What causes pulmonary tuberculosis. What is tuberculosis and how is it treated? Digestive tract injury

Tuberculosis(from Latin tuberculum - tubercle, English tuberculosis, Greek Φυματίωση) - infection humans and animals (usually cattle, pigs, chickens) caused by several varieties of acid-resistant mycobacteria (genus Mycobacterium) (the obsolete name is Koch's wand). An obsolete name for pulmonary tuberculosis is consumption(from the word to wither), in ancient Russia called dry. For a person, the disease is socially dependent. Until the 20th century, tuberculosis was practically incurable. Pulmonary tuberculosis- an infectious disease characterized by the formation of foci of specific inflammation in the affected tissues and a pronounced general reaction of the body. In many economically developed countries, in particular in Russia, the incidence of tuberculosis and mortality from it have significantly decreased. These epidemiological shifts are most pronounced among children, adolescents and women, and to a lesser extent among men, especially the elderly. Nevertheless, tuberculosis remains a common disease. According to the WHO, about 2 billion people, one third of the total population of the Earth, are infected with tuberculosis. Currently, 9 million people around the world fall ill with tuberculosis every year, of which 3 million die from its complications. (According to other sources, every year 8 million fall ill with tuberculosis, and 2 million die.) In Ukraine in 1995, WHO declared an epidemic of tuberculosis. It is noted that the incidence of tuberculosis depends on adverse conditions (prisons), as well as on the individual characteristics of the human body (for example, on blood type). There are several factors that cause an increased susceptibility of a person to tuberculosis, AIDS has become one of the most significant in the world.

What provokes / Causes of pulmonary tuberculosis:

The causative agents of tuberculosis are mycobacteria - acid-fast bacteria of the genus Mycobacterium. A total of 74 species of such mycobacteria are known. They are widely distributed in soil, water, among people and animals. However, tuberculosis in humans causes a conditionally isolated M. tuberculosis complex, which includes Mycobacterium tuberculosis(human species), Mycobacterium bovis (bovine species), Mycobacterium africanum, Mycobacterium bovis BCG (BCG strain), Mycobacterium microti, Mycobacterium canetti. AT recent times it includes Mycobacterium pinnipedii, Mycobacterium caprae, phylogenetically related to Mycobacterium microti and Mycobacterium bovis. The main species characteristic of Mycobacterium tuberculosis (MBT) is pathogenicity, which manifests itself in virulence. Virulence can vary significantly depending on environmental factors and manifest itself differently depending on the state of the macroorganism that is subjected to bacterial aggression. Tuberculosis in humans most often occurs when infected with human and bovine species of the pathogen. M. bovis shedding occurs predominantly in residents countryside, where the transmission route is mainly alimentary. Avian tuberculosis is also noted, which occurs mainly in immunodeficient carriers. MBT belong to prokaryotes (in their cytoplasm there are no highly organized organelles of the Golgi apparatus, lysosomes). There are also no plasmids characteristic of some prokaryotes, which provide the dynamics of the genome for microorganisms. Shape - slightly curved or straight stick 1-10 µm × 0.2-0.6 µm. The ends are slightly rounded. They are usually long and thin, but bovine pathogens are thicker and shorter. MBT are immobile, do not form microspores and capsules. Differentiates in a bacterial cell: - microcapsule - a wall of 3-4 layers 200-250 nm thick, firmly connected to the cell wall, consists of polysaccharides, protects mycobacteria from environmental influences, does not have antigenic properties, but exhibits serological activity; - cell wall - limits the mycobacterium from the outside, ensures the stability of the size and shape of the cell, mechanical, osmotic and chemical protection, includes virulence factors - lipids, with the phosphatide fraction of which the virulence of mycobacteria is associated; - homogeneous bacterial cytoplasm; - cytoplasmic membrane - includes lipoprotein complexes, enzyme systems, forms an intracytoplasmic membrane system (mesosome); - nuclear substance - includes chromosomes and plasmids. Proteins (tuberculoproteins) are the main carriers of antigenic properties of MBT and show specificity in delayed-type hypersensitivity reactions. These proteins include tuberculin. The detection of antibodies in the blood serum of patients with tuberculosis is associated with polysaccharides. Lipid fractions contribute to the resistance of mycobacteria to acids and alkalis. Mycobacterium tuberculosis is an aerobe, Mycobacterium bovis and Mycobacterium africanum are aerophiles. In organs affected by tuberculosis (lungs, lymph nodes, skin, bones, kidneys, intestines, etc.), a specific "cold" tuberculosis inflammation develops, which is predominantly granulomatous in nature and leads to the formation of multiple tubercles with a tendency to disintegrate.

Pathogenesis (what happens?) During Pulmonary Tuberculosis:

Primary infection with mycobacterium tuberculosis and the latent course of tuberculosis infection. Primary human infection with MBT usually occurs by aerogenic route. Other routes of penetration - alimentary, contact and transplacental - are much less common. The respiratory system is protected from the penetration of mycobacteria by mucociliary clearance (secretion of mucus by the goblet cells of the respiratory tract, which sticks together the incoming mycobacteria, and further elimination of mycobacteria with the help of wave-like oscillations of the ciliated epithelium). Violation of mucociliary clearance in acute and chronic inflammation of the upper respiratory tract, trachea and large bronchi, as well as under the influence of toxic substances, makes it possible for mycobacteria to penetrate into the bronchioles and alveoli, after which the likelihood of infection and tuberculosis increases significantly. The possibility of infection by the alimentary route is due to the condition of the intestinal wall and its suction function.

Tuberculosis pathogens do not release any exotoxin that could stimulate phagocytosis. The possibilities of phagocytosis of mycobacteria at this stage are limited, so the presence in tissues a small amount The causative agent does not appear immediately. Mycobacteria are outside the cells and multiply slowly, and the tissues retain their normal structure for some time. This condition is called "latent microbiism". Regardless of the initial localization, they enter the regional lymph nodes with the lymph flow, after which they spread lymphogenously throughout the body - primary (obligate) mycobacteremia occurs. Mycobacteria linger in organs with the most developed microvasculature (lungs, lymph nodes, cortical layer of the kidneys, epiphyses and metaphyses of tubular bones, ampullar-fimbryonic sections of the fallopian tubes, uveal tract of the eye). Since the pathogen continues to multiply, and immunity has not yet been formed, the pathogen population increases significantly. However, in the place of accumulation of a large number of mycobacteria, phagocytosis begins. First, pathogens begin to phagocytize and destroy polynuclear leukocytes, but to no avail - they all die after coming into contact with MBT, due to a weak bactericidal potential. Then macrophages are connected to MBT phagocytosis. However, MBT synthesize ATP-positive protons, sulfates and virulence factors (cord factors), as a result of which the function of macrophage lysosomes is impaired. Formation of the phagolysosome becomes impossible, so the lysosomal enzymes of macrophages cannot act on the absorbed mycobacteria. MBT are located intracellularly, continue to grow, multiply and more and more damage the host cell. The macrophage gradually dies, and the mycobacteria re-enter the intercellular space. This process is called "incomplete phagocytosis".

Acquired cellular immunity The basis of acquired cellular immunity is the effective interaction of macrophages and lymphocytes. Of particular importance is the contact of macrophages with T-helpers (CD4+) and T-suppressors (CD8+). Macrophages that have absorbed MBT express mycobacterial antigens (in the form of peptides) on their surface and secrete interleukin-1 (IL-1) into the intercellular space, which activates T-lymphocytes (CD4+). In turn, T-helpers (CD4+) interact with macrophages and perceive information about the genetic structure of the pathogen. Sensitized T-lymphocytes (CD4+ and CD8+) secrete chemotaxins, gamma-interferon and interleukin-2 (IL-2), which activate the migration of macrophages towards the location of the MBT, increase the enzymatic and general bactericidal activity of macrophages. Activated macrophages intensively produce reactive oxygen species and hydrogen peroxide. This is the so-called oxygen explosion; it acts on the phagocytosed causative agent of tuberculosis. With the simultaneous action of L-arginine and tumor necrosis factor-alpha, nitric oxide NO is formed, which also has an antimicrobial effect. As a result of all these processes, the destructive effect of MBT on phagolysosomes weakens, and bacteria are destroyed by lysosomal enzymes. With an adequate immune response, each subsequent generation of macrophages becomes more and more immunocompetent. The mediators secreted by macrophages also activate B-lymphocytes responsible for the synthesis of immunoglobulins, but their accumulation in the blood does not affect the body's resistance to MBT. But the production of opsonizing antibodies by B-lymphocytes, which envelop mycobacteria and promote their adhesion, is useful for further phagocytosis.

An increase in the enzymatic activity of macrophages and the release of various mediators by them can lead to the appearance of delayed-type hypersensitivity cells (HRCT) to MBT antigens. Macrophages transform into Langhans epithelioid giant cells, which are involved in limiting the zone of inflammation. An exudative-productive and productive tuberculous granuloma is formed, the formation of which indicates a good immune response to infection and the body's ability to localize mycobacterial aggression. At the height of the granulomatous reaction in the granuloma are T-lymphocytes (predominate), B-lymphocytes, macrophages (carry out phagocytosis, perform affector and effector functions); macrophages gradually transform into epithelioid cells (perform pinocytosis, synthesize hydrolytic enzymes). In the center of the granuloma, a small area of ​​caseous necrosis may appear, which is formed from the bodies of macrophages that died upon contact with MBT. The PCRT reaction appears 2-3 weeks after infection, and a sufficiently pronounced cellular immunity is formed after 8 weeks. After this, the reproduction of mycobacteria slows down, their total number decreases, and the specific inflammatory reaction subsides. But the complete elimination of the pathogen from the focus of inflammation does not occur. The preserved MBT are localized intracellularly (L-forms) and prevent the formation of phagolysosomes, therefore, they are inaccessible to lysosomal enzymes. Such anti-tuberculosis immunity is called non-sterile. The remaining MBT in the body maintain a population of sensitized T-lymphocytes and provide a sufficient level of immunological activity. Thus, a person can keep MBT in his body for a long time and even all his life. When immunity is weakened, there is a threat of activation of the remaining MBT population and tuberculosis. Acquired immunity to MBT decreases with AIDS, diabetes, peptic ulcer, alcohol abuse and long-term drug use, as well as fasting, stressful situations, pregnancy, treatment with hormones or immunosuppressants. In general, the risk of developing tuberculosis in a newly infected person is about 8% in the first 2 years after infection, gradually decreasing in subsequent years.

Occurrence of clinically expressed tuberculosis In the case of insufficient activation of macrophages, phagocytosis is ineffective, MBT reproduction by macrophages is not controlled and therefore occurs exponentially. Phagocytic cells cannot cope with the volume of work and die en masse. At the same time, a large number of mediators and proteolytic enzymes enter the intercellular space, which damage adjacent tissues. There is a kind of “liquefaction” of tissues, a special nutrient medium is formed that promotes the growth and reproduction of extracellularly located MBT. A large population of MBT upsets the balance in immune defense: the number of T-suppressors (CD8+) is growing, the immunological activity of T-helpers (CD4+) is falling. At first, PCT to MBT antigens sharply increases, and then weakens.

The inflammatory response becomes widespread. The permeability of the vascular wall increases, plasma proteins, leukocytes and monocytes enter the tissues. Tuberculous granulomas are formed, in which caseous necrosis. The infiltration of the outer layer by polynuclear leukocytes, macrophages and lymphoid cells increases. Separate granulomas merge, the total volume of tuberculosis lesions increases. Primary infection is transformed into clinically expressed tuberculosis.

Symptoms of pulmonary tuberculosis:

Pulmonary tuberculosis may be asymptomatic or oligosymptomatic for a long time and be discovered incidentally during a fluorography or x-ray of the chest. The fact of seeding the body with tuberculous mycobacteria and the formation of specific immunological hyperreactivity can also be detected when tuberculin tests are performed. In cases where tuberculosis manifests itself clinically, usually the very first symptoms are non-specific manifestations of intoxication: weakness, pallor, fatigue, lethargy, apathy, sub febrile temperature(about 37 ° C, rarely above 38 °), sweating, especially disturbing the patient at night, weight loss.

Lymphadenopathy, generalized or limited to any group of lymph nodes, is often detected - an increase in the size of the lymph nodes. Sometimes it is possible to identify a specific lesion of the lymph nodes - "cold" inflammation.

In the blood of patients with tuberculosis or seeded with tuberculosis mycobacteria, a laboratory study often reveals anemia (a decrease in the number of red blood cells and hemoglobin content), moderate leukopenia (a decrease in the number of leukocytes). Some experts suggest that anemia and leukopenia in tuberculosis infection are a consequence of the effects of mycobacterium toxins on the bone marrow.

According to another point of view, everything is exactly the opposite - mycobacterium tuberculosis mainly "attacks" mainly weakened individuals - not necessarily suffering from clinically pronounced immunodeficiency states, but, as a rule, having slightly reduced immunity; not necessarily suffering from clinically pronounced anemia or leukopenia, but having these parameters near the lower limit of normal, etc. In this interpretation, anemia or leukopenia is not a direct consequence of a tuberculosis infection, but, on the contrary, a precondition for its occurrence and a pre-existing (premorbid) factor before the disease .

Further, in the course of the development of the disease, more or less obvious symptoms from the affected organ. With pulmonary tuberculosis, this is cough, sputum discharge, wheezing in the lungs, runny nose, sometimes difficulty breathing or chest pain (usually indicating the addition of tuberculous pleurisy), hemoptysis. In case of intestinal tuberculosis, these or those intestinal dysfunctions, constipation, diarrhea, blood in the feces, etc. As a rule (but not always), lung damage is primary, and other organs are affected secondarily by hematogenous seeding. But there are cases of the development of tuberculosis of the internal organs or tuberculous meningitis without any current clinical or radiological signs of lung damage and without a history of such damage.

Diagnosis of pulmonary tuberculosis:

Differential Diagnosis between tuberculosis and a number of other lung diseases, often requiring surgical treatment, presents significant difficulties. In addition, often certain pathological processes (cancer, bronchiectasis, persistent atelectasis of the lobe or the entire lung, etc.) develop against the background of tuberculosis, or the latter is even the direct cause of its development.

Laboratory methods for detecting Mycobacterium tuberculosis Laboratory diagnostics ensures the fulfillment of the main task of diagnosing and treating tuberculosis - the detection of MBT in a patient. AT laboratory diagnostics At the present stage, the following methods are included:

• collection and processing of sputum;
• microscopic identification of MBT in secreted substances or tissues;
• cultivation;
• determination of drug resistance;
• serological studies;
• use of new molecular biological methods, including polymerase chain reaction (PCR) and determination of restriction fragment length polyphimorphism (RFLP).

Collection of sputum containing MBT, is carried out in a specially prepared room of the hospital or on an outpatient basis. Collected samples should be sent immediately for microbiological examination. To do this, you need to use special containers. They must be strong, resistant to destruction, have a wide mouth with a hermetically screwed stopper to prevent accidental leakage of contents from it.

There are two types of containers. One - distributed by the international organization UNICEF (United Nations Children's Fund) - is a plastic test tube with a black base, a transparent cap, the disposal of which can be ensured by incineration. On the container (not on the lid), the data of the subject are marked. Another type of container is made of durable glass with a screw cap. Such a container can be reused after disinfection, boiling (10 min) and complete cleaning. When collecting samples, the risk of infection is very high, especially when the patient coughs up sputum. In this regard, the procedure must be carried out as far as possible from unauthorized persons and in a special room.

Additional procedures for MBT collection Taking samples from the larynx with a swab. The operator must wear a mask and a closed gown. The patient's tongue is pulled out of the mouth, at the same time a swab is inserted behind the tongue space closer to the larynx. During the patient's cough, some of the mucus can be collected. The swab is placed in a closed vessel and sent to the bacteriological laboratory.

Flushing water of the bronchi. For the timely diagnosis of tuberculosis of the lungs and other organs, early recognition of bronchial lesions is of great importance. For this purpose, the study of bronchial washings is used in practice. The technique for obtaining wash water is not complicated, but one must remember about contraindications to its use. For older people, bronchial lavage should be done with great care. The procedure is contraindicated in bronchial asthma and symptoms cardiopulmonary insufficiency. To obtain washing water of the bronchi, the patient is anesthetized by the respiratory tract. 15-20 ml of saline, heated to 37 ° C, is injected with a throat syringe. This enhances the secretion of the bronchial mucosa. Coughing up, the patient secretes washings. a separate bronchus or a whole branch.The method of bacterioscopy of washing waters and especially their inoculation contributes to an increase in the number of MBT findings by 11-20%.

Wash water of the stomach. Gastric lavage is often examined in children who do not know how to cough up sputum, as well as in adults with a meager amount of sputum. The method is not difficult and gives a fairly large percentage of MBT detection in gastric lavage in patients with not only pulmonary tuberculosis, but also tuberculosis of other organs (skin, bones, joints, etc.). To receive washing water, the patient should drink a glass of boiled water in the morning on an empty stomach. Then the gastric tube collects the water of the stomach in a sterile dish. After that, the water is centrifuged, a smear is made from the purulent elements of the resulting sediment, processed and stained in the usual way, like sputum.

Study cerebrospinal fluid. If you suspect tuberculous meningitis it is necessary in the first days to do an analysis of the cerebrospinal fluid. When taking cerebrospinal fluid, attention is paid to the degree of pressure under which it flows out of the spinal canal. Liquid flowing out in a continuous stream and under high pressure indicates an increased intracranial pressure. A liquid released in large, frequent drops indicates normal pressure, and rare small drops indicate a reduced pressure or an obstacle to its outflow. Material for research is taken in two sterile test tubes. One is left in the cold, and after 12-24 hours a delicate cobweb-like film forms in it. CSF is taken from another tube for biochemical studies and the study of the cytogram.

Bronchoscopy. In the event that other methods failed to provide a diagnosis, material is collected directly from the bronchi, through a bronchoscope. A biopsy of the tissues lining the bronchi can sometimes contain changes typical of tuberculosis, detected by histological examination.

Pleural fluid. In the pleural fluid, MBT can be detected by flotation, but are usually found only in culture. How large quantity fluid is used for culture, the more likely a positive result is.

Biopsy of the pleura. Pleural biopsy may be useful in cases where there is a pleural effusion. It requires trained personnel, tools for histological examination, a special biopsy needle.

Lung biopsy. A lung biopsy should be performed by a surgeon in a hospital setting. The diagnosis can be made on the basis of histological examination or the detection of MBT in sectional material.

Sputum microscopy. For more than 100 years, there has been the simplest and most fast method detection of acid-resistant mycobacteria (AFB) - smear microscopy. CUBE are mycobacteria capable of remaining colored even after treatment with acidic solutions. They can be identified using a microscope in stained sputum samples. Mycobacteria differ from other microorganisms in the characteristic composition of their cell wall, which is composed of mycolic acids. Acids, due to their sorption properties, provide the ability to be stained according to methods that detect AFB. Resistance to standard methods staining and the ability of MBT to maintain early staining is a consequence of the high lipid content in the outer membrane of the cell. In general, gram-positive bacteria in their composition have approximately 5% lipids or wax, gram-negative organisms - about 20% and MBT - about 60%. Bacterioscopy of sputum or other discharge is carried out by the "simple" method and the flotation method. With a simple method, smears are prepared from sputum lumps or drops of a liquid substance (exudate, wash water, etc.). The material is placed between two glass slides. One of the smears is stained by Gram for general flora, the other - for tuberculosis mycobacteria. The main staining method is carbolic magenta (Ziehl-Neelsen method). The main principle of this method is the ability outer shell MBT adsorb carbol fuchsin. Absorbing red carbolic fuchsin, the outer membrane of the MBT binds the paint so strongly that it cannot be removed by treatment with sulfuric acid or hydrochloric alcohol. The sample is then treated with methylene blue. Emersion microscopy shows MBTs as red rods on a blue background. Since 1989, in modern laboratories, fluorescence microscopy has largely replaced the old methods based on the acid resistance of mycobacteria. This method is based on the same properties of MBT associated with the ability of the lipid-rich outer membrane of MBT to retain the corresponding dye, in this case, auramine-rhodamine. MBT, absorbing this substance, are simultaneously resistant to discoloration with hydrochloric alcohol. At the same time, MBTs stained with auramine-rhodamine fluoresce under the influence of ultraviolet or other light spectra isolated by appropriate filters. Under the influence of ultraviolet light, MBT appear as bright yellow sticks on a black background.

Genetic methods for diagnosing MBT. Deciphering the MBT genome has opened up unlimited prospects for the development of genetic and molecular tests, including the study and detection of MBT and diagnostics in the human body. The classical methods used to detect Mycobacterium tuberculosis in the body, such as bacterioscopy, culture, enzyme immunoassay, cytology, are very effective, but differ either in insufficient sensitivity or in the duration of MBT detection. The development and improvement of molecular diagnostic methods has opened up new prospects for the rapid detection of mycobacteria in clinical samples.

The most widespread polymerase chain reaction (PCR) method. This method is based on the amplification of specific fragments of bacillary DNA found in diagnostic samples. The test is designed to detect MBT in sputum or to identify the variety of bacteria that grow in the culture medium. The PCR reaction allows identification of the MBT in the diagnostic material in 5-6 hours (including processing of the material) and has high specificity and sensitivity (in the range of 1-10 cells per sample).

Serological methods studies of blood plasma components in tuberculosis were developed throughout the 20th century. Of particular interest to researchers has been the use of serological methods in the study of extrapulmonary forms of tuberculosis. However, unlike many infectious diseases for which serodiagnosis has proved to be an effective tool, for tuberculosis this type of test has not reached a sufficient level of sensitivity and specificity, which would determine the validity of its use in clinical practice. The results of many TB serodiagnosis studies indicate a variety of antigens potentially relevant to TB, as well as a variety of immune responses associated with different clinical forms of TB (with pulmonary degradation, without pulmonary degradation, and extrapulmonary). Recently, scientific research has focused on the study of the following antigens associated with tuberculosis: - an antigen from 38 Kilodaltons; - antigen 5; - A60 antigen; - antigen 88 Kilodaltons; - multi-antigen test. The use of nephelometry and turbidimetry methods makes it possible to increase the sensitivity and specificity of the study of individual proteins, with the direct participation of which almost all physiological and pathophysiological reactions occur in the body. According to the nature of their functions and a number of individual properties, these proteins can be conventionally divided into several groups. 1. Proteins associated with the immune response; IgG, IgA, IgM, C3, C4 are complement components. 2. Reactant proteins of the acute phase of inflammation: C-reactive protein, alpha 1 - acid glycoprotein, alpha 1 - antitrypsin. 3. Transport proteins: albumin, haptoglobin, macroglobulin, ceruloplasmin. 4. Proteins that enter the body mainly in the process of nutrition: transferrin, ferritin, prealbumin. Thus, while these methods do not allow to significantly increase the diagnostic and economic ability traditional methods detection of tuberculosis (microscopy of MBT and cultural methods for detecting MBT). However, as a result of rapid progress in the development of complex molecular biological methods, a new, effective and cheap serological test for the detection of tuberculosis will undoubtedly be created soon.

X-ray methods for diagnosing tuberculosis. In the diagnosis of pulmonary tuberculosis, the following X-ray methods of examination are most often used: 1) fluoroscopy; 2) radiography; 3) tomography; 4) fluorography.

Endoscopic methods for diagnosing tuberculosis

Tracheobronchoscopy. Inspection of the bronchi is carried out in combination with an examination of the trachea. For bronchoscopy, a rigid (metal) or flexible bronchoscope with fiberglass optics (bronchofiberscope) is used. When examining the bronchi, the condition and bleeding of the mucous membrane, the nature of the bronchial contents, the diameter of the lumen of the bronchi, the elasticity, tone and mobility of the bronchial wall are assessed. Other deviations from the norm are also recorded. Photograph the endoscopic picture. The study is completed, if necessary, with the collection of material for bacteriological and pathomorphological studies.

bronchoscopic lavage. The collection of lavage fluid during bronchoscopy makes it possible to obtain material for histological verification of the diagnosis of tuberculosis with negative bacteriological data. Sometimes MBT can be isolated from the lavage fluid, which cannot be detected by other methods.

Thoracoscopy (pleuroscopy). The study consists of examining pleural cavity thoracoscope. Other optical devices can also be used, for example, a bronchofibroscope.

Transbronchial biopsy A direct indication for its implementation is the presence of pathology in the main, lobar, segmental or subsegmental bronchi. Various techniques are used for biopsy: biting with forceps (forcep biopsy), scraping with a curette, brush (sponge or brush biopsy), pressing with a foam rubber sponge (sponge or sponge biopsy), puncture, aspiration.

Transthoracic needle biopsy. It is used to obtain: - material for histological and cytological studies of pleura and lung tissues; - biopsy of the lung, pleura or lymph nodes by opening the chest cavity.

Pleural puncture and puncture biopsy of the pleura. The method of aspiration biopsy (needle puncture) can remove material from the pleura and pleural fluid. From the fluid obtained by pleural puncture, samples are taken into sterile test tubes for laboratory research. Determine relative density fluids, cellular composition, etc. Needle biopsy pleura produce a special needle under the control of fluoroscopy. Usually, two biopsy specimens of the pleura are obtained, which are examined histologically and for the presence of MBT.

Treatment of pulmonary tuberculosis:

Treatment of pulmonary tuberculosis should be continuous and must be carried out simultaneously with several anti-tuberculosis drugs. Each of the 4-5 drugs that the patient takes daily for 6 months has a different effect on Koch's sticks, and only their combined use can achieve the goal - to completely destroy it. For a qualitative cure, anti-tuberculosis drugs alone are not enough. Patients are also prescribed physiotherapy, breathing exercises and drugs that boost immunity.

Surgical treatment of pulmonary tuberculosis

A large number of patients with various forms of pulmonary tuberculosis are shown surgical intervention - the removal of the affected part of the lung. Indications for lung resection for tuberculosis can be summarized in the following groups: 1. The presence of open caverns - with the release of sputum containing bacteria, with failure drug treatment within 3-6 months, - life-threatening bleeding from cavities, - persistent or repeated hemoptysis, - thick-walled cavities formed from cavities, in which scarring of the cavity is impossible, there is always a threat of infection and relapse, - reactivation of the process. 2. Presence of significant residual focal processes without bacteriocarrier Anti-tuberculosis drugs do not penetrate into these foci through fibrous tissue and do not ensure their sterilization. 3. Cicatricial strictures of the bronchi after tuberculous lesions. 4. The presence of foci of infection caused by atypical acid-fast bacilli, since in such patients the infection is resistant to medicines. 5. Complication focal lesion pleural empyema and lung collapse. 6. Suspicion of the development of neoplasms against the background of tuberculosis. Surgical treatment usually needs to be combined with intensive anti-tuberculosis drug therapy. Improper treatment turns an easily curable form of the disease into difficult to treat drug-resistant tuberculosis. If left untreated, the mortality rate from active tuberculosis reaches 50% within one to two years. In the remaining 50% of cases, untreated tuberculosis becomes chronic. Tuberculosis treatment is a complex matter that requires a lot of time and patience, as well as an integrated approach. The basis of the treatment of tuberculosis today is multicomponent anti-tuberculosis chemotherapy.(J04 Anti-tuberculosis drugs).

Three-component treatment regimen

At the dawn of anti-tuberculosis chemotherapy, a three-component first-line therapy regimen was developed and proposed: - streptomycin - isoniazid - para-aminosalicylic acid (PAS). This scheme has become a classic. She reigned in phthisiology for many decades and allowed to save the lives of a huge number of patients with tuberculosis.

Four-component treatment regimen

At the same time, due to the increase in the resistance of mycobacteria isolated from sick strains, it became necessary to strengthen the regimens of anti-tuberculosis chemotherapy. As a result, a four-component first-line chemotherapy regimen was developed (DOTS - a strategy used when infected with sufficiently sensitive strains): - rifabutin or rifampicin - streptomycin or kanamycin - isoniazid or ftivazid - pyrazinamide or ethionamide This scheme was developed by Karel Stiblo (Netherlands) in 1980- x years. To date, the treatment system of the so-called. first-line drugs (including isoniazid, rifampicin, streptomycin, pyrazinamide, and ethambutol) is widely accepted in 120 countries, including developed countries. In some post-Soviet countries(Russia, Ukraine), a number of experts consider this scheme to be insufficiently effective and significantly inferior in terms of the level of the comprehensive anti-tuberculosis strategy developed and implemented in the USSR, based on a developed network of anti-tuberculosis dispensaries.

Five-component treatment regimen

Many centers specializing in the treatment of tuberculosis today prefer to use an even more powerful five-component regimen, adding a fluoroquinolone derivative, for example, ciprofloxacin, to the four-component regimen mentioned above. The inclusion of drugs of the second, third and higher generation is the main one in the treatment of drug-resistant forms of tuberculosis. The treatment regimen with second and higher generation drugs implies at least 20 months of daily medication. This mode much more expensive than first-line treatment, at the equivalent of about US$25,000 for the entire course. A significant limiting point is also the presence of a huge number of various side effects from the use of drugs of the second and higher generation. If, despite the 4-5-component chemotherapy regimen, mycobacteria still develop resistance to one or more of the chemotherapy drugs used, then second-line chemotherapy drugs are used: cycloserine, capreomycin, etc. In addition to chemotherapy, much attention should be paid to intensive, high-quality and varied nutrition of patients tuberculosis, weight gain with reduced weight, correction of hypovitaminosis, anemia, leukopenia (stimulation of erythro- and leukopoiesis). People with tuberculosis, alcoholism or drug addiction must undergo detoxification before starting anti-tuberculosis chemotherapy. Patients with tuberculosis who receive immunosuppressive drugs for any indication are trying to reduce their doses or completely cancel them, reduce the degree of immunosuppression, if the clinical situation for the disease that requires immunosuppressive therapy allows. Patients with HIV infection and tuberculosis are shown specific anti-HIV therapy in parallel with anti-tuberculosis.

Glucocorticoids in the treatment of tuberculosis, they are used very limitedly due to their strong immunosuppressive effect. The main indications for the appointment of glucocorticoids are severe, acute inflammation, severe intoxication, etc. At the same time, glucocorticoids are prescribed for enough short term, in minimal doses and only against the background of powerful (5-component) chemotherapy. Spa treatment also plays a very important role in the treatment of tuberculosis. It has long been known that Mycobacterium tuberculosis does not like good oxygenation and prefers to settle in the relatively poorly oxygenated apical segments of the lobes of the lungs. Improved lung oxygenation observed with intensified breathing in rarefied air mountain resorts, promotes inhibition of growth and reproduction of mycobacteria. For the same purpose (creating a state of hyperoxygenation in places where mycobacteria accumulate), hyperbaric oxygenation is sometimes used, etc. Surgical methods of treating tuberculosis also retain their importance: in advanced cases, it may be useful to apply an artificial pneumothorax, remove the affected lung or its lobe, drain the cavity, empyema pleura, etc. However, the unconditional and most important effective means is chemotherapy - therapy with anti-tuberculosis drugs that guarantee bacteriostatic, bacteriolytic effects, without which it is impossible to achieve a cure for tuberculosis.

Complementary Therapies

At the beginning of the 21st century, a new method of treatment used in conjunction with chemotherapy was developed and put into practice in Russia - valvular bronchoblocking. This method is effective in a number of cases of complicated tuberculosis, including: multidrug resistance, bleeding, etc.

Bronchoblock method especially effective in cases where the cavity has thick walls, does not decrease during treatment, or the dynamics of reduction is insufficient. Previously, in such cases, the only treatment option was lung surgery. With the advent of the method of bronchoblocking, it became possible to completely cure such cavities with less traumatic medical intervention for the patient.

Valve bronchoplasty method has not yet received wide distribution due to the rather complex technique and the need for specialized equipment and materials. In addition, the use of the method significantly increases the frequency of purulent-septic complications and does not lead to an effective stop of bleeding in all cases. This method is auxiliary, since it cannot fully replace surgical treatment and is ineffective in the absence of chemotherapy.

Prevention of pulmonary tuberculosis:

Tuberculosis is one of the so-called social diseases, the occurrence of which is associated with the living conditions of the population. The reasons for the epidemiological troubles for tuberculosis in our country are the deterioration of socio-economic conditions, the decline in the living standards of the population, the increase in the number of people without a fixed place of residence and occupation, and the intensification of migration processes. Men in all regions suffer from tuberculosis 3.2 times more often than women, while the incidence rate in men is 2.5 times higher than in women. The most affected are persons aged 20-29 and 30-39 years. The morbidity of contingents serving sentences in institutions for the execution of sentences of the system of the Ministry of Internal Affairs of Russia is 42 times higher than the average Russian indicator.

In order to prevent it is necessary to carry out the following measures:- carrying out preventive and anti-epidemic measures adequate to the current extremely unfavorable epidemiological situation in tuberculosis. - early detection of patients and allocation of funds for drug provision. This measure can also reduce the incidence of people who come into contact with patients in the outbreaks. - carrying out mandatory preliminary and periodic examinations upon admission to work in livestock farms that are unfavorable for tuberculosis in cattle. - an increase in the isolated living space allocated to patients suffering from active tuberculosis and living in multi-occupied apartments and hostels. - timely conduct (up to 30 days of life) primary vaccination of newborns.

Which doctors should you contact if you have pulmonary tuberculosis:

Phthisiatrician

Pulmonologist

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Other diseases from the group Respiratory diseases:

Every third inhabitant of the planet is a carrier of the bacterium that causes tuberculosis. Approximately 10% of carriers of the disease become ill. Tuberculosis is the second leading cause of death after AIDS.

Tuberculosis: what is it?

The name of the disease latin word"tubercle" - tuberculum. Painful granulomas - sites of lung damage - look like tubercles.
The disease is caused by numerous bacteria of the species Mycobacterium tuberculosis complex.

In more than 90% of cases, the bacterium affects the lungs. Rare 8-9% are affected by the organs of the lymphatic, nervous and genitourinary systems, bones, skin or the whole body (miliary form of the disease).

When the pathogen enters the body, a small granuloma forms in the lungs. healthy body With good immunity he copes with the disease himself, the granuloma heals after symptoms similar to SARS and overwork. It is possible to detect a healed granuloma only later - through an X-ray examination.

The body, weakened by disease, stress, diet or overwork, is not able to give an adequate immune response to the invasion of Mycobacterium tuberculosis.

The granuloma begins to grow, forming a cavity inside itself - a cavity - filled with blood. From the cavity, blood inhabited by pathogenic bacteria enters the general circulation and creates new granulomas. The body can still cope with one granuloma, but as soon as there are several of them, without medical help, the person will soon die.

Cavities grow in the lungs, close cavities merge and form large cavities filled with disease-causing fluids. In the chest cavity, fluid appears between the lungs and the sternum. Sick active form tuberculosis is highly contagious.

Patients who fall ill with active tuberculosis for the second time die in 30% of cases, despite treatment.

Tuberculosis: when did it appear

The ill-fated disease has haunted mankind almost from the appearance of the species. Archaeologists have unearthed 3,000-year-old skeletons containing bone lesions consistent with tuberculosis.

Fatal consumption in Russia - what kind of disease? This was the name of pulmonary tuberculosis, which for many centuries was a death sentence for the patient. They tried to treat consumption in Russia back in the 11th century by cutting out and cauterizing tuberculous cavities in the lungs.

In ancient Greece, the disease was called phtisis - exhaustion. From the Greek name of the disease comes the name "phthisiology" - a branch of medicine that deals with the treatment and prevention of tuberculosis.

Even ancient healers, including Hippocrates and Avicenna, tried to fight the disease. We can say that the struggle of doctors with tuberculosis lasted for thousands of years. Tuberculosis was defeated only in the 20th century, when antibiotics came to the aid of doctors - the only drugs that can fight Mycobacterium tuberculosis.

Tuberculosis: how does infection occur

98% of infections occur by airborne droplets.

A patient with an active form of tuberculosis, when coughing, sneezing, releases bacteria and can infect up to 15 people a year. Also, the causative agents of the disease are excreted with sweat, urine, saliva and other physiological fluids of the patient.

Science has more than 70 types of mycobacteria - the causative agents of tuberculosis. Mycobacteria live everywhere: in soil, water, air, in the bodies of birds, animals and people.
In addition, the tubercle bacillus can break into tiny particles or cling to a huge octopus, while retaining its dangerous properties.

Mycobacteria are amazingly viable in all conditions. They live in street dust for 10 days, on the pages of books - 3 months, in water - 5 months.

Dried bacteria caused disease in six months guinea pig. Frozen bacteria are dangerous even after 30 years!

The most favorable environment for mycobacteria: moist warm environment with a temperature of 29-42 °C. At a temperature of 37-38 ° C, mycobacteria multiply intensively, so the human body is an ideal habitat for tubercle bacilli.

Tuberculosis bacillus is constantly evolving and adapting to conditions environment. Mycobacteria adapt to medicines, therefore, new stronger drugs have to be developed to fight the disease.

There are cases when the patient abandoned the treatment he had begun - in this case, the tubercle bacillus in the body became resistant to drugs, and it became impossible to cure the patient.

Tuberculosis: the first symptoms

Tuberculosis is easily diagnosed with simple medical tests. Regular examination has saved the lives of millions of people, because the earlier treatment is started, the more favorable the prognosis.

How does tuberculosis manifest itself?

• Dry cough - more than 2 weeks.
• Weight loss.
• Sweating during sleep. In addition, sleep becomes restless.
• Loss of appetite.
• Constant subfebrile temperature 37-37.5 °C.
• Chronic weakness, fatigue.

As the disease progresses, secondary symptoms of the disease appear.

• The cough becomes excruciating, with the release of a large amount of sputum. After an attack, the patient feels a temporary improvement. One of the tell-tale signs of TB is bloody sputum, or just the discharge of blood from the throat when coughing.
• There is pain in the chest, especially when taking a deep breath.
• Under the skin, more in the region of the legs, nodules of a reddish-brown hue appear, painful when touched.

Tuberculosis: diagnosis

There are simple medical tests to diagnose TB.

Mantoux test

Tuberculin solution inoculation is injected under the skin of a child older than 1 year or a teenager. After 3 days, a reddish spot appears at the vaccination site, which is used to judge the adequacy of the body's immune response to the pathogen. With a normal reaction of the body, the spot takes on sizes of 5-15 mm.

Fluorography

under the weak x-rays taking a chest x-ray. It clearly reflects all tuberculous granulomas.

Radiography

It is carried out to study the existing foci of tuberculosis.

Sputum examination

The patient may require a sputum test for the presence of tuberculous mycobacteria if he has been coughing for a long time.

ELISA blood test

Allows you to determine the presence of the causative agent of the disease in the body. The analysis is relevant for the detection of extrapulmonary forms of tuberculosis.

Tuberculosis: treatment

Tuberculosis treatment is carried out only permanently under the supervision of a phthisiatrician.

The standard course of treatment lasts six months - during this period the body, supported by intensive treatment completely free from the disease.

For the period of treatment, a person completely drops out of active life, since the treatment is very intensive.

The main treatment is antibacterial, aimed at the destruction of tuberculosis mycobacteria that affected the body.

Tuberculosis: extrapulmonary forms

Such forms of tuberculosis are extremely rare, they are treated according to the same schemes as pulmonary tuberculosis.

Damage to the urinary organs

Diagnosed by urinalysis. The main symptom is the cloudy color of urine and the presence of blood in it. Urination is frequent and painful. Women are bleeding aching pain lower abdomen. For men - painful bloating in the scrotum.

Damage to joints and bones

This form of the disease is characteristic of HIV-infected people. Tuberculosis bacillus affects the knees, spine and hip joints. The result is lameness, sometimes a hump.

Damage to the central nervous system

It occurs in HIV-infected and infants with a congenital form of tuberculosis. Mycobacterium infects the lining of the brain. Symptoms: severe headaches, fainting, convulsions, impaired hearing and vision. The disease is practically incurable.

miliary lesion

Microgranulomas - up to 2 mm in diameter - are scattered throughout the body. The inflammatory process occurs in addition to the lungs in the kidneys, liver and spleen and requires long-term treatment.

Digestive tract injury

This form tuberculosis is characteristic of HIV-infected people. The abdomen swells, pain, diarrhea and constipation appear, with stool blood is released. Apart from conventional treatment often requires surgery.

Skin lesion

The entire body of the patient is covered with subcutaneous dense painful nodules. They break through when pressed, white curdled contents are released from them.

A simple medical examination can detect tuberculosis in the early stages of lung damage, when it can be cured relatively easily. This is especially important for children, debilitated and elderly people whose body can hardly cope with the disease.

Tuberculosis is the most dangerous disease known for a long time. Despite numerous advances in medicine, it is still not possible to prevent the development of the disease and defeat it.

What causes tuberculosis is difficult to say. Several million people die from it every year. The pathology is infectious, the symptoms of its appearance and provoking factors, we will consider below.

Only a doctor can answer where tuberculosis comes from. The causative agent of the disease is Koch's wand.

Other mycobacteria can also provoke pathology:

1. Tuberculosis humanus are the most common bacteria. Examination often reveals this type.
2. tuberculosis africanus- found in African countries.
3. Tuberculosis microti- occurs in humans only in extreme cases. The carriers are rodents.
4. Tuberculosis bovines- the most dangerous form diseases, the BCG vaccine was created for it.

After the multiplication of microbacteria, an immune reaction occurs. Under favorable conditions, bacteria can live up to six months.

Important! Duration incubation period can be up to many years, while the person does not suspect that he is carrying a serious illness.

Ways of transmission of tuberculosis

It is important not only to know what causes tuberculosis, but also how it is transmitted.

There are several ways to do this:

Unfortunately, TB is easy to get. According to public health data, about two billion people have TB. The video in this article talks about exactly how the disease develops.

The first symptoms of tuberculosis

At the first stage of development, it is difficult to differentiate tuberculosis from acute respiratory infections or other diseases. A person feels weakened, overwhelmed, he is constantly sleepy.

Appetite disappears, mood disappears, even minor stress can cause a violent reaction. The body temperature is kept at around 37 - 38 degrees, the cough is paroxysmal, at night and in the morning it worries especially much. The first symptoms may appear both together and separately.

Symptoms progress as follows:

1. Appearance changes- the face of a sick person becomes haggard, the complexion is pale. Shine in the eyes indicates poor health. The patient is rapidly losing weight, at the first stage of the disease the symptoms are not very noticeable, but in chronic tuberculosis they are constantly disturbing. Diagnosis at this stage is easy.
2. Temperature. This is another sign of tuberculosis - the temperature lasts for a month, in addition to it, there may not be any symptoms. A person often sweats, but even this does not help bring down the temperature, as the infection constantly leads to a fever. At a late stage of the development of the disease, the temperature becomes febrile, that is, the mark on the thermometer is 39 and above.
3. Cough- the patient almost constantly coughs, initially it is dry, after which it develops into a paroxysmal. After some time it becomes wet, the patient at this moment experiences significant relief. Important! A cough that does not go away for three or more weeks is a reason to visit a phthisiatrician.
4. Hemoptysis- a dangerous symptom, indicates the development of an infiltrative form of tuberculosis. To make a definitive diagnosis, it is necessary to differentiate the disease from heart failure and malignant tumor, since these pathologies also cause hemoptysis. With tuberculosis, blood is released after coughing, in rare cases it can pour out in a "fountain", which indicates a rupture of the cavity. To save the life of a sick person is required immediate help specialists.
5. Chest pain- this is rare symptom. The symptom often occurs in the chronic or acute stage.

The photo below is an example of what a sick person looks like with the development of tuberculosis.

Can the disease be cured?

Tuberculosis is a pathology that requires a long and difficult treatment, it depends on the stage of development and other nuances.

Therapy may include the following:

• chemotherapy;
• taking medications;
• surgical intervention;
• rest in sanatoriums.

The first and foremost goal of treatment is to stop inflammatory process, this will avoid further destruction of tissues, the infiltrate will resolve, mycobacteria will no longer be excreted from the body of a sick person to the outside. In other words, doctors will do everything possible to ensure that the patient is not contagious to others. Such treatment takes about six months.

The next treatment regimen is a three-component one. Antibiotics are prescribed: Isoniazid, Streptomycin. There are also complementary therapy, which includes the following:

1. Immunostimulants - the body of a sick person will be able to overcome tuberculosis mycobacteria.
2. Sorbents - prescribed for the abolition of chemotherapy.
3. Vitamin complexes.
4. Glucocorticoids are the most extreme measure in treatment, helping to eliminate the inflammatory process.

Instructions for taking medications are indicated by the doctor, the course of treatment is different for each patient. In advanced cases, surgery may be required.

The following methods are currently used:

1. Speleotomy - resection of large cavities occurs, conservative methods treatment in this case is ineffective.
2. Valved bronchoblocking - they put small valves, so that the mouths of the bronchi do not stick together, this provides the patient with full breathing.

In order to prevent the development of such an ailment, you need to know what causes pulmonary tuberculosis. With timely treatment, the prognosis is favorable.

Tuberculosis is an infectious disease caused by different types of mycobacteria (the most common is Koch's bacillus). The disease usually affects lung tissue, rarely affecting other organs. Mycobacterium tuberculosis is transmitted by airborne droplets when the patient coughs, sneezes and talks. After infection with tuberculosis, the disease often proceeds in a latent form (tuberculosis), but sometimes it becomes active.

The causative agent is Mycobacterium tuberculosis. Tuberculosis in humans can be caused by Mycobacterium tuberculosis, Mycobacterium bovis, Mycobacterium africanum, Mycobacterium bovis BCG, Mycobacterium microti, Mycobacterium canettii, Mycobacterium caprae, Mycobacterium pinnipedii. There are such ways of transmission of tuberculosis infection:

• Airborne (most common): Bacteria are released into the air when a person with active illness coughs, sneezes, or talks. The infection enters the lungs of a healthy person.
• Alimentary: penetration of bacteria with food.
• Contact: with direct contact. Usually infection occurs through the mucous membrane.
• Intrauterine infection: the possibility of infection of the fetus in utero has been established.

Types of disease: classification of tuberculosis

There are pulmonary and non-pulmonary forms of tuberculosis. Phases of the tuberculous process: infiltration, decay, seeding; resorption, compaction, scarring, calcification.

More than 90% of cases account for the pulmonary form of tuberculosis. It is also possible to lose urinary organs, brain, bones, intestines and other organs.

Depending on whether a person fell ill with tuberculosis for the first time or not, primary and secondary tuberculosis are distinguished.

• primary tuberculosis is acute form a disease that begins to manifest itself after the pathogen enters the bloodstream. Often, primary tuberculosis occurs in children under 5 years of age. This is because the immune system is not yet fully formed in children, which is not able to cope with mycobacteria. Although the disease is given period is difficult, it is not dangerous to others. At the beginning, with primary tuberculosis, a small granuloma forms in the lungs. This is the primary lesion of the lungs, which, in the event of a favorable outcome, can heal itself. So, the patient may not suspect that he actually had tuberculosis, attributing his well-being to a cold. However, after another x-ray, it turns out that he has a healed granuloma in his lungs. The development of a bad scenario involves an increase in the granuloma with the formation of a cavity in which tubercle bacilli accumulate. Mycobacteria are released into the blood, where they are carried throughout the body.
• secondary tuberculosis. This form of the disease occurs when a person has already had tuberculosis once, but he became infected with another type of mycobacteria. Or secondary tuberculosis can proceed in the form of an exacerbation of the remission of the disease. Secondary tuberculosis is much more severe than primary. New lesions form in the lungs. In some cases, they are located very close to each other, which merge, forming extensive cavities. Approximately 30% of patients with secondary tuberculosis die within 2-3 months after the onset of the disease.

Symptoms of tuberculosis: how the disease manifests itself

At the beginning of the disease, tuberculosis is quite difficult to distinguish from ordinary acute respiratory infections. The patient has constant weakness and "brokenness". In the evening, there is a slight chill, and sleep is accompanied by sweating, and sometimes nightmares.

Body temperature in the initial stage of tuberculosis is kept at 37.5 - 38 degrees. The patient has a dry cough that worsens in the morning. Note that all of the above symptoms may appear simultaneously or all together.

And now let's take a closer look at the main symptoms of tuberculosis:

• Change in appearance. In tuberculosis, the face becomes pale and haggard. The cheeks seem to sink, and the facial features are sharpened. The patient is rapidly losing weight. At the initial stage of the disease, these symptoms are not very noticeable, but with chronic form tuberculosis, the change in appearance is so striking that the doctor, with a high degree of probability, can only make a preliminary diagnosis only by appearance.
• Heat. Subfebrile temperature (37-38 degrees), which does not subside within a month, is a characteristic sign of tuberculosis. In the evening, body temperature may rise slightly - up to 38.3 - 38.5 degrees. Despite the fact that the patient sweats all the time, the body temperature does not subside, because the infection constantly provokes the development of a feverish state. In the later stages of tuberculosis, a febrile temperature may appear, reaching 39-40 degrees and above.
• Cough. With tuberculosis, the patient coughs almost constantly. At the beginning of the disease, the cough is usually dry and intermittent. However, with the progression of the disease, when cavities form in the lungs, the cough intensifies and is accompanied by copious excretion sputum. If a person is worried about coughing for more than three weeks, then this is a reason to contact a phthisiatrician!
• Hemoptysis. This is a rather dangerous symptom, indicating an infiltrative form of the disease. In this case, the diagnosis must be differentiated from a lung tumor and acute heart failure, since hemoptysis is also characteristic of these diseases. AT severe cases blood may gush out, indicating a rupture of the cavity. In this case, the patient requires urgent surgical intervention.
• Chest pain. Usually, pain in the chest and in the area of ​​​​the shoulder blades disturb patients with both acute and chronic forms of tuberculosis. If pains are observed at the beginning of the disease, then they are mild and look like discomfort. The pain gets worse when you take a deep breath.

Patient's actions in case of tuberculosis

At the slightest suspicion of illness, you should contact your family doctor. Protracted cough, which is not stopped by conventional antitussive drugs, should alert a person. You should consult a doctor and undergo all the necessary examinations for the presence / absence of tuberculosis.

Diagnosis of tuberculosis

To detect tuberculosis, fluorography is performed (or computed tomography). At productive cough a sputum sample is taken for examination to determine the pathogen, as well as its sensitivity to antibiotics. Sometimes a bronchoscopy is done. If you suspect the presence of non-pulmonary forms of tuberculosis, tissue samples of these organs are examined.

Children under 18 years of age undergo the Mantoux reaction annually. A positive Mantoux test indicates infection with tuberculosis bacilli.

The basis of tuberculosis therapy is multicomponent anti-tuberculosis chemotherapy. There are several treatment regimens:

The three-component scheme of therapy includes the use of isoniazid, streptomycin, para-aminosalicylic acid (PAS). This classical scheme, however, is not currently used due to the high toxicity of PAS, the impossibility of prolonged use of streptomycin.

Quadruple regimen: isoniazid, rifampicin (or rifabutin), ethambutol, pyrazinamide.

Five-component scheme: A fluoroquinolone derivative (ciprofloxacin) is added to the four-component scheme. In the treatment of drug-resistant forms of tuberculosis, drugs of the second, third and next generations of this group are included.

With insufficient effectiveness of 4-5-component chemotherapy regimens, second-line (reserve) chemotherapy drugs (capreomycin, cycloserine), which are quite toxic to humans, are used.

Much attention is paid to the quality, varied nutrition of patients, correction of hypovitaminosis, leukopenia, anemia. TB patients suffering from alcohol or drug addiction undergo detoxification before starting chemotherapy.

In the presence of HIV infection in combination with tuberculosis, specific anti-HIV therapy is used in parallel with anti-tuberculosis therapy, and the use of rifampicin is also contraindicated in such patients.

In some cases, glucocorticoids may be prescribed. The main indications for their appointment are severe inflammation, severe intoxication. Glucocorticoid preparations are prescribed for a short period of time and in minimal doses, which is associated with their immunosuppressive effect.

An important role in the treatment of tuberculosis is played by sanatorium treatment. Improving the oxygenation of the lungs when inhaling the rarefied air of mountain resorts helps to reduce the reproduction and growth of mycobacteria. For the same purpose, hyperbaric oxygen therapy is used.

In advanced cases, surgical methods of treatment are used: the imposition of an artificial pneumothorax, drainage of a cavity or empyema of the pleura, removal of the affected lung or its lobe, and others.

Complications of tuberculosis

Complications of tuberculosis include hemoptysis or pulmonary hemorrhage, pulmonary heart failure, spontaneous pneumothorax, atelectasis, renal failure, bronchial, thoracic fistulas.

The main prevention of tuberculosis is the BCG vaccine (Bacillus Calmette-Guerin). Vaccination is carried out in accordance with the calendar of preventive vaccinations. The first vaccination is carried out in the hospital in the first 3-7 days of a newborn's life. At 7 and 14 years old, in the absence of contraindications, a negative Mantoux reaction, revaccination is carried out.

The entire adult population, in order to detect tuberculosis in the early stages, must undergo a fluorographic examination at least once a year.

tuberculosis) is an infectious disease caused by bacilli of the species Mycobacterium tuberculosis (they were first identified by Koch in 1882) and characterized by the formation of nodular lesions (tuberculous tubercles (tubercles)) in various tissues. With pulmonary tuberculosis - previously it was called general depletion of the body (consumption), or consumption (phthisis) - tuberculosis bacilli enter the lungs, where the primary tuberculosis focus is formed, from where the disease spreads to the nearest lymph nodes (the so-called primary complex ( primary complex)). At this stage, the body itself, with the help of its own immunity, can cope with the infection; sometimes the disease can go unnoticed for months and even years, gradually weakening the body's resistance. Many people are completely asymptomatic. In others, it can go into a chronic stage; such patients are carriers of an infection that spreads by airborne droplets. Symptoms of acute tuberculosis are: fever, profuse sweating at night, significant weight loss and coughing up bloody sputum. Sometimes tubercle bacilli pass from the lungs into the bloodstream, giving rise to the formation of multiple small tuberculous tubercles throughout the body (miliary tuberculosis) or migrate to the meninges, causing tuberculous meningitis. In some cases, tuberculosis is transmitted through the mouth, most often by eating an infected cow's milk, giving rise to the development of the primary complex in the lymph nodes of the abdominal cavity; this leads to peritonitis and spread of the disease to other organs, joints, and bones (see Pott's disease). Various combinations of antibiotics (streptomycin, ethambutol, isoniazid, rifampicin, and pyrazinamide) are used to treat tuberculosis. To prevent the spread of the disease, periodic fluorographic examination of the population and inoculation of immunocompromised persons with BCG vaccine are carried out (tuberculin test is used to identify these persons).

TUBERCULOSIS

chronic infectious disease caused by Mycobacterium tuberculosis. Respiratory tuberculosis is more common; among extrapulmonary lesions, tuberculosis of the genitourinary system, eyes, peripheral lymph nodes, bones and joints predominates.

The causative agent of tuberculosis in humans are predominantly human mycobacteria (rarely bovine and very rarely avian), which are very resistant to environmental factors. Under the influence various factors Mycobacterium tuberculosis is capable of transforming into ultrafine filterable particles and into giant branched forms. Once in favorable conditions, Mycobacterium tuberculosis can again acquire a typical form. More often, tuberculosis pathogens enter the body through the respiratory system (airborne or airborne dust), less often through gastrointestinal tract and damaged skin. The main source of infection are sick people (as a rule, patients with pulmonary tuberculosis, whose sputum contains mycobacteria), excreting mycobacterium tuberculosis, as well as animals suffering from tuberculosis, mainly cattle, chickens. Sick animals excrete mycobacteria with milk, sputum, feces, urine. Infection can occur when eating milk, meat, eggs obtained from sick animals and birds. The most dangerous in epidemiological terms are people with tuberculosis who have abundant constant bacterial excretion. One such patient, who does not follow the rules of personal hygiene, is capable of infecting up to 10-12 people in a year. With a scanty intermittent bacterioexcretion, the risk of contracting tuberculosis exists only in conditions of close contact with the patient.

The pathogenesis of the disease is complex and depends on the variety of conditions in which the interaction of the pathogen and the organism occurs. Mycobacterium tuberculosis infection does not always cause the development of the tuberculosis process. The leading role in the occurrence of tuberculosis is played by unfavorable living conditions, as well as a decrease in the body's resistance. In the development of tuberculosis, primary and secondary periods are distinguished, which occur under conditions of different reactivity of the organism.

Primary tuberculosis is characterized by high tissue sensitivity to mycobacteria and their toxins. In the zone of penetration of Mycobacterium tuberculosis into the body (respiratory organs, gastrointestinal tract, skin), inflammatory focus, or primary affect. In response to its formation in connection with the sensitization of the body, a specific process develops along the course of the lymphatic vessels and in the regional lymph nodes with the formation of the primary complex. It is more often found in the lungs and intrathoracic lymph nodes. From the first days of penetration into the body of Mycobacterium tuberculosis, bacteremia is observed and the activity of the immune system increases, aimed at destroying the causative agent of the disease. During the formation of foci of primary tuberculosis, lymphogenous and hematogenous dissemination can be observed with the formation of tuberculosis foci in various organs - lungs, bones, kidneys, etc. The healing of foci of primary tuberculosis is accompanied by an immune restructuring of the body, the acquisition of immunity. With a decrease in immunity (in adolescence or old age, against the background of stress, alcoholism, treatment with glucocorticosteroids, when infected with HIV infection or the development of diabetes mellitus), these foci can become more active and progress - a secondary period of tuberculosis begins.

Clinical manifestations of tuberculosis are diverse. More often, a gradually increasing chronic course of the disease is noted, and for some time it proceeds unnoticed by the patient and others. Syndrome of general intoxication varying degrees expressiveness. It is caused by the reproduction of mycobacteria and their dissemination; manifested by fever, weakness, decreased performance, sweating, tachycardia, loss of appetite, weight loss, and sometimes mental disorders. Local symptoms depend on the location of the lesion. So, with pulmonary tuberculosis, patients are worried about coughing with yellowish or greenish sputum (hemoptysis appears in the later stages of the disease), shortness of breath. According to the intensity of local changes, limited focal changes(the so-called small forms of tuberculosis), in which the activity of the tuberculosis process can be proven or rejected only after long-term observation, and sometimes trial treatment with anti-tuberculosis drugs; widespread changes without destruction, including those with damage to several organs; progressive destructive process.

Diagnosis. Preventive examinations play an important role in the detection of tuberculosis. To detect tuberculosis of the respiratory organs, chest fluorography is used, and tuberculin diagnostics is performed for children. The presumptive diagnosis of tuberculosis is established on the basis of clinical manifestations; the diagnosis is confirmed by the detection of Mycobacterium tuberculosis in sputum, urine, fistula discharge, bronchial washings, etc., or by histological examination of the biopsy of the affected organ. X-ray method research is one of the main in the diagnosis of tuberculosis of the respiratory system, as well as tuberculosis of the bones and joints, organs of the genitourinary system. It allows you to determine the localization, extent of the process, the nature of morphological changes.

Bacteriological research is aimed at isolating the infectious agent from sputum, urine, fistula, etc. In the absence of sputum, it is possible to examine the washings of the bronchi, stomach. Bacteriological research includes bacterioscopic, cultural methods, as well as a biological sample. Cultural methods for detecting mycobacterium tuberculosis are highly sensitive, they make it possible to obtain a pure culture of mycobacteria, identify it, and also determine sensitivity to drugs. The most sensitive method for detecting Mycobacterium tuberculosis is a biological test - infection of guinea pigs with pathological material. Tuberculous changes in the organs of a guinea pig can be detected when 1 ml of the material contains single mycobacteria.

Tuberculin diagnostics is based on the use of tuberculin skin tests. It allows you to identify the infection of the body with Mycobacterium tuberculosis, as well as to study the reactivity of the body of infected or vaccinated individuals. Tuberculin is a biologically active drug obtained from the culture filtrates of mycobacterium tuberculosis. Most often used intradermal and cutaneous tuberculin tests. The main method of tuberculin diagnostics is a more sensitive intradermal Mantoux test, which is carried out with purified tuberculin (PPD-L) in a standard dilution in the amount of 2 tuberculin units (TU). A skin tuberculin test (Pirquet test) is carried out by applying a drop of 100% tuberculin to the inner surface of the forearm, followed by scarification. To clarify the nature of sensitivity to tuberculin, a scarifying graduated test with tuberculin in various dilutions is also used.

The reaction to tuberculin is considered negative if there is no infiltrate or hyperemia of the skin after 48-72 hours, doubtful - if a papule with a diameter of 2-4 mm is formed or only hyperemia is present. A test is considered positive when a papule is formed with a diameter of 5 mm or more. In cases of infiltration with a diameter of 17 mm or more, the reaction is considered hyperergic. A negative reaction is observed in healthy unvaccinated and uninfected individuals, as well as in patients with severe widespread tuberculous process with reduced immunity. In elderly and senile people, a positive reaction to tuberculin may appear later (after 72–96 hours), papules are small, the area surrounding them is not hyperemic, and hyperergic reactions are rare.

The results of clinical blood tests (for example, increased ESR, leukocytosis, a shift of the leukocyte formula to the left, sometimes lymphopenia, monocytosis) and urine (for example, proteinuria, cylindruria, etc.), as a rule, do not reveal signs specific to tuberculosis, however, in combination with other data, they play an important role in establishing a diagnosis and monitoring the dynamics of the process during treatment.

AT doubtful cases carry out additional research, including a repeated study to detect Mycobacterium tuberculosis in sputum, bronchial lavage, fistula discharge, urine by a biological test; tomography of the lungs and mediastinum; various immunological and instrumental studies (survey bronchoscopy with biopsy of the bronchial mucosa and lung tissue puncture of peripheral lymph nodes). Of great importance, especially in extrapulmonary localization of the process, is an in-depth tuberculin diagnosis. For this purpose, a more sensitive Koch test is used with subcutaneous injection from 10 to 50 TU PPD-L (for children, the Koch test is carried out only with a negative Mantoux reaction). When setting up the Koch test, local (in the area of ​​tuberculin injection), focal (in the area of ​​the focus of specific inflammation) and general reaction organism, including changes in the blood.

Treatment. The main goal of treating tuberculosis patients is the stable healing of tuberculous foci in the affected organs and the complete elimination of all clinical manifestations of the disease (clinical cure). The effectiveness of the treatment of tuberculosis detected on early stages(even with destructive forms), significantly higher than with a running process. Treatment must be long-term. On average, with successful therapy, the cure occurs after 1 year, sometimes after 2-3 years or more. Treatment usually begins in a hospital. Upon reaching the clinical and radiological effect (cessation of bacilli excretion, healing of foci of destruction), patients are sent to sanatoriums (local and climatic). Complete treatment on an outpatient basis.

Treatment must be comprehensive. Its main component is chemotherapy, during which the correct choice of antibacterial drugs and their combination, optimal daily dose, multiplicity and method of administration, duration of treatment. At the first stage, intensive chemotherapy is carried out in order to suppress the reproduction of mycobacteria and reduce their number. So, in destructive and widespread processes, the use of a combination of three drugs with the mandatory inclusion of isoniazid and rifampicin is effective. Premature termination of chemotherapy can lead to an exacerbation of the tuberculosis process. An important task is to ensure regular intake of prescribed drugs by patients during the entire period of treatment. Therefore, in hospital and sanatorium conditions, and, if possible, in outpatient treatment, the prescribed drugs should be taken in the presence of medical staff.

In cases where conservative treatment does not allow to achieve a clinical cure, resort to surgical treatment. Surgical treatment is used for the cavernous form of tuberculosis of the respiratory organs, as well as for a number of complications and consequences of tuberculosis. The most widely used economical resection of the lungs with complete or partial removal one or more lung segments.

In the treatment of a patient with tuberculosis, regimen and nutrition are of great importance. Complete rest is indicated only in a serious condition of the patient, for example, after surgery, with hemoptysis. As intoxication decreases, training factors (walks, physiotherapy exercises, occupational therapy). The nutrition of the patient should be high-calorie, food easily digestible with high content protein and vitamins, especially C and group B. Sanatorium treatment is indicated, as a rule, during the period of the reverse development of the process. Favorable climatic factors, balneotherapy have a stimulating effect and contribute to the termination of the process. Patients are sent to seaside, mountain climatic resorts, to sanatoriums located in the forest-steppe, as well as in the local climatic and geographical zone.

Forecast. In most patients, under the influence of treatment, the signs of the disease are eliminated. At the same time, inflammatory and destructive changes in organs completely disappear or are significantly reduced. Residual changes may be completely absent, or scars, fibrosis, single or multiple foci remain at the site of the tuberculous process. In the latter, Mycobacterium tuberculosis can remain in a dormant state and, under favorable conditions for them, begin to multiply, causing a relapse of the disease. In this regard, after achieving a clinical cure, patients should be under the supervision of an anti-tuberculosis dispensary for a long time. In most patients who have had tuberculosis, the reactivity of the body that has changed during the course of the disease, as a rule, does not return to its original state, and a positive tuberculin reaction persists. The elderly age of the patients, as well as accompanying illnesses, especially diabetes mellitus and chronic alcoholism, worsen the prognosis.

Prevention. Sanitary and preventive measures are carried out by anti-tuberculosis dispensaries together with institutions of the general medical network and centers of the State Sanitary and Epidemiological Supervision. The object of special attention of TB dispensaries are patients open forms tuberculosis, secreting mycobacteria, and their surrounding faces. Persons who have been in contact with sick animals are also under observation (within 1 year).

A significant proportion of newly diagnosed patients with tuberculosis and patients excreting mycobacteria are persons aged 60 years and older. Contact with them, especially within the family, is very dangerous, in particular for children. Infection of others is observed in cases where patients do not follow the rules of personal hygiene, do not receive full treatment, and persons living with the patient do not undergo chemoprophylaxis. Given the insufficient coverage of elderly and especially senile people with preventive examinations, it is necessary to conduct their X-ray examination more often when contacting medical institutions about various diseases.

The complex of preventive measures in the outbreaks includes current and final disinfection, isolation of children from bacterial excretors by hospitalizing the patient or placing children in children's institutions, vaccination of newborns and revaccination of uninfected persons in contact with patients, their regular examination and chemoprophylaxis, hygienic education of patients and members their families, improvement of living conditions, treatment of a patient in a hospital, followed by outpatient controlled chemotherapy.

A preventive measure is also to prevent patients who are bacterial excretors from working in medical children's institutions, educational institutions, catering establishments, and the food industry.

Specific prophylaxis is aimed at increasing the body's resistance to tuberculosis infection through active immunization (vaccination and revaccination) of BCG or the use of anti-tuberculosis drugs (chemoprophylaxis). The incidence of tuberculosis among the vaccinated is 4-10 times lower than among the unvaccinated. Tuberculosis in vaccinated BCG proceeds more benignly: in children vaccinated during the neonatal period, the development of the disease is limited mainly to lesions of the intrathoracic lymph nodes. Mass vaccination of newborns is carried out, as well as revaccination of clinically healthy people with a negative Mantoux reaction. Vaccination and revaccination are prescribed taking into account medical contraindications. Immunity occurs approximately 2 months after the introduction of the vaccine. For this period, it is necessary to isolate the vaccinated (especially newborns) from patients who excrete Mycobacterium tuberculosis. Vaccination immunity sharply weakens after 5-7 years.

An important role in the prevention of tuberculosis in healthy individuals of the group increased risk, especially among children and adolescents, plays chemoprophylaxis. There are two types of chemoprophylaxis: primary, which is carried out to uninfected persons with a negative reaction to tuberculin who have been in contact with a patient with active tuberculosis, and secondary, carried out to infected persons. For chemoprophylaxis, isoniazid is used for 3 months.

Features of tuberculosis in children. In childhood, primary forms of tuberculosis are predominantly found, since infection occurs as a result of the first contact of a child with a tuberculosis infection. Mycobacterium tuberculosis, getting into the body, may not cause local pathological changes, but lead to immune restructuring and the appearance of a positive tuberculin reaction (tuberculin reaction turn). Prophylactic treatment with isoniazid during this period prevents the disease in most children. If chemoprophylaxis is not carried out, children often develop a special, inherent in childhood clinical form tuberculosis - tuberculosis intoxication (tuberculosis without a specific localization of the process). It is characterized by increased fatigue, decreased appetite, periodic low-grade fever, excitability or, conversely, lethargy. The examination reveals pale skin, decreased tissue turgor and muscle tone. There is an increase of up to 5 - 6 mm in the diameter of the peripheral lymph nodes, a slight increase in the liver, sometimes the spleen, blood changes. The Mantoux reaction is moderately or significantly pronounced. Children with tuberculosis intoxication are subject to treatment in a hospital or sanatorium for 5-6 months with two anti-tuberculosis drugs. Recovery is possible without treatment, but often (with a decrease in the body's resistance) the outcome of tuberculosis intoxication is a local form of primary tuberculosis.

The features of primary tuberculosis in children are: a tendency to involve the lymphatic system in the inflammatory process, as well as to the spread of infectious agents by the hematogenous route, the presence of extensive perifocal changes, frequent reactions of a toxic-allergic nature (for example, erythema nodosum), as well as a high ability to heal. The most common form of primary tuberculosis is tuberculosis of the intrathoracic lymph nodes. In 1/3 of patients with this localization of the process, small forms are diagnosed, which are usually detected during tuberculin diagnosis in children at risk, as well as with tuberculosis intoxication. With untimely diagnosis and late initiation of treatment of small forms of tuberculosis of the intrathoracic lymph nodes, its pronounced forms often develop with damage to the lung tissue, characterized by significant intoxication, distinct clinical and radiological symptoms.

In 20% of children with severe forms of primary tuberculosis, inflammatory changes in full treatment completely disappear after 6-8 months. The rest develop fibrotic changes or calcifications in the lymph nodes and pulmonary focus, which in the future can become a source of exacerbation of the process. Late diagnosis of these forms of tuberculosis can lead to the development of atelectasis, disintegration of the lung tissue, dissemination of the process, exudative pleurisy which significantly aggravate the course and outcomes of the disease and require long-term treatment. Early detection of tuberculosis in children can prevent the development of its local and severe forms. main method early detection Tuberculosis in children is an annual tuberculin diagnosis, which allows to detect a turn of tuberculin reactions or a change in sensitivity to tuberculin. Along with tuberculin diagnostics, children over 12 years of age undergo an X-ray or fluorographic examination once a year.