CLINICAL CLASSIFICATION OF TUBERCULOSIS. PRIMARY TUBERCULOSIS

Respiratory tuberculosis       

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

Respiratory tuberculosis    

Extrapulmonary tuberculosis: Pleural tuberculosis Tuberculosis of intrathoracic lymph nodes Other forms of upper airway tuberculosis

Extrarespiratory tuberculosis Tuberculosis of central nervous system  Skeletal tuberculosis (bone and joint)  Intestinal tuberculosis, tuberculous peritonitis,  Lymph node tuberculosis  Genitourinary tuberculosis  Cutaneous tuberculosis 

Confirmation of the diagnosis by    

direct microscopy of samples cultures histopathological examination clinic-radiological examination

Characteristics of tuberculous process: Localization and extension:  in the lungs: limited (1, 2 segments) and extended (3 and more segments)  in other organs 

Phase    

progressing (infiltration, destruction, dissemination) regressing (desorption, consolidation) stationary (without roentgenological dynamics) stabilization (recovery)

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

Primary Tuberculosis Primary tuberculosis complex.

Background Tuberculosis (TB) is increasing among adults in many areas  TB is major cause of childhood morbidity and mortality worldwide  Limited information on epidemiology of TB in children 

Features of primary tuberculosis Primary tuberculosis develops after the child's first contact with the Mycobacterium tuberculosis  It is mainly in children and adolescents  With conversion of tuberculin test  Develop delayed-type hypersensibility, so appear hyperergical tuberculin tests 

Features of primary tuberculosis    

Paraspecifical reactions are characteristic : erythema nodosum phlyctenular conjunctivitis poliarticular syndrome (Poncet’s rheumatism is an “allergic” type of joint swelling which may disappear in two to three weeks, and does not indicate the presence of tubercle bacilli in the joint space)

Features of primary tuberculosis  

In the pathologic process is involved lymphatic system Tuberculosis in infants and children younger than 3 years old is much more likely haematogenous dissemination of the organisms occurs and spreads the organisms throughout the body, leading to acute disseminated TB (milliary TB) and tuberculosis meningitis, a very dangerous forms of the disease

Features of primary tuberculosis In most cases, tuberculosis in children is a mild disease and may heal on its own without treatment  The record multidrogresistent primary M.tuberculosis to antituberculosis drugs 

The diagnosis can be established on the following considerations history of contact with case of pulmonary tuberculosis  significant reaction to the tuberculin skin test  absence of elevated white cell count in the blood  absence of clinical and/or radiological improvement after treatment with a broad-spectrum antibiotics 

PRIMARY TUBERCULOSIS COMPLEX 

is a form of primary tuberculosis in children and adolescents with morphological substrate - specific inflammation of lung parenchyma (primary focus), involved in the process of lymphatic routes (lymphangitis) and mediastinal lymphadenopathy

Lesions associated with primary tuberculosis 



Initial infection with Mycobacterium tuberculosis in an immunocompetent individual usually occurs in an upper region of the lung producing a sub-pleural lesion called a Ghon focus Granulomatous involvement of peribronchial and/or hilar lymph nodes is frequent in primary tuberculosis due to lymphangitic spread from the Ghon focus

Lesions associated with primary tuberculosis The early Ghon focus together with the lymph node lesion constitutes the Ghon complex  These lesions undergo healing and over time usually evolve to fibrocalcific nodules  The combination of late fibrocalcific lesions of the lung and lymph node which evolved from the Ghon complex is referred to as the Ranke complex 

Clinical manifestations of intoxication syndrome 

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the central nervous system - general weakness, asthenia, excitability, headaches, sleep disturbances, feverish, night sweats endocrine system - the growing disorder children, the dysfunction of the thyroid gland in the age of puberty (hyperplasia of gr. II-III, hyperfunction), the disorder of the ovarian function (primary or secondary irregular of the menstrual cycle), decreased of the function adrenal glands (adynamy, hypotonia)

Clinical manifestations of intoxication syndrome immune system - children are frail, often respiratory tract infection (influenza, recurrent bronchitis and pneumonia), reactivation of chronic infections (sinusitis, tonsillitis, pyelonephritis etc.)  the heart – toxico-allergic myocarditis (tachycardia, cardiac tone I reduced, apical systolic functional murmur)  digestive system – diminished appetite and progressive weight loss, subacid gastritis 

Pulmonary syndrome Cough - is most frequently, usually more marked in the morning and is commonly productive  Chest pain – may result from involvement of the pleura  Dyspnoea – due to consolidation, cavitation, fibrosis and pleural affection  Haemoptysis - appears in complicated cases with primary cavity, most common in adolescents 

Mucocutaneous manifestations Erythema nodosum appears in the form of bluish red tender subcutaneous nodules several millimeters to several centimeters in diameter on the shins, sometimes on the backs of the arms and rarely on the front, in two to three bursts  They are painful, raised lesions that may turn purple and take on the appearance of a bruise 

Mucocutaneous manifestations 

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Phlyctenular conjunctivitis begins with generalized pain and irritation in one eye accompanied by watering and photophobia On examination, grey or yellow lesions can be observed where the cornea joins the white of the eye; a number of blood vessels enter the lesions, giving an appearance of vascular engorgement of the conjunctiva Each lesion persists for about a week, and then disappears, to be replaced by others In severe cases the cornea may ulcerate

Local symptoms Often the chest physical examination normal, with radiological discrepancy  Notice any limitation of movements on the affected part  Dullness  Harsh vesicular breathing and many diffuse rales of small caliber 

Radiographic picture of a primary tuberculosis complex 

1. 2. 3. 4.

The primary complex has four stages of development. There are four stages of primary complex development : I stage – pneumonic II stage - resorption III stage - condensation IV stage - calcination

Pneumonic stage 

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consists of a small area of infiltration at any location in the lung parenchyma, accompanied by unilateral mediastinal lymphadenopathy The infiltration forms when the bacilli are first inhaled (as a defence reaction around the location at which the bacilli first deposit); it is characteristically small (3 to 10mm in diameter) This nodular shadow is sometimes surrounded by a lighter, less dense shadow with irregular edges On lateral X-ray, mediastinal lymphadenopathy appears as a rounded or oval latero-tracheal or hilar shadow

Pneumonic stage 

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On X-ray general view three components of a complex are visible: 1) the focus in lung tissue by the size 2-4 cm. in diameter or more, of oval or irregular form, various intensity (more often average and even high), with an indistinct, obscure contour; 2) the flow out to a root lymphangitis, which is defined as linear tension bars from focus to the hilum; 3) in a hilum - enlarged infiltrated lymphatic nodes. The hilum is represented to be extended, it’s structure) is blurry, the intensity is increased. The contours outlining lymphatic nodes, or are dim, or more precisely depict the increased nodes.

Stage of resorption 

The radiological picture is that of a primary focus in the lung with accompanying mediastinal lymph nodes enlargement united by an opaque tape (lymphangitis – the draining lymphatics become beaded by tubercles, distended and tortuous)

Stage of resorption 

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The size of the focus in lung tissue decreases, its intensity raises, the contours become precise The flow out to a hilum and infiltration of lymphatic nodes decreases

Stage of condensation 

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On a place of focus area remains with the size up to 1 cm, inside of it inclusions of calcinations appear as fine spots of sharp intensity Same spots of calcinations are noticeable and in lymphatic nodes of the lung hilum Thin tension bars are determined between the focus and the hilum

Stage of condensation

Calcination-stage 

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The focus in lung tissue becomes even smaller, more densely, of high intensity, with distinct contour, frequently rugged and rough Calcinations are intensified also in hilum lymphatic nodes Calcinations in certain cases are represented by solid, dense formations, in others they have less intensive shadows of inclusions, which testify about incomplete calcifications of the focus and preservation of caseous regions in it

Outcome of primary tuberculosis 

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At favorable course of primary tuberculous complex with time calcification increases up to ossification at the place of former caseosis located in peripheral parts of lungs. This is Gohn's focus When primary complex is revealed in time and the patient receives valuable treatment, frequently could be achieved complete dissolution of pathological changes in lung tissue and in root, with complete restoration of their initial structure

Gohn's focus 

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The lesion is small and usually cannot be detected during its active stage; not until calcium salts are deposited in the healed lesion can its presence be detected In a large majority of instances healing takes place with fibrosis and calcification (Gohn's focus pointed be arrow)

The tuberculin skin test 

in most cases is hyperergical and coincides with a tuberculin conversion

Bacteriologic diagnosis 

 

Sputum can rarely be collected from children Can try sputum induction in older children Bronchoalveolar lavage is invasive, expensive and should be reserved for situations where the diagnosis is in question

 Gastric aspirates •

people swallow mucus in their sleep

•

collect gastric contents before the stomach empties

TUBERCULOSIS OF INTRATORACIC LYMPHATIC NODES

Definition is a primary form of extrapulmonary tuberculosis with specific inflammation of intratoracic lymphatic nodes, in children and adolescents  It affects mostly lymph nodes after Suchenicov - Esipov scheme (paratracheal, tracheo-bronchial, interbronchial, bronho-pulmonary lymph nodes) and Engel (para-aortic lymph nodes) 

Clinical-radiological forms  Infiltrative  Tumor-like

(pseudotumor)

 Traheobronchial

lymphadenopathy of small volume

Infiltrative form morphologically characterized by partial lymph nodes necrosis, predominate exudative inflammation type involving adjacent tissue  In clinical picture prevails intoxication syndrome 

Tumor-like (pseudotumor) form is characterized by morphological total caseation of lymph nodes  In clinical picture predominates bronchopulmonary syndrome with compression bronchus (bitonal spasmodic cough), dyspnoea expiratory 

Traheobronchial lymphadenopathy of small volume   

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is a variant of pseudotumor form and meet and young adults Clinical manifestations are moderate, or even missing This form should be suspected in children and adolescents from foci of tuberculosis with syndrome of intoxication, with conversion of tuberculin test or tuberculin tests hypererergical Groups of affected lymph nodes has diameter up to 1 cm and are hidden in the shadows of mediastinum and heart, invisible on X-ray standard To detect them is required chest x-ray in profile, mediastinal tomography, and computerized tomography

Infiltrative form •

•

On chest x-ray the shadow of the lung hilum is extended on the damaged part, the outside contour is unclear, the structure is heterogeneous and intensity is increased Shadows of enlarged lymphatic nodes are clearly come to light on x-ray tomogram

Infiltrative form

The pseudotumor form 

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The shadow of the hilum looks same, as an infiltrative form, but its exterior contour is clear, regular or polycyclic. The shadow of the upper part of mediastinum is expanded at a defeat of para-tracheal and tracheo-bronchial lymphatic nodes The defeat of bifurcation lymphatic nodes is revealed usually on the chest x-ray or tomograms

Pseudotumor form

Traheobronchial lymphadenopathy of small volume 



Groups affected lymph nodes with diameter up to 1 cm are hidden in the shadows of mediastinum and heart, invisible on X-ray standard For detect them is required a lateral chest radiograph, mediastinal tomography, computerized tomography.

Local complications of primary tuberculosis Fistulation of the lymph node into the bronchi: the lymph node swells and erodes into the bronchus (usually between the 4th and 7th month of development)  This can be a serious event for small infants, where the caseous material can create acute bronchial obstruction; in older children it usually causes cough 

Local complications of primary tuberculosis 

The formation of a primary tuberculous cavity at the site of infiltration is a more unusual complication

Delayed local complications Bronchiectasis may develop in the poorly ventilated area of the lung, creating bronchial superinfections and repeated episodes of haemoptysis.  The most characteristic feature of this type of sequelae is “hilar disease” or “right middle lobe syndrome”:  Atelectasis  hilar calcification  recurrent haemoptysis. 

Atelectasis

Differential diagnosis  sarcoidosis,

st. I  lymphogranulomatosis  lymphosarcoma  leukemia  adenopathy nonspecific

Infants may have acquired TB • • •

•

by trans placental spread through the umbilical vein to the fetal liver by aspiration or ingestion of infected amniotic fluid via airborne inoculation from close contacts (family members or nursery personnel) About 50% of children born to mothers with active pulmonary TB develop the disease during first year of life if chemoprophylaxis or BCG vaccine is not given

Neonatal TB   

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The clinical presentation nonspecific Multiple organ involvement Usually fever, lethargy, respiratory distress, hepatosplenomegaly, or failure to thrive may indicate TB in an infant with a history of TB exposure For diagnosis: culture and smear of tracheal aspirates, urine, gastric washings for acid-fast bacilli, chest x-ray (milliary infiltrates) Biopsy of the liver, lymph nodes, or lung and pleura may be needed Skin test results may be negative

Cerebrospinal fluid analysis in TB meningitis  

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CSF is clear or opalescent, pressure is elevated CSF pleocytosis with lymphocytic predominance: presence of more than 50 white cells/mm³ on microscopic examination of the CSF, with more lymphocytes than polymorphonuclear cells Decreased CSF glucose: value of CSF glucose 50% or less than simultaneous serum glucose determination. Increased CSF protein: value of CSF protein more than the upper limit of normal of the performing laboratory's reference values, i.e. > 0.45 mg/dl. Abnormal CSF: presence of all 3 of the above CSF findings (CSF pleocytosis with lymphocytic predominance + decreased CSF glucose + increased CSF protein.

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