1. SECONDARY TUBERCULOSIS
LECTURE
doc. Kravchenko N.S.

2. THERE IS ACUTE, SUBACUTE AND CHRONIC
DISSEMINATED TUBERCULOSIS - APPERARS DURING LYMPHOHEMATOGENOUS DISSEMINATION OF THE INFECTION AND IS CHARACTERISED BY BILATERAL SYMETRIC FOCAL LESION, WHICH IS LOCALISED IN SUPERIOR AND CORTICAL PARTS OF LUNGS.
THERE IS ACUTE, SUBACUTE AND CHRONIC
DISSEMINATED TUBERCULOSIS OF LUNGS.
THIS FORM OF TUBERCULOSIS AFFECTS BONES,
KIDNEYS, GENITAL ORGANS , LARYNX, PLEURA, MORE FREQUENTLY.

3. PPATHOGENIC FACTORS ARE:
PPATHOGENESIS
PPATHOGENIC FACTORS ARE:
1.   - Presence of tuberculous infection in the organism.
2.   - Bacteriemia.
3.   - Hypersensibilization and hyperpermeability of pulmonary vessels. More frequently mycobacteries appear in blood from affected intrathoracic lymthatic nodes. Through thoracic duct subvclavian vein in right ventricle and futher in pulmonary bifurcation and lungs.

4. Ways of MBT spreading.
1 – haematogenous
2 – lymphogenous
3 - bronchogenous

5. MILIARY TUBERCULOSIS
Miliary tuberculosis defines the presence of innumerable, tiny, discrete tuberculous lesions in the lungs and other organs owing to the seeding of these tissues by blood-borne tubercle bacilli. The word "miliary" was used originally by John Jacob Manget in 1700' to denote the small size of such lesions, generally less than 2 mm in diameter, or approximately the size of millet seeds. "Lymphohematogenous dissemination" designates the entry of tubercle bacilli, usually from a parenchymal pulmonary focus, into the lymphatics, lymph nodes, and ducts, with ultimate drainage into the bloodstream, producing bacillemia.

6. PATHOLOGY
The pathologic features of miliary tuberculosis are similar but with certain specific characteristics. Grossly, the lungs or other organs have small, punctate, rounded lesions of more or less uniform size. Their color varies from gray to reddish-brown, depending on the organ examined and their stage of development. Мал 1
Miliary foci lead to the classic changes de scribed as tubercles. Lymphocytes and macrophages are intermixed with epithelioid cells ar ranged in roughly spherical dimensions. Caseation necrosis affects the central core of some lesions, whereas others are entirely free of caseation. With appropriate staining, acidfast bacilli may be found within macrophages or epithelioid cells or in the central caseum.

7. Miliary
tuberculosis

8. Organ Involvement in Miliary Tuberculosis at Necropsy
TABLE 1.
Organ Involvement in Miliary
Tuberculosis at Necropsy
Organ (% involved):
Spleen
86%
Liver 91
Lungs
100
Bone marrow 24
Kidneys 62
Adrenals 14
Eye —
Thyroid 19

10. AS TO CLINICAL PROGRESS MILIARY TUBERCULOSIS IS CONDITIONALLY DIVIDED INTO:
-   LUNG
-  TYPHOID
- MENINGEAL
- SEPTIC FORMS.

11. FIGURE 1. Chest radiograph of a patient with miliary tuberculosis.
Note the extensive, symmetrical distribution of 2- to 3-mm lesions throughout both lungs.

12. CHEST RADIOGRAPHS
The chest radiograph is the single most important means for detecting miliary tuberculosis. The classic pattern of diffuse, bilateral, symmetrical, discrete, pinpoint 2- to 3-mm densities is illustrated in Figures 1 and 2.
Figure 1 illustrates the typical appearance of miliary lesions in a standard chest radiograph. Some of the apparent variations in the size of the lesions are due to densities in various depths of the lung parenchyma superimposed on the chest film.
Figure 2 is the magnified view of a portion of this chest radiograph.
Computed tomography (CT) often is useful to demonstrate tiny miliary lesions that are too small to be visualized on a conventional radiograph. This is especially important in the early stages of the disease when chest radiographs can be read as normal.

13. FIGURE 2. Close-up view of the chest radiograph in Figure 1
FIGURE 2. Close-up view of the chest radiograph in Figure 1. Note the uniform distribution of nodules throughout the lung parenchyma.

15. Subacute disseminated tuberculosis
This form of the tuberculosis develops during decreased resistance of the organism, in senile age, during immunodepression therapy.
Pathologic anatomy. Subacute disseminated tuberculosis appears during affection of intralobular veins and intralobular branches of pulmonary artery.
It results formulation of great simetric focuses (5-10 mm) in the superior parts of pulmonary fields.

16. Clinical picture. The start of disseminated tuberculosis can be acute or gradual. In case of gradual start there are such symptoms: fatiquabiliti, general weakness, poor apetite, dry couph, then pus-mucus couph, blood sputum, chest pain, dyspnea.
General state of the patient changes for the worse, develops circulatory insufficiency, caused by overload of right heart chambers.
In some cases onset signs can be larynx lesion (painful swallowing, hoarse voice) or kidneys’ affection.
Objective investigation is characterized by symmetric dull sound under upper and middle pulmonary parts, auscultation - of harsh or vesicular-bronchial breathing, moist fine bubbling rales.

17. Laboratory investigation
Laboratory investigation. Hypochromic anemia, leucocytosis (12-17x109), neutrophils elevation (10-15%), lymphopenia, monocytosis, elevation of the erythrocyte sedimentation rate are observed in blood picture. During distruction process mycobacterium in sputum can be observed.
Mantu`s test is positive. Negative unergic process appears during progressive of the process.
X-ray examination. It is characterized by large symmetric focal shadows with uneven outlines, total or subtotal affection.
These X-ray changes are typical and imitate the picture of “dropping snow”. Then appear lightings with irregular shape situated symmetrically in the upper lung segments.

18. Disseminated lung tuberculosis
(subacute)

19. Disseminated lung tuberculosis
(subacute)

20. “Stamped cavern” in the apper
part of the right lung

21. Chronic disseminated tuberculosis of lungs.
Appears in case of not entirely effective therapy of the subacute disseminated tuberculosis, its observed more frequently as independent form. Characterized by presence of temporary remission of a disease and acute condition, which is caused by bacteriemia, dissemination and infiltrating changes in lungs.
Pathologic anatomy. The process has apica-caudal . Dissemination calcific focuses are situated in the upper segments of lungs, but there are lower fresh focuses. Symmetric cavities are formed in the upper segments, emphysema prevails in lower segments.

22. Chronic disseminated
lung tuberculosis

23. X-ray examination. During hematogenic dissemination on the X-ray we can observe symmetrically situated focal shadows with weak intensity and unclear outlines of shadows. Typical X-ray picture of chronic disseminated tuberculosis formulates during long course: multishaped focal shadows, with different intensity in superior and median segments of lungs, deformation of the lung picture. In the inferior segments we observe particulary clear lung field and poor lung picture, wich is caused by emphysema.
Old focuses are situated in the superior segments, they are more intensive with well contured outlines. Fresh focuses are in the inferior segments, characterized by low intencity. Deformation of the roots of lungs with superior disposition ("sign of willow branches") is observed.

24. Chronic disseminated
lung tuberculosis

26. Differential diagnosis. - bilateral focal pneumonia,
More frequently differential diagnosis carries out with:
- bilateral focal pneumonia,
- carcinomatosis
-silicosis
- sarcoidosis
-pulmonary congestion
For the comfirmation of diagnosis of the tuberculosis it is neccessary to pay attention on contact with affected persons, enduring of primary tuberculosis, pleuritis, focuses in the superior and cortical segments.

27. Bilateral nidus pneumonia

28. Sarcoidosis of the lungs and intrathorasic limph. nodes

29. Sarcoidosis of the lungs and intrathorasic limph. nodes

30. Carcinomatosis

31. Lung stagnation phenomena

32. Lung stagnation phenomena.
Left-side transsudate

33. Focal ( Nidus) lung tuberculosis (FLT)
In this form of tuberculosis, foci of specific inflammation are formed in the lungs with a size up to 1cm, single or multiple, 1-side or 2-side, localized in 1-2 segment.

34. Pathogenesis and pathanatomy
Pathogenesis and pathanatomy. FLT belongs to secondary tuberculosis, meaning that it develops in long-time infected organisms the with presence of some infectious immunity and has features of limited organ injury.
Theories of secondary tuberculosis development:
- exogenic super infection;
- endogenic reactivation of remining foci of infection;
- formation of focal tuberculosis is involution of other forms – infiltrative, disseminated and even cavernous

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

36. fig. 1 Focal lung tuberculosis

37. The main X-ray criteria of FLT diagnosis:
X-ray examination plays first role for diagnosis of FLT. As the most frequent localization at the clavicles, focal shadows are often covered with bone formations, that’s why, besides common fluorographic investigation, it is necessary to provide fluorogram in posterior angled position, roentgenogram, tomograms on optimum section.
The main X-ray criteria of FLT diagnosis:
- Presence of foci in the lungs (shadows up to 1 cm);
- Spreading in 2 segments.

38. fig.2 Roentgenogram. Focal lung tuberculosis

39. Differential diagnosis. Clinical symptoms of FLT may simulate: - flu;
- chronic sepsis;
- hyperthyreosis.
But in all these diseases X-ray signs are absent

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

41. The most informative criteria of activity of tuberculosis process:
- Finding of MBT;
- X-ray criteria;
- Involution of the process under the test treatment.

42. Infiltrative lung tuberculosis (ILT)
ILT is a zone of specific inflammation mostly of exudative character, with size more than 1 cm, with ability to progressing and destruction.

43. Pathogenesis and pathanatomy.
1 - Infiltrate develops as a result of perifocal inflammation around fresh foci that appeared due to exogenic superreinfection or endogenic reactivation. Thus it may be continuation of soft-focal tuberculosis.
2 - Tuberculosis infiltrate may be a result of perifocal inflammation around severed old foci formed at involution of lung tuberculosis. Fast development of infiltrate is a result of hyperergic reaction of lung tissue to a high quantity of virulent MBT that quickly reproduces. Different endogenic and exogenic factors also have some value, they decrease the organism’s resistance.

44. Clinic.
In % of cases it has acute onset and simulates flu or pneumonia. Body temperature is increased to 38-39C, there develops general weakness, sometimes appear chest pain, cough with excretion of sputum, sometimes with blood inclusions.
2) At the subacute disease’s development (in 40 % of cases) patients complain of tiredness, decreased appetites, general weakness, sweating, subfebrile temperature, coughing. Often patient don’t pay attention to these symptoms, connecting them with overtiredness, smoking.
3) The beginning may be without any symptoms (inapercept) onset of ILT, but in detailed questioning in such cases there may be revealed trivial functional disorders (tiredness, disorders of sleep etc.). In such cases ILT is revealed in prophylactitic fluorographic investigation.

45. variants of infiltrate
fig. 5. Cloudlike infiltrate

46. fig. 6. Round shaped infiltrate

47. Fig. 7. Lobitis.

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

49. Infiltrative tuberculosis

50. fig.3 Roentgenogram. Infiltrative lung tuberculosis
С6 left lung with decay

51. fig.4 Roentgenogram. Cloudlike infiltrate
of left lung.

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

53. Pneumonia of inferior part of left lung.
fig.8 Roentgenogram.
Pneumonia of inferior part of left lung.

54. fig.9 Roentgenogram.
Eosinophilic pneumonia.

55. fig.10 Roentgenogram. Central cancer of left lung.

56. fig.11 Tomogram of right lung. Infarct of lung .

57. Caseous pneumonia
Caseous pneumonia is a clinical form of tuberculosos with massive caseous changes in lungs and severe, progressive clinical course.

58. Variants of caseous pnemonia:
1. Lobar is a total caseous necrosis of cloudlike infiltrate or lobitis.
2. Lobuluar:
- As a result of aspirative pnemonia after bleeding;
- Malignant course of subacute disseminative tuberculosis of
lung;
- Complications of terminal stages of chronic form of
tuberculosis;
- Spreading of caseous masses in bronchi and lungs through the
fistula with lymphatic nodes.

59. fig. 12 Lobar caseous pneumonia.

60. X-ray investigation determines massive uneven darkness of entire lung lobe during caseuos pneumonia, there can be separate intensive foci on the background of it. While next progressing of process shadow becomes almost homogenic, than on its background lightening of cavity destruction appears or gigantic caverns form. Lower lobar shadow in other regions of either lung’s broncho-dissemination processes appear.
During lobular caseous pneumonia big processes with irregular margins are defined (if lobular caseous pneumonia appears on the background of disseminative tuberculosis, they are localized symmetrically in both lungs). During the progressing of disease in pneumonic foci appears multiple lightening of cavity destruction, in other lungs there are new bronchogenic injured places, which are united rapidly and destruct.

61. fig.13 Caseous pneumonia of left lung.
Bronchogenic dissemination of right lung.

62. Differentiated diagnosis of lobar caseous pneumonia should be made with simple (croup) pneumonia, which is also develops acute, but sometimes begins with rhinitis, herpes; those are not specific signs for caseous pneumonia. Body temperature during croup pneumonia is persistent, while during caseous pneumonia it is irregular with remissions. For caseous pneumonia profuse night sweat is usual, while during croup pneumonia it appears during crisis. More expressed leukocytosis (20-40*1012/l) can be during croup pneumonia.

63. Caseous pneumonia

64. X-ray signs of croup pneumonia are the following:
Homogeny shadow limited in a lobe.
X-ray signs of caseous pneumonia:
1. Uneven shadow, that can be spread;
2. Appearing of lightening because of emptiness destruction;
3. Injured places of bronchogenic dissemination in other
places in the same lung or another lung.
For full determination of tubercular origin of disease multiple searching of mycobacterium tuberculosis in sputum is necessary. Diagnosis of lobular pneumonia, which develops as a complication of other forms lung tb is difficult.

65. Staphylococcal pneumonia

66. LUNG TUBERCULOMA Lung tuberculoma is a distinct by genesis encapsulated caseous formation exceeding 1 cm in diametre and having a chronic torpid course.

67. Homogenous tuberculoma

68. Layer-by-layer tuberculoma

69. Conglomerate tuberculoma

70. Tuberculoma of the cerebellum

71. Tuberculoma

72. FIBROUS-CAVERNOUS LUNG TUBERCULOSIS
Fibrous-cavernous lung tuberculosis is a chronic destructive process, characterized by the presence of an old fibrous cavern, expressed fibrosis and nidi of bronchogenic dissemination in lung tissue, surrounding the cavern, or in other parts of the lungs; protracted undulant course with aggravations and remissions periods, constant or periodic bacterial secretion. In the social aspect fibrous-cavernous lung tuberculosis patients are invalids, predominantly of the 2-nd group.

73. Pathomorphism.
Fibrous-cavernous tuberculosis is formed at the unfavourable course of infiltrative, disseminated, nidus lung tuberculosis. Lung changes spreading may be various and the progress is both unilateral and bilateral with the presence of one or several caverns, as well as pneumosclerosis, emphysema and bronchoectases.
The cavern wall has a three-layer structure: inner-piogenous, middle-granulation, outer-fibrous.

74. Fibrous-cavernous lung tuberculosis

76. Fibrous-cavernous lung tuberculosis

77. Stages of destructive process in lungs.
Fresh elastic cavity fibrous cavity
disintegration    

78. elastic cavity

79. Clinic.
Clinical manifestations of fibrous-cavernous tuberculosis are varied. They are caused by both tuberculosis itself, the process spreadness and phase, changes in lung tissue and complications.
Several clinical variants of fibrous-cavernous lung tuberculosis course are discriminated:
1. Limited fibrous-cavernous lung tuberculosis with a stable course (progress);
2. Limited or wide-spread fibrous-cavernous lung tuberculosis with a progressing course;
3. Fibrous-cavernous lung tuberculosis with complications.

80. Fibrous-cavernous lung tuberculosis

81. fibrous-cavernous lung tuberculosis

82. Possible ways of cicatrization of cavities.
1. scar;      
2. hearths;      
3. blocked cavity;      
4. pseudocysts.

83. The diagnostics is based on the anamnesis data, roentgenologic picture (presence of caverns, fibrosis and nidi), deformity of thoracic cage, physical data, blood changes, MBT presence in sputum.
The differential diagnostics is done with:
chronic abscess,
polycystosis,
cancer in the decay phase,
bronchoectasia.

86. chronic abscess

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

89. Cirrhotic lung tuberculosis

90. Cirrhotic lung tuberculosis

91. Pathomorphism.
Cirrhotic tuberculosis develops as a result of involution of fibrous-cavernous, chronic disseminated, infiltrative tuberculosis of lung, pleura, tuberculosis of intrathoracic lymphatic nodes complicated with atelectasis.

92. Cirrhotic tuberculosis

93. Pleurogenic
cirrhosis of
the left
lung