TUBERCULOSIS

TUBERCULOSIS - a chronic infectious disease caused by Mycobacterium tuberculosis. Tuberculosis of the respiratory system is more common; Among extrapulmonary lesions, tuberculosis prevails in the organs of the genitourinary system, the eye, peripheral lymph nodes, bones and joints.

The causative agent of tuberculosis in humans are predominantly mycobacteria of the human species (less common bovine and very rarely - avian), very resistant to environmental factors. Under the influence of various factors, mycobacterium tuberculosis is able to transform into ultra-fine filter particles and into giant branchy forms. Getting into favorable conditions, mycobacterium tuberculosis can again acquire a typical form. Most pathogens of tuberculosis enter the body through the respiratory system (airborne or airborne dust), less often - through the gastrointestinal tract and damaged skin. The main source of infection are sick people (usually patients with pulmonary tuberculosis, which contain mycobacteria in the sputum), which release mycobacterium tuberculosis, as well as tuberculosis-infected animals, mainly cattle and chickens. Sick animals produce mycobacteria with milk, sputum, feces, urine. Infection can occur when eating in food received from sick animals and birds milk, meat, eggs. The most dangerous in epidemiological terms are people with tuberculosis people with copious permanent bacterial release. One such patient, who does not comply with the rules of personal hygiene, is able to infect up to 10-12 people per year. With a scarce inconstant bacteriovirus, the risk of contracting tuberculosis exists only in close contact with the patient.

The pathogenesis of the disease is complex and depends on the variety of conditions in which the causative agent of infection and the organism interacts. Infection with mycobacteria tuberculosis does not always cause the development of the tuberculosis process. The leading role in the emergence of tuberculosis is played by unfavorable living conditions, as well as a decrease in the body's resistance. In the development of tuberculosis, the primary and secondary periods are isolated, which occur in conditions of different reactivity of the organism.

Primary tuberculosis is characterized by high sensitivity of tissues to mycobacteria and their toxins. In the zone of penetration of mycobacterium tuberculosis into the body (respiratory system, gastrointestinal tract, skin), an inflammatory focus, or primary affect, may occur. In response to its formation in connection with the sensitization of the body, a specific process develops along the lymphatic vessels and in regional lymph nodes with the formation of the primary complex. It is more often detected in the lungs and hilar lymph nodes. From the first days of penetration into the organism Mycobacterium tuberculosis observed bacteremia and increased activity of the immune system, aimed at the destruction of the pathogen. In the process of formation of foci of primary tuberculosis, lymphogenous and hematogenous dissemination with the formation of tuberculous foci in various organs - lungs, bones, kidneys, etc. can be observed. The healing of the foci of primary tuberculosis is accompanied by immune restructuring of the organism, the acquisition of immunity. With a decrease in immunity (in adolescence or old age, against stress, alcoholism, treatment with glucocorticosteroids, with HIV infection or the development of diabetes mellitus), these foci can become more active and progress - a second period of tuberculosis sets in.

The clinical manifestations of tuberculosis are diverse. More often there is a gradually growing chronic course of the disease, and for some time it flows unnoticed for the patient and others. Characterized by a syndrome of general intoxication of varying degrees of severity. It is caused by the reproduction of mycobacterium and their dissemination; Manifested by increased body temperature, weakness, decreased efficiency, sweating, tachycardia, deterioration of appetite, weight loss, and sometimes mental disorders. Local symptoms depend on the localization of the lesion. Thus, pulmonary tuberculosis patients worried cough with branch yellowish or greenish sputum (hemoptysis occurs in the later stages of the disease), shortness of breath . In terms of the intensity of local changes, limited focal changes (the so-called small forms of tuberculosis) can be identified, in which the activity of the tuberculosis process can be proven or rejected only after prolonged observation and sometimes trial treatment with anti-tuberculosis drugs; Common changes without destruction, including with the defeat of several organs; Progressive destructive process.

Diagnosis. Preventive examinations play an important role in the detection of tuberculosis. To detect tuberculosis of the respiratory organs, fluorography of the thorax is used, the children are subjected to tuberculosis diagnostics. Presumptive diagnosis of tuberculosis is established on the basis of clinical manifestations; The diagnosis is confirmed when a mycobacterium tuberculosis is detected in sputum, urine, fistula, bronchial flushing waters, etc., or when a biopsy specimen of the affected organ is histologically examined. X-ray method of investigation is one of the main methods in the diagnosis of tuberculosis of the respiratory system, as well as tuberculosis of bones and joints, organs of the genitourinary system. It allows to determine the localization, the length of the process, the nature of the morphological changes.

Bacteriological study is aimed at isolating the causative agent of infection from sputum, urine, fistula, etc. In the absence of sputum, it is possible to examine the flushing waters of the bronchi, the stomach. Bacteriological study includes bacterioscopic, culture methods, as well as a biological test. Cultural methods for detecting mycobacterium tuberculosis are very sensitive, they make it possible to obtain a pure culture of mycobacteria, to identify it, and to determine sensitivity to medicines. The most sensitive method for detecting mycobacteria tuberculosis is a biological test - infection with pathological material of guinea pigs. Tuberculosis changes in organs of guinea pig can be detected with the content of 1 ml of material of single mycobacteria.

Tuberculin diagnostics is based on the use of cutaneous tuberculin samples. It allows to detect the infection of the organism with mycobacteria of tuberculosis, and also to study the reactivity of the organism of infected or vaccinated persons. Tuberculin is a biologically active drug obtained from culture filtrations of mycobacterium tuberculosis. Often used intradermal and cutaneous tuberculin tests. The main method of tuberculin diagnostics is a more sensitive intradermal Mantoux test, which is performed with purified tuberculin (PPD-L) in standard dilution in the amount of 2 tuberculin units (TE). The tuberculin skin test (Pirke 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 grading test with tuberculin in various dilutions is also used.

Reaction to tuberculin is considered negative in the absence of infiltration or hyperemia of the skin after 48-72 hours, doubtful - with the formation of a papule with a diameter of 2 -4 mm or the presence of only hyperemia. A test is considered positive when forming a papule 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 tuberculosis with reduced immunity. In elderly and elderly people, a positive reaction to tuberculin may appear later (72 to 96 hours), papules are small, their surrounding zone is not hyperemic, and hyperergic reactions are rare.

Results from clinical blood tests (e.g., increased ESR, leucocytosis , shift leukocyte left sometimes lymphopenia monocytosis) and urine (e.g., proteinuria, cylindruria et al.), As a rule, does not reveal the specific tuberculosis signs, but in combination with Other data, they play an important role in establishing a diagnosis and monitoring the dynamics of the process during treatment.

In case of doubt, an additional study is carried out, including a re-examination to detect mycobacteria of tuberculosis in sputum, bronchial flushing waters, fistula and urine to be separated by biological test; Tomography of the lungs and mediastinum; Various immunological, as well as instrumental studies (bronchoscopy with biopsies of bronchial mucosa and pulmonary tissue, puncture of peripheral lymph nodes). Of great importance, especially with extrapulmonary localization of the process, is deepened tuberculin diagnostics. For this purpose, a more sensitive Koch test with a subcutaneous injection of 10 to 50 TE PPD-L is used (Koch test is performed only with negative Mantoux reaction). When Koch test is performed, local (in the field of tuberculin administration), focal (in the region of the focus of specific inflammation) and the general reaction of the organism, including changes in blood, are taken into account.

Treatment. The main goal of treatment of patients with tuberculosis is persistent healing of tuberculosis foci in affected organs and complete elimination of all clinical manifestations of the disease (clinical cure). The effectiveness of treatment of tuberculosis, detected in the early stages (even with destructive forms), is much higher than when the process is running. Treatment should be lengthy. On average, with successful therapy, the cure comes in 1 year, sometimes in 2 - 3 years or more. Treatment, as a rule, begins in a hospital. Upon the achievement of clinical and radiological effect (stopping bacilli, healing of foci of destruction), patients are sent to sanatoria (local and climatic). Finish treatment on an outpatient basis.

Treatment should be complex. Its main component is chemotherapy, in which the proper choice of antibacterial drugs and their combination, the optimal daily dose, the frequency and the mode of administration, the duration of treatment is of great importance. At the first stage, intensive chemotherapy is carried out to suppress the reproduction of mycobacteria, reducing their number. Thus, with destructive and widespread processes, the 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 admission to patients of prescribed medications throughout the treatment period. Therefore, in hospital and sanatorium settings, and, if possible, in case of outpatient treatment, prescribed medication should be administered in the presence of medical staff.

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

In the treatment of a patient with tuberculosis, regime and nutrition are of great importance. Full rest is shown only in case of a serious condition of the patient, for example after surgery, with hemoptysis. By. As the intoxication is reduced, the regimen includes training factors (walks, exercise therapy, occupational therapy). Nutrition of the patient should be high-calorie, food easily digestible with high protein and vitamins, especially C and group B. Spa treatment is usually shown in the period of the reverse development of the process. Favorable climatic factors, balneotherapy have a stimulating effect and contribute to the cessation of the process. Patients are sent to the seaside, mountain climatic resorts, sanatoriums located in the forest-steppe, as well as in the local climatic geographic zone.

Forecast. In most patients, the symptoms of the disease are eliminated under the influence of treatment. At the same time, inflammatory and destructive changes in organs disappear completely or significantly. Residual changes may be completely absent, or scar tissue, fibrosis, single or multiple foci remain at the site of the tuberculosis process. In the latter, mycobacterium tuberculosis can remain dormant 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 long-term supervision of an anti-tuberculosis dispensary. In most patients who have undergone tuberculosis, the reactivity of the organism changed in the course of the disease, as a rule, does not return to the initial state, and the positive tuberculin reaction remains. The elderly patients and associated diseases, especially diabetes mellitus and chronic alcoholism , worsen the prognosis.

Prevention. Sanitary and preventive measures are carried out by anti-tuberculosis dispensaries together with the institutions of the general medical network and the centers of the State Sanitary Epidemiological Service. The object of special attention of TB dispensaries are patients with open forms of tuberculosis, which secrete mycobacteria, and the people around them. Under supervision (for 1 year) are also persons who have contacted sick animals.

A significant proportion of newly diagnosed tuberculosis patients and patients who secrete mycobacteria are people aged 60 years and over. Contact with them, especially the family, is very dangerous, in particular for children. Infection of others is observed in cases when patients do not observe the rules of personal hygiene, do not receive adequate treatment, and those who live with the patient do not undergo chemoprophylaxis. Given the inadequate coverage of persons of elderly and especially senile age with preventive examinations, their X-ray examination should be carried out more frequently when applying to medical institutions for various diseases.

The complex of preventive measures in the outbreaks includes the conduct of current and final disinfection, isolation of children from bacilli by hospitalization of the patient or placement of 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 setting followed by outpatient administration of controlled chemotherapy.

A preventive measure is also the prevention of patients who are bacterio-liberators, to work in medical institutions for children, schools, public 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 vaccinated people is 4-10 times lower than among the unvaccinated. Tuberculosis in vaccinated BCG is more benign: in children vaccinated during the newborn period, the development of the disease is limited mainly to the involvement of the intrathoracic lymph nodes .. Mass vaccination of newborns is conducted, as well as revaccination of clinically healthy people with negative Mantoux reaction. Vaccination and revaccination is 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 vaccinated (especially newborns) from patients who secrete mycobacterium tuberculosis. Vaccination immunity sharply decreases after 5 - 7 years.

Chemoprophylaxis plays an important role in the prevention of tuberculosis in healthy individuals at high risk, especially among children and adolescents. There are two types of chemoprophylaxis: primary, which is carried out by uninfected persons with a negative reaction to tuberculin, in contact with a patient with active tuberculosis, and secondary, conducted to infected persons. For chemoprophylaxis use of isoniazid for 3 months.

Features of tuberculosis in children. In childhood, mostly found primary forms of tuberculosis, since the infection occurs as a result of contact with the first child TB infection. Mycobacterium tuberculosis, getting into the body, may not cause local pathological changes for some time, but lead to immune reconstruction and the appearance of a positive tuberculin reaction (the turn of tuberculin reactions). Preventive treatment with isoniazid during this period prevents the disease in most children. If chemoprophylaxis is not carried out, children often develop a special clinical form of tuberculosis inherent in childhood: tuberculosis intoxication (tuberculosis without definite localization of the process). It is characterized by increased fatigue, a decrease in appetite, periodic subfebrile, excitability or, on the contrary, lethargy. When the examination reveals pallor of the skin, a decrease in the turgor of tissues and muscle tone. There is an increase to 5 - 6 mm in diameter of peripheral lymph nodes, a small increase in the liver, sometimes a spleen, changes in blood. The Mantoux reaction is moderately or significantly pronounced. Children with TB intoxication are to be treated in a hospital or a sanatorium for 5-6 months with two anti-TB drugs. Recovery is possible without treatment, but often (with a decrease in the resistance of the body), the outcome of tuberculous intoxication becomes a local form of primary tuberculosis.

The peculiarities of primary tuberculosis in children are: a tendency to involve the lymphatic system in the inflammatory process, as well as the spread of pathogens with hematogenous pathogens, the presence of extensive perifocal changes, frequent toxic-allergic reactions (eg, erythema nodosum), and high healing ability. The most common form of primary tuberculosis is the 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 in tuberculin diagnostics in children at risk, as well as with tuberculous intoxication. When untimely diagnosis and late treatment of small forms of tuberculosis of the intrathoracic lymph nodes often develop its pronounced forms with a lesion of the lung tissue, characterized by significant intoxication, a clear clinical and radiologic symptomatology.

In 20% of children with severe forms of primary tuberculosis, inflammatory changes with complete treatment disappear completely after 6 to 8 months. The rest form fibrotic changes or calcifications in the lymph nodes and pulmonary focus, which can later 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 expressed forms. The main method of early detection of tuberculosis in children is the annual tuberculin diagnostics, which allows finding out the turn of tuberculin reactions or changing the sensitivity to tuberculin. Along with tuberculin diagnostics, children older than 12 years once a year undergo an X-ray or fluorographic examination.