tuberculosis.

Further analysis showed that in cases where there are 2 cavities with a diameter of 2-4 cm or (rarely) a combination of one such cavity with one or more small cavities (up to 1.5 cm), the timing of closure with conventional chemotherapy is the same as for single cavities and differ sharply from the healing time of multiple (system) cavities of the same size. This forced us to combine both groups of processes into one category of limited destructive pulmonary tuberculosis. Closure of cavities in such diseases occurs 2-4 months later than in tuberculosis with minimal destruction.

3. Common destructive pulmonary tuberculosis (PDT). Based on the timing and frequency of cavity healing, we included in this group, firstly, processes with multiple decay cavities. In isolated cases there were 3 cavities, and most patients had a system of decay cavities, the number of which often could not be counted. Secondly, this category includes processes with large and giant caverns. In approximately half of these cases, such cavities were single; in the remaining patients, simultaneously with large cavities in the lungs, there were one or several medium-sized cavities (2-4 cm). Although healing of the latter was observed earlier, closure of large cavities occurred as late and rarely as in cases where they were single.

The table shows that the frequency and timing of cavities closure in widespread destructive pulmonary tuberculosis differs sharply from limited processes. And although these indicators in the presence of large cavities are significantly worse than in the case of multiple medium-sized cavities, we classified them into one category, because in both cases, equally intensive therapy is required. With conventional chemotherapy only after 8-12 months. the frequency of cavity closure reaches the same level as with limited destructive tuberculosis after 4 months.

The abrupt decrease in the effectiveness of treatment from group to group in terms of the frequency and timing of cavity closure in itself seems to be quite convincing evidence of the need to divide destructive pulmonary tuberculosis in infiltrative and disseminated processes into 3 distinct categories. They also differ in other indicators of the clinical course of the disease. In particular, the prevalence of infiltrative and focal changes in the lungs in most cases corresponded to the number and size of cavities. In cases of discrepancy, the timing of cavity closure depended more on their size than on infiltrative and focal changes. Therefore, we came to the conclusion that it is advisable to divide destructive processes into categories according to the main feature - the number and size of decay cavities.

This indicator usually corresponded to the severity of the intoxication syndrome and the timing of improvement in the condition of patients, as well as the massiveness of bacilli discharge and the timing of its cessation.

Due to the peculiarities of the dynamics of decay cavities and differences in treatment methods, when dividing newly diagnosed destructive pulmonary tuberculosis into categories based on qualitative characteristics, it becomes necessary to separate pulmonary tuberculomas with decay and fibrous-cavernous processes into separate groups.

4. We observed tuberculomas with decay in 75 patients. In less than half of the cases they were diagnosed immediately when patients were identified. In other observations, they were formed from infiltrative processes with decay during chemotherapy. The patients received a variety of treatments, but it was not possible to evaluate the effectiveness of individual regimens, because When divided into groups, each group contained a very small number of observations. The overall effectiveness of conservative therapy is presented in the table. It shows that the closure of decay cavities, sometimes as a result of their filling, occurs at a later date.

5. We observed the fibrocavernous process in 32 newly diagnosed patients. Since cavities in this disease are very rarely identified, the results of treatment are not presented in Table 1.

The outcomes of pulmonary tuberculosis are another important indicator of the qualitative characteristics of destructive pulmonary tuberculosis. Observations of patients for 2 years or more showed that the final results depend on many factors: the age of the patients, concomitant diseases, chemotherapy tolerance, drug resistance of the pathogen, etc. But most of all, the outcome of the disease was influenced by its severity and prevalence, the method and duration of treatment in the hospital, and the discipline of patients regarding treatment at the outpatient stage. Under all circumstances, Table 1 shows clear differences in disease outcomes according to the identified categories of destructive pulmonary tuberculosis, which once again confirms the legitimacy of such a division and the reliability of the developed criteria.

Thus, it has been proven that destructive pulmonary tuberculosis in people who become ill for the first time, according to qualitative and quantitative characteristics, in order to develop differentiated treatment methods, it is advisable to divide into 5 categories. This made it possible to carry out differentiated treatment of patients, increase the effectiveness of treatment of severe forms of the disease, including caseous pneumonia, and reduce the drug burden of patients with relatively small tuberculosis processes in the lungs. The development of principles for differentiated treatment of patients depending on the qualitative and quantitative characteristics of the destructive process in the lungs is a new direction in the development of tuberculosis chemotherapy.

When testing new treatment methods in order to develop indications for them, and so that the results of studies by different authors are comparable, it is advisable to evaluate the effectiveness separately for each category of destructive pulmonary tuberculosis.

Based on long-term observation of patients with destructive pulmonary tuberculosis, new approaches to assessing the timeliness of their detection have been proposed.

Based on the comparative effectiveness of inpatient and outpatient treatment of patients with destructive pulmonary tuberculosis, we have shown that a significant part of them can be transferred to outpatient treatment or in a day hospital without waiting for the closure of the decay cavities, soon after the cessation of bacterial excretion and significant resorption of inflammatory changes in the lungs, which significantly reduces financial expenses.

R.Sh. Valiev

Honored Doctor of the Russian Federation, Honored Doctor of the Republic of Tatarstan,

Head of the Department of Phthisiology and Pulmonology KSMA,

Doctor of Medical Sciences, Professor

From the speech on April 22, 2009 at an extended meeting of the Academic Council of the Kazan State Medical Academy of Roszdrav
“IMPROVING METHODS OF DIAGNOSIS, TREATMENT AND PREVENTION OF PULMONARY TUBERCULOSIS IN CONDITIONS OF SOCIO-ECONOMIC TRANSFORMATIONS AND SPREAD OF HIV INFECTION”