Pthisiopulmonology

1. Secondary tuberculosis.
Focal tuberculosis. Tuberculoma.
Infiltrative tuberculosis.
Lecture № 7.
The Department of Tuberculosis of KSMA.
Doc. Fydorova S.V.

2. Secondary tuberculosis
develops in persons which have been
infected with MBT ill with primary TB
or before.

3. Endogenous reactivation
 is reactivation of old TB infection in
residual TB changed
 sometimes Erlich’s tetrad may be
detected by sputum microscopy
(changed MBT, elastic fibers, calcium,
cholesterol)

4. Exogenous superinfection
 repeated (sometimes numerous)
infection with new strains of MBT
 development of new tuberculous foci in
intact areas of lung tissue
 elimination of drug-resistant strains of
MBT (primary drug resistance) in new
TB cases

5. High risk factors of
tuberculosis
 Hereditary factor – presence of disease-
susceptibility genes are located mainly in B-,
D-, R-locus
 HIV-infection
 drug-abuse
 alcoholism
 diabetes mellitus and other severe diseases
 long taking of steroids, cytostatics
 malnutrition etc.

6. Secondary tuberculosis
 mainly occurs in adults older than 30
 tuberculin skin test is usually positive (10-12
mm)
 process is located in only single system or
organ (mainly lungs)
 TB process spreads by natural canals (in
pulmonary TB – by bronchi, in TB of kidneys
– by ureters, etc.) or by contact way

7. Secondary tuberculosis
 secondary TB doesn’t have tendency
to recovery without treatment. Usually
there is tendency to the destruction of
affected organ and impairment of it’ s
function.

8. Limited forms of secondary
tuberculosis
When not more than two segments of
lung tissue are affected only. The size
of opacity on the chest X-ray film is
not more than 10 cm² (squarer cm).
Classical limited forms of secondary
TB are focal TB and tuberculoma .

9. Focal tuberculosis
is specific tuberculous
inflammation of lung
tissue with size until 10
mm. Focal TB may be as
independent form as
outcome of different
forms of TB. Mainly
productive reaction is
typical.
It is the most favourable
form of secondary TB.

10. Classification of focal
tuberculosis
 new or soft focal TB
 old or fibrous focal TB

11. Clinical symptoms of focal
tuberculosis
 Asymptomatic pathway is usually
observed in about 35% of patients.
So focal TB is mainly detected by
prophylactic fluorographic
examinations.

12. Clinical symptoms of focal
tuberculosis
 Patients with focal TB sometimes may have
cough, a little of mucous sputum, subfebrile
fever, chest pain. The pain is associated with
breathing. Muscle’s tenderness of chest wall
during palpation may be detected in affected
side. By percussion – dullness of sound over
the upper areas of lungs may be observed.
By auscultation - a little of wheezes. But
usually physical findings are negative.

13. Diagnosis of focal tuberculosis
 MBT are detected in sputum by
microscopy only in 5% of cases,
informativeness increases to 50% by
cultural method.
 Tuberculin skin test is usually 10-12
mm as in infected asymptomatic
persons.

14. X-ray – findings
 Innumerous focal
shadows are observed,
their size is from 1-2 to
10 mm, their intensity is
usually low, form is
irregular, contours are
unclear. Transparency of
surrounded lung tissue
may decrease. Soft focal tuberculosis
of the left upper lobe

15. X-ray – findings
 Intensity of foci is
high, their borders are
clear. Fibrosis of
surrounding lung
tissue increases.
Usually the first, the
second and the sixth
segments of lungs are
affected – typical
localization.
Fibrous focal tuberculosis
of the left upper lobe

16. Differential diagnose:
 focal pneumonia
 echinococcus at early stage
 tumor at early stage
 focal fibrosis
etc.

17. Tuberculoma
area of caseous
necrosis with size
more than 10 mm
surrounded with
connective tissue
capsule and
elements of specific
granulations.

18. Tuberculoma
 may form in young people with high
immune response
 specific treatment at early stage of
disease may cause changes of
exudative stage of inflammation to
proliferation – tuberculoma formation

19. Classification of tuberculoma
 Morphological types:
 infiltrative-pneumonic tuberculoma (is a
consequence of infiltrative TB –
productive reaction predominates)
 caseoma (alterative reaction
predominates)
 pseudotuberculoma (when tuberculous
cavity is crowded with caseous mass)

20. Classification of tuberculoma
 Morphological
structure:
 homogenous and
heterogeneous with
layers of connective
tissue and caseous
necrosis
 solitary and
conglomerate
homogenous
solitary tuberculoma
heterogeneous
solitary tuberculoma
conglomerate
tuberculoma

21. Classification of tuberculoma
 Size:
 small (diameter is from 1 to 2 cm)
 medium (diameter is from 2 to 4 cm)
 large (diameter is from 4 cm to 6 cm)
 gigantic (diameter is from 6 cm and
more)

22. Classification of tuberculoma
 Clinical course:
 stable pathway – without any clinical
symptoms
 progressive pathway – exacerbations,
sometimes destruction of lung tissue and
formation of tuberculous cavity
 regressive pathway – dissolving of
granulations and consolidation of caseous
necrosis, fibrosis and sclerosis of lung tissue

23. Clinical picture of tuberculoma
 Patients with tuberculoma are usually
asymptomatic, so this clinical form is
detected by preventive fluorography
examination
 Sometimes patients may have
progression of disease – pulmonary
symptoms and intoxication appear

24. Diagnosis of tuberculoma
 Tuberculoma may be detected by occasional
X-ray or fluorographic examination
 Tuberculin skin test may be positive or
hyperergic
 X-ray diagnosis – round opacity is detected in
the lung tissue, it is usually located in the 1st,
2nd, 3rd segments, it’s intensity may be
medium or high, it may be heterogeneous
with calcifications. Sometimes there are
calcifications in the root and surrounded lung
tissue

25. Radiological signs of
progressive tuberculoma
 borders are getting
unclear
 size of round shadow is
getting bigger
 appearance of
destruction
 appearance of
bronchogenous foci in
surrounded lung tissue
 relation between round
focus and lung root as
road-like shadow
 numerous round
opacities

26. Differential diagnosis
 tumor
 echinococcus
 abscess
 pneumonia
 fungal diseases
etc.

27. Infiltrative tuberculosis
is area of caseous necrosis with size
more than 1 cm and wide zone of
exudation around it.

28. Infiltrative tuberculosis
may develop in intact lung tissue, but
often it forms in the area of old
specific lesions. Exacerbation of TB-
infection in calcified lymph nodes can
cause formation of infiltrative TB in
pulmonary tissue too. TB-infection
usually spreads by lymphatic and
bronchial ways.

29. Morphological types of infiltrative
TB
 broncholobular
infiltrate

30. Morphological types of
infiltrative TB
 round or oval infiltrate (Assman’s infiltrate)

31. Morphological types of
infiltrative TB
 own cloudy-like
infiltrate

32. Morphological types of
infiltrative TB
 periscissuritis

33. Morphological types of
infiltrative TB
 pseudotumorous
infiltrate

34. Morphological types of
infiltrative TB
 lobitis

35. Diagnosis of infiltrative
tuberculosis
 MBT are often detected in sputum by
microscopy
 tuberculin skin test is usually positive
or hyperergic
 X-ray-findings – syndrome of total or
subtotal opacity of lung tissue

36. Differential diagnose
 pneumonia
 lung cancer or lung tumor with
atelectasis
 fungal disease
 mycobacteriosis
 viral diseases
 infectious diseases (rheumatism,
brucellosis, tularemia)
etc.

37. Thank you
for your attention!