Development of fibrous-cavernous form of tuberculosis. Fibrous-cavernous tuberculosis: symptoms, diagnosis and treatment Treatment of fibrous-cavernous tuberculosis

Back in the beginning of the last century, tuberculosis (consumption - obsolete) was almost 100% fatal. Modern medicine has the means to treat tuberculosis patients, but poor social conditions or neglect of one's health still results in a significant number of patients with severe forms of the disease.

What is fibro-cavernous tuberculosis

The fibrous-cavernous form is one of the last stages of tuberculosis. The destructive process in the lungs proceeds chronically, as a result of which cavities (cavities) of a specific structure are formed in the lung tissue. In the fibrous-cavernous form, the cavities are enclosed in a fibrous capsule. The fibrous form is characterized by a three-layer structure of the walls of the cavity:

Internal - caseous, contains molten necrotic tissue.
Granulation - altered tissue with a granular structure.
Fibrous - connective tissue, clearly delimited wall of the outer wall of the cavity.

Connective tissue changes are also observed in the nearby tissues of the lung.

In the caverns are the decay products of the tissue, which are brought out (sputum). With the development of the destructive process, nearby blood vessels are involved in necrosis. The walls of the vessels are perforated, and therefore blood is present in the sputum (hemoptysis).

A deeper ulceration of the vessel can lead to bleeding, which in turn is fraught with aspiration pneumonia. General bleeding leads to death - drowning in one's own blood.

Features of the disease

The disease is characterized by an undulating course: periods of remission are replaced by relapse. The patient's condition during the period of improvement is assessed as satisfactory, during the period of exacerbation - medium-severe.

Cavernous tuberculosis as a step towards the development of fibrous-cavernous pathology

Cavernous capsules are formed due to necrosis of the affected areas of the lung. Further, the caseous masses are liquefied and brought out by the draining bronchi. At the site of the lesion, a void is formed, filled with liquid, pus or air. This cavernous stage, as a result of the progression of the disease, becomes fibrous-cavernous: the capsule becomes overgrown with fibrous tissue, acquiring a more rigid shell.

Fibrotic changes also occur in the nearby lung parenchyma. It should be noted that any form of tuberculosis can lead to the cavernous form (in the absence of treatment or inadequate therapy): infiltrative, dessimilated, etc.

Symptoms of the disease

The undulating course of the process is characterized by seasonality: periods of relief for patients in summer and winter, worsening in spring and autumn. During the period of remission, the symptoms of the disease are much weaker:

Weakness;
cough with phlegm;
Subfebrile temperature;
Shortness of breath (heart failure).

As the destruction develops, blood appears in the sputum. Further, there is an increase in symptoms in a negative direction, loss of appetite and, accordingly, body weight - up to dystrophy or cachexia. In addition, complications appear - damage to nearby organs and systems, giving symptoms characteristic of their pathology.

Causes of the disease

The fibrous-cavernous form is more often diagnosed in adults. The destructive process progresses:

Due to massive dissemination (contamination) of pathogenic microorganisms.
Incorrect treatment (or lack thereof) of the previous stage of the disease.
Low immunity.
Weakening of the body due to bad habits (smoking), adverse environmental conditions.

The appearance of new cavities and the further development of tuberculosis are facilitated by bronchogenic seeding: the caseous contents of the cavity (sputum) contain a large number of bacteria that spread through the bronchi draining the cavity (the bronchus mouth is part of the cavity capsule) to other parts of the lung. In this case, the foci are located in the upper lobes, forming infiltrates and microperforations of the bronchi near the lumen of the bronchi.

In addition, the infection can spread:

Hematogenous way - through the bloodstream;
Lymphogenous - according to the lymphatic system.

In these ways, the seeding of organs and tissues remote from the focus, such as kidneys, bones, eyes, etc., occurs.

The main phases of the disease

The fibrous-cavernous form is diagnosed if there is a cavern with a formed fibrous membrane. Depending on the size of the lesion, the number of cavities, associated complications, there are several clinical forms:

Stable form with a single fibrous capsule. It is characterized by rare short bursts and a long period of calm.
Slowly progressive form - long and / or frequent exacerbations with short periods of calm.
Progression of destruction with the capture of neighboring blood flow organs and complications in the form of hemoptysis, periodic bleeding. The clinic present aspiration pneumonia, bronchiectasis changes.
Severe destructive changes in the form of a huge cavity formed by the fusion of several, extensive fibrous lesions, as a result of which the lung is deformed. The extreme form is characterized by bone deformities (barrel chest), displacement of nearby organs, cachexia.

Note: The clinical form with periodic bleeding was previously diagnosed as hemophthisis (blood consumption).

Frequent complications

The fibrous-cavernous form is epidemiologically dangerous, since the patient's sputum contains a large number of pathogens. This moment is also dangerous for the patient himself: bronchogenic and hematogenous mutes of mycobacteria inseminate an increasing area of the organ, and the disease also affects other human systems:

Brain;
Intestines;
The osteoarticular apparatus;
Kidneys, etc.

Damage to organs and systems gives specific symptoms inherent in the pathology of the corresponding organs: tuberculosis of the meninges, tuberculosis of the bones, etc. Purulent necrolysis of newly formed foci give massive intoxication, inflammation, complications in the form of purulent foci (pleurisy, empyema). Displacement of the mediastinal organs, tissue deformation still aggravate the symptoms and course.

Diagnostic methods

Diagnosis is based on:

Patient complaints - cough with sputum, fever, weakness, shortness of breath, sweating.
Examination - pallor of the skin, thinness, circles under the eyes, chest deformity (barrel-shaped), sub- and supraclavicular fossae sinking.
Auscultation - wet and dry rales are heard. Above the giant caverns are sharp and piercing sounds arising from the calcification of the walls.
Percussion - tapping gives a dull shortened sound over the affected areas.

More often, the fibrous-cavernous form in the primary diagnosis is found in patients with a history of social disadvantage - in the initial stages and during remission, the patient's condition is satisfactory and he does not (has no opportunity to go) to the doctor.

The complex of additional examination and diagnostics includes:

Bacteriological analysis of sputum - to confirm the diagnosis of tuberculosis and determine the type of mycobacterium.
Complete blood count - elevated ESR, leukocytes, lymphopenia. Anemia is present if bleeding has occurred.
Urine analysis - an increased protein content may be observed.
X-ray of the lungs - cavities are visible on the pictures, their size, number, shape, fibrous bands are visible, the presence of fluid in the cavities in the form of horizontal lines.
Tomography - complements the picture of tissue damage, allows you to see deformations that are invisible on the R-image due to the abundance of fibrous inclusions, new foci of necrosis.

Based on the obtained picture of the disease, a treatment strategy is chosen.

Principles of therapy

Treatment of the fibrous-cavernous stage is long. Closure of caverns during drug therapy occurs in 19% of cases (according to some authors, even less - 8 - 12%). In advanced cases and with the presence of complications (empyema), surgical and complex treatment.

Conducting chemotherapy

Another goal of drug treatment (in addition to recovery) is abacillation - to stop further destruction, dissemination, and prevent the epidemiological danger of the patient.
There are several chemotherapy strategies: short-term (6-8 months) and long-term. Taking anti-tuberculosis drugs should be combined with measures to increase the body's defenses:

diet;
improvement of living conditions;
giving up bad habits (alcohol, smoking, drugs).

Important! Due to the lack of discipline of patients - the contingent does not have social responsibility - there are drug-resistant strains of bacteria. If the formula for taking the drug is not followed, mycobacteria become resistant to it.

In the case of diagnosing a drug-resistant form of tuberculosis, chemotherapy is supplemented by surgical measures.

Surgery

Excision of a single cavity gives a positive result. But more often, due to the massive presence of mycobacteria in the cavity cavity, the destructive process is extensive. In this case, only the removal of foci does not give a result; the probability of a lethal outcome is high with extensive resections.

For the treatment of fibrous-cavernous tuberculosis, complicated by a drug-resistant form, comorbidities, surgery is combined with various procedures according to individual schemes:

Preoperative chemotherapy + aerosol therapy + intravenous laser blood irradiation (BJIOK) + treatment of the cavity walls with a laser using a videoscope (BJIO) + resection surgery.
LEP (local extrapleural pneumolysis) + cavernotomy + laser treatment of the cavity walls, draining bronchi + final operation.

The choice of scheme and methods is selected taking into account all the nuances of the disease.

Disease prognosis

Mortality is high enough for the last stages of the disease. However, if you follow all the recommendations of the doctor, sleep and nutrition, the rejection of addictions allows you to count on a successful outcome.

Preventive measures

To protect yourself from a disease that takes lives even in the 21st century, the following conditions must be observed:

Do not neglect the primary vaccination of children;
Lead a healthy lifestyle that promotes strong immunity;
Observe sanitary rules when living with a patient with active tuberculosis;
Attentive attitude to one's health, timely treatment to a medical institution;
On a national scale - a mandatory medical preventive examination when applying for a job, an annual medical examination at enterprises;

Providing tuberculosis patients with adequate treatment, sanatorium and resort rest, separate housing (while living in a densely populated area) will help to avoid epidemiological situations.

Fibrous-cavernous tuberculosis is a deadly disease (including for others). Only modern methods, coupled with close cooperation between the doctor and the patient, careful execution of prescriptions, give not only hope, but a complete cure.

The fibrous-cavernous process in the lungs is a far advanced and epidemiologically most dangerous form of tuberculosis, since patients with fibrous-cavernous tuberculosis in most cases are bacilli excretors. The initial form of fibrous-cavernous pulmonary tuberculosis can be any form of tuberculous lesions of this organ.

Most often, fibrous-cavernous tuberculosis develops from an infiltrative, less often from a disseminated and focal pulmonary process.

Fibrous-cavernous tuberculosis has specific signs, and only if they are present and severe can an appropriate diagnosis be made.

Fibrous-cavernous tuberculosis is characterized by the presence of a cavity with a pronounced fibrous capsule, fibrous changes in the lung on the side of the localization of the process, displacement of the mediastinal organs to the diseased side, bronchogenic dissemination in the lungs and the duration of the disease.

The destruction of lung tissue and the formation of a cavity can be observed in any clinical form of tuberculosis, but the transition to the fibrous-cavernous form is proved not by the fact of destruction, but by a change in the nature of the morphological process in the cavity and in the lung and often by a change in the entire clinical syndrome of the disease.

Pathological changes in the lungs with fibrous-cavernous tuberculosis are very characteristic. On fig. 42 (pathoanatomical preparation) one can see an isolated cavity on the left with a wide tortuous draining bronchus and foci of various sizes and density; cicatricial changes and single foci are visible in the apex of the lung on the right; in the lower lobe there is a group of foci.

The above illustration cannot give a complete picture of the whole variety of changes in the lungs in fibrous-cavernous tuberculosis, but only clearly demonstrates the characteristic features of this form: the presence of an old cavity, the development of connective tissue and bronchogenic metastases in various parts of the lungs.

The clinical diagnosis of fibrous-cavernous tuberculosis in most cases is not difficult, as there are a number of symptoms characteristic of this form of tuberculosis, but in some cases these symptoms are not very pronounced or are incorrectly interpreted.

Clinical manifestations and a variety of symptoms depend on the prevalence of the process, its localization, complications and concomitant diseases.

In the anamnesis of most patients with fibrous-cavernous tuberculosis, there are indications of a long and often undulating course of the disease, i.e., a change in periods of exacerbation of tuberculosis with periods of clinical well-being. The intervals between these periods can sometimes be very long, and in a number of patients, on the contrary, short-term.

Symptoms of fibro-cavernous tuberculosis are cough, sputum production, chest pain, weakness, weight loss, poor sleep and appetite, hemoptysis, fever, sweating during sleep at night.

Each patient may have one or another of the listed symptoms, and in different periods of the disease, the severity of the symptoms may be different.

The most common symptom is cough. It can be insignificant in some periods of the disease and disturb the patient a little, in others - painful, not stopping from taking various medicines. A painful cough develops mainly as a result of tuberculosis of the bronchi, which is often observed in fibrous-cavernous tuberculosis. Patients with fibrous-cavernous pulmonary tuberculosis may have a large amount of mucopurulent sputum, mostly viscous, separated with difficulty. The patient is forced to cough repeatedly and for a long time in order to excrete 30-50 ml of sputum.

Rapid fatigue and general weakness are usually observed during the period of exacerbation of the fibrous-cavernous process.

In patients with fibrous-cavernous tuberculosis, during the period of remission of the process, the body temperature may not rise, despite large changes in the lungs. More often, normal body temperature is observed with the development of fibrotic changes. The occurrence of infiltrative paracavernous changes, as well as bronchogenic metastases, is accompanied by severe fever. With the formation of pneumonic areas in the lungs, the body temperature reaches high numbers and lasts a long time. In patients with large and giant caverns containing a large amount of pus, caseous masses and abundant microbial flora, high body temperature can be recorded as a result of a secondary infection on the body and, to a lesser extent, due to tuberculosis.

Hemoptysis and pulmonary bleeding are common symptoms of fibro-cavernous tuberculosis. It is with this form that abundant, sometimes prolonged and life-threatening pulmonary hemorrhages occur. Complications of pulmonary bleeding from aspiration pneumonia also occur more often in patients with fibrous-cavernous tuberculosis than in other clinical forms of this disease.

When examining patients suffering from fibrous-cavernous pulmonary tuberculosis, one can sometimes note a normal appearance, the correct configuration of the chest, satisfactory and even good development of the subcutaneous fat layer, but more often the appearance of the patient still has characteristic features for a chronic tuberculous process.

The duration and extent of the pathological process in the lungs and pleura, the presence of chronic intoxication lead to a change in the external appearance of the patient. A significant loss of body weight, a wrinkled face, a dull look, dry, flaky skin, weakly expressed muscles are characteristic of a patient suffering from extensive pulmonary tuberculosis for a long time. Retraction of the supraclavicular and subclavian spaces, retracted intercostal spaces, an acute epigastric angle, a flattened and elongated chest, lagging behind one half of it when breathing, and sometimes a sharp flattening of the same side indicate large changes in the lungs and pleura on the side of the lesion.

Habitus phthisicus is observed most often in patients with fibrous-cavernous and cirrhotic pulmonary tuberculosis.

When percussion in patients, a shortening of the sound is determined in places of thickening of the pleura and extensive development of fibrosis in the lungs, as well as over massive infiltrative and pneumonic foci.

In areas of fibrous compaction of the lung and pleural thickenings, weakened breathing is heard, over massive infiltrative-pneumonic foci - vesico-bronchial, over a large cavity (4-6 cm in diameter) with wide draining bronchi - bronchial, and with a smooth-walled giant cavity (more than 6 cm in diameter) - amphoric. Above the cavity, large-bubble voiced moist rales are also heard.

Over small caverns or deep-seated rales, the sonority of wheezing will be less. With a thick consistency of the contents of the cavity, wheezing can be heard only at the height of inspiration or, conversely, when coughing, that is, with forced exhalation. Directly around the cavity, the patient may develop a zone of infiltrative changes in the lung tissue. On auscultation, small bubbling and less often medium bubbling wet rales are heard in these areas.

The number and sonority of large-bubbly moist rales that occur in the cavity decrease as the liquid content of the cavity decreases, and, finally, when the walls of the cavity are cleaned and epithelialized, the rales disappear, although the cavity has not closed. When the cavity is closed and scar tissue forms in its place, catarrhal phenomena disappear. Above the old cavity with a cirrhotic capsule, often coarse rales are heard, resembling a "squeak" and "creak".

With the closure of the lumen of the bronchus, listening to all the listed signs of the cavity ceases and the cavity turns into a "silent" one. Depending on the reasons for the closure of the lumen of the bronchus, the absence of auscultatory signs of a cavity can be temporary or permanent. "Silent" cavities are determined only by X-ray examination.

Altered breathing and wheezing are also not audible over deep-seated caverns in a fibrous-altered lung due to a massive layer of lung tissue and a thickened pleura. Such cavities are not “silent”, since the bronchi that drain them function and there are conditions for the occurrence of wheezing. There are only no conditions for the conduction of wheezing. In such cases, you can hear "oral" wheezing.

X-ray examination in most patients with fibro-cavernous tuberculosis determines various changes in the configuration of the chest and the position of the organs of the chest cavity. Pathological changes in the lungs in this form of tuberculosis can be unilateral, and if the process is bilateral, then the pathological changes are asymmetrically located.

Only in cases of development of fibrous-cavernous tuberculosis from disseminated, signs of symmetry remain. As a consequence of the extensive development of fibrous tissue in the lung, radiographically, the displacement of the mediastinal organs in the direction of the localization of the fibrous-cavernous process is very often determined.

Due to the duration of the course of fibrous-cavernous tuberculosis in the lungs and its high prevalence, changes in the pleura occur, therefore, with fluoroscopy or on an x-ray in patients with this form of the process, thickening of the pleural sheets, pleural adhesions, restriction of diaphragm mobility are almost always determined. On the radiograph, you can find, in addition to cavities, heaviness from cicatricial changes in the lungs (Fig. 43).

With massive and extensive fibrous transformations of the lung parenchyma, one can see a decrease in lung volume due to its wrinkling.

Bronchogenic metastases are displayed as foci of various sizes and intensity. The cavern with fibrous-cavernous tuberculosis has characteristic features on the radiograph. Surrounded by a little elastic lung tissue, it rarely retains the correct rounded shape, may have an irregular shape, with a dense internal capsule and often with an inflammatory zone around. In one lung there can be several cavities of various sizes: gigantic, large and small.

With temporary or permanent closure of the draining bronchus, the contents of the cavity are not released through the bronchi, and the horizontal level in the cavity can be determined on the radiograph.

In the sputum of patients with fibrous-cavernous tuberculosis, a large amount of Mycobacterium tuberculosis is found. With the introduction into practice of antibacterial drugs that have a bacteriostatic effect, in fibrous-cavernous tuberculosis, sometimes a cessation of bacilli excretion is observed despite the presence of a cavity. This should be considered a positive epidemiological factor, since the use of chemotherapy drugs can maintain the state of abacillarity for a long time.

In addition to Mycobacterium tuberculosis, elastic fibers are found in sputum, and staghorn elastic fibers are characteristic of the fibrous-cavernous form.

When endoscopy of the cavity, as well as when opening the cavity surgically, you can see its inner surface. The inner surface of the cavity before treatment is an extensive ulcer, covered with dirty-gray, sometimes grayish-yellow masses, consisting of mucus, pus, fibrin clots and caseous masses. In some areas, necrosis of the lung tissue is sometimes visible. Under the influence of treatment with antibacterial drugs, the inner surface of the cavity is cleaned and the wall of the cavity becomes clean, smooth, pinkish-pale, shiny. In smears from the inner surface of the cavity in such cases, microbial flora is not detected.

In the blood of patients with fibrous-cavernous pulmonary tuberculosis, there may be changes characteristic of active pulmonary tuberculosis in general, and not for this clinical form. Anemization of the patient can occur only with abundant or prolonged pulmonary or intestinal bleeding, amyloidosis. Without these complications, no noticeable pathological changes are observed in the red blood of patients with cavernous tuberculosis. Significant changes can be observed in the white blood of the patient. During an exacerbation of tuberculosis, the number of leukocytes increases to 10 10 9 / l - 12 10 9 / l (10,000-12,000 per 1 mm 3 of blood). Higher leukocytosis in patients with fibrous-cavernous tuberculosis is observed with secondary infection of the contents of the cavity. With the elimination of nonspecific inflammation and with the suppression of the secondary flora by various medicinal substances, leukocytosis also disappears. From the side of the leukocyte formula during the outbreak of the tuberculosis process, an increase in the number of stab neutrophils is noted, and the number of lymphocytes decreases in the peripheral blood; there is an increase in ESR.

In the urine of patients with fibrous-cavernous pulmonary tuberculosis, changes occur when the disease is complicated by amyloidosis of the internal organs or severe intoxication. It is with this form of tuberculosis, mainly due to the impact on the body of the joining infection, that amyloidosis most often develops compared to other clinical forms of the disease.

With a long progressive course of fibrous-cavernous pulmonary tuberculosis, pulmonary heart failure develops due to extensive tuberculous and mainly fibrotic changes developing in the lungs.

Fibrous-cavernous pulmonary tuberculosis has to be differentiated from such chronic diseases as bronchiectasis, lung cancer, pneumosclerosis of various etiologies.

These diseases have a number of very similar diagnostic features; in addition, the same person may have a mixed lung disease; tuberculosis and bornchoectatic disease, tuberculosis and cancer, tuberculosis and nonspecific pneumosclerosis.

Rarely occurring chronic lung diseases (syphilis, actinomycosis, cystic lung) also have clinical and radiological signs similar to fibrous-cavernous tuberculosis.

Clinically pronounced bronchiectasis has peculiar manifestations. The appearance of a patient with bronchiectasis differs markedly from that of a patient with fibro-cavernous tuberculosis. A puffy face, thickened lips, changes in the terminal phalanges of the fingers and toes in the form of "drumsticks" are characteristic of a patient with bronchiectasis. The amount of sputum in patients with bronchiectasis; at the same time, sputum is separated easily, it is purulent in nature and may have a putrid odor.

The rales in the bronchiectasis cavities are coarser, resembling the crunch of snow: these rales are sometimes audible at a distance of 20-30 cm from the chest. On x-ray, unfilled bornchiectasis may appear as multiple, round, thin-walled cavities. In addition to round saccular bronchiectasis, there may be cylindrical bronchiectasis.

Often, bronchography is necessary to diagnose the disease. An X-ray bronchogram more clearly reveals the location and shape of bronchiectasis and helps to establish the correct diagnosis of the disease.

Differential diagnosis between fibrous-cavernous tuberculosis and lung cancer in many cases, especially with decaying cancer, is very difficult due to the great similarity of clinical symptoms. Cough with sputum, hemoptysis, fever, chest pain, catarrhal phenomena in the lungs are observed, moreover, and another disease. One can note a significantly greater intensity and persistence of pain, a painful cough and frequent admixture of blood in the sputum in lung cancer. Characteristic of lung cancer is often observed recurrent hemorrhagic pleurisy. A more pronounced dullness of the percussion sound is noted above the canary area of the lung. On the radiograph, you can find significantly more diagnostic differences between cancer and tuberculosis than with all other research methods.

The high intensity of darkening in the root zone with heaviness to the lateral parts of the lung, detected in cancer, is sometimes very similar to the massive fibrous changes in the lungs observed in tuberculosis. The absence of focal shadows in the lung, both on the side of the lesion and on the opposite side, indicates a cancerous etiology of the disease. The collapse of the lung in bronchogenic cancer occurs only in an advanced stage of the disease.

Pneumosclerosis of non-tuberculous etiology may present with symptoms similar to those of fibro-cavernous tuberculosis. Pneumosclerosis can develop after exudative pleurisy, traumatic injuries of the chest organs, lung abscesses and other inflammatory processes in the lungs and pleura.

Radiologically with pneumosclerosis, homogeneously darkened areas of the lung can be detected. The absence of focal shadows and visible caverns, the uniformity of darkening are the basis for the X-ray determination of pneumosclerosis and the denial of the diagnosis of fibrous-cavernous tuberculosis. Mycobacterium tuberculosis is absent in the sputum of patients with pneumosclerosis.

Actinomycosis of the lungs is a rare disease; it has symptoms similar to those of fibro-cavernous tuberculosis. Prolonged fever, persistent chest pain, cough with sputum, frequent hemoptysis are typical of actinomycosis. The pathological process in most cases spreads from the pleura and peripheral parts of the lung to the center. The superficially located actinomycotic process causes a sharp compaction and soreness of the tissues of the chest wall, followed by the formation of fistulas.

On the radiograph with actinomycosis of the lung, large, merging foci of compaction can be seen, sometimes with areas of enlightenment in them, heaviness and wrinkling of the affected lung, massive thickening of the pleura.

For differential diagnosis between actinomycosis and pulmonary tuberculosis, the detection of radiant fungus drusen in the sputum, the causative agent of actinomycosis, is of paramount importance.

In the differential diagnosis of fibrous-cavernous tuberculosis, it is necessary to exclude cystic formations in the lungs. The rounded outlines of the cyst are very similar to the display of the cavity on the radiograph.

In the vast majority of cases, patients with cystic lung do not complain and cysts are found during an accidental examination of the patient or in connection with any disease.

Treatment of patients with fibrous-cavernous tuberculosis should always be long, continuous and complex. With this form of pulmonary tuberculosis, in most cases it is impossible to limit oneself to any one treatment method. The task of the doctor in the treatment of fibrous-cavernous tuberculosis is the correct combination of several methods and means and the timely transition from one method to another, for example, from therapeutic (antibacterial) treatment to surgical, from hospital to sanatorium and resort-climatic.

Before the introduction of antibacterial drugs into practice, cavern closure and sputum abacillation occurred in a small group of patients, mainly with the use of collapsotherapy and extrapleural surgical treatment.

At present, with the use of antibacterial drugs and operations on the lungs, it has become possible to cure many patients with fibrous-cavernous tuberculosis.

Treatment begins in a hospital setting. Until the elimination of severe clinical symptoms, all three main drugs are used: streptomycin or rifadin, isoniazid and PAS. After the disappearance of symptoms of intoxication, treatment with isoniazid and PAS should be continued in combination with second-line drugs. In many patients, after 6-7 months of chemotherapy, bronchogenic metastases disappear, the size of the cavity decreases. In such cases, surgical treatment is necessary. For some patients, after treatment in hospitals, sanatorium treatment, and then treatment on an outpatient basis, may be recommended. With this scheme, the patient is treated for 3-4 months in a hospital, 2-3 months in a sanatorium and 6-8 months on an outpatient basis.

Naturally, the treatment should be individualized depending on the severity of the course of the process, its prevalence, as well as on the tolerability of chemotherapy drugs and the sensitivity of Mycobacterium tuberculosis to them. In patients with fibrous-cavernous pulmonary tuberculosis, side effects are often observed when using antibacterial drugs and resistance to them of Mycobacterium tuberculosis is formed, therefore, along with the main antibacterial drugs, it is necessary to use second-line drugs in various combinations. It is possible to enhance the effect of anti-tuberculosis drugs by their intravenous and intratracheobronchial administration in combination with pathogenetic therapy, which increases the permeability of histohematic tissue barriers, facilitating the penetration of tuberculostatic drugs into tuberculous foci. Complex antibacterial treatment is carried out against the background of restorative therapy and a sanatorium-hygienic regimen.

With all types of treatment, the healing of a cavity with a dense fibrous capsule occurs slowly, and such a cavity never disappears without a trace. Under the influence of antibiotic therapy, extrapleural operations, a stellate (rarely linear) scar or a dense focus remains at the site of the cavity.

In some cases, under the influence of antibacterial drugs, the inner wall of the cavity is cleaned, epithelialized and the cavity is likened to a cyst, the so-called open cure of the cavity occurs.

The cleansing of the cavity can be considered a favorable result of antibiotic therapy, but temporary, since Mycobacterium tuberculosis can still remain in such a cyst-like cavity, which, under certain conditions, can later give rise to new outbreaks of tuberculosis with a recurrence even of bacillus excretion. In addition, such cavities can be secondarily infected with a variety of microflora or pathogenic fungi - aspergillus. It is always necessary to strive to eliminate the cavity.

V.Yu. Mishin

Fibrous-cavernous pulmonary tuberculosis is a chronic form characterized by the presence of a fibrous cavity, the development of fibrous changes in the lung tissue surrounding the cavity. It is characterized by foci of bronchogenic screening of various prescriptions. Occurs in 5-10% of cases.

Pathogenesis and pathomorphology. Fibrous-cavernous tuberculosis occurs as a result of the progression of any other form of pulmonary tuberculosis. In the absence of a tendency of the cavity to scarring, connective tissue begins to grow around it, which leads to deformation of the cavity. This is how the aging of the cavity and the development of fibrous-cavernous tuberculosis occur. This period is usually 1.5-3 years.

Fibrous-cavernous tuberculosis is characterized by the presence in one or both lungs of one or more caverns located among the fibrously altered lung tissue.

The wall of the chronic cavity consists of three layers: caseous, granulation and fibrous, however, a distinctive feature of this form is the sharp predominance of the fibrous layer. As a result, the walls of such a cavity have a cartilaginous density.

Around the cavity, fibrous growths are also visible along the bronchi and blood vessels, which cause deformation of the lung tissue. Caverns are usually rounded, slit-like or irregular in shape, but there are cavities consisting of a system of cavities. As a rule, the bronchi draining the cavity are affected.

It should be noted that the caseous layer of the cavity in this form of tuberculosis almost never disappears, i.e. the cavity is not cleared. The long-term existence of conditions for necrosis of the cavity wall leads to vascular erosion, which is a constant threat of pulmonary hemorrhage.

The resulting bleeding can rarely be stopped in a conservative way, since the arrosed vessels in the wall of the cavity gape and do not subside due to massive fibrous growths around it.

Fibrous-cavernous tuberculosis is the result of a long-term ongoing process. As a result, around the cavity, as a rule, multiple foci of dissemination are visible in the form of small foci of caseosis, millet-like rashes (epithelioid cell granulomas) and small infiltrates without clear boundaries. The presence of these foci against the background of fibrotic changes in the lung tissue leads to a sharp reduction in the lung surface and the development of respiratory failure.

Clinical picture. Patients with fibrous-cavernous tuberculosis complain of weakness, cough with sputum, shortness of breath. Their condition is often satisfactory, with widespread lung damage - of moderate severity. Body temperature before treatment is usually subfebrile.

The progressive course of the disease is accompanied by severe weakness, weight loss, increased moisture of the skin, and acrocyanosis is observed. A long progressive course leads to the development of cachexia (habitus phtysicus). The chest is barrel-shaped; on the side of the lesion, there is a retraction of the supraclavicular and subclavian cavities and a lagging of the affected side of the chest during breathing.

Percussion always noted a shortening of the sound over the affected areas and a box sound over the less affected lobes. Breathing is hard or bronchial, a moderate amount of various wet rales is heard.

In the blood, there is a moderate leukocytosis and a shift of the formula to the left, lymphopenia, an increase in ESR. With a long course of the disease, the content of hemoglobin and erythrocytes decreases.

Before treatment, patients with fibro-cavernous tuberculosis are always isolated with sputum MBT. Bronchoscopy often reveals specific changes in the bronchi; there is also a violation of the function of external respiration, mainly of a restrictive type, and hypoxemia.

Progressing, the disease takes a wave-like course with the appearance of new caverns and foci, almost constant bacterial excretion.

The patient's condition worsens, numerous complications develop (respiratory failure, CHLS, hemoptysis, etc.), often in combination with the development of MBT drug resistance.

Nevertheless, in some cases, it is possible to stabilize the tuberculous process and achieve a positive therapeutic effect in the form of a decrease in the clinical manifestations of the disease, an improvement in the somatic condition of the patient, and even the onset of sputum abacillation and sanitation of the cavity. In such cases, most often the process is transformed into cirrhotic tuberculosis.

X-ray picture. With fibrous-cavernous tuberculosis, cavities, fibrous changes in the lung tissue and focal formations around the cavities and in other parts of the lungs are determined.

Caverns are usually irregular in shape, the outlines of the inner contour are sharper, the outer border is usually unclear and is lost in the adjacent fibrous zone.

Fibrotic changes in the lung tissue are characterized primarily by changes in the skeleton of the chest, which is due to wrinkling of the lung tissue and pleura. The shadows of the ribs are located asymmetrically, more obliquely on the side of the predominant lesion.

The intercostal spaces become narrower in the upper sections, where more often and, as a rule, more “old” pulmonary changes are located.

Fibrosis and wrinkling lead to changes in the position of the mediastinal organs. The shadow of the heart, trachea and bronchi is shifted towards fibrous-cavernous changes.

The root of the lung is deformed and pulled up towards fibrosis. The less affected side usually has limited or widespread fibrofocal changes; there may be fresh foci of bronchogenic seeding.

Due to the fact that with this form there is a tendency to periodic exacerbations, the former and newly appeared foci of bronchogenic seeding "merge" into infiltrates. Fresh decay cavities can have both rounded and irregular shapes; surrounded by a zone of inflammatory tissue adjacent to the cavity.

Diagnostics is carried out on the basis of a long history of the disease and a characteristic clinical and radiological picture of the disease, characteristic of the chronic course of a specific lung lesion.

Patients with fibrous-cavernous pulmonary tuberculosis, as a rule, are permanent bacterial excretors, which allows them to be classified as patients with open and epidemiologically dangerous tuberculosis.

Differential diagnosis carried out mainly with other chronic inflammatory destructive diseases of the lungs - chronic abscess, bronchiectasis, fungal infections.

Treatment carried out in a hospital of an anti-tuberculosis institution against the background of a hygienic-dietary regimen. Therapeutic and motor modes are determined by the patient's condition. Medical nutrition corresponds to diet No. 11.

Fibrous-cavernous pulmonary tuberculosis is classified as a chronic form of the disease, which includes patients who have been treated with anti-tuberculosis drugs for a long time and ineffectively.

Chemotherapy such patients are prescribed strictly individually in accordance with the MBT drug susceptibility data.

As a rule, in the presence of resistance to the main anti-TB drugs, treatment is carried out in accordance with the IV regimen of chemotherapy with a combination of reserve drugs, including kanamycin (capreomycin), prothionamide, cycloserine, PAS and fluoroquinolone. In this case, the main course of chemotherapy is carried out for at least 15-18 months.

Patients with fibrous-cavernous pulmonary tuberculosis require a full pathogenetic therapy aimed at correcting various body functions impaired under the influence of chronic tuberculosis intoxication. Patients are prescribed metabolic, immunomodulatory and hormonal therapy. In some cases, according to indications, surgical treatment is performed.

is not an independent disease. In most cases, it does not affect the quality of human life and does not affect the functionality of organs.

However, when issuing an x-ray report, patients think about pulmonary fibrosis: what is it, how to treat this disease, and what forecasts regarding its course and what outcome to expect.
Fibrosis is formed as a result of an inflammatory process in the lungs or exposure to negative factors (smoking, inhalation of toxic substances, radiation, etc.). Very often, pulmonary fibrosis is a consequence of tuberculosis.
Many patients fear that this may lead to a relapse. But in fact, their fears are in vain, since fibrosis is an ordinary connective tissue in which there are no bacteria.

Treatment of pulmonary fibrosis

Usually this condition goes unnoticed, but in some cases, fibrosis can grow and then complex treatment is necessary. It is important to understand that scar tissue does not dissolve and is not replaced by normal tissue. Therefore, all further measures will be aimed at stopping the process of fibrosis growth and improving the quality of human life.

Severe fibrosis can cause a decrease in the ability of the lung tissue to stretch and the loss of a normal level of elasticity. This can make it difficult for carbon dioxide and oxygen to pass through the walls of the alveoli. As a result, the patient suffers from a lack of oxygen and the breathing process is disturbed. In the early stages of the disease, a person may not feel any discomfort or complain of slight shortness of breath during physical exertion. As the disease progresses, symptoms such as coughing, chest pains appear, the patient often begins to get sick with bronchitis. This prompts a person to think about a relapse (with tuberculosis). For the diagnosis of pulmonary fibrosis, an X-ray of the chest is prescribed.

Complicated pulmonary fibrosis is accompanied by the following symptoms:

frequent shortness of breath;
possible weight loss;
wheezing when breathing;
chest discomfort;
dry cough with little sputum;
fast fatiguability.

Organization of a healthy lifestyle: a balanced diet, good rest with sleep from 7 to 9 hours.
Treatment of inflammatory processes in the lungs and bronchi, if any.
Administration of corticosteroid drugs.
Breathing exercises.
oxygen therapy.

Fibrosis after tuberculosis: how dangerous is that?

After tuberculosis, fibrosis is diagnosed in the vast majority of patients. Usually it affects a very small part of the lungs and does not cause concern on the part of doctors and patients themselves. It does not require any treatment. Surgical removal of the affected areas is recommended in severe cases, with an increase in the above symptoms and the growth of fibrosis. It is impossible to make a diagnosis based on the presence of scar tissue alone, so in the future no one will suspect that the patient has suffered tuberculosis.

Fibrous-cavernous pulmonary tuberculosis is a chronically occurring form of the disease, in which there is a formation of a cavity in the lungs and the growth of fibrous tissue around this neoplasm. According to statistics, a similar form of tuberculosis is observed in 10% of people suffering from this disease.

This form of the course of the disease is considered extremely dangerous, since during the development of cavities, too much healthy lung tissue can be converted into fibrous foci, which can lead to a violation of the respiratory process. Usually, the development of this form of tuberculosis is observed in patients who do not receive the necessary care and treatment and at the same time lead an asocial lifestyle that aggravates the course of the disease.

Etiology and pathogenesis of development of fibrous-cavernous tuberculosis

The main reason for the development of fibrous-cavernous pulmonary tuberculosis is the damage to the lung tissue of one of the varieties of mycobacteria that can cause the development of the disease in humans. It is far from always possible to determine by external signs whether a patient with tuberculosis with this form is contagious or not. In most cases, the spread of mycobacteria occurs during an exacerbation of the disease and the appearance of a severe cough, along with which pathogenic microorganisms can also spread. Since the exacerbation of this form of tuberculosis in most patients is observed constantly, but has short periods of remission, such people can be contagious.

irrational nutrition;
addiction to alcohol;
addiction;
reduced immunity;
increased physical activity;
hypothermia;
chronic lung diseases.

Fibrous-cavernous pulmonary tuberculosis is a kind of complication of the course of a milder form of the disease. The pathogenesis of the development of fibrous-cavernous pulmonary tuberculosis is currently fully understood. It is believed that after a certain time, infiltrated tuberculosis creates favorable conditions for the formation of a cavity. In addition, in some cases, a hematogenous disseminated form of tuberculosis can become a source of formation of cavities. As fibrotic processes develop in one or both lungs, the formation of one or more cavities may occur.

The cavity is a rather specific formation in the lung tissue. The walls of such a neoplasm have a complex structure, consisting of 3 main layers: fibrous, cavernous and granulation. A mature cavity has a very thick fibrous layer, so the density of the cavity is very similar to that of cartilaginous tissue. Around the cavity, there is an overgrowth of fibrous tissue, and in the vast majority of cases this occurs along the bronchi or blood vessels, which leads to compression of normal lung tissue and disruption of its functioning.

Considering that fibrous-cavernous pulmonary tuberculosis proceeds in a chronic form, the cavity of the cavity cannot be cleaned, respectively, favorable conditions are created for the development of necrotic processes, which often affect blood vessels. Thus, with this form of tuberculosis, the risk of developing pulmonary hemorrhages is extremely high. In addition, with fibrous-cavernous tuberculosis, other morphological changes in the lung tissue may also appear, for example, emphysema, bronchoecstasis, pneumosclerosis, etc.

Clinical picture in fibrous-cavernous tuberculosis

Symptoms of fibrous-cavernous pulmonary tuberculosis are extremely diverse. This form of tuberculosis can proceed according to 2 main scenarios: limited and progressive. A limited variant of the course of tuberculosis, as a rule, is observed against the background of successful chemotherapy. In this case, for several years, symptomatic manifestations indicating an exacerbation of the disease may be absent. The progressive form of the course of the disease, as a rule, is accompanied by frequent relapses of the acute course of the disease, and the periods of improvement over time are significantly reduced. The characteristic symptomatic manifestations of an exacerbation of a disease such as fibrous-cavernous pulmonary tuberculosis include:

increase in body temperature;
prolonged hacking cough;
wheezing;
asthma attacks;
significant loss of body weight;
increased sweating;
severe weakness;
hemoptysis.

As the disease progresses, as a rule, the patient's chest becomes barrel-shaped, there is a pronounced atrophy of the muscles of the back and intercostal group. One of the most dangerous complications of the course of this form of tuberculosis is extensive pulmonary bleeding, since in the absence of timely assistance, the patient can suffocate in the shortest possible time.

How is fibro-cavernous tuberculosis diagnosed?

Diagnosis of fibrous-cavernous pulmonary tuberculosis is currently not very difficult. Due to the fact that usually patients with this form of tuberculosis already had a previously diagnosed diagnosis confirming the defeat of the respiratory organs by mycobacteria, when a patient is treated, a pulmonologist should first of all take an anamnesis and percussion of the lungs. With fibrous-cavernous tuberculosis, a shortening of the sound is clearly audible in places of thickening due to the formation of cavities. In addition, with this variant of the course of tuberculosis, a shortening of the percussion sound may occur, which in the vast majority of cases is associated with the spread of an additional infection due to a decrease in local immunity of the tissues of the affected lung.

Despite the fact that listening to the lungs provides enough information to the pulmonologist about the nature of the existing damage in the lungs, additional studies are often required to clarify the clinical picture of the course of the disease. First of all, radiography is performed, which accurately determines the location of the cavities and the spread of fibrous tissue. A blood and sputum test is also performed, establishing the presence of additional pathogenic microflora and the phase of the development of the disease. If there are complaints from other authorities, additional tests may be prescribed.

Methods of treatment of fibrous-cavernous tuberculosis

Treatment of fibrous-cavernous pulmonary tuberculosis is a significant challenge. More recently, after confirming this form of the course of the disease, the life expectancy of patients did not exceed 2-3 years, since standard anti-tuberculosis therapy is not able to stop or at least slow down the process of formation of fibrosis foci.

Currently, the treatment of pulmonary tuberculosis occurring in this form is more effective and can significantly increase the life expectancy of patients. Since patients in the phase of exacerbation of the disease pose a danger to others, as they are contagious, treatment is carried out in a hospital in the infectious diseases department. Depending on the characteristics of the patient's condition, his motor mode is determined. In addition, a patient with fibro-cavernous tuberculosis requires diet No. 11.

Given that anti-tuberculosis drugs are ineffective in this form, chemotherapy is the main method of treatment. The chemotherapy scheme is selected for each patient individually, based on the available clinical manifestations and the general condition of the body. The combination of drugs used in chemotherapy usually includes:

Kanamycin.
Cycloserine.
PASK.
Protionamide.
Fluoroquinolone.

Fibrous-cavernous pulmonary tuberculosis requires a sufficiently long treatment. The main course of chemotherapy is about 15-18 months. The thing is that the cavities that form in the lung tissue heal very slowly, and if the treatment was interrupted, an exacerbation of the disease and a significant deterioration in the condition can be observed.

It is now known that if a patient has interrupted a course of chemotherapy, its resumption may no longer give the desired effect.

In the process of treatment, the therapy of concomitant deviations, which are the result of tuberculous intoxication, is also prescribed. Maintenance therapy involves the appointment of metabolite immunomodulatory and hormonal drugs. In addition, a long course of taking vitamins is required. If the healing of cavities against the background of ongoing chemotherapy is too slow, to improve the general condition, surgery may be prescribed, during which not only cavernous tissues are removed, but also foci of fibrosis. Such a reconstruction of the lungs is considered too radical a measure and is used only in very severe cases, when further progression of the disease can lead to the death of the patient. After improvement of the patient's condition, a course of physiotherapy is required. With complex treatment, the prognosis is quite favorable, but at the same time, the patient must follow all the recommendations of doctors in the future in order to prevent an exacerbation of the course of the disease.

Prevention of fibrous-cavernous tuberculosis

To prevent the development of such a disease as fibrous-cavernous pulmonary tuberculosis, it is very important to take measures aimed at timely detection and treatment of milder forms of the disease. Tuberculosis is now known to be a social disease. Most often, this disease affects people with low incomes and living in adverse conditions. Usually, the most active part of the population aged 25 to 30 years is infected, and often patients belonging to this age category do not seek medical help in a timely manner. Thus, in order to prevent the spread of tuberculosis and the development of its complications, all people at risk must:

timely preventive examinations;
undergo fluorography at least 2 times a year;
do not contact with carriers of an open form of tuberculosis;
lead an active lifestyle, including sports and proper nutrition;
engage in hardening of the body.

This video talks about the disease of tuberculosis and its prevention:

Despite the fact that preventive measures do not allow 100% to exclude the possibility of contracting tuberculosis, nevertheless, these measures help to detect the disease in a timely manner and carry out directed treatment of the disease, preventing its transition to more severe forms.