Tuberculosis

Tuberculosis . Early tuberculous intoxication. Increased fatigue, irritability, headache, decreased appetite, poor weight gain, unstable subfebrile condition. Enlarged peripheral lymph nodes of soft-elastic consistency; Sometimes the phenomena of periadenitis. Many children are diagnosed with bronchitis, tachycardia, in young children - dyspeptic disorders, pain in the abdominal cavity, sometimes enlargement of the liver and spleen. All these symptoms coincide in time with the curve of sensitivity to tuberculin in the Mantoux sample. The Mantoux test is stably positive, often its intensity increases. In the blood-lymphocytosis, eosinophilia, increased ESR. The protein fraction of albumins is reduced, the globulins and fibrinogen are increased. Radiographic examination of the lungs reveals an increase in the vascular pattern. Outcome: recovery without treatment, transition to chronic tuberculous intoxication, into local forms of tuberculosis.

Chronic tuberculous intoxication. Letharginess, fatigue, irritability, periodic subfebrile condition, pale skin, poor appetite, decreased tissue turgor, and backwardness in physical development are characteristic. Especially characteristic are peripheral lymph nodes that are densified, enlarged, changed in their configuration, sometimes soldered, multiple; The number of groups is increased. The Mantoux test is positive for more than 1 year, but is less intense compared to local forms of tuberculosis.

The disease is more common in older children, it proceeds for a long time, wave-like. In this period, recurrent flickens, chronic blepharitis, keratoconjunctivitis are often observed.

Differentiate necessary from chronic tonsillitis, sinusitis, latent current rheumatism, chronic cholecystitis, pyelonephritis, chronic eating disorders and digestion.

Primary tuberculosis complex. The onset of the disease can be acute, subacute, sometimes occurs under the guise of acute pneumonia, influenza, pleurisy, and may be asymptomatic. The nature of the temperature reaction and its duration are different. The child's state of health suffers little, rarely marked symptoms of intoxication, cough, shortness of breath. Physical data is usually scarce. Sometimes there is a noticeable shortening of the percussion sound, a slightly weakened or harsh breathing in this area. Dry and wet rales are heard less often. In the blood-leukocytosis, moderate neutrophilia, elevated ESR, with process silencing - eosinophilia and lymphocytosis. The Mantoux test is positive, the graded skin test can be equalizing or paradoxical. Radiographically, a darkening is defined, not completely homogeneous, associated with a "path" with the root of the lungs, or bipolarity. Often, the primary complex is complicated by pleurisy, rarely there are limited hematogenous or lymphogematogenic disseminations, usually on the side of the lesion.

Distinguish the infiltrative phase, which gradually goes into the phase of compaction and resorption. Then follows the phase of petrification.

Differentiate is necessary from acute and chronic nonspecific pneumonia.

Bronchoadenitis is more common than the primary tuberculosis complex. Clinical manifestations depend on the extent of damage and the prevalence of the process in the lymph nodes and the root of the lung. Conditionally distinguish infiltrative and tumor-like (tumorous) bronchoadenitis. The latter occurs in young children, sometimes in adolescents. The onset of the disease is usually subacute. There are general symptoms of tuberculous intoxication, fever, malaise, decreased appetite, bronchoadenitis often occurs asymptomatically or with few symptoms. With the infiltrative form of bronchoadenitis, percussion and auscultatory symptoms are absent, they are found only in severe forms of tumor necrosis bronchodenitis. In the presence of compression symptoms, there is an expiratory stridor, a bitonal and a pertussis-like cough. Expansion of the capillary network in the region of the 7th cervical and 1 thoracic vertebra (Frank's symptom) or the expansion of the subcutaneous veins in the upper chest and back. Shortening of percussion sound in the paravertebral region, usually on one side. Sometimes a positive symptom of the Koran. In the area of ​​shortening of percussion sound, the breathing is weakened or rigid. Rarely dry rales are heard, determined by the symptom of D'Espin. Radiographically determined increase in root size, the root shadow is less differentiated, the border is outwardly aligned, fuzzy, fuzzy. With tubercular bronchoadenitis, an isolated shadow of the lymph node or bulging protrusions are found, which are especially clearly visible on the roentgenogram in the lateral position. One-sidedness of defeat is characteristic. Tomography helps to detect the deformation of the discharge bronchus, as well as the lymph nodes. The changes in blood are the same as in the primary complex. Mycobacterium tuberculosis can sometimes be found in the washing waters of the stomach and bronchi. Tuberculin samples are positive.

The most frequent complication of tuberculous bronchoadenitis and the primary complex is changes in the trachea and bronchi adjacent to the lymph nodes affected by tuberculosis. The changes are of the nature of endobronchitis, which occurs in the form of infiltrates, ulcers, fistula and scars. Clinical symptoms of bronchial tuberculosis may be absent, with severe damage, there is a severe dry cough, stridor breathing, the formation of atelectasis or emphysema bloating.

Acute miliary tuberculosis is more common in young children and proceeds under the guise of an acute infectious disease. Harbinger of the general process of miliarization are the general symptoms of intoxication: lethargy, irritability, loss of appetite, headache, sometimes febrile condition. Often the disease begins acutely, with severe general phenomena, the temperature rises to high figures, dyspnea, cyanosis appears; The pulse is fast and weak. Physical data in the lungs are weakly expressed. The liver and spleen are enlarged. Occasionally, the skin is tuberculides. In the blood - a shift of neutrophils to the left, increased ESR; In the urine - positive diazoreaction. The Mantoux test of the positive sometimes becomes negative. Radiographic examination reveals a diffuse decrease in the transparency of the pulmonary fields or typical symmetrically located miliary eruptions in both lungs. Acute miliary tuberculosis is often complicated by meningitis, pleurisy and other organ damage. Differentiate follows from influenza, acute interstitial pneumonia, toxicosis state.

Hematogenous disseminated pulmonary tuberculosis (subacute and chronic). In children of senior school age, the disease develops gradually and often unnoticed. At the beginning of the process, symptoms of general chronic intoxication are observed: fatigue, headache, irritability, appetite worsens. There is pallor of the skin, children grow thin. The temperature gives a swing to 38 * C or is set to subfebrile digits. In a number of cases, the disease occurs under the mask of repeated respiratory-viral diseases, chronic bronchitis. With percussion of the lungs there is a dull-tymponic sound, limiting the mobility of the edges of the lungs. Auscultative changes are meager; Breathing in places hard, wheezing dry, less damp, scattered, unstable. The liver and spleen are enlarged. Radiographically, foci of different sizes and densities are located symmetrically in both pulmonary fields, the pulmonary pattern is mesh, sometimes emphysema. Often observed exudative pleurisy, lymphadenitis. Tuberculin samples are positive.

Meningitis tuberculosis often develops gradually. During the course of meningitis, it is possible to trace the sequence of development of the periods of the disease: prodromal, irritation and paralytic periods. In the prodromal period there is a slight lethargy, drowsiness; Irritability, pallor, worsening of appetite, mild headache, fever. The most typical symptoms of the first meningitis period include the appearance of vomiting, a permanent headache, drowsiness; Constipation develops; The temperature is elevated or normal. Then, vasomotor disorders begin to appear in the form of red persistent dermographism, sometimes rapidly passing erythema on the body (Tricso patches). There is hyperesthesia, sharply increased headache. Signs of irritation of the meninges are expressed: rigidity of the occipital muscles, symptoms of Kernig, Brudzinsky, Lassega. In this period, eye symptoms are noted - paresis of cranial nerves, eyelids wide open, rare flashing, motionless glance, wide, sluggish pupils, nystagmus, strabismus reacting to light. The pulse slows down; The abdomen is dragon-shaped.

Then there is a period of paralysis: pronounced drowsiness, lack of consciousness, prostration, there may be seizures, ptosis of the eyelids, respiratory distress. The position of the child is on the side with the head thrown back. Children of the first 3 years of life often have an acute onset, anxiety, and not drowsiness, characteristic of older age. The duration of the illness periods is shorter; More often there is a serious condition, less pronounced meningeal symptoms. Of great importance are the early symptoms of hydrocephalus (tympanic skull with percussion and protrusion of a large fontanel) and the appearance of seizures in the first 2 weeks of the disease.

Crucial for diagnosis is the study of cerebrospinal fluid. With tuberculous meningitis, the fluid is clear; Can be opalescent. The Pandi reaction and other globulin reactions are positive, the protein level rises to 0.033-0.09%; Pleocytosis is small, in the initial period there is a mixed-lymphocyte-neutrophilic, later-lymphocytic. The sugar content drops to 15-45 mg%, the amount of chlorides decreases. When standing after 12-24 hours, a tender film falls out, in which tuberculous mycobacteria are found.

Important is also the presence of a positive Mantoux test with its subsequent extinction. Often, tubercular meningitis is difficult to distinguish from other forms of meningitis. First of all, it is necessary to exclude viral serous meningitis, then meningococcal and purulent meningitis, meningoencephalitis. Less often it is necessary to differentiate in the initial period from respiratory-viral infections, pneumonia, typhoid fever.

Pleurisy is tuberculous. With serous pleurisy, acute onset, elevated temperature, pain in the side, dry cough, shortness of breath. The sick side lags behind when breathing, voice breath is weakened. The percussion sound is considerably shortened, the Sokolov-Damuazo lines are defined, the triangles of Groco-Rauchfussa. Breath weakened or absent, over exudate - sometimes with bronchial shade. Noise of friction of the pleura at the beginning of the disease and with resorption of exudate. The Mantoux test is positive.

When X-ray examination is a characteristic picture. When puncturing a serous fluid with a predominance of lymphocyte exudates, neutrophils may predominate at the onset of the disease. Occasionally, bacterial mycobacterium tuberculosis is detected in the exudate. If necessary, sowing and inoculation to guinea pigs should be performed. In the blood-leukocytosis and elevated ESR.

Fibrinous pleurisy occurs in children quite often. The disease often begins subacute, fever, weakness, dry cough, pain in the side, the pleural friction noise is heard. Differential diagnosis is carried out with viral and allergic pleuritis, croupous pneumonia.

Tuberculosis of mesenteric lymph nodes. The main complaints are periodic pain in the abdomen, more often in the navel, which does not depend on food intake. Often there is constipation, less often diarrhea, at times nausea, vomiting. There are always marked manifestations of tuberculous intoxication. When palpation is noted tenderness in different parts of the abdominal cavity, the pain points of Stenberg can be detected at the sites of attachment of the peritoneum (on the right 2-5 cm above the point of McBurney and on the left at level II of the lumbar vertebra). In case of tumor-like enlargement of mesenteric lymph nodes in the region of the mesentery root, small, clearly defined rounded tumors are probed (after cleansing of the intestine); In the perifocal reaction around the nodes, their contours are indistinct.

When rectal examination, deep-lying enlarged lymph nodes are sometimes prominent. Diagnosis is assisted by contrast radiography of the intestine. Tuberculin samples are positive. Differential diagnosis should be carried out with nonspecific mezadenitis, chronic appendicitis, cholecystitis, pseudotuberculosis, neoplasms in the abdominal cavity, cholelithiasis and urolithiasis, and helminthic invasions.

Tuberculosis of peripheral lymph nodes. Tuberculous lymphadenitis develops in children in the period of the current primary tuberculosis with lymphogenically disseminated infection. It is possible to develop a primary isolated lesion of the cervical or vertebral lymph nodes when the mycobacterium tuberculosis penetrates through the tonsils or the oral cavity. Axillary and inguinal lymph nodes are less often affected. Clinical manifestations of the disease depend on local changes in the lymph nodes and the activity of the overall tuberculosis process. In the infiltrative process or in the period of decay of the nodes, the general condition of the child worsens, there is a rise in temperature, weight loss, cough often increases, and ESR increases. The intensity of the Mantoux test is increasing.

When palpation is determined by a package of dense, mobile. Painless, partially welded together lymph nodes. When caseous decay occurs, the nodes are emptied of the caseous masses with the subsequent formation of scars. In untreated children of early age, lymph nodes can melt, forming fistulas followed by a prolonged course.

Tubercular lymphadenitis in a number of cases has to be differentiated from lymphogranulomatosis, benign and malignant tumors (cysts, lymphosarcoma, etc.).

Treatment is complex, long, continuous, stage. It is necessary to create the correct regime: sufficient sleep, daytime rest, long stay in the fresh air. For tempering the body using air baths, water procedures, physical therapy. Physical and mental loads should be reduced. Only with decompensated forms of tuberculosis or in the acute period of the disease is needed a bed rest with a wide use of fresh air.

The food should be high-grade and contain an increased number of animal proteins, fresh fruits, vegetables and, in addition, vitamins, especially C, B1, B2, A and nicotinic acid. A complex of vitamins B can be added as a yeast drink. It is recommended to increase the daily calorific value by 15-20%.

Children with early and chronic tuberculous intoxication should be referred to a hospital in order to exclude other similar diseases in the clinical picture and prevent the development of local forms of tuberculosis.

The main method of treating children with tuberculosis is the use of tuberculostatic drugs. Children with early and chronic tuberculosis intoxication are prescribed two basic chemotherapeutic drugs - tubazid or ftivazid and PASK for at least 6 months. Then they are sent to a sanatorium. Doses of the drug, see in Table. 14.

Children with local forms of tuberculosis are treated in a hospital until the activity of the process subsides, then they are sent to a sanatorium until complete clinical recovery.

With the primary tuberculosis complex, bronchoadenitis in the infiltration phase, three main agents are used: streptomycin, preparations of the GIN K group (tubazid, phtivazide, metazide, salusid, etc.) and PASK for 1.5-2, less than 3 months, then streptomycin is canceled and treatment is continued Two of these drugs lasting at least 8 months; With tumescent bronchoadenitis - not less than 1-1,5 years. With bronchoadenitis and the primary complex in the consolidation and calcination phase, tubazid and PASK are prescribed; In the absence of clinical signs of activity - for 3 months, if there is activity - for 6-8 months.

With miliary and hematogenically disseminated tuberculosis, the administration of streptomycin, a drug of the GINK and PASK group, lasts from 3 to 6 months with the subsequent administration of two drugs (tubazid and PASK) for a period of at least 1.5 years.

If bronhoadenitis is complicated by bronchial tuberculosis, then inject a solutisone in the form of an aerosol in 1-2% solution in an amount of 1.5-3 ml; Course of treatment 1-2 months.

Only with the development of direct or cross resistance of mycobacterium tuberculosis to tuberculostatistical drugs of the 1st row, in the absence of clinical effect, when there are no signs of improvement during 1.5-2.5 months or there is an exacerbation or complication of the process against the background of the treatment, II series drugs are used. They are weaker and more toxic. At present, new drugs are being used increasingly: ethambutol, rifampicin, rifamycin. They are close in their activities to the preparations of the GINC group, are well absorbed, low-toxic, do not have cross-resistance. Treatment is carried out in combination with preparations of the GINC group.

With long-term use of anti-TB drugs, side effects develop: dizziness, headache, fever, allergic rash, eosinophilia in the blood. With the reception of PASK, tibona possible pain in the abdomen, nausea, vomiting, flatulence.

In order to reduce the gourealergic condition, the exudative phase is sometimes prescribed corticosteroid preparations (prednisolone, etc.). Duration of treatment is 1.5-2 months with simultaneous massive chemotherapy. Indications for the use of hormonal drugs: tuberculosis of serous membranes (pleurisy, meningitis, peritonitis), infiltrative lesions of the lungs, acute dissaminic forms of tuberculosis, atelectasis, cavity decay.

To prevent side effects of drugs from the GINC group, vitamin B6 is injected in / m in the form of a 2.5-5% solution of 0.5-1 ml every other day for 1.5-2 months, vitamins B12 and B1, glutamic acid.

To remove the allergic reaction that occurs when streptomycin is administered, calcium pantothenate is prescribed at 0.4-0.8 g / day in 2 doses during the entire course of streptomycin treatment.

When treated with cycloserine, glutamic acid is given at 1.5-2 g / day, ATP is administered per 1 ml of 1% solution for 1-1.5 months and vitamin B6. For the purpose of hyposensibilization, calcium gluconate, dimedrop, suprastin or diprazine is prescribed. To improve metabolism and improve liver function, the administration of vitamin 6,5 (calcium pangamate), cocarboxylase, ATP, vitamin B12 at age dosages is indicated; With poor appetite - gastric juice, apilac.

Stimulant therapy is used in children with chronic tuberculosis intoxication, which is difficult to treat, and then with chronic course of primary tuberculosis in children who do not have long compensation for the process. With this chain is introduced gamma globulin, aloe, according to indications, a plasma transfusion is performed. Sunbaths are shown in extrapulmonary forms of tuberculosis (lymphadenitis of the cervical lymph nodes, tuberculosis of the bones, mazadenitis), chronic tuberculous intoxication.