SECONDARY

TUBERCULOSIS

LECTURE
doc. Kravchenko N.S.
 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.
 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.
Ways of MBT spreading.
1 haematogenous
2 lymphogenous
3 - bronchogenous
 Miliary
tuberculosis
 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
AS TO CLINICAL PROGRESS MILIARY
TUBERCULOSIS IS CONDITIONALLY
DIVIDED INTO:

- LUNG

- TYPHOID

- MENINGEAL

- SEPTIC FORMS.
FIGURE 1. Chest radiograph of a patient with miliary tuberculosis.
Note the extensive, symmetrical distribution of 2- to 3-mm lesions
throughout both lungs.
FIGURE 2. Close-up view of the chest radiograph in Figure 1. Note the uniform
distribution of nodules throughout the lung parenchyma.
 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.
 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.
 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.
Mantu`s 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.
Disseminated lung tuberculosis
Disseminated lung tuberculosis
(subacute)
Stamped cavern in the apper
part of the right lung
 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.
Chronic disseminated
lung tuberculosis
 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.
Chronic disseminated
lung tuberculosis
 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.
Bilateral nidus pneumonia
Sarcoidosis of the lungs and intrathorasic limph. nodes
 Sarcoidosis of the lungs
and intrathorasic limph. nodes
Carcinomatosis
Lung stagnation phenomena
Lung stagnation phenomena. Left-side transsudate
 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.
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.
fig. 1 Focal lung tuberculosis
fig.2 Roentgenogram. Focal lung tuberculosis
 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. .
The most informative criteria of activity of
tuberculosis process:
- Finding of MBT;
- X-ray criteria;
- Involution of the process under the
test treatment.
 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.
variants of infiltrate

fig. 5. Cloudlike infiltrate

fig. 6. Round shaped infiltrate
Fig. 7. Lobitis.
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.
Infiltrative tuberculosis
fig.3 Roentgenogram. Infiltrative lung tuberculosis
6 left lung with decay
fig.4 Roentgenogram. Cloudlike infiltrate
of left lung.
 Differential diagnosis at infiltrative tuberculosis (table)
Main signs Infiltrative Pneumonia Infarct of lung Eosinophilic Cancer of lung
tuberculosis infiltrate
Sometimes contact Caught a cold, Operation, trauma, Allergic diseases, Patients are men after
ANAMNESIS with tb patients, catharrh of upper trombophlebitis, helminths 40, smoking
previous tb respiratory ways, heart diseases
angina

Beginning often is The beginning is The beginning is The beginning is not Gradual beginning,
gradual, acute. At acute, fast regress acute visible, rare acute progressive worse
COURSE tuberculostatic after antibiotics condition
therapy regress is
slow

Moderate toxication, High temperature, Pain in chest, None complains, Pain in chest,
fever, sweating, dyspnea, cough. Full dyspnea. Above sometimes cough, dyspnea, cough, a big
SYMPTOMS cough. Few ausculataive picture the infiltrate zone, impermanent dry or tumor or complicated
ausculatative (wet and dry there is dullness, wet rhonchi with atelectasis
changes rhonchi) bronchial dullness, sometimes
breathing dry rhonchi above
infiltrate
Not homogenic Shadow in most Triangle Shadow with unclear At peripheral cancer
infiltrate in1, 2 or 6 cases is homogenic homogeny margins like cotton the shadow is
ROENTGENO- segment. Road to shadow, apex tampon, often homogenic and
LOGIC PICTURE root, injured places towards the root. homogeny. Rapid tuberose. At central
on the background Rare shadow is appearance and one the shadow goes
and around infiltrate round or oval. disappearance of out of root
High state of infiltrate.
diaphragm
OTHER Positive Mantu test. At bronchiscopy On ECG there are Positive skin tests Direct and indirect
METHODS OF At bronchoscopy there is unspecific signs of with specific signs of tumor at
INVESTIGATION there is a specific endobronchitis overloading of allergen bronchoscopy
endobronchitis right heart
 fig.8 Roentgenogram.
Pneumonia of inferior part of left lung.
fig.9 Roentgenogram.
Eosinophilic pneumonia.
fig.10 Roentgenogram. Central cancer of left lung.
fig.11 Tomogram of right lung. Infarct of lung .
 Caseous pneumonia

Caseous pneumonia is a clinical

form of tuberculosos with massive
caseous changes in lungs and
severe, progressive clinical course.
fig. 12 Lobar caseous pneumonia.
 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.
fig.13 Caseous pneumonia of left lung.
Bronchogenic dissemination of right lung.
Caseous pneumonia
Staphylococcal pneumonia
 LUNG TUBERCULOMA
Lung tuberculoma is a distinct
by genesis encapsulated
caseous formation exceeding 1
cm in diametre and having a
chronic torpid course.
Homogenous tuberculoma
Layer-by-layer tuberculoma
Conglomerate tuberculoma
Tuberculoma of the cerebellum
Tuberculoma
 FIBROUS-CAVERNOUS LUNG
TUBERCULOSIS

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

Fresh elastic cavity fibrous cavity

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

1. scar;

2. hearths;

3. blocked cavity;

4. pseudocysts.
chronic abscess
 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 %).
Cirrhotic lung tuberculosis
Cirrhotic lung tuberculosis
Cirrhotic tuberculosis
Pleurogenic
cirrhosis of
the left
lung