(tuberculosis, lat. tuberculum tubercle + -ōsis)
Mycobacterium tuberculosis disease. The respiratory organs are most often affected (see. Respiratory tuberculosis (Respiratory tuberculosis)), among other organs and systems - mainly the genitourinary system, peripheral lymph nodes, skin, eyes, bones and joints (see Extrapulmonary tuberculosis (Extrapulmonary tuberculosis)). A special form of T. in children and adolescents is tuberculous intoxication (Tuberculous intoxication), or T. without specific localization.
Etiology. The causative agents of T. are acid-resistant mycobacteria, discovered by the German bacteriologist Koch (R. Koch) in 1882, mycobacterium tuberculosis. Most often T. at the person cause mycobacteria of a tuberculosis of a human species, more rarely a bovine species. Mycobacterium tuberculosis are thin, straight or slightly curved rods 1-10 μm, 0.2-0.6 wide μmhomogeneous or granular with slightly rounded ends (fig.) They are resistant to environmental factors: in street dust they last up to 10 days, on the pages of books - up to 3 months, in water - up to 5 months. Under the influence of sunlight, the culture of mycobacterium tuberculosis dies after 90 minultraviolet rays kill her in 2-3 min. When boiling, mycobacterium tuberculosis die in wet sputum after 5 minin dried sputum - after 45 min. Under the influence of drugs releasing free active chlorine (3-5% solutions of chloramine, 1-2% solutions of chloramine activated by ammonium sulfate, 10-20% solutions of bleach, etc.), the death of pathogens T. occurs in 3-5 h. Under the influence of various factors of Mycobacterium tuberculosis, they are able to transform both into ultrafine filtering particles and into giant branched forms. Getting in favorable conditions, mycobacterium tuberculosis can again take on a typical form.
Epidemiology. In T.'s epidemiology, biomedical factors associated with the interaction of the human body and the causative agent of the disease, and social factors that determine the health status of the population as a whole and its individual groups are important.
The main source of the causative agents of infection is sick T. person who releases them into the environment. As a rule, these are patients with T. lungs, whose sputum contains mycobacterium tuberculosis. The most dangerous from the epidemiological point of view are patients with constant abundant bacterial excretion. One such patient, not observing the rules of personal hygiene, is capable of infecting up to 10-12 people in a year. At meager, unstable bacterial excretion, the danger of infection with T. exists only in close contact with the patient. In most cases, T.'s infection occurring by airborne droplets, less often by airborne dust and alimentary. About 100 cases of intrauterine infection of a fetus at T. are described at pregnant women.
The second most important source of infectious agents is patient T. cattle. To rarer sources of pathogens include patients T. pigs, sheep, camels, cats, dogs, birds and other animals. A person can become infected from a sick T. animal by airborne droplets, by airborne dust, by contact, as well as by eating unboiled and unpasteurized milk (and dairy products from it), less often the meat of a sick animal. Breeders and members of their families are at greatest risk of infection with T. from sick animals.
Infection of the body with mycobacterium tuberculosis does not always lead to disease. Leading role in the development of T.unfavorable living conditions and a decrease in the body's resistance play. Susceptibility to T. increases with poor nutrition, prolonged physical stress, emotional stress, some chronic diseases (for example, diabetes mellitus, peptic ulcer disease, chronic alcoholism, drug addiction, pneumoconiosis, systemic diseases requiring long-term use of glucocorticosteroid and cytotoxic drugs). A hereditary predisposition or resistance to tuberculosis also matters.
Tuberculosis is ubiquitous. According to the WHO (1990), about 8 million people become ill every year in the world, and 3-4 million people die from this disease. The greatest number of patients T. is registered in the countries of Asia, Africa, Latin America. In most foreign countries, when calculating epidemiological indicators (incidence, morbidity), only bacteriostatic agents are considered. In our country, the incidence of T. is calculated by the number of patients with active T. who were first diagnosed for the year per 100 thousand people (in the second half of the 80s, it averaged about 40 per 100 thousand people in the USSR with fluctuations in individual regions) , soreness (prevalence) - according to the number of all patients registered in the current year with active T. per 100 thousand population. Analysis of the structure of morbidity and morbidity by individual clinical forms of T. in different age groups makes it possible to assess the epidemiological situation of T. and the quality of TB work in the region. For example, a high incidence of fibro-cavernous T. lungs or its predominance among other forms of T. respiratory organs, as well as a high incidence of T. children of the first year of life indicate the presence of a large reservoir of infection and insufficient work on the early detection of tuberculosis.
An important indicator of the epidemiological situation for T. is infection. It is determined on the basis of the results of tuberculin tests (see Tuberculin diagnostics) as a percentage of the number of people who respond positively to tuberculin (except for people with post-vaccination allergy) to the total number of patients. Infection increases with the age of the subjects, among people 40 years old it reaches 70-90%.
Pathogenesis, pathological anatomy and immunity. The pathogenesis of T. is complex and depends on the diverse conditions in which the pathogen and the human body interact. Depending on the mechanism of development of the disease, primary and secondary tuberculosis is distinguished.
Tuberculosis is called primary, which develops as a result of primary infection with tuberculosis mycobacteria of individuals who do not have anti-tuberculosis immunity, and is characterized by a high sensitivity of tissues to these microorganisms. Primary T. is observed more often in children. Children of the first year of life and from the age of 1 to 5 years are especially susceptible to the disease. This is due to the insufficient development of their immune responses and imperfect resistance of the body.
After the penetration of mycobacterium tuberculosis into the body of a previously uninfected T. human, phagocytosis develops as the first protective reaction, the effectiveness of which depends on many factors, including and hereditary. The central link of organism resistance to T. are reactions of cellular immunity. Effector cells have a regulatory effect on the course of T., enhancing the phagocytic activity of macrophages both directly and with the help of mediators synthesized by them. From the first days of penetration into the body of mycobacterium tuberculosis, bacteremia develops and the activity of the immune system manifests itself, aimed at destroying the causative agent of the disease. The activity of phagocytosis and the state of the immune system largely determine the nature of the tissue reaction (alternative, exudative or productive) and, accordingly, the course of the tuberculous process.
In the zone of penetration of mycobacterium tuberculosis into the body (for example, respiratory organs, gastrointestinal tract, skin), an inflammatory focus occurs - the primary affect. In response to its appearance, in connection with the sensitization of the body, specific inflammation develops along the lymphatic vessels and in the regional lymph nodes, i.e. primary tuberculosis complex is formed. In the process of forming foci of primary T., lymphogenous and hematogenous dissemination of infection pathogens can develop with the formation of tuberculous foci in various organs - lungs, bones, kidneys, etc. Healing of foci of primary T. can be accompanied by a restructuring of the body's immune system and the acquisition of specific immunity. Tuberculosis immunity is non-sterile, i.e. it is maintained if there is either a vaccine strain of BCG in the body or mycobacterium tuberculosis, or persistent (dormant) pathogens. In recent years, data have been obtained on the presence of immune memory mechanisms that support anti-tuberculosis immunity and in the absence of tuberculosis mycobacteria in the body.
Persons who have undergone primary T., but have retained increased sensitivity to tuberculin and have significant immunity to tuberculosis, in the presence of residual changes in the form of foci-screenings in various organs or not fully healed foci in the lymph nodes, hematogenous tuberculosis may develop. Three types of hematogenous T are distinguished: generalized hematogenous T. (tuberculous sepsis, miliary and large focal T.), hematogenous T. with primary lung damage (acute miliary, chronic miliary and large focal), hematogenous T. with predominantly extrapulmonary lesions (focal or destructive changes in various organs with acute or chronic course).
Secondary is called T., which develops in individuals previously infected with tuberculosis mycobacteria, against the background of relative acquired immunity. It is mainly observed in individuals with residual changes after primary T. Endogenous reactivation of T. occurs as a result of the multiplication of mycobacterium tuberculosis, persistent in the healed primary tuberculosis foci, with a decrease in anti-tuberculosis immunity under the influence of adverse social factors and chronic diseases. Less often secondary T. develops as a result of superinfection. This is possible with massive exogenous infection and a decrease in immunity. Secondary T. is characterized by high tissue sensitization to tuberculosis antigens, a tendency to tissue destruction and the spread of infectious agents via the intracanalicular route (through the bronchi, intestines), and a variety of clinical and morphological forms. Secondary T. of lungs is most often met, its clinical and morphological forms are focal and infiltrative T., tuberculoma, cavernous, fibrous-cavernous and cirrhotic T. (see. Respiratory tuberculosis (Respiratory tuberculosis)).
The basis of tissue manifestations of T. lies specific inflammation. It is caused only by mycobacteria of tuberculosis and is characterized by a change in tissue reactions (determined by the restructuring of the immune system), a chronic course with alternating periods of exacerbation and subsidence, the predominance of a productive tissue reaction with the development of granulomas, the occurrence of necrosis. There are primary necrosis, which develops with an alternative tissue reaction, and secondary, which occurs against the background of exudative and (or) productive changes.
The general picture of morphological manifestations of T. in tissues and organs consists of a combination of three main types of changes: alterative (tissue damage up to necrosis), exudative (vascular reaction of the microvasculature, the formation of exudate, the appearance of inflammatory cell infiltrate, the development of caseous necrosis is possible) and productive ( development characteristic of tuberculous inflammation of granulomas). Alterative and exudative changes occur against the background of immediate hypersensitivity, productive - against the background of delayed hypersensitivity.
The formation of tuberculous granuloma is usually preceded by tissue damage, then neutrophils migrate to the lesion, followed by mononuclear cells and active macrophages, which have high phagocytic activity and inhibit the multiplication of mycobacterium tuberculosis. The increase in cellular immunity is manifested by the transformation of macrophages into epithelioid cells, which are located in a picket fence around the lesion. By fusion of epithelioid cells, giant Pirogov-Langhans cells are formed. Along the periphery of the inflammatory focus (granulomas), T- and B-lymphocytes (mainly T-lymphocytes) appear, as well as fibroblasts. The capillaries, blood and lymph vessels are almost completely absent in granuloma (see fig. 1 to the article Granuloma (Granuloma)).
The cellular composition of tuberculous granuloma changes at different stages of its formation and involution. Depending on the predominance of a particular population of cells, epithelioid-cell, lymphoid, and giant-cell granulomas are distinguished, and granulomas of a mixed type are possible.
In addition to a granuloma having a diameter of 1-2 mm (miliary tubercle), other manifestations of tuberculous inflammation can be observed in tissues and organs. Larger foci of tuberculous inflammation occur when several granulomas merge (drain tubercles). Similar foci exceeding 1 in diameter cmare called solitary tubercles. In the lungs, the focus of tuberculous inflammation can be occupied by the acinus, lobule, segment or lobe (respectively, acinous, lobular, segmental, lobar focus), a productive focus in the lung with a diameter of 1-2 cm called nodose. The focus of tuberculous inflammation in organs and tissues can be encapsulated. Encapsulated caseous lesion with a diameter of more than 1 cm called tuberculoma. With the breakdown of foci of tuberculous inflammation, ulcers form on the mucous membranes and skin, and cavities in the internal organs. With the delimitation of the decay cavity, a 2-3-layer wall forms a cavity. The healing of foci of T. is accompanied by the formation of scars, calcification, sometimes ossification. Healed ossified tuberculous affect in the lung is called the focus of Gon. With an exacerbation of the process and a change in the productive reaction to exudative granuloma and the adjacent tissue, necrotize.
Granulomatous inflammation at T. is combined with a number of non-specific (para-specific) tissue changes. Their morphological equivalent are various mesenchymal cell reactions: diffuse or nodular proliferation of lymphocytes and macrophages, hyperplastic processes in the hematopoietic tissue, fibrinoid changes in the connective tissue and arteriole walls in organs, dysproteinosis, and even amyloidosis. Thus, tissue morphological substrate of T. is tissue inflammatory changes determined by the complex interaction of tuberculosis mycobacteria with a macroorganism and features of immune homeostasis.
Modern methods of drug therapy of T. using anti-tuberculosis drugs change the clinical and morphological manifestations of the disease (therapeutic drug pathomorphosis). The main morphological signs of therapeutic drug pathomorphism of T. include predominantly nonspecific manifestations of the inflammatory process and the predominance of productive (granulomatous) tissue reaction over exudative, weaker severity of perifocal edema, restriction of hematogenous dissemination and bronchogenic screenings, acceleration of fibrotization of tuberculous foci.
Minimal manifestations of the tuberculosis process (the equivalent of a "minor disease") are also observed with intradermal vaccination and revaccination with BCG vaccine. At the injection site and in the regional lymph nodes, inflammatory manifestations of a vaccination reaction are found of varying intensity, which are based on the mechanisms of anti-tuberculosis immunity.On the first day, an expansion of capillaries, accumulations of white blood cells and mast cells is noted at the injection site. By the 3rd week, tuberculoid granulation tissue forms, the development of limited caseous necrosis is possible. Regional lymph nodes can enlarge; epithelioid-cell granulomas are formed in them, which usually come to light in 1-2 months. - 1 year after the introduction of the vaccine. Granulomas also develop in the spleen, liver, lungs, necrotization, they do not undergo, are scarred for 1-2 years.
If the vaccination technique is violated, as well as against the background of immunodeficiency conditions, complications develop: ulceration or a cold subcutaneous abscess at the injection site, regional lymphadenitis, including with abscess formation, fistula formation and calcification. Osteomyelitis and generalization of the vaccine process with the development of sepsis are also possible. The risk of the latter increases in children infected with the human immunodeficiency virus.
Classification. The clinical classification of T. used in our country was adopted in 1938 and was revised several times taking into account scientific achievements and practice requirements: the main clinical forms of T., the characteristic of the tuberculous process (localization and extent, phase of bacterial excretion), complications and residual changes after tuberculosis (tab.).
Clinical classification of tuberculosis
A. The main clinical forms
Tuberculosis intoxication in children and adolescents
Primary tuberculosis complex
Thoracic lymph node tuberculosis
Disseminated pulmonary tuberculosis
Focal pulmonary tuberculosis
Infiltrative pulmonary tuberculosis
Cavernous pulmonary tuberculosis
Fibrous cavernous pulmonary tuberculosis
Cirrhotic pulmonary tuberculosis
Tuberculous pleurisy (including pleural empyema)
Tuberculosis of the bronchi, trachea, larynx, upper respiratory tract
Respiratory tuberculosis combined with dust occupational pulmonary diseases (konyotuberculosis)
Tuberculosis of other organs and systems
Tuberculosis of the meninges and central nervous system
Tuberculosis of the intestine, peritoneum and mesenteric lymph nodes
Tuberculosis of bones and joints
Urinary and genital tuberculosis
Peripheral lymph node tuberculosis
Tuberculosis of other organs
B. Characterization of the tuberculosis process
Localization and extent (in lungs by lobes and segments)
a) infiltration, decay, seeding,
b) resorption, densification, scarring, calcification
a) with the release of mycobacterium tuberculosis (CD +),
b) without isolation of mycobacterium tuberculosis (BK-)
B. Complications: hemoptysis and pulmonary hemorrhage, spontaneous pneumothorax, pulmonary heart failure, pulmonary atelectasis, amyloidosis, renal failure, fistulas (bronchial, thoracic, etc.).
G. Residual changes after cured tuberculosis
Residual changes in the respiratory system: fibrous, fibro-focal, bullous changes, calcifications in the lungs and lymph nodes, pleuropneumosclerosis, pulmonary cirrhosis, bronchiectasis, condition after surgery, etc.
Residual changes in other organs: cicatricial changes and their consequences, calcification, condition after surgical interventions.
Based on the requirements of medical statistics, the clinical classification of T. is brought in line with the International Classification of Diseases. In addition to the clinical classification of T. used to formulate the diagnosis, there is also a dispensary group for tuberculosis patients, which meets the practical goals of the dispensary.
Features of the clinical manifestations of tuberculosis. Clinical manifestations of T. are diverse. Characteristic for all forms of T.is an intoxication syndrome caused by the multiplication of mycobacterium tuberculosis and the accumulation in the body of their metabolic products. Intoxication syndrome is manifested by fever, weakness, decreased performance, sweating, tachycardia, poor appetite, weight loss. Mental disorders may develop. In the acute period of T. the Astenic syndrome most often meets. Physical asthenia prevails over mental, and weakness, fatigue, general malaise are expressed mainly in the morning. With effective treatment, the phenomena of irritable weakness, emotional instability, and autonomic disorders are more pronounced. Asthenia is often combined with personality reactions to the disease. At detection of T., unexpected for the patient, reactive subdepressive state can develop. More diverse and pronounced mental disorders with a tendency to a chronic course are observed with fibro-cavernous T. lungs. Asthenic syndrome in these patients can be combined with euphoria or apathy. As a rule, asthenia increases with a somatic condition worsening. It is extremely rare at T. there are psychoses in the form of an amentia (see. Amentative syndrome), depressive or manic syndrome (see. Depressive syndromes, Manic Syndromes), delirium (see. Delirious syndrome), hallucinosis (see. Hallucinations). Delirious syndrome often develops in patients who abuse alcohol, it is characterized by severe auditory hallucinations.
Local changes in organs in T. are usually divided into limited (the so-called small forms of T.), in which the presence of active tuberculosis inflammation can be proved by a detailed clinical and radiological examination or during the observation process, and sometimes after trial treatment with anti-TB drugs, common changes without destruction, incl. with damage to several organs, destructive processes.
The course of T. depends on many factors: the massiveness of the infection, the genetically determined susceptibility to tuberculosis, the state of the immune system, the timely detection of the disease and the start of treatment, concomitant diseases, drug resistance of mycobacterium tuberculosis, etc. In recent years, thanks to the created system of preventive and therapeutic measures T. in many cases it proceeds favorably, with minimal lesions and healing without pronounced residual changes. Severe acute forms of T. are much less common (caseous pneumonia, miliary T., tuberculous meningitis) and generalized forms of T. with damage to various organs. Secondary tuberculosis, which in the past was characterized by an acute course with an unfavorable outcome, often proceeds chronically, undulating, with a change in periods of exacerbation and subsidence.
The course and clinical manifestations of T. essentially differ depending on the age of the patient. In children, primary T is more often observed. Its features are more frequent involvement in the inflammatory process of the lymphatic system, the spread of pathogens mainly by the hematogenous route, extensive perifocal changes, frequent para-specific toxic-allergic reactions (e.g., erythema nodosum), and also high healing ability.
Favorable epidemiological and immunological changes led to T. pathomorphosis in children. Against the background of a sharp decrease in the incidence of T., the number of severe acute and generalized forms significantly decreased. In most children and adolescents, primary infection with mycobacterium tuberculosis, detected by a Mantoux test with 2 TE tuberculin, is asymptomatic, T. develops only in 6.7% of cases. At the same time, tuberculous intoxication (T. without specific localization) and T. of intrathoracic lymph nodes are mainly observed. Moreover, 1 /3 patients T.intrathoracic lymph nodes are diagnosed with small forms of the disease. In case of untimely diagnosis and late treatment of small forms of T. intrathoracic lymph nodes, severe forms of T. often develop with damage to the lung tissue.
In modern conditions, the line between the clinical manifestations of primary and secondary T. is erased in children at prepubertal and puberty. In newly infected individuals of this group, not only T. intrathoracic lymph nodes and primary tuberculosis complex are observed, but also limited focal and infiltrative forms of T. lungs. The main factors contributing to the reactivation of endogenous tuberculosis infection in long-infected children are endocrine rearrangement of the body at prepubertal age and chronic diseases of non-tuberculous etiology. Therefore, among patients with T. children, children of prepubertal age occupy a significant place.
At puberty, secondary T. prevails, which is a consequence of a previous illness. Currently, under the conditions of mass vaccination and BCG revaccination, there is a tendency towards an increase in the incidence of primary T. in adolescents, which is associated with the gradual movement of primary infection in older age groups. T. at teenagers begins and proceeds peculiarly with insignificant clinical, but expressed x-ray morphological changes. Outcomes of the disease largely depend on the timeliness of diagnosis. Therefore, special attention should be paid to the early detection of T. in adolescents (tuberculin diagnostics, chest organ fluorography, monitoring of frequently ill patients). At identification of small forms of T. at teenagers recovery is possible with insignificant residual changes or without them.
At persons of advanced and senile age T. develops against the background of age-related changes in various organs and associated diseases, which complicates its recognition. T., observed in old and senile age, is usually divided into senile and old. T. is called senile. It develops in people of advanced or senile age usually as a result of reactivation of old foci in the lungs or intrathoracic lymph nodes. In some cases senile T. can be result of repeated infection. In advanced and senile age the limited focal or infiltrative forms of T. lungs are often observed. At the same time, despite the scanty symptoms, a tendency to destruction of the affected tissue and bacterial excretion are noted. In connection with the features of the clinical manifestations of senile T. timely diagnosis of it is difficult. With an adenogenic development of the process (activation of old calcified lesions in the lymph nodes of the roots of the lungs), infiltration and expansion of the roots of the lungs with the presence of reactive pleural changes are often mistakenly interpreted as manifestations of pneumonia or lung cancer.
Tuberculosis is called old, which usually begins in adolescence or adulthood, lasts for years, and sometimes with a favorable course is diagnosed only in old or old age. At old T. most often the fibrous cavernous or cirrhotic process in the lungs develops. Patients often have hemoptysis and pulmonary hemorrhage (pulmonary hemorrhage), symptoms of respiratory failure (respiratory failure) and chronic pulmonary heart (pulmonary heart). Difficulties in treating patients of T. elderly and senile age, as a rule, are associated with concomitant diseases and aggravation of age-related disorders of the functions of organs and systems due to the toxic effects of anti-TB drugs.
T.'s course at pregnancy also has features. An exacerbation of T. is most likely in the early stages of pregnancy and in the postpartum period. The postpartum aggravation of T. proceeds violently, with the expressed intoxication and propensity of the process to generalization.If T. is suspected in any period of pregnancy, repeated bacteriological studies of sputum are necessary to detect mycobacterium tuberculosis and X-ray of the lungs with careful diaphragm of X-ray radiation, radiation protection of the patient's abdomen and pelvis. Anti-TB drugs are prescribed taking into account their possible toxic effects on the fetus. The drugs of choice are rifampicin, isoniazid, ethambutol, protionamide. Ototoxic drugs from the aminoglycoside group (streptomycin, kanamycin, etc.), as well as sodium paraaminosalicylate, cycloserine, pyrazinamide, ethionamide are not recommended. High doses of anti-TB drugs should not be prescribed. The termination of pregnancy is justified in those cases when T. is difficult to treat, there are widespread destructive changes in the lungs. In addition, it is indicated in the first 2 years after suffering miliary T. and tuberculous meningitis, with diabetes mellitus, kidney pathology and pulmonary heart failure, as well as if there is evidence of exacerbation of T. during previous pregnancies. Artificial abortion is performed in the first 3 months. pregnancy, at a later date it is allowed in exceptional cases. In patients with T. women, as a rule, full, practically healthy children are born. In most cases, they are not infected and are subject to vaccination against T. Breastfeeding a child is allowed if the mother is not a bacteriostatic. In doubtful cases, the child immediately after childbirth is isolated and transferred to artificial feeding. Intrauterine infection is extremely rare. The features of T., which developed as a result of intrauterine infection, include the early (in the first weeks of life) manifestation of the disease, a tendency to generalize the process, and mandatory liver damage. Intrauterine infection of T. is confirmed by a positive tuberculin test in the newborn, BCG vaccination is not carried out in this case, the child is prescribed anti-tuberculosis therapy.
The current T. has certain features in patients with some chronic diseases. The incidence of T. patients with diabetes mellitus (Diabetes mellitus) is 2-5 times higher than the entire population. T. in the majority of patients with diabetes mellitus is characterized by a tendency to exudative reactions, the formation of caseous necrosis, the involvement of the bronchi in the process, and the bronchogenic spread of infection pathogens. An unfavorable course of T. is facilitated by metabolic and immune disorders, which are especially pronounced in type I diabetes. For effective treatment of T. in patients with diabetes mellitus, stable compensation of metabolic disorders and longer periods of anti-tuberculosis chemotherapy are necessary.
In patients with chronic alcoholism T. (chronic alcoholism) occurs 18-20 times more often than in individuals who do not suffer from this disease. According to N.M. Rudogo and T.Ch. Chubakova (1985), among patients with destructive forms of T., registered in TB dispensaries, patients with chronic alcoholism account for 42.8%. At a combination of T. and chronic alcoholism the course of both diseases becomes heavier. At alcohol abusers find, as a rule, the widespread destructive forms of T. with bacterial excretion. Due to lack of discipline, such patients allow interruptions in taking anti-TB drugs, which contributes to the development of drug resistance in tuberculosis mycobacteria. Frequent violations of the functions of various organs in chronic alcoholism also limit treatment options. To increase the effectiveness of treatment, it is recommended to give complex therapy of T. and chronic alcoholism, make more extensive use of parenteral administration of anti-TB drugs, strictly monitor the administration of oral dosage forms, and if indicated, carry out surgical treatment earlier.
Tuberculosis in patients with HIV infection (HIV infection) is often atypical, characterized by a tendency to generalization with damage to several organs and systems. T. in these patients can be treated with existing anti-tuberculosis drugs, but requires longer treatment.
Diagnosis T. is established on the basis of the results of a comprehensive examination of the patient and is confirmed by the detection of mycobacterium tuberculosis in sputum, urine, discharge of the fistula and other pathological material or by the identification of characteristic morphological changes in the biopsy specimens of the affected organs. An indirect confirmation of the tuberculosis nature of the disease can serve as the data of immunological studies. The activity of the tuberculosis process is determined on the basis of characteristic clinical and radiological signs (symptoms of intoxication, fibrous and focal formations in organs with a perifocal reaction or infiltrative changes with or without destruction), bacterial excretion, positive results of a tuberculin provocation test (Koch test), changes in hemogram and biochemical tests .
Currently, a comprehensive step-by-step examination of patients is being carried out in TB facilities, including a mandatory diagnostic minimum, additional and optional research methods. The mandatory diagnostic minimum used at the initial stage of the examination of all patients for whom T. is suspected includes a medical history, patient complaints, physical examination, radiography, three-time bacterioscopic and cultural studies of pathological material for tuberculosis mycobacteria, formulation of tuberculin samples, clinical blood tests and urine.
Additional research methods are necessary to clarify the diagnosis and differential diagnosis. These include repeated studies of pathological material on mycobacterium tuberculosis by flotation, a biological sample, radiopaque and tomographic methods, protein and hemotuberculin tests, immunological studies, study of proteinograms, biochemical inflammatory tests (determination of C-reactive protein, ceruloplasmin, haptoglobin, etc. ), endoscopic examinations, diagnostic operations and biopsies. Optional research methods are aimed at identifying functional disorders of various organs and metabolic disorders.
One of the main diagnostic methods for T. respiratory organs, bones and joints, urinary and genital organs is an X-ray examination.. It allows you to determine the localization, the extent of the pathological process, the nature of morphological changes. Using tomography (tomography) clarify the nature of local changes, confirm the presence of tissue decay cavities. In cases difficult for diagnosis, computed tomography can be used. If necessary, carry out radiopaque studies: bronchography (Bronchography), excretory urography (Urography), etc.
A bacteriological study (see Microbiological Diagnostics) is aimed at isolating the causative agent T. from sputum, urine, excreted fistula, etc. If sputum is small, then mycobacterium tuberculosis is more likely to be detected in its daily amount. In the absence of sputum, one can examine the washings of the bronchi and stomach. Bacteriological research includes bacterioscopic (microscopic), cultural methods and biological samples. Bacterioscopy can detect mycobacterium tuberculosis in the presence of more than 100 thousand microorganisms in 1 ml the studied material. More effective luminescent microscopy. The determination of the massiveness of bacteriological isolation using quantitative bacterioscopic and cultural methods has the necessary diagnostic and prognostic value.
Cultural methods for detecting mycobacterium tuberculosis are more informative than bacterioscopic ones. They make it possible to obtain a pure culture of the causative agent T., identify it and determine the sensitivity to drugs.
The most sensitive method for detecting mycobacterium tuberculosis is a biological sample - infection with pathological material of guinea pigs. Tuberculous changes in the organs of an animal can be detected if there are even single tuberculosis mycobacteria in the test material. The complex of examination of patients with T. respiratory organs also includes various methods for detecting other microorganisms in sputum, including fungi, as well as serological tests for the determination of antibodies to isolated pathogens.
Tuberculin diagnostics, based on the use of tuberculin samples, it allows to detect the infection of the body with mycobacterium tuberculosis, as well as to study the reactivity of the body of infected or vaccinated individuals.
Changes in indicators of clinical blood tests are not specific to T., however, in combination with other data, they play an important role in establishing the activity of the disease and monitoring its course. An increase in the number of leukocytes in the blood is not always observed, but in severe cases of T. leukocytosis can reach 12-15․10 9 /l and more. Evidence of the activity of the process is an increase in ESR and a shift of the leukocyte formula to the left (the number of stab neutrophils in the destructive process reaches 10-20%). In proportion to the severity of the disease, the number of neutrophils with pathological granularity of the cytoplasm also increases. Lymphocytosis is characteristic of the early period of primary T. and the period of subsidence of infiltrative and focal T. lungs. At progressing T. the maintenance in blood of lymphocytes and monocytes decreases. Anemia at T. is observed seldom (as a rule, at miliary T. and caseous pneumonia). Side effects of anti-TB drugs can be manifested by eosinophilia, thrombocytopenia, agranulocytosis, leukemoid reactions.
Changes in clinical tests of urine at T. of any localization can be connected with severe intoxication ("febrile proteinuria"). A decrease in the specific gravity of urine is observed with renal amyloidosis, which complicates the prolonged course of fibrocavernous and cirrhotic T. lungs. At T. of kidneys and urinary tracts in the urine the quantity of leukocytes and erythrocytes increases, and in its sediment at microscopy tuberculosis mycobacteria can be found.
Biochemical blood tests at T. are also not specific tests, but they give information about the activity of the process and its change under the influence of treatment. The indicators of the active inflammatory process are an increase in the blood content of haptoglobin, ceruloplasmin, the appearance of C-reactive protein, as well as dysproteinemia with a decrease in the albumin-globulin coefficient. In the absence of these changes, the latent activity of the tuberculosis process can be established on the basis of an increase in the level of haptoglobin and α2-globulin more than 10% after 48 h after subcutaneous administration of tuberculin to the patient. The determination of the genetic type of haptoglobin is of significant prognostic value: in patients with genetic type 2-2 haptoglobin, tuberculosis often proceeds unfavorably and is less treatable than in patients with genetic type 1-1 or 1-2 haptoglobin.
The study of liver function indicators (aminotransferases, γ-glutamyltransferases, bilirubin, etc.) must be repeated throughout the course of anti-tuberculosis therapy for early detection of side effects of anti-tuberculosis drugs, most of which are hepatotoxic.Determination of filtration and nitrogen excretory function of the kidneys allows you to identify side effects of anti-TB drugs from the group of aminoglycosides (streptomycin, kanamycin, etc.), to evaluate the amount of functional impairment in T. kidneys, the development of amyloidosis.
Immunological research methods can be useful in differential diagnosis of T., assessment of the activity of the tuberculosis process and the effectiveness of the treatment, as well as in determining the prognosis of the disease. In addition, immunological tests help identify drugs that cause an allergic reaction.
Widely used leukocyte tests: test of rosette formation, reactions of blastotransformation of lymphocytes and inhibition of white blood cell migration. Determining the number of T-lymphocytes using the rosette test and assessing their functional activity according to the results of the blastotransformation of lymphocytes with mitogens (phytohemagglutinin, concanavalin) make it possible to judge the activity of the tuberculosis process (with active T., the number of T-lymphocytes and their functional activity decrease) and determine the indications to the appointment of immunomodulators. To detect the sensitization of the body to mycobacteria of tuberculosis, the reactions of blastotransformation of lymphocytes and inhibition of migration of leukocytes are carried out with the addition of tuberculin to the suspension of leukocytes. In healthy individuals not infected with mycobacterium tuberculosis, the response rate of blastotransformation of lymphocytes with tuberculin does not exceed 1%, with a progressive course of T. it can significantly decrease, and its increase during treatment is a favorable prognostic sign. The leukocyte migration index, determined by the inhibition of leukocyte migration with tuberculin, in healthy individuals is 0.8-1.2, with T. it decreases. To identify the latent activity of T., the response rate of the blastotransformation of lymphocytes and the inhibition index of leukocyte migration are examined before and after 48 h after subcutaneous administration to the patient 25-100 TE tuberculin. A decrease in the blastotransformation rate of lymphocytes by 20% or more and a decrease in the leukocyte migration index by 0.11 indicate an active tuberculosis process.
In phthisiology, other immunological research methods are also used, for example, counting the number of B-lymphocytes and assessing their functional activity, studying non-specific reactivity (phagocytosis intensity, level of lysozyme and complement components). A change in immunity indicators during repeated research during treatment makes it possible to evaluate its effectiveness. The presence in the body of antibodies to mycobacterium tuberculosis can be determined by enzyme-linked immunosorbent assay.
Instrumental methods of research are used to clarify the nature of the pathological process and conduct differential diagnosis. At T. of respiratory organs bronchoscopy is widely applied (Bronchoscopy), allowing to study the state of the inner surface of the bronchi and perform a biopsy of the wall of the bronchi, lung tissue and intrathoracic lymph nodes. Materials of bronchial lavage and lavage of the bronchoalveolar (Lavage of bronchoalveolar) are used for cytological, immunological, microbiological and biochemical studies. At extrapulmonary T. for confirmation of the diagnosis quite often make a puncture biopsy of the affected organs (more often peripheral lymph nodes).
In the modern TB clinic, other laboratory and instrumental methods of research are also used to clarify the nature of the functional and metabolic disturbances of patient T.
The basic principles of treatment. The goal of treating patients with T. is the persistent healing of tuberculous foci in the affected organs and the complete elimination of all clinical manifestations of the disease - a clinical cure.The effectiveness of the treatment of T. revealed in the early stages of development (even destructive forms) is significantly higher than the neglected process (fibro-cavernous, cirrhotic). A necessary condition for the successful treatment of T. is the continuity of observation of the patient. As a rule, treatment begins in a hospital. Upon reaching the clinical and radiological effect (cessation of bacterial excretion, closure of tissue decay cavities), patients are sent to sanatoriums (local or climatic). Patients with small forms of T. can be sent to a sanatorium after 2-3 months of treatment in a hospital. End the treatment on an outpatient basis under the supervision of a TB specialist at a TB dispensary.
T.'s treatment should be complex. Its main component is chemotherapy, during which the right choice of drugs, their optimal daily dose, frequency and route of administration, as well as the duration of treatment is of great importance (see Anti-TB drugs (Anti-TB drugs)). At the first stage, intensive chemotherapy is carried out in order to suppress the multiplication of mycobacterium tuberculosis and reduce their number. In destructive and common processes, the use of three drugs with the mandatory inclusion of isoniazid and rifampicin is effective. There are reports of high efficiency of treatment of T. in the first 2-3 months. four anti-TB drugs. The duration of the main course of chemotherapy T. is 6-12 months. and more, with common and destructive forms of T. - at least 9 months. In the next 2 years, twice a year in a sanatorium or on an outpatient basis for 2-3 months. conduct treatment with anti-TB drugs. Premature termination of chemotherapy can lead to an exacerbation of the tuberculosis process. An important task is to ensure that patients regularly receive prescribed drugs throughout the treatment period, therefore, in a hospital or sanatorium, and if possible with outpatient treatment, the prescribed drugs should be taken in the presence of medical personnel.
The pathogenetic treatment of patients with T. is aimed at normalizing impaired body functions, reducing the inflammatory response, stimulating regeneration processes, eliminating metabolic changes. As pathogenetic agents, glucocorticosteroids, immunomodulators (tuberculin, levamisole, diutsifon, taktivin, thimalin, etc.), antihypoxants (riboxin, glutamevit, sodium hydroxybutyrate), antioxidants (sodium thiosulfate, tocopherol acetate, dibmninol) are used. anabolic drugs (insulin, retabolil, etc.), stimulators of energy metabolism (cocarboxylase, ATP, lipoic acid), B vitamins. Physiotherapy is effective (inductothermy, exposure to ultrasound, decimeter waves, electro phrophoresis of anti-TB drugs).
Collapsotherapy, i.e. artificial Pneumothorax and Pneumoperitoneum for the purpose of compressing the affected lung, with T. are currently rarely used, for example, with drug resistance of Mycobacterium tuberculosis or complete intolerance of anti-TB drugs to patients, with contraindications for chemotherapy in pregnant women, persistent hemoptysis.
In those cases when conservative methods do not allow achieving clinical cure, as well as with a number of complications and consequences of the transferred T., they resort to surgical treatment. The most common in T. lungs were economical resections of the organ - complete or partial removal of one or two pulmonary segments. Less often, one or two lobes of the lung or the entire lung are removed. In chronically current common forms of T. lungs, thoracoplasty is performed (removal or resection of the ribs in a specific area of the chest wall in order to create conditions for the affected sections of the lung to subside), plastic closure of the cavity.At patients with tuberculous empyema of a pleura apply a decortication of a lung and pleurectomy (see. Pleura). With caseous-necrotic lesion of the lymph nodes, they resort to their removal.
In the treatment of patients with T., diet and nutrition are of great importance. Complete rest is shown only in a serious condition of the patient, hemoptysis, after operations. As toxicity decreases, the regimen is expanded, including training factors: walking, exercise therapy, occupational therapy. The food of patients with T. should be high-calorie and easily digestible with a high content of proteins and vitamins, especially C and group B.
Sanatorium-resort treatment is indicated, as a rule, during the period of involution of the tuberculosis process (see. Sanatorium-resort selection). Patients T. are sent to seaside sanatoriums (the southern coast of Crimea. The Black Sea coast of the Caucasus), mountain climatic (Abastumani, Teberda), forest-steppe (Shafranovo) resorts, as well as to the sanatorium of the local climatogeographic zone. Favorable climatic factors, balneotherapy have a stimulating effect and contribute to aftercare.
Forecast with timely adequate therapy in most patients, T. is favorable. Under the influence of treatment, the signs of the disease are eliminated, destructive and inflammatory changes in the affected organs completely disappear or significantly stop. There may not be any residual changes, or scars form in the tuberculosis lesion site, single or multiple densified foci remain. In the last mycobacteria, tuberculosis can persist and, under favorable conditions, begin to multiply, causing reactivation of the disease. In this regard, after achieving clinical cure, patients T. must be under the supervision of a TB doctor for a long time. In the majority of patients who have undergone T., the reactivity of the organism that has changed during the disease, as a rule, does not return to its original state, and a positive reaction to tuberculin is maintained. The elderly patient, various immunodeficiency conditions, concomitant diseases, especially diabetes mellitus and chronic alcoholism, worsen the prognosis.
Rehabilitation and examination of disability. Medical rehabilitation of patients with T. occurs with a clinical cure, which is characterized by a lack of activity of the process (which is established on the basis of the results of clinical, radiological and laboratory research methods) and stabilization of residual changes. Modern methods of complex treatment of T. make it possible to achieve medical rehabilitation of most patients of T., especially those who first become ill, after 2-3 years from the start of treatment. At patients with the widespread destructive T. who accepted a chronic course, medical rehabilitation comes later or is impossible. Due to the fact that in some patients who have undergone T., dysfunctions of the affected organs associated with residual post-tuberculous changes can be detected, functional rehabilitation of solo T. is important. The restoration of the function of seated organs is facilitated by the early use of dosed physical activity during inpatient and sanatorium treatment, pathogenetic therapy.
Social and labor, including and vocational, rehabilitation is heavily dependent on medical rehabilitation. However, there is no full correspondence between medical and social and labor rehabilitation, since not all clinically cured persons from T. become able-bodied. Disability can be caused by the consequences of T. Especially often, its causes are severe functional disorders after the clinical cure of T. lungs (residual post-tuberculous changes in the lungs that caused the development of respiratory and pulmonary heart failure), as well as T. of bones and joints (kyphosis, contracture, ankylosis).At the same time, some patients with T., in whom the process remains active, but has stabilized or has taken a regressive course, can begin to work, including professional. In such cases, social and labor rehabilitation is ahead of medical.
Social and labor rehabilitation also depends on the age of the patient, his education, profession, nature and working conditions. In some patients, due to the impossibility of professional rehabilitation, only partial social and labor rehabilitation can be achieved. This applies to persons whose labor activity is associated with significant physical stress and adverse microclimatic conditions, as when they return to work after an illness, they have to change working conditions and their nature, sometimes change their profession in order to exclude the influence of adverse factors. More often professional rehabilitation of persons engaged in mental work is achieved. Vocational rehabilitation of persons who cannot be allowed to work in connection with epidemiological contraindications (for example, employees of childcare centers and catering establishments excreting mycobacterium tuberculosis) is excluded.
The most important for patient T. is social and labor rehabilitation in a broad sense, i.e. his return to normal life with ordinary social relationships and the performance of socially useful work, corresponding to the state of his health.
Social and labor rehabilitation of patient T. begins during the treatment period. At the same time, special events can be held, for example, training a patient in a new profession in accordance with his desire and professional skills. The rehabilitation of patient T. is an important social and psychological factor. A significant role in the conduct of early social and labor events, including professional, rehabilitation belongs to the CWC of anti-tuberculosis institutions, which study the nature of the work carried out before the disease, working conditions and decide on the possibility of the patient returning to his previous labor activity or on the need for specific restrictions (for example, transferring to one-shift work, exemption from business trips, etc.). The decision of the VKK on restrictions on labor activity is drawn up by relevant documents indicating the duration of these restrictions.
Features of the examination of temporary and permanent disability of patients with T. are due to the fact that T. is a disease, the cure of which requires a long-term conduct of a variety of medical, preventive and social measures. The exemption of T. patients from work and their discharge to work is carried out on the basis of medical factors (the form and phase of the tuberculosis process, bacterial excretion, the nature of the course of the disease, the treatment being carried out, the degree of functional disorders) and factors. Exemption from work is confirmed by a sick leave issued by the attending physician, which for the first time revealed to a sick patient T. or a patient with a relapse of T. prolongs the ICC up to 10 months. from the day of incapacity for work continuously or for a total of 12 months. In some cases, with a favorable clinical and labor prognosis, the sick leave can be extended for more than 10 months. (for aftercare) by decision of VTEK. When examining the disability, the CWC can also determine partial temporary disability, in which the patient in a certain period can only do lightweight work. For this period (no more than 2 months), the so-called additional sick leave is issued, giving the right to maintain the average salary in the main profession.
Examination of persistent incapacity for work at T. is carried out by VTEK in the direction of the treating institution no later than after 10 months. from the day of temporary disability.
Organization of the fight against tuberculosis. A network of TB institutions has been created in our country: dispensaries, hospitals (including day care centers), sanatoriums, sanatoriums, dispensaries, forest schools, and specialized preschool institutions. Tuberculosis work is also carried out by the institutions of the general treatment and prevention network.
The most important role in organizing the fight against T. belongs to the TB dispensary - an institution that plans, organizes and, to a large extent, directly carries out TB control in the service area. In addition to independent tuberculosis dispensaries, there are tuberculosis dispensary departments and offices in polyclinics, hospitals, and medical units operating under the supervision of a regional tuberculosis dispensary.
The objectives of a TB dispensary are the prevention of T., the early detection of patients T., the registration of all patients T. and people at risk of disease and relapse, the active monitoring of all persons registered, and the differentiation of therapeutic and preventive measures, proper treatment patients with T. in order to achieve the most perfect clinical cure, i.e. with minimal residual changes in the affected organ and maximum restoration of impaired body functions, a systematic study of the epidemiology of T. in the service area, taking into account social and hygienic factors, analysis of the annual effectiveness indicators of anti-TB measures and the use of the results of such analysis for planning and methodological management of all anti-TB measures carried out in the service area of the dispensary.
Preventive measures are carried out by TB dispensaries in conjunction with other medical institutions. To prevent T., in addition to health measures that increase the body's natural resistance, specific prophylaxis that increases the body's resistance to tuberculosis infection and sanitary prophylaxis aimed at preventing mycobacterium tuberculosis from healthy individuals are important.
Specific prevention of T. includes carrying out anti-tuberculosis vaccinations, i.e. active immunization (vaccination and revaccination) with BCG vaccine (see Immunization), and the use of anti-TB drugs (chemoprophylaxis). T.'s incidence among vaccinees is 4-10 times lower than among unvaccinated persons. T. at vaccinated BCG proceeds more benignly. In children vaccinated against T. during the neonatal period, the disease is limited mainly by the involvement of intrathoracic lymph nodes. In our country, mass vaccination of newborns is carried out, as well as revaccination of healthy children and adolescents with a negative Mantoux test with 2 TE. Since 1993, there has been a transition from triple to double revaccination of children and adolescents - at 6–7 and 14–15 years. Revaccination of persons 21–22 and 27–30 years of age is carried out selectively (students, military personnel, etc.) in areas where the incidence rate of T. is 30 or more per 100 thousand people.
Vaccination and revaccination are prescribed taking into account medical contraindications. Contraindications for vaccination of BCG in newborns are purulent-septic diseases, intrauterine infection, generalized skin lesions, moderate and severe forms of hemolytic disease of the newborn, acute illness, severe birth injury with neurological symptoms: the occurrence of generalized BCG infection in other children in the family, body weight of the child with birth less than 2000 g. Contraindications for BCG revaccination are acute and chronic diseases during the exacerbation period, immunodeficiency conditions, generalized BCG infection detected in other children in the family, T. infection, malignant blood diseases and neoplasms, a positive or dubious Mantoux test with 2 TE tuberculin, complications from the previous the introduction of the BCG vaccine. For vaccination of newborns with a weakened postnatal period after the disappearance of contraindications, the BCG-M vaccine is used, which contains less vaccine strain mycobacteria than the BCG vaccine. Due to the fact that immunity develops after about 2 months. after the introduction of the tuberculosis vaccine, for this period the vaccinated and revaccinated (especially newborns) must be isolated from patients who excrete tuberculosis mycobacteria. Vaccination immunity is significantly weakened after 5-7 years.
Chemoprophylaxis plays an important role in the prevention of T. in healthy individuals (especially children and adolescents) who have an increased risk of the disease. There are primary chemoprophylaxis, which is carried out to uninfected persons with a negative reaction to tuberculin in contact with a patient with active T., and secondary, carried out by infected people who are constantly in contact with an epidemiologically dangerous patient T., people with a turn of tuberculin reactions and with persistent hyperergic reactions to the tubercle newborns vaccinated with BCG vaccine in the maternity hospital who were fed milk from patients of T. mothers, people with post-tuberculosis changes and an increased risk of tuberculosis evacuation. For chemoprophylaxis, isoniazid is used at a rate of 10 mg / kgbut not more than 0.6 g per day, for 2-3 months.
The most important part of sanitary prevention is preventive measures in the centers of T. including current and final disinfection (Disinfection), treatment of patients with T. in a hospital followed by outpatient chemotherapy: isolation of children from bacterial excretion by hospitalization of the patient or placement of children in TB facilities (motels, forest schools), vaccination of newborns and revaccination of uninfected people in contact with patients T., BCG vaccine, regular examination of persons in contact with patient T., and their chemoprophylaxis, training of patients T. and their families with hygiene rules, ul chshenie living conditions of patients with T. T. recovery plan the hearth and order monitoring are determined by the degree of its epidemiological danger for them (see. Patronage, tuberculosis patients).
A preventive measure is also to prevent patients with Mycobacterium tuberculosis from working in medical and child care facilities, educational institutions, catering, public utilities, food and pharmaceutical industries, and public transport.
To combat T. farm animals and prevent infection of people, TB dispensaries and institutions of the sanitary-epidemiological service control the conduct of tuberculin samples to animals (including in private households) and the slaughter of animals that respond positively to tuberculin. Persons in contact with a sick animal are subject to follow-up.
An important element of the prevention of T. is health education, which includes mass propaganda of knowledge on the prevention of T. among various population groups.
The main measure aimed at reducing the reservoir of tuberculosis infection is the early detection of patients with T. and their treatment. For early detection of patients T. a TB dispensary organizes mass preventive examinations of the population. Tuberculin tests are carried out to children and teenagers annually (see. Tuberculin diagnostics). An objective indicator of primary infection T.serves as the appearance of a positive reaction to tuberculin after a previously negative or a significant increase in the positive reaction (increase in papule diameter by 6 mm and more) - turn of tuberculin reaction. Children and adolescents with a turn of the tuberculin reaction (with the exception of the post-vaccination allergy) are monitored by a TB specialist for a year, they undergo chemoprophylaxis. To establish the source of infection, people from the environment of a child or teenager with a turn of the tuberculin reaction are examined.
Chest x-ray is the main method of mass prophylactic examination of a population aged 15 years and older. With a favorable epidemiological situation according to T., it is carried out once every 3 years, with an unfavorable one - fluorography begins from a younger age and the interval between examinations is reduced. Employees of children's institutions, food industry enterprises and other compulsory contingents have chest x-ray performed once a year. Preventive fluorographic examinations of the population are performed by X-ray fluorography departments (groups, rooms). which are part of the x-ray department of the city, regional, central district hospital (clinic), TB dispensary. Organizational and methodological guidance in cities is provided by the city (district, inter-district) X-ray fluorography unit, in rural areas - by the regional (inter-district) X-ray fluorography unit, which is part of the TB dispensary or other treatment and prevention institution.
In cases when it is impossible to carry out fluorography and tuberculin tests to identify T., use the bacteriological method.
Of great importance for the timely detection of T. is the allocation of contingents of the population most susceptible to the disease (risk group), and clinical observation of them. Tuberculosis dispensaries take into account the most threatened T. contingents - persons with large residual changes after tuberculosis (including after spontaneously cured) or small residual changes in combination with other aggravating factors. In outpatient clinics of the general treatment network, people who are threatened by T. are allocated, including people suffering from some chronic diseases (diabetes mellitus, peptic ulcer, dust and other non-specific respiratory diseases, chronic alcoholism), people undergoing radiation therapy, treatment with glucocorticosteroids, cytostatics, often sick children and adolescents. The registration of contingents subject to follow-up in a TB dispensary is greatly facilitated by their distribution into groups. The grouping of contingents is based on the treatment and epidemiological principle and allows the district TB specialist to correctly form observation groups, timely attract the contingent of the dispensary for examination, correct treatment tactics, carry out the necessary rehabilitation and preventive measures, and resolve the issues of transferring patients from one group to another, as well as removal from dispensary accounting.
The contingents of adults to be registered in the dispensary are divided into the following groups: 0 (zero) - persons with T. respiratory organs of dubious activity, I - patients with active T. respiratory organs (subgroup A - patients with newly established T., with exacerbation or relapse , subgroup B - patients who, as a result of ineffective treatment, when observed in subgroup A for at least 2 years, have developed a chronic tuberculosis process that is progressing or does not tend to heal), II - patients with dying active T. respiratory organs, Ill - persons with clinically cured T.respiratory organs (subgroup A - persons with large residual changes, as well as small ones in the presence of aggravating factors, subgroup B - persons with small residual changes in the absence of aggravating factors), IV - persons who are in contact with patients T. who excrete mycobacteria tuberculosis, or with farm animals, sick T., V - patients with extrapulmonary T. and persons cured of it (subgroup 0 - extrapulmonary T. of dubious activity, subgroup A - active extrapulmonary T., subgroup B - silent active full-time T., subgroup B - inactive extrapulmonary T., subgroup G - cured extrapulmonary T. with pronounced residual changes), VII - person with residual changes after a cured (including spontaneously) T. respiratory system, with an increased risk of reactivation tuberculosis. Group VI in adults is not allocated.
The contingents of children and adolescents observed by TB dispensaries are divided into groups 0, I, II, III, IV, V and VI. Groups I, II, Ill and V are the same as in adults. The 0 (zero) group in children and adolescents is diagnostic, it includes patients with suspected tuberculosis. Group IV includes children and adolescents in contact with patients with active forms of T. and bacterial isolators, as well as children and adolescents from families of livestock farmers working in unfavorable T. households, and from families with sick T. farm animals. Group VI includes children and adolescents infected with T., and also not vaccinated against T. during the neonatal period and with complications after BCG vaccination and revaccination. VII group for children and adolescents is not provided. Children and teenagers with big residual changes after the transferred T. are observed in the III group of the account till 18 years of age. After reaching 18 years, they are transferred to the VII group of accounting for adults.
Scientific research on the problem of T. is carried out by special research institutes, as well as departments of phthisiology of medical institutes and institutes for the improvement of doctors. Research institutes of tuberculosis have organizational and methodological departments that provide methodological assistance in tuberculosis work to practical healthcare institutions.
The fight against T. is an important international problem. In 1920, the International Tuberculosis Union was created, of which more than one hundred national societies are currently members, including association of society of our country. The main objectives of this union are the organization of international conferences, information on scientific research conducted in different countries and the dissemination of practical experience in tuberculosis in a special bulletin, which is published in English, French and Spanish, the exchange of experience in scientific and practical work and scientific commissions in various sections Phthisiology, collecting and studying statistics on the prevalence of T. in various countries, periodically conducting seminars for doctors from developing countries and the provision of practical assistance to a number of countries in Asia and Africa in anti-tuberculosis work.
Bibliography: Wilderman A.M. Evgrafova Z.A. and Busygina R.N. Liver damage in patients with tuberculosis, Chisinau, 1977, bibliogr., Zemskova Z.S. and Dorozhkova I.R. Hidden tuberculosis infection, M, 1984, bibliogr., Leshukovich Yu.V. and Feigin M.I. Tuberculosis work in rural areas, L., 1976, bibliogr .: Neilin S.E., Greimer M.S., Protopopova N.M. Tuberculosis Dispensary, M., 1989, Perelman M.I., Koryakin V.A., Protopopova N.M. Tuberculosis, M., 1990, Strukov D.I. and Soloviev I.P. Morphology of tuberculosis in modern conditions, M., 1986, bibliogr .: Tuberculosis in children and adolescents, ed. E.N. Yanchenko and M.S. Greimer, L., 1987, Tuberculosis of the respiratory system, ed. A.G. Khomenko. M., 1988, Shmelev N.A. and Stepanyan E.S. Side effect of anti-TB drugs, M., 1977, bibliogr.
Fig. b)Mycobacterium tuberculosis in the preparation of sputum, electron diffraction pattern, negative contrast, × 200,000.
Fig. a). Mycobacterium tuberculosis in the preparation of sputum, luminescent microphotogram, stained with rhodamine and auramine, × 500.
(tuberculosis, Tuberculosis- + -osis, syn. tubercle - obsolete.)
an infectious disease caused by mycobacterium tuberculosis and characterized by the formation of specific granulomas in various organs and tissues (usually in the lungs) and a polymorphic clinical picture.
Tuberculosis actandclear (t. activa) - phase T., characterized by the presence of pronounced signs of the disease.
Tuberculosis secandchny (t. secundaria, synonym T. post-primary) - T., developing in individuals who have undergone primary T. and have developed relative resistance to it.
Tuberculosis toaboutMs. (t. cutis) - the general name for pathological skin changes in T.
Tuberculosis toaboutMs. Beardsaflared (t. cutis verrucosa, synonym: Anderson's verrucous lupus, Rilya - Paltaufa warty tuberculosis of the skin) - because, characterized by the formation on the extensor surfaces of the limbs of dense, bluish-red, slowly growing, merging papules with foci of rough keratinization in the central parts of their surface, occurs more often when the pathogen enters the skin of people who already have T.
Tuberculosis toaboutMs. Hinduandclear (t. cutis indurativa, Latin: induratio, hardening, compaction, synonym: Bazena disease, erythema indurative) - because, characterized by the formation of dense, round, almost painless subcutaneous nodes of a bluish-purple color on the legs, less often on the hips, observed in women, mainly young, with hematogenous dissemination of the pathogen.
Tuberculosis toaboutMs. Hinduandclear Ilink (t. cutis indurativa ulcerosa, syn. Hutchinson's ulcerative inductive skin tuberculosis) - a variety because and., in which ulcers with smooth edges and serous-purulent discharge are formed in the central part of the nodes.
Tuberculosis toaboutMs kollikvatandclear (t. cutis colliquativa, synonym of scrofuloderma) - because, characterized by the formation in the thickness of the skin and subcutaneous fatty tissue (on the neck and extremities) of mobile, round, dense, slightly painful nodes, gradually fusing with the skin and opening with the formation of ulcers with undermined edges and purulent-necrotic bottom, observed with generalization of infection.
Tuberculosis toaboutji lichenaboutidyllic (t. cutis lichenoidea, Lichen + Greek-eidēs similar, synonym: scrofulous lichen - obsolete, miliary scrofuloderma, micro-papular tubercoderma, scrofulous folliculitis) - because it is characterized by the appearance of (mainly on the trunk) grouped into rings and arches or scattered multiple small yellow-brown papules observed with hematogenous dissemination of the pathogen.
Tuberculosis toaboutwomen facesa milesadisseminandrounded (t. cutis miliaris disseminata faciei, synonym: lupus erythematosus disseminated miliary face, Fox lupus erythematosus disseminated) - because, characterized by the formation on the face skin of non-merging soft hemispherical miliary nodules of a reddish-brown color, in which the phenomenon of "apple jelly ”and a positive test with a Pospelov probe, observed with hematogenous dissemination of the pathogen.
Tuberculosis toaboutMs. Papulonecrotandchesky (t. cutis papulonecrotica, synonym: acnit, Hamburger tuberculoid, tuberculoid papulonecrotic) - because, characterized by the appearance on the extensor surfaces of the limbs of dense pale red papules, necrotic in the center with the formation of scarring sores, is observed with hematogenous dissemination of the pathogen.
Tuberculosis toaboutMs and slandzymaboutcheck mileadifferent Ilink t. cutis (mucosae) miliaris ulcerosa, syn. secondary tuberculous ulcer - T., characterized by the appearance on the mucous membranes of the mouth, nose, rectum, external genitalia and adjacent areas of the skin of many small dense red nodules that suppurate and open with the formation of painful bleeding fused ulcers, along the periphery of which there are points Trela, observed with early hematogenous dissemination of the pathogen.
Tuberculosis toaboutMs. Ifirst linkandchny (t.cutis ulcerosa primaria) - because, characterized by the formation of ulcers with rough edges and a dirty gray bottom at the site of the pathogen, as well as the development of regional purulent lymphadenitis, it is observed in children in the case of primary infection through damaged skin.
Tuberculosis boneeth and sustainawow - see Tuberculosis of the osteoarticular.
Tuberculosis toaboutosteoarticularaboutth (t. osseoarticularis, synonym: tuberculous arthritis, tuberculous polyarthritis, T. bones and joints) - T. form with a predominant lesion of bones and joints, characterized by a prolonged course with the appearance of foci of cheesy necrosis in the pineal glands and metaphyses, destruction of articular cartilage, the formation of external fistulas.
Tuberculosis Latent (obsolete., t. latens) - see chronic tuberculosis intoxication (chronic tuberculosis intoxication).
Pulmonary tuberculosis (t. pulmonum) - a form of T., characterized by the primary localization of the pathological process in the lungs.
Disseminium pulmonary tuberculosisandrounded (t. pulmonum disseminata) - the clinical form of T. l., characterized by bilateral localization, uniformity and symmetry of pathological changes in the lungs, is observed with lymphogenous and hematogenous dissemination of the pathogen.
Pulmonary tuberculosis infiltrateandvpo-pneumonandchesky (t. pulmonum infiltrativa pneumonica) - see. Pulmonary tuberculosis infiltrative.
Pulmonary tuberculosis infiltrateandclear (t. pulmonum infiltrativa, syn. T. lung infiltrative-pneumonic) - a clinical form of T. l., characterized by the appearance in the lungs of the focus of exudative inflammation, usually with curdled necrosis in the center.
Tuberculosis of the lungsaboutknow (t. pulmonum cavernosa) - the clinical form of T. l., characterized by the formation of a thin-walled cavity with unchanged remaining lung tissue.
Tuberculosis of the lungsabouthigh (t. puimonum focalis) - the clinical form of T. l., characterized by the development of limited foci of inflammation.
Pulmonary tuberculosisabouthot cavernaboutknow (t. pulmonum fibrosa cavernosa) - the clinical form of T. l., characterized by the formation of caverns with fibrotic changes in the lungs and thickening of the pleura.
Pulmonary tuberculosisabouthotbedabouthigh (t. pulmonum fibrosa focalis) - focal T. l., in which the foci of inflammation undergo fibrosis, now in a separate form T. l. do not emit.
Pulmonary cirrhotisandchesky (t. pulmonum cirrhotica) - the clinical form of T. l., arising as an outcome of diseases with extensive damage to lung tissue and characterized by the development of massive fibrosis.
Tuberculosis lymphanddufatra - see. Chronic tuberculosis intoxication (chronic tuberculosis intoxication).
Tuberculosis milesadifferent (outdated., t. miliaris) - a form of T., developing during hematogenous dissemination of the pathogen and characterized by a severe acute course with the formation of small tuberculous tubercles in all organs.
Tuberculosis inactivityandclear (t. inactiva) - phase T., characterized by the absence of clinical manifestations of the disease while maintaining residual pathological changes in the body.
Tuberculosis Occatcast Engelya (deprecated.) - see Chronic tuberculosis intoxication (Chronic tuberculosis intoxication).
Tuberculosis firstandchny (t. primaria) - T. in persons newly infected with tuberculosis mycobacteria.
Tuberculosisaboutbilnik - see Tuberculous spondylitis.
Tuberculosis after the firstandchny - see. Secondary tuberculosis.
What is tuberculosis?
Tuberculosis - a contagious infectious disease, the main cause of which is infection of the body with Koch sticks (Mycobacterium tuberculosis complex). The main symptoms of tuberculosis, in its classical course, are cough with sputum (often with an admixture of blood), weakness, fever, significant weight loss, night sweats, and others.
Among the other names of the disease, especially in the old days, it can be noted - "consumption", "dry disease", "tubercle" and "scrofula". The origin of the name tuberculosis takes in Latin "tuberculum" (tubercle).
The most common organs susceptible to tuberculosis are the bronchi and lungs, less commonly the bones, skin, lymphatic, genitourinary, nervous, lymphatic systems, as well as other organs and systems.Infection can affect not only people, but also representatives of the animal world.
Mycobacterium tuberculosis complex infection is transmitted predominantly by airborne droplets - through coughing, sneezing, talking at close range with an infected interlocutor.
The insidiousness of tuberculosis infection lies in the nature of its behavior - when it enters the body, a person does not feel anything. At this time, the infection in a passive form (asymptomatic course of the disease - tuberculosis) can be in the patient for many days, and even years, and only in 1 out of 10 cases, go into active form.
If we talk about the types of tuberculosis, the most important for most people is the classification of the disease in form - they distinguish open and closed forms of tuberculosis.
Open tuberculosis characterized by the detection of mycobacteria in sputum, urine, feces, as well as obvious signs of the disease, while at the point of contact of the affected organ and the external environment, the infection cannot be detected. An open form of tuberculosis is the most dangerous, and represents a threat of infection to all people who are nearby.
Closed form it is characterized by the difficulty of detecting infection in sputum by available methods, and is a non-hazardous form of this disease for others.
The main methods for diagnosing tuberculosis are fluorography, radiography, Mantoux tuberculin test, PCR and microbiological examination of sputum, urine and feces.
Prevention of tuberculosis is mainly based on screening, mass screening and vaccination of children, but despite the large amount of information on the diagnosis, prevention and treatment of tuberculosis, this disease continues to march on Earth, infecting an increasing number of people, many of whom die from it.
How is tuberculosis transmitted? (ways of infection). The cause of tuberculosis is the ingestion of a tuberculosis infection - Mycobacterium tuberculosis complex, or, as it is also called, Koch's bacillus.
The main source of tuberculosis infection (Koch's bacillus) are carriers of infection, i.e. people or animals with an open form of tuberculosis that excrete it into the environment.
In order for tuberculosis to settle in the body and gain its further development within the body, a number of conditions must be met.
1. Mycobacterium tuberculosis entering the body
The main mechanisms of infection in the body:
Airborne path - the infection enters the external environment through conversation, sneezing, coughing a patient with an open form of the disease, and even when dry, the wand retains its pathogenicity. If a healthy person is in this room, especially poorly ventilated, then the infection gets inside him through breathing.
Alimentary path - the infection enters a person through the digestive tract. This is usually caused by eating food with unwashed hands or if food products that are infected and unprocessed are not washed. For example, homemade milk can be noted - a cow suffering from tuberculosis produces infected milk. A person who purchases homemade dairy products rarely checks it for infection. A special animal that carries many diseases dangerous to humans is a pig.
Contact way - the infection enters the person through the conjunctiva of the eyes, with kisses, sexual contact, through the contact of contaminated objects with human blood (open wounds, scratches, manicure, pedicure, tattooing with contaminated objects), the use of patient hygiene items. You can also become infected with tuberculosis when caring for a sick animal - a cat, a dog, and others.
Intrauterine infection - the infection is transmitted to the infant through the placenta damaged by tuberculosis, or during childbirth, from the mother.However, this occurs when the infection of the whole organism is defeated, but if the expectant mother has pulmonary tuberculosis, the probability of infection of the baby is minimal.
2. Impaired functioning of the upper respiratory tract
Respiratory organs (nasopharynx and oropharynx, trachea, bronchi) are protected from infection of the body with mucociliary clearance. In simple terms, when an infection enters the body, special cells located in the mucous membrane of the respiratory system secrete mucus, which envelops and glues pathological microorganisms together. Further, by sneezing or coughing, the mucus along with the infection is ejected from the respiratory system to the outside. If inflammatory processes are present in the respiratory system, the functioning of the body’s defense is at risk because the infection can freely enter the bronchi, and then into the lungs.
3. The weakening of immunity against tuberculous mycobacteria
Such diseases and conditions as diabetes mellitus, AIDS, peptic ulcers, stressful situations, hypothermia, starvation, hypovitaminosis, alcohol and drug abuse, treatment with hormones and immunosuppressants, pregnancy, smoking can weaken the immune system, especially sweat against the Koch’s wand. other. It is established that a pack of cigarettes smoking a day increases a person’s risk of developing the disease by 2-4 times!
Koch's wand, settling in the lungs, if the immune system does not stop it, begins to multiply slowly. The delayed immune response is also due to the properties of this type of bacteria not to produce exotoxin, which could stimulate the production of phagocytosis. Absorbing into the blood and lymphatic system, the infection spreads throughout the body, enslaving primarily - the lungs, lymph nodes, cortical layer of the kidneys, bones (pineal glands and metaphyses), fallopian tubes and most other organs and systems.
The incubation period of tuberculosis
The incubation period of tuberculosis, i.e. the period from the moment of getting the Koch stick to the first signs of the disease is from 2 to 12 weeks, an average of 6-8 weeks, sometimes a year or more.
Doctors note that with the initial entry of Koch's bacillus into the body, the development of tuberculosis occurs in 8% of cases, with each subsequent year, this percentage decreases.
Fighting the immune system with tuberculosis
At this stage, the immune system, if it does not have immunity to Koch's wand, begins to produce it, and leukocytes enter the fight against infection, which die due to their low bactericidal potential. Further, macrophages are involved in the fight, however, due to its peculiarity, Koch's wand penetrates into the cells, and macrophages cannot do anything with them at this stage, and also begin to die gradually, and the infection is released into the intercellular space.
An effective fight against tuberculosis mycobacteria begins when macrophages begin to interact with lymphocytes (T-helpers (CD4 +) and T-suppressors (CD8 +)). So, sensitized T-lymphocytes, secreting gamma-interferon, interleukin-2 (IL-2) and chemotoxins activate the movement of macrophages towards the settling of Koch's bacillus, as well as their enzymatic and bactericidal activity against infection. If tumor necrosis factor-alpha is synthesized by macrophages and monocytes at that time, then nitric oxide is formed in combination with L-arginine, which also has an antimicrobial effect. Together, all these processes inhibit the activity of mycobacterium tuberculosis, and the formed lysosomal enzymes generally destroy them.
If the immune system is in good condition, each subsequent generation of macrophages becomes more stable and competent in the fight against Koch's bacilli, the body develops a stable immunity to tuberculosis.
The formation of tuberculous granuloma indicates a normal immune response to infection of the body, as well as the ability of the immune system to localize mycobacterial aggression. The appearance of tuberculosis granuloma is due to the production of B-lymphocytes by macrophages, which in turn produce opsonating antibodies that can envelop and adhere to the infection. The increased activity of macrophages and the production of various mediators by them are transformed into epithelioid giant Langhans cells, limiting the site of infection sedimentation, and, accordingly, localization of the inflammatory process. The appearance in the center of the granuloma of a small area of caseous necrosis (curdled, white shade soft tissue) is caused by the bodies of the dead in the fight against tuberculous infection of macrophages.
The expressed adequate immune response to mycobacterium tuberculosis in the body usually forms after 8 weeks, from the moment the infection enters the person, and it usually begins after 2-3 weeks. After 8 weeks, thanks to the destruction of Koch's wand, the inflammatory process begins to subside, but the immune system fails to completely remove the infection from the body. The saved infection remains inside the cells, and preventing the formation of phagolysosomes, they remain inaccessible to lysosomal enzymes. This helps to maintain a sufficient level of immunological activity, but at the same time, the infection can be in the body for many years, or even for life, and if necessary, i.e. adverse factors weakening the immune system, re-activated and causing an inflammatory process.
Tuberculosis statistics in figures and facts:
- More than tuberculosis, people only die from AIDS,
- Against the backdrop of HIV infection, a quarter of patients infected with Koch's bacillus die from tuberculosis,
- As of 2013, during the year, tuberculosis was recorded in 9,000,000 people, of which 1,500,000 died. In 2015, according to WHO statistics, there were 10.4 million new cases of the disease, of which 5.9 million were men, 3.5 million were women and 1 million were children.
- About 95% of all infections occur in people in Africa and Asia,
- One person with a chronic open form of tuberculosis infects about 15 people in one year,
- Most often, the disease is noted in people aged 18 to 26 years, as well as in old age,
- Thanks to the efforts of modern medicine, and of course the grace of God, in recent years the tendency for the number of deaths from tuberculosis has decreased, and every year it continues to decline. For example, in Russia, compared with 2000, in 2013 the number of deaths decreased by about 33%.,
- In many cases, tuberculosis develops among health care providers of TB facilities.
The story of tuberculosis
The first mention of tuberculosis was made in ancient times - during the time of Babylon, ancient India. The excavations of archaeologists, who noticed signs of tuberculosis on some bones, also testify to this. The first scientific notes about this disease belong to Hippocrates, and later to the medieval Persian doctor Avicenna. The disease was noted in the ancient Russian chronicles - the Kiev prince Svyatoslav Yaroslavich in 1076 suffered from tuberculosis of the lymphatic system.
The tuberculosis epidemic first spread in the 17th and 18th centuries, when people began to actively build cities, develop industry, transport, expand trade, work in distant countries, and travel. Thus, the Koch wand began an active migration around the world. During this period, the number of deaths from tuberculosis in Europe was about 15-20% of the total number of deaths.
Among the most active researchers of this disease, we can distinguish Francis Sylvia, M. Beilli (1761-1821), Rene Laennec (1781-1826), G.I.Sokolsky (1807–1886), Jean-Antoine Wilman, Julius Kongheim.
For the first time, the term "tuberculosis", with a description of several of its species, was introduced by the French scientist Rene Laennec.
Koch’s wand was able to identify, and in 1882 the German doctor Robert Koch, using a microscope. He managed to do this by staining the infected sample with methylene blue and vesuvine.
Robert Koch was also able to isolate a solution with a bacterial culture - Tuberculin, which is used for diagnostic purposes in our time.
Symptoms of tuberculosis and its course largely depend on the form of the disease and the organ / system in which it was developed. First, consider the first signs of tuberculosis, which are very similar to the symptoms of acute respiratory diseases (ARI).
First signs of tuberculosis
- Feeling of weakness, malaise, tiredness, fatigue, increased drowsiness,
- The patient has no appetite, there is increased irritability,
- May have insomnia, nightmares,
- Increased sweating
- Elevated body temperature of 37.5-38 ° C, which does not subside for a long time (a month or more), slight chills,
- Dry cough, worse at night and in the morning, having a paroxysmal character,
- The face becomes pale in color, while there is an unnatural blush on the cheeks,
- Eyes have an unhealthy glow.
The main symptoms of tuberculosis
For greater accuracy, we suggest you familiarize yourself with a brief overview of the signs of tuberculosis, depending on the organ or system where the disease has developed.
Pulmonary tuberculosis characterized by chest pain, sometimes with a return in the hypochondrium or region of the scapula, intensifying with a deep breath, wheezing in the lungs, runny nose, rapid weight loss, an increase in the size of the lymph nodes (lymphadenopathy). Cough with pulmonary tuberculosis is wet, with sputum. With an infiltrative form of tuberculosis, there are particles of blood in the sputum, and if blood literally flows from the patient, immediately call an ambulance!
Genitourinary tuberculosis usually accompanied by turbid urine with the presence of blood in it, frequent and painful urination, aching pains in the lower abdomen, bloody discharge, painful bloating of the scrotum with exudate,
Tuberculosis of bones and joints accompanied by the destruction of cartilage, intervertebral discs, severe pain of the musculoskeletal system, and sometimes kyphosis, a violation of the motor function of a person, up to complete immobility,
Digestive tract tuberculosis accompanied by bloating and aching pains, constipation, diarrhea, the presence of blood in the feces, rapid weight loss, persistent low-grade fever,
Lupus accompanied by the appearance under the skin of the patient dense painful nodules erupting when combing, from which a white curdled infiltrate is allocated,
Tuberculosis of the central nervous system (central nervous system) accompanied by headaches, impaired visual function, tinnitus, impaired coordination, hallucinations, fainting, and sometimes mental disorders, inflammation of the lining of the brain (tuberculous meningitis), the appearance of granulomas in the brain,
Miliary tuberculosis characterized by numerous foci of lesion - the appearance of multiple microspheres, the size of each of which is up to 2 mm in diameter. The reason for this process is the spread of infection throughout the body against the background of a weakened immune system.
Pulmonary tuberculosis often proceeds in an asymptomatic form, and is detected only during a routine check, using fluorography or chest x-ray, as well as with tuberculin samples.
Causes of tuberculosis
The causes of tuberculosis lie in two main factors - infection of the body and immunity vulnerable to this infection.
1.Causative agent of tuberculosis - Mycobacterium tuberculosis (MBT, Mycobacterium tuberculosis - affects a person), or as they are also called - Koch's bacilli, as well as Mycobacterium bovis (causing disease in cattle), Mycobacterium africanum (African type of MBT), Mycobacterium microti, Mycobacterium can. To date, scientists have identified 74 types of MBT, but this type of infection is prone to mutation, and in a fairly short time, which in some sense also complicates the timely diagnosis and adequate treatment of tuberculosis.
Koch's bacillus under the influence of various factors tends to break up into small particles, then re-assemble into a single organism and continue to infect a person or animal. The sizes of the office are only 1-10 microns (length) and 0.2-0.6 microns (width).
Outside of a living organism, the office remains viable from a few days to many years, depending on environmental conditions, for example, in dried form - 18 months, in dairy products - 12 months, in water - 5 months, dried up sputum on clothes - about 4 months, on the pages of the book - 3 months, while on a dusty road - 10 days. Koch's sticks do not like sunlight, boiling water.
The best conditions for settling and reproduction of the office is a temperature of 29-42 ° C, a dark, warm and humid room. Tuberculosis bacteria freeze freely, retaining their pathological activity even 30 years after thawing.
Important! The clinical manifestations (symptoms) of tuberculosis largely depend on the type of MBT, as well as the health status of the infected organism.
Mycobacterium tuberculosis is transmitted by airborne droplets, contact and alimentary routes, as well as in utero. We talked about ways to transmit the Office at the beginning of the article.
2. Weakening of the immune system mainly due to the presence of chronic diseases, especially of an infectious nature (HIV infection, AIDS, ARI), diabetes mellitus, adverse living conditions (stress, asocial and unsanitary conditions), hypothermia, poor or insufficient nutrition, hypovitaminosis, and the use of certain medications ( immunosuppressants, etc.), smoking, the use of alcoholic beverages and drugs.
3. If we talk about human infection by airborne droplets, then for the settling and penetration of the office inside the body, an inflammatory process in the upper respiratory organs is necessary, otherwise the infection will simply be glued together and thrown back into the environment through a cough or sneeze.
According to the localization of the disease:
Pulmonary form - tuberculosis of the lungs, bronchi, pleura, trachea and larynx, which can proceed as follows:
- primary tuberculosis complex (tuberculous pneumonia + lymphadenitis, lymphangitis)
- tuberculous bronchoadenitis, isolated lymphadenitis.
- Tuberculosis of bones and joints,
- Digestive system tuberculosis,
- Genitourinary tuberculosis
- Tuberculosis of the central nervous system and meninges,
- Tuberculosis of the eyes.
- latent tuberculosis,
- focal (limited) tuberculosis,
- miliary tuberculosis,
- infiltrative tuberculosis,
- disseminated tuberculosis,
- cavernous tuberculosis,
- fibrocavernous tuberculosis,
- cirrhotic tuberculosis,
- caseous pneumonia.
Primary tuberculosis is an acute form of the disease. The development of the disease occurs for the first time, and is usually observed in children under 5 years of age, which is due to not fully formed immune system. There is no threat to those around him, although the course of the disease is acute, with a pronounced clinical picture.
Secondary tuberculosis characterized by the development of the disease after remission, due to its exacerbation, or due to infection of the body with another type of Koch bacillus. In this regard, adult patients are more susceptible to the secondary form of the disease.The internal course of the disease is accompanied by the formation of new foci of inflammation, sometimes merging with each other, forming extensive cavities with exudate. Secondary tuberculosis is a chronic form of the disease, and with complications, despite the efforts of doctors, many patients die. A great rarity is the spontaneous return of the disease from the stage of exacerbation, to the stage of remission. A patient with a chronic form of tuberculosis is a danger to those around him, because when coughing, sneezing and other aspects of life, a pathogenic infection is released into the environment.
How to treat tuberculosis? Tuberculosis treatment can only begin after a thorough diagnosis, as well as identifying the type of Koch bacillus, stage of the disease and associated pathologies.
Tuberculosis treatment includes:
1. Drug treatment
1.2. Supportive care
2. Surgical treatment
3. Rehabilitation in sanatorium and specialized institutions.
Important! A patient with tuberculosis must strictly adhere to the treatment regimen prescribed by the attending physician, otherwise the results of many months of work may come to naught.
Mycobacterium tuberculosis (MBT) refers to bacteria, so the treatment of tuberculosis is primarily based on the use of antibacterial drugs.
Due to the predisposition of the office to a rapid mutation and a large number of its genotypes, as well as resistance (resistance) to certain substances, antibiotic therapy most often involves the use of several antibiotics simultaneously. Based on this, modern medicine has identified 3 treatment regimens:
- ternary (2 antibiotics + PASK) - Isoniazid, Streptomycin and Paraaminosalicylic acid (PASK)
- four-component (4 pairs of antibiotics), in international practice is indicated by the term “DOTS” - “Isoniazid” / “Ftivazid”, “Streptomycin” / “Kanamycin”, “Rifabutin” / “Rifampicin”, “Pyrazinamide” / “Ethionamide”.
- five-component - 4 pairs of antibiotics of the DOTS scheme + 1 antibiotic of the 2nd, 3rd or 4th generation (Ciprofloxacin, Cycloserin, Capreomycin and others)
For best effectiveness, the attending physician selects and combines certain drugs, as well as the duration of their administration.
Tuberculosis treatment also consists of two main phases of therapy:
- Intensive (duration 2-6 months), which is aimed at stopping the infection and stopping the destructive process in the body, preventing the active release of the infection into the environment and resolving the infiltrate with exudate,
- Prolonged (up to 2-4 years) - is aimed at the complete healing of tissues damaged by infection, as well as the restoration and strengthening of the patient's immune system.
1.2. Supportive therapy
The following groups of drugs are aimed at improving the course of the disease, strengthening the body and accelerating recovery.
Probiotics This group of drugs restores the normal microflora in the digestive organs, necessary for the normal absorption and digestion of food. This is due to the fact that antibiotics, along with pathogenic microflora, destroy the majority and beneficial bacteria that are in the intestines of any healthy person. Among the probiotics can be distinguished - "Linex", "Bifiform".
Hepatoprotectors. The conditional group, which includes means aimed at strengthening and restoring liver cells. In fact, hepatoprotectors protect the liver from the pathological effects of antibiotics on it. Among the hepatoprotectors, one can distinguish - “Karsil”, “Lipoic acid”, “Silimar”, “Ursonan”, “Phosphogliv”, “Essentiale”.
Sorbents. Microflora in the course of its life emit toxins, which together with the infection that died from antibiotics poison the body, causing symptoms such as loss of appetite, nausea, vomiting, and others.Sorbents (detoxification therapy) are used to remove toxic substances from the body, among which are Acetylcysteine, Atoxil, Albumin, Reosorbilact, as well as heavy drinking, preferably with the addition of vitamin C.
Immunostimulants. This group of drugs stimulates the immune system, which in turn leads to an increase in the fight of immunity against infection and to a faster recovery. Among the immunostimulants can be distinguished - “Biostim”, “Galavit”, “Glutoxim”, “Imudon”, “Ximedon”.
Vitamin C (ascorbic acid) is a natural immunostimulant, a large amount of which is present in rosehip, viburnum, raspberry, cranberry, lemon.
Antipyretic drugs. They are used to relieve high body temperature, but remember that this group of drugs is recommended to be used at a high temperature - from 38.5 ° C (if it lasts 5 or more days. Among the antipyretic drugs, Ibuprofen, Nurofen, Paracetamol can be distinguished) .
Nonsteroidal anti-inflammatory drugs (NSAIDs) - are used to relieve pain. Among them can be distinguished - “Indomethacin”, “Ketanov”, “Naproxen”, “Chlotazole”.
Glucocorticoids (hormones) - are used in cases where the pain could not be stopped by NSAIDs, as well as in the severe course of tuberculosis with unbearable pain. However, they can not be used for a long time, since they have an immunosuppressive effect, as well as a number of other side effects. Among glucocorticoids can be distinguished - "Prednisolone", "Hydrocortisone."
To preserve the central nervous system from damage, as well as to maintain its normal functioning, are prescribed - B vitamins, glutamic acid and ATP.
To accelerate cell regeneration and restoration of tissues affected by the infection is prescribed - “Glyunat”, “Methyluracil”, “Aloe vera” and others.
2. Surgical treatment of tuberculosis
Surgical intervention in the treatment of tuberculosis implies the following types of therapy:
- Collapsotherapy (artificial pneumothorax or pneumoperitoneum) - based on squeezing and fixation of the lung by introducing sterile air into the pleural cavity, which leads to the gradual fusion of caverns and preventing the active release of the Koch bacillus into the environment,
- Speleotomy or cavernectomy - the removal of the largest caverns that are not amenable to conservative treatment,
- Lobectomy, bilobectomy, pneumonectomy, pulmonectomy - removal of one lobe or part of the lung that is not amenable to conservative treatment, or complete removal of such a lung.
- Valvular bronchial blocking - is designed to normalize the respiration of patients, and is based on the installation of miniature valves in the mouths of the bronchi to prevent them from sticking together.
With the early detection of Koch bacillus in the body, a thorough diagnosis and strict adherence to the patient’s instructions of the attending physician, the prognosis for recovery from tuberculosis is very positive.
The unfavorable outcome of the disease in most cases is due to the advanced form of the disease, as well as the frivolous attitude of patients to it.
However, remember that even if doctors put an end to the sick, there is a lot of evidence when such a person turned to God in prayer and received a full recovery, even with such deadly diseases like cancer.
Folk remedies for tuberculosis
Important! Before using folk remedies for the treatment of tuberculosis, be sure to consult your doctor!
Pine Pollen. Essential oils of conifers have a bactericidal effect, in addition, they fill the air with pure ozone, improving the functioning of the respiratory system, and more simply, it is much easier for people to breathe among conifers. For the preparation of folk remedies for tuberculosis based on coniferous gifts, you need 1 tbsp.mix a spoonful of pine pollen with 150 g of linden honey. You need to use the drug for 1 teaspoon 20 minutes before eating, 3 times a day, for 60 days, after a 2-week break is made and the course is repeated. Keep this folk remedy for tuberculosis in the refrigerator.
Pine pollen tea. Mix 2 tbsp. tablespoons of pine pollen, chamomile, dried linden blossom and marshmallow root. Prepared collection pour 500 ml of boiling water, let it insist for about an hour. After pouring 100 g of infusion into a glass and add boiling water to it so that the glass is full. You need to drink such tea 4 times a day, in a glass, 30 minutes before a meal.
Garlic. Grind 2 cloves of garlic, pour them with a glass of water, let it brew for a day, and in the morning, before eating, drink the infusion. The course of treatment is 2-3 months.
Garlic, horseradish and honey. Make a slurry of 400 g of garlic and the same amount of horseradish, then mix it with 1 kg of butter and 5 kg of honey. Next, the mixture must be infused in a boiling water bath for 5-10 minutes, stirring it periodically, cool and take 50 g before meals. The drug is considered effective for pulmonary tuberculosis.
Icelandic Moss (Cetraria). Put 2 tbsp in an enameled saucepan. tablespoons of chopped Icelandic moss and pour it in 500 ml of clean cold water, then bring the product to a boil, simmer it for another 7-10 minutes with the lid closed. Next, the remedy needs to be filtered, set aside in the bank for insisting. The remedy needs to be drunk during the day, for 3-4 approaches, before meals. The course of treatment is 1 month, with advanced forms - up to 6 months, however, after each month do a 2-3 week break. To improve the taste, a little honey or milk can be added to the broth.
Aloe. Mix in a enameled saucepan 1 chopped large meaty leaf of aloe with 300 g of liquid linden honey and fill them with half a glass of clean cold water. Bring the mixture to a boil, then simmer it for about 2 hours with the lid tightly closed. Next, the tool must be filtered and taken for 1 tbsp. spoon before meals, 3 times a day, for 2 months, and you need to store it in a glass jar in the refrigerator.
Vinegar. Add in a glass container 100 g of fresh grated horseradish, 2 tbsp. tablespoons of 9% apple cider vinegar and 1 tbsp. spoon of honey, mix thoroughly and take this folk remedy for tuberculosis 1 teaspoon 20 minutes before meals, 3 times a day until the medicine is over. Then a 2-3-week break is made and the course is repeated. Store the product in the refrigerator.
Dill. Pour in a small enameled saucepan 1 tbsp. spoon with a hill of dill seeds and fill them with 500 ml of clean cold water. Bring the product to a boil, boil it under a covered lid over low heat for about 5 more minutes, then set the product aside for the night to insist. In the morning strain the product and drink it throughout the day, in 5 receptions. You need to take this medicine for tuberculosis for 6 months, and it is better to store it in a glass container in a refrigerator or a cool dark place.
Prevention of tuberculosis includes the following activities:
- Vaccination is a BCG vaccine (BCG), but in some cases this vaccine itself may contribute to the development of certain types of tuberculosis, such as joints and bones,
- Conducting tuberculin samples - Mantoux reaction,
- Periodic (1 time per year) fluorographic examination,
- Personal hygiene
- You need to save yourself from stress, if necessary, change jobs,
- Avoid hypothermia,
- Try to eat foods enriched with vitamins and minerals,
- In the autumn-winter-spring period, take additional vitamin complexes,
- Do not allow the transition of various diseases into a chronic form.
Tuberculosis - A chronic infection caused by the bacteria Mycobacterium tuberculosis complex. When affected by tuberculous mycobacteria, respiratory organs most often suffer, in addition, tuberculosis of bones and joints, genitourinary organs, eyes, and peripheral lymph nodes occurs. Diagnosis of tuberculosis consists in conducting a tuberculin test, an X-ray examination of the lungs, identifying mycobacterium tuberculosis in sputum, flushing from the bronchi, detachable skin elements, additional instrumental examination of organs affected by tuberculosis. Tuberculosis treatment is a complex and long-term systemic antibiotic therapy. Surgical treatment is indicated according to indications.
Tuberculosis - A chronic infection caused by the bacteria Mycobacterium tuberculosis complex. When affected by tuberculous mycobacteria, respiratory organs most often suffer, in addition, tuberculosis of bones and joints, genitourinary organs, eyes, and peripheral lymph nodes occurs. Most often, infection occurs by airborne droplets, less often - contact or alimentary.
Mycobacterium tuberculosis complex is a group of bacterial species that can cause tuberculosis in humans. The most often the causative agent is Mycobacterium tuberculosis (obsolete. - Koch's bacillus), is a gram-positive acid-resistant bacillus of the family of actinomycetes, the genus of mycobacteria. In rare cases, tuberculosis is caused by other representatives of this genus. Endotoxins and exotoxins do not emit.
Mycobacteria are extremely resistant to environmental influences, persist for a long time outside the body, but die under the influence of direct sunlight and ultraviolet radiation. They can form low-virulent L-forms, which, when present in the body, contribute to the formation of specific immunity without the development of a disease.
The reservoir of infection and the source of infection with tuberculosis are sick people (most often, infection occurs when they come into contact with pulmonary tuberculosis patients in an open form - when tuberculosis bacteria are excreted in sputum). In this case, a respiratory infection pathway is realized (inhalation of air with dispersed bacteria). A patient with active secretion of mycobacteria and severe cough is able to infect more than a dozen people during the year.
Infection from carriers with scanty bacteria and a closed form of tuberculosis is possible only with close constant contacts. Sometimes infection occurs alimentary (bacteria enter the digestive tract) or by contact (through damage to the skin). Sick cattle, poultry can become a source of infection. In this case, tuberculosis is transmitted with milk, eggs, when animal feces get into water sources. It is far from always the entry of tuberculosis bacteria into the body causing the development of infection. Tuberculosis is a disease often associated with unfavorable living conditions, decreased immunity, and protective properties of the body.
During tuberculosis, the primary and secondary stages are distinguished. Primary tuberculosis develops in the pathogen introduction zone and is characterized by a high sensitivity of tissues to it. In the very first days after infection, the immune system activates, producing specific antibodies to kill the pathogen. Most often, in the lungs and intrathoracic lymph nodes, and with an alimentary or contact path of infection, and in the gastrointestinal tract and skin, an inflammation center is formed. In this case, bacteria can disperse with the flow of blood and lymph throughout the body and form primary foci in other organs (kidneys, bones, joints).
Soon, the primary focus heals, and the body acquires persistent anti-tuberculosis immunity.However, with a decrease in immune properties (in adolescence or senility, with weakening of the body, immunodeficiency syndrome, hormonal therapy, diabetes mellitus, etc.), infection is activated in the foci and secondary tuberculosis develops.
Tuberculosis is distinguished into primary and secondary. Primary, in turn, can be dolocal (tuberculous intoxication in children and adolescents) and localized (primary tuberculosis complex, which is a focus at the site of infection, and tuberculosis of the intrathoracic lymph nodes).
Secondary tuberculosis varies in localization into pulmonary and non-pulmonary forms. Pulmonary tuberculosis, depending on the prevalence and degree of damage, is miliary, disseminated, focal, infiltrative, cavernous, fibro-cavernous, cirrhotic. Caseous pneumonia and tuberculoma are also distinguished. Tuberculous pleurisy, pleural empyema, and sarcoidosis were identified as separate forms.
Outside the lungs, there is tuberculosis of the brain and spinal cord and meninges, tuberculosis of the intestines, peritoneum, mesenteric lymph nodes, bones, joints, kidneys, genitals, mammary glands, skin and subcutaneous tissue, eyes. Sometimes damage to other organs is noted. In the development of tuberculosis, the phases of infiltration, decay, seeding, resorption, compaction, scarring and calcification are distinguished. With respect to the isolation of bacteria, an open form is distinguished (with isolation of bacteria, MBT-positive) and closed (without isolation, MBT-negative).
Pulmonary tuberculosis can be complicated by hemoptysis and pulmonary hemorrhage, atelectasis, pneumothorax, and cardiopulmonary failure. In addition, tuberculosis can contribute to the occurrence of fistulas (bronchial and thoracic, other localization in extrapulmonary forms), organ amyloidosis, and renal failure.
Diagnosis of pulmonary tuberculosis
Since tuberculosis is often asymptomatic at first, preventive examinations play a significant role in its diagnosis. In the diagnosis of pulmonary tuberculosis are used:
- Screening Methods. Adults need to have a chest x-ray every year, for children a Mantoux test (a tuberculin diagnostic technique that reveals the degree of infection of the body with tubercle bacillus and tissue reactivity). As an alternative to the tuberculin test and diaskin test, laboratory methods have been proposed to detect latent and active tubinfection: T-SPOT test and quantiferon test.
- Topical radiation diagnostics. The main method for diagnosing tuberculosis is radiography of the lungs. In this case, it is possible to detect foci of infection, both in the lungs and in other organs and tissues. If necessary, perform a CT scan of the lungs.
- The study of biological environments. To determine the causative agent, sputum is sown, washings of the bronchi and stomach, separated from skin formations. If it is impossible to sow the bacterium from biological materials, we can talk about the ICD-negative form.
- Biopsy. In some cases, to clarify the diagnosis, bronchoscopy with a biopsy, a lymph node biopsy are performed.
Diagnosis of extrapulmonary tuberculosis
Laboratory analysis data are nonspecific and indicate inflammation, intoxication, sometimes (proteinuria, blood in the stool) can talk about the localization of the focus. However, a comprehensive study of the state of the body with tuberculosis is important when choosing treatment tactics.
If you suspect an extrapulmonary form of tuberculosis, they often resort to a more in-depth tuberculin diagnosis than Mantoux - the Koch test. Diagnosis of tuberculous meningitis or encephalitis is often carried out by neurologists. The patient is examined using rheoencephalography, EEG, CT or MRI of the brain.To isolate the pathogen from the cerebrospinal fluid, a lumbar puncture is performed.
With the development of tuberculosis of the digestive system, a consultation with a gastroenterologist, an ultrasound of the abdominal organs, and a coprogram are necessary. Tuberculosis of the musculoskeletal system requires appropriate x-ray studies, CT of the spine, arthroscopy of the affected joint. Additional examination methods for tuberculosis of the genitourinary system include ultrasound of the kidneys and bladder. Patients with suspected skin tuberculosis need to consult a dermatologist.