Tuberculosis of the respiratory system

Tuberculosis of the respiratory system is an infectious disease characterized by the formation of specific inflammation in the affected tissues and the expressed general reaction of the organism. In many economically developed countries, in particular in Russia, the incidence of tuberculosis and mortality from it have significantly decreased. These epidemiological shifts among children, adolescents and women are most pronounced, and to a lesser extent among men, especially the elderly. Nevertheless, tuberculosis remains a common disease.

Etiology. The causative agent is mycobacterium tuberculosis (MT), mainly human, rarely bovine and in exceptional cases of bird type. The main source of infection - sick people or pets, mostly cows. Infected usually by airborne by inhalation with air of the patient's finest droplets of sputum, which contain MT. In addition, it is possible to penetrate the body of the infection when consuming milk, meat, eggs from sick animals and birds. In these cases, the microbes are introduced into the lungs or from the pharyngeal tonsils, or through the lymphatic and bloodways from the intestine. The overwhelming majority of the newly diagnosed sputum smearers have MT, sensitive, and 5-10% - resistant to various anti-TB drugs. In the latter case, infection occurs from patients who are ineffectively treated with specific medications and isolate resistant strains of MT. In a special study in sputum and in the organs of patients, it is sometimes possible to detect L-forms of MT, which are characterized by relatively low virulence and pathogenicity, but capable of transforming into a typical microbial form under certain conditions.

Pathogenesis, symptoms, course. For the first time, penetrated into the organism of MT are spread in it by various ways-lymphogenic, hematogenic, bronchopulmonary. In different organs, mainly in the lymph nodes and lungs, separate or multiple tuberculous tubercles or larger foci may be formed, which are characterized by the presence of epithelioid and giant cells, as well as elements of curdled necrosis. Simultaneously there is a positive reaction to tuberculin, the so-called tuberculinic virage, established by the intradermal Mantoux test. Subfebrile body temperature, hyperplasia of the outer lymph nodes, mild lymphopenia and shift of the leukocyte formula to the left may be observed, ESR, as well as protein fractions of blood serum, are often changed. With sufficient resistance of the organism and infection with a small amount of MT, tubercle tubercles and foci dissolve, cicatrize or calcify, although MTs remain in them for a long time. All these changes often go unnoticed or occur under the guise of various intercurrent diseases, are eliminated spontaneously; They are detected only with careful dynamic observation of newly infected children, adolescents or adults.

With massive infection, under the influence of other unfavorable factors (malnutrition, severe diseases leading to a decrease in the immunobiological resistance of the body), a clinically pronounced primary tuberculosis develops in the form of bronchoadenitis, the primary complex, more or less extensive discourses in the lungs and other organs, Exudative pleurisy, inflammation of other serous membranes. In this case, often noted increased sensitivity of the body and a tendency to hyperergic reactions in the form of erythema nodosum, keratoconjunctivitis, allergic vasculitis, etc. Primary tuberculosis occurs mainly in children, adolescents, less often in young people and extremely rarely in the elderly and elderly , Have already suffered in the past the primary infection, resulting in a biological cure.

Remaining in the "healed" tuberculosis foci and scars in the lungs and lymph nodes MT can "wake up" and multiply. This is facilitated by the same conditions that favor the development of primary tuberculosis, and in addition, re-infection (exogenous superinfection). Then around the old foci there is a perifocal inflammation, the integrity of their capsules is broken, the areas of caseous necrosis are melted and the infection spreads lymphogenous, bronchogenic or hematogenous. This is how secondary tuberculosis develops, that is, the disease of people who have already undergone a primary infection and possess a known, albeit inadequate, immunity. In such patients, the process proceeds with a variety of pathomorphological and clinical changes, more often chronically.

Recently, tuberculosis in elderly and elderly people has increased. The clinical picture of the disease is often atypical. Even the evolutionary forms of the process over a long period can go unnoticed, but sometimes they are similar to malignant diseases or chronic nonspecific inflammations of the respiratory system. This leads to untimely diagnosis of the disease. A number of patients of this age have miliary tuberculosis and extrapulmonary lesions (meningitis, tuberculosis of the bones, adrenal glands, etc.). Tuberculosis can also develop as a complication of corticosteroid therapy. This "steroid" tuberculosis tends to progress, which is often mistakenly regarded as a feature of the course of the underlying disease.

According to the classification adopted in 1974, the following forms of tuberculosis of respiratory organs are distinguished: 1) primary tuberculosis complex; 2) tuberculosis of the intrathoracic lymph nodes; 3) disseminated pulmonary tuberculosis; 4) focal pulmonary tuberculosis; 5) infiltrative pulmonary tuberculosis; 6) pulmonary tuberculoma; 7) cavernous pulmonary tuberculosis; 8) fibrous-cavernous pulmonary tuberculosis; 9) cirrhotic tuberculosis of the lungs; 10) tuberculous pleurisy (including empyema); 11) tuberculosis of the upper respiratory tract, trachea, bronchi; 12) REF = "des328.shtml"> tuberculosis of the respiratory system, combined with pneumoconiosis. In addition, the process is characterized by its location in various segments and segments of the lungs, developmental phases (resorption, compaction, scarring, calcification, decay, infiltration, seeding), the presence of bacterial excretion. Consider the most important complications (pulmonary hemorrhage, atelectasis, amyloidosis, renal failure, pulmonary heart failure, bronchial, thoracic fistulas, etc.), as well as residual changes in the lungs after cured tuberculosis (fibrotic, fibro-focal, pleuropneumoclima- Roses, etc.).

Primary tuberculosis complex - the most typical primary tuberculosis farm - is presently relatively rare: pulmonary foci of specific inflammation (primary affect) and regional bronchoadenitis are identified. Sometimes the disease has a hidden nature, but often begins subacute and manifests subfebrile body temperature, sweating, fatigue, a small dry cough. In acute cases, the disease initially acts as a nonspecific pneumonia with high fever, cough, chest pain, sometimes shortness of breath, moderate leukocytosis with a shift of the leukocyte formula to the left, increased ESR. With a small amount of primary affect, physical changes in the lungs are usually not determined. With more massive inflammation, areas of dulling of percurgical current, vesicular-bronchial respiration, wet, small bubbling rales are noted. In some patients, external lymph nodes often increase. Tuberculin samples in 30-50% are significantly expressed. In the absence of pulmonary tissue disintegration in sputum and washings of bronchi, MT is usually not detected. In the same cases, with tracheobronchoscopy, there are no specific changes in the bronchi, but they are detected during the formation of a cavern in the lungs or the spread of the process from the intrathoracic lymph nodes and bronchogenic colonization. Then MT detection is possible. Radiological picture is characterized by the appearance of a symptom of bipolarity in the form of a small lobular or segmental focus, rarely lobar pneumonia and a group of enlarged hilar lymph nodes in the root of the lung.

Even with a favorable course of the process and the application of modern methods of treatment, the primary complex is cured slowly. Only after a few months, sometimes only 1-2 years after the detection and the beginning of treatment, there is a resorption or encapsulation and calcification of the elements of the primary complex with the formation of the Gon focus. With a complicated course of the disease, the primary focus in the lung and the formation of a cavity may decay. Sometimes there is exudative pleurisy. Possible limfogematogennoe distribution of MT and the formation of foci in the hands, kidneys, meningeal membranes and other organs.

The most common form of primary tuberculosis is tuberculosis of the intrathoracic lymph nodes. Clinical manifestations of the disease depend on the reactivity of the organism, the prevalence of lymph node involvement. If separate and small foci of curdled necrosis without perifocal inflammation are formed in them, and the overall reactivity is not clearly reduced, then such a "small" form of the process can proceed latent or with insignificant intoxication. With a more massive infiltrative or tumor-like bronchoadenitis, high fever, general weakness, sweating, decreased ability to work, increased excitability. A common symptom is a dry cough. In infants and young children due to compression of large bronchi and mediastinal organs with enlarged lymph nodes, coughing may be ringing, bitonal or pertussis. In adults this symptom is rare. In physical examination, especially in adult patients, it is difficult or even impossible to detect enlarged hilar lymph nodes. Sometimes in the interscapular space with percussion, it is possible to mark the triangular section of blunting, and when listening, changes in breathing and a small number of dry, rarely moist, finely bubbling rales.

In both adults and children, cervical and axillary lymph nodes are enlarged in some cases. Tuberculin reactions are relatively common, but not always pronounced. The number of leukocytes in the blood is normal or somewhat increased with a shift to the left, the ESR is increased. MT is rarely found. Radiographically determine the expansion of the root of one, less often both lungs; Its shadow is not very structured, it is deformed, especially with massive perifocal inflammation, which is typical for infiltrative bronchoadenitis. With a sharp increase in bronchopulmonary and other groups of lymph nodes, the root contours acquire a polycyclic character (tumor-like bronchoadenitis). Symptoms of intoxication, increased ESR, hyperergic tuberculin reactions can persist for a long time even against vigorous specific treatment. Gradually, the perifocal inflammation around the roots of the lungs resolves and their compaction takes place. Only 1-2 years after the onset of the disease and treatment in the lymph nodes there are areas of calcification. Calculation of caseous foci occurs faster in children, slower in adults.

The disease is often complicated by a specific lesion of the bronchi; When violations of their patency occur segmental or lobar atelectasis of the lung. When they become infected with secondary flora, a picture of chronic, often relapsing pneumonia develops. When breakthrough through the bronchial wall of caseous masses from the lymph nodes and the MT contained in them, tuberculosis foci are formed mainly in the basal and lower, less often in other parts of the lungs (adenobruhchlear-pulmonary form of the process). In such cases, bacterial excretion is detected when sputum or washing water of the bronchi is examined. There may also be a complication of interstitial, mediastinal, less often costal exudative pleurisy. From the intrathoracic lymph nodes, the infection can spread lymphogenically and cause damage to other organs. In the chronic course of the disease, the state of increased sensitivity of the organism remains, which contributes to the occurrence of paraspecific reactions. So there is a picture of a chronically current and slowly progressing primary tuberculosis, often occurring under the guise of a polyserositis, hepatolenal syndrome, etc.

Disseminated pulmonary tuberculosis is more often of hematogenous origin. The source of bacteremia is newly formed, as well as insufficiently healed or activated tuberculosis foci in lymph nodes or other organs. The process can develop as a form of primary or secondary tuberculosis. Various types of it are observed: miliary, medium- and large-focal, limited or widespread, and along the course of acute, subacute, chronic forms.

Miliary tuberculosis is usually generalized, but sometimes it is localized primarily in the lungs, and occasionally in some of their areas, for example, in the apexes. There are typhoid, pulmonary and meningeal forms of the disease. It manifests itself first as a general malaise, subfebripic temperature of the body, headache. Soon the patient's condition sharply worsens: fever reaches 39-40 gr. C, shortness of breath, tachycardia, acrocyanosis. Physical changes in the lungs are insignificant (a small amount of scattered dry or finely bubbly wet wheezing). The liver and spleen are not enlarged. Tuberculin tests, at first normal, become mild or even negative as the process progresses. Leukopenia and lymphocytosis are replaced by mild leukocytosis with a shift to the left, lymphopenia, increased ESR. MT in sputum is usually absent. Radiographically in the lungs, multiple foci are determined to the size of millet grain, unsharply outlined, located in a chain-like and symmetrical manner in both lungs against the background of a small-looped network of inflammatory altered interstitial tissue. Despite the considerable severity and severity of the course of miliary tuberculosis, patients with this form of the process can be fully cured if they are recognized and treated correctly.

Frequent observed subacute disseminated tuberculosis of the lungs, which can occur under the guise of typhoid fever, influenza, focal pneumonia or prolonged bronchitis with subfebrile body temperature, coughing (dry or with sputum, which sometimes find MT). In some cases, the symptoms are typical for extrapulmonary localization of the process (lesions of the pharynx, larynx, kidneys, appendages of the genital organs, bones and joints). A harbinger or a companion of disseminated pulmonary tuberculosis is exudative pleurisy. Physical changes in the lungs are insignificant - a small number of small wet rales. Tuberculin reactions are sometimes pronounced, often normal. Moderate leukocytosis with a shift to the left, ESR within 20-30 mm / h. Radiographically symmetrical in both lungs, mainly in their upper outer areas, scattered single-type foci are found on the background of a densely coarse or small-mesh net. With timely-initiated rational therapy, a subacute process can be cured.

If the disease in this phase has not been recognized, then slowly progressing, it goes into a chronic form: in the lungs, foci of different density, interstitial sclerosis, emphysema are formed, in the breakdown of foci, separate or multiple caverns are formed that can become a source of bronchogenic spread of the infection. There are shortness of breath, sometimes of an asthmatic nature, cough with sputum, containing MT, hemoptysis, cardiovascular system. Often marked vegetative disorders, poor sleep, sweating, tachycardia. A lot of absent dry and wet wheezing is heard in the lungs. With an exacerbation of the process, moderate leukocytosis with a leftward shift, eosin- and lymphopenia, monocytosis is determined; ESR is enhanced. When tracheobronchoscopy is often found specific changes in the bronchi. X-rays in the lungs show foci of varying size and density, located less symmetrically than in subacute form, mesh sclerosis, emphysema, sometimes bullous type, thin-walled "stamped" caverns. The roots of the lungs are pulled upward, the heart and large vessels have a middle "hanging" position. Quite often there are pleural layers and diaphragmatic fusion. The cure of such patients requires a longer period and is not always achieved.

Focal pulmonary tuberculosis - the most common form (noted in 40-50% of all newly diagnosed patients) - may occur during the primary infection as a result of hematogenous or lymphogenic spread of the infection; It also develops during exacerbation of old foci and fibrous scars, less often with exogenous superinfection as a manifestation of secondary tuberculosis. Possible intoxication phenomena. There is no coughing, or it is rare and dry, sometimes with the allocation of scanty mucus-purulent sputum, where MT is relatively rare (usually by flotation, seeding or infection of an animal). Chrypses in the lungs with fresh focal tuberculosis are heard only with the progression of the disease or as a result of the development of fibro-sclerotic changes in the lungs. Lymphocytosis, a slight left shift in the leukocyte formula, ESR up to 20 mm / h. Tuberculin reactions are mostly normal, with the first forms of the process sometimes hyperergic. Radiologically in the subclavian areas and in the apex, less often in other parts of the lungs, small or medium-sized foci of irregularly rounded or oblong forms are found on the background of interstitial inflammatory changes (lymphangitis). When the old foci are exacerbated, a zone of perifocal inflammation is revealed around them. When the process fades away, fresh foci dissolve; When it goes into a chronic form, they decrease, become denser, and sometimes form separate conglomerates; Thus there are cicatricial changes and pleural adhesions. With progression, the foci coalesce, merge with each other, and their disintegration with the formation of small caverns is possible.

Infiltrative pulmonary tuberculosis. Its specific gravity in the total incidence of tuberculosis of respiratory organs in adults is 2 5-40%. The pathomorphological substrate of the process is predominantly exudative perifocal inflammation around old or newly formed tuberculosis foci and in the zone of interstitial-sclerotic changes. Its development is promoted by diabetes, influenza, treatment with glucocorticoids, massive superinfection, etc. The nature and dynamics of tissue reactions, as well as the shape and magnitude of the infiltrate are different. Most often it is a broncholobular focus of 1.5-2 cm or more. But the process can extend to a segment or a whole fraction of the lung. Curdous pneumonia with predominance of caseo-necrotic reactions is rare. Usually, the process begins under the guise of influenza, nonspecific pneumonia, or a febrile state of unclear etiology. The first symptom may be hemoptysis or pulmonary hemorrhage. Even with a significant amount of inflammatory focus, physical changes in the lungs in the initial phase of the disease are often meager. Moderate leukocytosis with a shift of the leukocyte formula to the left, lymphopenia, ESR of 20-40 mm / h, in sputum or in bronchial flushing waters in some patients find MT. Caseous pneumonia begins acutely, fever often of a hectic type, chills, shortness of breath, chest pain, cough with discharge of purulent sputum, tachycardia, cyanosis; Over the affected area, an intensive blunting of the percussion tone, bronchial breathing, crepitating or sonorous wheezing; In sputum MT and accumulation of elastic fibers; Significant leukocytosis, marked lymphopenia, ESR up to 50-60 mm / h; Tuberculin tests are weak or negative.

Radiographically, there are different types of infiltrative tuberculosis; Large broncholobular foci of irregular shape with diffuse boundaries, fused (cloud-like) foci, oval or rounded shadow formations, pericissurites, beaten. Usually from these foci to the root of the lung a "path" departs, which is a projection of the inflammatory compressed walls of the bronchi and vessels. In the breakdown of caseous sections of infiltrates, bay-shaped or rounded caverns are formed. When the drainage bronchi are affected at the bottom of the decay cavity, the meniscus fluid level can sometimes be determined. As a result of bronchogenic colonization, separate or multiple foci are formed in different parts of the lungs, and sometimes large foci. Caseous pneumonia Radiologically often the name of the species is beaten with small decay sites or large irregular drainage foci. The process is characterized by a tendency to rapid progression by the type of so-called pulmonary pulmonary tuberculosis. With timely therapy, a cure is sometimes possible with the outcome in massive cirrhosis of the lung. When the infiltrative pulmonary tuberculosis subsides, the foci gradually decrease or completely dissolve. Sometimes they become denser and encapsulate, acquiring the character of tuberculosis or smaller foci.

Tuberculoma of the lung is characterized by the presence of a rounded focus, delimited from the surrounding tissue, with a diameter of 2 cm or more. It can form with the involution of the infiltrate or as a result of the fusion of several small foci in the course of a chronic course of focal or disseminated process. When the cavern is filled with caseous masses, fibrin, and leukocyte accumulations, a focus, called pseudotuberculoma, is formed. The pathomorphological substrate of tuberculosis is different. Sometimes it is a major focus of solid curdled necrosis, surrounded by a fibrous capsule (solitary homogeneous tuberculoma or caseoma). More often there is a layered structure of a curdled hearth surrounded by a thin hyalineized capsule (laminated tuberculoma). If a fusion of several small foci, united by a common wide capsule, forms the so-called conglomerate tuberculoma. Tuberculoma is often a stable formation that can persist for many years. But sometimes tuberculomas, especially large ones, are softened, destruction is formed and bronchogenic foci appear in different parts of the lungs.

Clinic of tuberculoma depends on its nature, magnitude, and also on the phase of the process. With a stable condition, there are no painful symptoms. They arise when the process is exacerbated, when the focus in the lung increases, and furthermore softens with the formation of a cavity. Then there are symptoms of intoxication, coughing with sputum, hemoptysis. In the area of ​​tuberculosis, small wet rales are heard. MT is found in the sputum. Lymphopenia with a shift of the leukocyte formula to the left, an increase in ESR. Increase in the level of alphabet (two) and gamma fractions in serum. Tuberculin reactions are sometimes expressed significantly. At X-ray examination, usually in the upper lobes, less frequently in the VI segment, foci of different size with distinct contours are defined, often with the interspersing of single or multiple small dense or calcified foci. The same foci can be around tuberculoma or in other parts of the lungs. At the same time, pleural fusion and scars are visible. During the decay of tuberculoma, a crescent-shaped, less often centrally located enlightenment and an inflammatory pathway to the lung root is revealed; With the allocation of a significant part of the curdled masses, a wall of cavity wide with uneven inner contours. Tuberculomas usually do not respond well to antibiotic treatment and collapse therapy; The most effective method of treatment is the operative removal of the affected area of ​​the lung.

With the progression of various forms of pulmonary tuberculosis, caseous softening of the foci and the formation of cavities of decay occur. If infiltrative inflammation and foci of bronchogenic or hematogenous origin dissolve, and the cavity of disintegration of lung tissue persists, then cavernous pulmonary tuberculosis is diagnosed. It is often observed in connection with the widespread use of tuberculostatic therapy, under the influence of which fresh foci and areas of perifocal inflammation dissolve relatively quickly, the size of the cavity diminishes and its walls become thinner, but its complete closure and scarring does not occur.

Symptoms of intoxication, and if the cavern is small and deeply located in the pulmonary parenchyma, there is no atelectasis around it and no significant pleural reaction, then the physical changes are poorly expressed or absent (especially if the drainage bronchus is closed with a mucopurulent stopper, and even more obliterated: such blocked Cavities, even significant sizes, for a long time remain "mute"). With decay cavities with an open draining bronchus, which is not fully sanitized yet, bacterial excretion is a natural phenomenon. In the initial period of destruction, reticulocytosis appears, the lymphocyte content decreases, and a shift to the left in the leukocyte formula increases, with some of the neutrophils acquiring pathological granularity; ESR up to 30-40 mm / h. With the elimination of an acute outbreak of the process and its transition to cavernous tuberculosis, the hemogram and ESR normalize. Radiographically fresh and elastic caverns are located in a relatively unchanged lung tissue and often have a rounded shape. Cavities in the fibrous-sclerotic regions of the lung have irregular contours. Sanitized caverns are usually thin-walled and resemble cysts. Sometimes, at the lower pole of the cavern, there is a clear meniscuscular shadow of the fluid, shifting when the patient's position changes. This symptom, associated with a violation of the drainage function of the bronchi, acquires an important diagnostic value in the vague contours of the cavity. Inflammatory path to the root of the lung as the process involution disappears.

With the progression of various forms of pulmonary tuberculosis, fibro-cavernous tuberculosis develops. The disease proceeds long and wavy. In case of exacerbation, intoxication phenomena are manifested, cough and sputum increase, hemoptysis and pulmonary hemorrhages appear, new bronchogenic foci and decay sites are formed in various parts of the lungs, which is often promoted by tuberculous and nonspecific lesions of the bronchi. As the disease progresses, the intensity of oxidative processes decreases, dystrophic changes occur in various parts of the nervous and endocrine systems, arterial hypotension increases, and secretion of gastric juice decreases.

The condition worsens due to secondary specific (tuberculosis of the larynx or intestine) or nonspecific (amyloidosis of the parenchymal organs, pulmonary heart failure, etc.) complications. Auscultatory symptoms are usually pronounced. Patients are isolated with MT sputum. Significant pathological changes are noted in the hemogram and protein fractions of blood serum, an increase in ESR. Radiographically, fibro-indurative changes, pleural layers, dense or calcified foci are detected, and in their background, mainly in the upper parts of the lungs, caverns of various sizes are irregular, sometimes bean-shaped with a fibrous wall. When exacerbating, in addition, visible "soft" newly arisen foci, often in the middle or lower parts of the lungs. This form of tuberculosis is observed mainly in ineffectively treated patients, people suffering from alcoholism and drug addiction. The most common cause of death in fibro-cavernous tuberculosis is its progression and pulmonary-cardiac failure.

Cirrhotic tuberculosis of the lungs is the outcome of infiltrative, disseminated and fibro-ka-true tuberculosis in connection with the intensive formation of fibro-sclerotic changes in the lungs and the process activity is calming down. Bronchi and blood vessels are deformed, passive pleural changes develop, emphysema is expressed, the organs of the mediastinum are displaced. Patients complain of significant shortness of breath, sometimes of asthmatic nature, cough with sputum, often purulent, periodic hemoptysis. Dullness of the percussion sound, bronchial breathing, a large number of different types of rales. The boundaries of the heart are changed, its tones are muffled, the sharp accent of the 2nd tone on the pulmonary artery, the tendency to hypotension. With the development of the pulmonary heart, edema appears, the size of the liver increases, ascites arises. Complications are amyloidosis of the liver and kidneys. The hemogram and ESR correspond to the phase of the process. With exacerbation, MT appears in the sputum.

In cirrhosis as a result of the involution of infiltrative tuberculosis, a massive compaction and a decrease in the volume of the lobe or the entire lung are noted radiologically with a displacement of the trachea and the median shade towards the lesion, emphysema of the lower lobe of the same and opposite lung. Cirrhosis, formed against disseminated tuberculosis, differs by diffuse fibrotic sclerotic changes, the presence of disseminated dense or calcified foci, the upwardly rooted roots of the lungs, the medial location of the mediastinal organs (hanging, often the heart of the asthenic is the drip heart). Against this background, individual or multiple cavities can be identified (bullous-dystrophic changes or residual, often sanitized caverns). Emphysema of the lungs is sharply expressed. Cirrhotic tuberculosis of the lung is an irreversible process, usually proceeding for a long time, sluggishly, but with exacerbations. Treatment gives only a symptomatic effect.

Tuberculous pleurisy - inflammation of the pleura as a result of exposure to toxic substances, products of tissue decay or its specific damage with the formation of tubercle, caseous foci in the spread of the process from the lung or from the intrathoracic lymph nodes by contact, lymphogenous or hematogenous pathways.

Symptoms see Pleurisy. Usually exudate serous. An important diagnostic value is the detection in the exudates of MT. However, with a small number of them, the results of a bacterioscopic examination are usually negative. More often MT is found when sowing exudate on special nutrient media and when vaccinating it with guinea pigs. Purulent purulence is the result of suppuration of serous-fibrinous exudate or an acute primary purulent process on the basis of pleuroses rheumatism. An extremely serious condition is observed in patients with pleural empyema, which is rapidly developing as a result of violation of the integrity of the cavern. In a purulent liquid in 65-90% of cases MT is found. Hemorrhagic pleurisy is rare and occurs mostly in severe specific pleural lesions with the development of a miliary or caseous process. In a number of patients, hemorrhagic pleurisy is detected after a long-standing rigid pneumothorax has disappeared. Sometimes, to establish an etiological diagnosis, in addition to examining exudate, a pleural biopsy is used. These or other forms of tuberculous pleurisy occur most often in children and young people.

Tuberculosis of the upper respiratory tract, trachea, bronchi is usually a secondary process that complicates various forms of pulmonary tuberculosis and intrathoracic lymph nodes. The most important is bronchial tuberculosis, which occurs mainly in destructive and bacillary forms of the process in the lungs, as well as in the complicated course of bronchoadenitis. Its clinical signs are a strong paroxysmal cough, pain behind the sternum, shortness of breath, localized dry rales, atelectasis or emphysema bloating, "bloating" or blockage of the cavity, appearance of a liquid level in it. There may be an asymptomatic course. The diagnosis is confirmed by bronchoscopy, when infiltrates, ulcers, fistulas, granulations and scars are revealed, which often cause bronchial obstruction.

Rarely is there tuberculosis of the larynx: dryness, perspiration and burning in the throat, fatigue and hoarseness of the voice are noted, pain is independent or when swallowing. When narrowing the glottis as a result of infiltration, edema or scarring, there is a difficult stenotic breathing. The diagnosis of tuberculosis of the larynx is established with laryngoscopy. Tracheal tuberculosis is extremely rare; Manifested a stubborn, nauseating loud cough, pain behind the sternum and shortness of breath. The diagnosis is made with laryngotracheoscopy.

Among the forms of tuberculosis of the respiratory system, combined with pneumoconiosis, silico-tuberculosis is of the greatest practical importance. It occurs mainly in workers exposed to prolonged exposure to quartz dust (in mines for the extraction of gold and other metals, in coal mines, sandblasters, etc.). Tuberculosis, as a rule, joins silicosis. Most often, focal, less often other forms of pulmonary tuberculosis are detected. In addition, there are silicotuberculous bronchoadenitis, nodular or so-called massive silicotuberculosis. During the silicotuberculosis, two phases are conventionally isolated. The first (more often with focal tuberculosis) usually occurs without significant clinical signs, in the second, associated with the progression of tuberculosis, there is general weakness, fatigue, subfebrile, sweating, cough, wet wheezing in the lungs, sometimes in sputum, MT; The corresponding shifts in the hemogram are determined, the ESR is increased.

Radiologically, silicotuberculosis is characterized by changes typical of silicosis, in the form of nodules predominantly in the middle and lower sections of the lungs on the background of diffuse large-mesh fibrosis, tuberculous foci, infiltrates, caverns located mainly in the upper lobes of the lungs.

Treatment. The main method for all forms of tuberculosis is chemotherapy with drugs that affect MT. These include derivatives of isonicotinic acid hydrazide (isoniazid, or tubazid, phtivazide, metazide, saluside, etc.), ethambutol, protionamide and ethionamide, pyrazinamide, cycloserine, thioacetazone (tibon) and solutisone, sodium para-aminosalicylate (PAS K) and others ., As well as antibiotics: rifamp-picin (rifadin, benemycin), streptomycin, kanamycin, florimycin (viomycin). As a rule, three, at least two anti-TB drugs are used simultaneously for a long period (6-12 meshes more), taking into account their tolerability and sensitivity of MT. The daily dose of all medications is usually prescribed in a single dose, except for ethionamide, protionamide, pyrazinamide, cycloserine, thioacetazone and PASC, which take in divided doses 2-3 meals per day after meals. At the beginning of the daily treatment, and after a certain period they switch to intermittent therapy (2-3 times a week). It is important that the treatment is regular and constantly monitored by medical personnel both in the hospital and in the outpatient setting. To prevent and eliminate adverse reactions, desensitizing agents (sometimes glucocorticoids), vitamins, etc. are used.

Chemotherapy is combined with other methods of treatment aimed at restoring the physiological state of the body and increasing its resistance to infection. These include a certain regime, rational nutrition, aerotherapy, tempering procedures, sanatorium treatment in different climatic conditions, some physiotherapy methods of treatment (electrophoresis, inductothermy, etc.). Relatively rarely use different types of collapse, in particular, artificial pneumothorax. With no prospects for conservative therapy, a significant role is played by surgical methods (mainly resection of the affected parts of the lungs and intrathoracic lymph nodes); The surgery is performed with chemotherapy.

When hemoptysis or pulmonary hemorrhage apply aminocaproic acid, vikasol, transfusions of fresh frozen plasma, sometimes resort to surgery. Rational treatment allows 90-95% of newly diagnosed patients to stop bacterial excretion, in 80-90% - to close caverns in the lungs.

Prevention includes social and preventive and sanitary-hygienic measures to improve the living, working and living conditions of the population, physical culture and sports. Vaccine vaccinations BCG are carried out in the USSR in all newborns, as well as uninfected children and adolescents 7,12 and 17 years. Negative TB patients under 30 years of age are revaccinated every 7 years. Chemoprophylaxis is shown primarily to children, adolescents and adults who have close contact with patients who isolated MT, as well as children and adolescents with a pronounced reaction to Mantoux and others at increased risk of disease. To this end, isoniazid is usually used (10 mg / kg once daily for 2-3 months twice a year for 1 to 2 years).

For the timely detection of tuberculosis patients, tuberculin samples are used; Streets older than 12 years, fluorography, which is carried out at least 1 time in 1-2 years. This survey is subject to all residents of cities and rural areas. In regular preventive examinations, people who are in contact with bacillary patients, workers in medical and prophylactic institutions, orphanages and orchards, students and school employees, public transport workers, the food industry, consumer services, workers in harmful industries, etc., are especially in need. Less than once a year they examine those who have recovered from tuberculosis, as well as those who have traces of a tubercular process that has been unnoticed in the past.