Pulmonary tuberculosis

Description:

The name of a disease tuberculosis came from the word tuberculum, in translation from Latin designating a hillock.
Tuberculosis is the infectious disease of lungs caused by a mycobacterium of a human, intermediate or bull look with development of a characteristic specific inflammation with the general reaction of an organism. Tuberculosis not only people, but also animals, in particular, cattle, hens and pigs have.
The pulmonary tuberculosis is known for a long time. The disease was called a tuberculosis that is caused by gradual "zachakhaniye" of the person.
Up to the 20th century the pulmonary tuberculosis was incurable, the diseased inevitably died. Now incidence of tuberculosis though decreased, but remains quite high therefore speak about tuberculosis epidemic. More often women, elderly people and children get sick with tuberculosis. Tuberculosis mortality makes up to 2 million people a year. Statistical data say that a third of the population of the planet are infected with mycobacteria.

Pulmonary tuberculosis reasons:

The pulmonary tuberculosis is most often caused by one of three types of mycobacteria – human, intermediate or bull type. Except specified, there are about 70 more types which freely live in the environment and have no epidemiological value. Ability of a mycobacterium to cause a disease  it is caused by virulence and pathogenicity. Aggression of a microbe in relation to an organism directly depends on environment conditions.
Mycobacteria of a bull look have bigger epidemiological value at alimentary infection, is preferential in rural areas. M. avium is an etiological agent at tuberculosis at an immunodeficiency.
Cells of mycobacteria are not prokariota, do not incorporate Goldzhi's complex, lysosomes, a plasmid. The microbe has the stick form (the old name – Koch's stick), reaches the ends of a bacterium of a zaokruglena, the size 1 on 10 microns. They have no flagellums therefore are not mobile. The cell wall of a mycobacterium consists of polysaccharides that provides protection of a bacterium against unfavorable conditions, stability of the sizes of a cell. Besides, the cell wall in connection with the content of phospholipids is a virulence factor.  Special specific proteins – tuberkuloproteida (tuberculine) which bear on themselves antigenic function are a part of a mycobacterium. Carrying out hypersensitivity reactions to tuberculine is based on this fact. Resistance to effect of alkalis and acids is provided by lipid fraction.

Pathogeny:

The main way of infection at tuberculosis is aerogenic, contact, alimentary and transplacental ways have smaller value.
Normal the respiratory path protects from penetration of various infectious agents, including mycobacteria. It becomes possible as a result of products of slime scyphoid cells of a respiratory epithelium and to the physiological wavy movements of a ciliary epithelium. In the presence of diseases of a respiratory organs or influence of toxic substances on mucous a respiratory path, passing protective barriers, mycobacteria get into bronchioles, and then into alveoluses. At infection with such way the probability of infection is highest.
The probability of alimentary infection with tuberculosis depends on a condition of the soaking-up function of intestines.
Mycobacteria are extracellular parasites and therefore their presence at the initial stage of a disease is not shown in any way. This stage of a pathogeny of a tuberculosis infection carries the name "latent mikrobizm". Then pathogenic microbes get to absorbent vessels, lymph nodes and with current of a lymph extend on all organism. This stage has the name of primary mikobakteriyemiya. First of all bodies with the developed microcirculation – lungs, lymph nodes, an epiphysis and metaphyses of bones, adrenal glands, generative organs suffer). Despite lack of any immunity of an organism at primary infection and the sharp jump of growth of mycobacteria caused by this fact, in the place of implementation of a microbe begins phagocytosis. Polynuclear leukocytes which the first come into contact to Koch's stick perish because of weak bactericidal action. The second reacts macrophages, however under the influence of virulence factors macrophages lose the viability. After that, mycobacteria leave in intercellular space that is characteristic of a stage of incomplete phagocytosis.
Clinical displays of tuberculosis are shown at inefficiency of phagocytosis therefore there is an uncontrollable rapid growth of mycobacteria. An exit in intercellular space of a large amount of proteolytic enzymes leads to peculiar "fluidifying of fabrics" that promotes further progressing of a disease. Specific manifestation is formation of the centers of a caseous necrosis with further education of tubercular granulomas.

Pulmonary tuberculosis symptoms:

Clinical manifestations at tuberculosis comes not at once. Even it is long the existing tubercular process can proceed in the hidden or erased form, the patient can not guess existence of a disease.
Nonspecific symptom of tuberculosis is intoksikatsionny reaction: insignificant rise it is long the remaining body temperature, asthenic manifestations, the increased perspiration at night, weight loss is possible. In the same time increase in lymph nodes in the form of a limited or generalized limfoadenopatiya is noted. Then respiratory symptoms join, the patient notes cough with a phlegm, the catarral phenomena, thorax pain.

Diagnosis:

Diagnosis of a pulmonary tuberculosis is based not only on clinical data, but also additional researches: the analysis of a phlegm, detection of mycobacteria in a phlegm and other emitted organism liquids, bacteriological, serological and molecular and biological methods. The microbiological research of a phlegm allows to find in it mycobacteria and then and to define their sensitivity to certain drugs. Samples of a phlegm it is necessary to place in special containers which happen 2 types: one-time plastic test tubes or glass vessels which can be reused after sterilization. Except a phlegm, samples of smears from a throat, washing waters of bronchial tubes and a stomach are subject to a research. The intake of washing waters from bronchial tubes demands carrying out anesthesia. For the procedure use 20 ml of normal saline solution which is entered special guttural syringes.
The further diagnostic program of a pulmonary tuberculosis includes a bronkhoskopiya, a research of pleural liquid, a biopsy of a pleura and lung.
PTsR-diagnosis of tuberculosis was widely adopted recently. The method of polymerase chain reaction is based on identification of DNA of a mycobacterium, found in the studied samples. This method has exclusive advantage – the results of a research can be known in 5-6 hours.
However the most available diagnostic method of pulmonary tuberculosis is radiological inspection which is possible for carrying out in the form of a X-ray analysis, roentgenoscopy, a tomography or fluorography.
Primary detectability of a tubrkulez is carried out by means of the mass fluorography which is carried out in policlinics at least once a year. Special danger is constituted by the so-called "dekretirovanny contingent" - employees of the food industry, medical employees, etc. The increased risk of a disease is observed at patients with a diabetes mellitus, the patients receiving immunosuppressants (glucocorticoids and cytostatics). At detection of pathological changes in lungs at a flyuorogramma, the patient should be sent for further inspection in the conditions of a tubdispanser. The program of mass fluorographic inspection in our country allowed to increase detectability of tuberculosis already at early stages of a disease. The X-ray analysis of bodies of a chest cavity allows to specify the diagnosis and to define localization and a form in the presence of tubercular process. Pathological elements can have various form, an arrangement, the sizes. Quite often the phenomena of a pneumofibrosis,  bronchiectasias and emphysema of lungs come to light. Detection of the calcinated centers indicates the inactive or postponed in the anamnesis tubercular process. Carrying out a tomography and MRT will allow to specify data.

Mantoux reaction (tuberculinodiagnosis):

Koch prepared the first tuberculine by a water extract from the bacteria received at crops in a test tube. Further the equipment was improved. The "Old tuberculine of Koch" in abbreviated form designated by ATK is made of cultures of mycobacteria of tuberculosis (bull and human strains in equal quantity), grown up for 4% beef-extract (now – glyceric) broth.
As the international unit of tuberculine its such quantity which does not cause too strong reactions is accepted, but gives positive reactions at 80-90% of the persons infected with tuberculosis. The international unit – 1 THOSE is on the basis of PPD-S tuberculine contains 0,00002 mg of pure drug, on the basis of PPD-L – 0,00006 mg.
Tuberculine in standard cultivation and the specified dose is obligatory at mass inspections. In clinical practice, except Mantoux reaction about 2 THOSE, it is possible to apply Mantoux reaction with various doses of tuberculine and other methods of a research of sensitivity to tuberculine of PPD-L or ATK (the graduated skin test, hypodermic test of Koch, definition of a tuberkulinovy caption, eosinophilic туберкулиновая, haemo - and proteinaceous туберкулиновые tests, etc.).
Tuberkulinovy reaction is allergic reaction of the slowed-down type. Interaction of a tuberkuloprotein (antigen) with immune lymphocytes on which surface antibodies are fixed is its cornerstone. The mechanism of skin tuberkulinovy reaction (Mantoux test) can be presented as follows. To an injection site of tuberculine lymphocytes, sensibilized to tuberculine migrate from the moment of infection of an organism with tuberculosis. The last adsorb on the surface allergen – tuberculine. At interaction of lymphocytes with tuberculine biologically active agents influencing a vascular wall and surrounding fabrics are emitted. There is an inflammatory process in the form of a papule and a hyperemia in a reaction zone.
Data on a histologic structure of a tuberkulinovy papule are various. Before the papule was considered as an analog of a tuberculous focus with specific elements inherent to it. Further researches testify to lack of signs of a specific inflammation in the daddy. Only at sharply expressed, and also repeated reactions on site of the former tuberkulinovy tests slight elements of a specific inflammation can be observed.
In the clinical practician use an intracutaneous test with tuberculine – Mantoux reaction.
It is better to carry out Mantoux reaction on border between an upper and average third or in an average third of a front surface of a forearm. The conducted researches show that despite the lack of reliable distinctions of the average sizes of papules in 48 h and 72 h after administration of tuberculine, it is necessary to consider that to 72 h development of skin reaction to tuberculine in most cases comes to the end. Therefore if it is necessary to be limited to the single account result of a tuberculinodiagnosis, then it should be seen off in 72 h. The amount of reaction in mm is considered on a half-sum of cross diameters of a papule, at the odd sum – with exceeding. Test is recognized a papule of 5 mm, positive at the size, and more. At doubtful (3-4 mm) or negative test on cultivation No. 4 ATK or on 2 THOSE PPD repeat test with more strong solution – cultivation No. 3, then - No. 2, alternating the right and left forearm. At positive reaction to the specified concentration test with more considerable cultivations of tuberculine can be put. The greatest cultivation on which reaction in the form of a papule not less than 5 mm is received (or 3 mm on cultivation No. 5 and No. 6) designates a threshold of skin sensitivity to tuberculine. Process of its definition is called titration.
For acceleration of titration put simultaneous statement of tests with cultivations No. 4 into practice (on one forearm), No. 5 and No. 6 (on another). A sensitivity threshold on cultivation No. 5 above, reactions to test about 1 THOSE more than 19 mm, on test about 2 THOSE more than 22 mm, and also reaction with a vesicle, a lymphangitis, lymphadenitis characterize sharply increased tuberkulinovy sensitivity – a hyperergy; the sensitivity threshold on cultivation No. 3 characterizes a hypergia below. Papules of 5-19 mm in size on test about 1 THOSE and 8-22 mm on test about 2 THOSE are estimated as normergichesky. It is necessary to remember that for mass diagnosis only 2 THOSE tuberculines are used. At giperergichesky at children and teenagers reactions reckon with the size of papule of 17 mm, adults have 21 mm and above.
As it was already noted, term is 48072 hours optimum for the account Mantoux reaction. Reaction develops as follows. In 1,5 hours after administration of solution there is a resorption of a tuberkulinovy tumor – "a lemon crust", reaction of skin in the form of a pink spot appears by 2 o'clock. From 4 h some patients, to 8 h – at most of them have softish, watery papules of pink color. By 12 o'clock these early papules ripen, reach the maximum size. To 14 h a part, at 16-20 h at most of patients has a differentiation of an early papule: in the center there is a consolidation with more intensive coloring, i.e. the main papule on which Mantoux reaction is estimated further arises. To 24 h almost always the differentiation is finished. In the center the main papule, skin on site of an early papule is hyperemic. To 48 h at all patients the juicy papule and a bright hyperemia around it is noted. To 72 h the papule becomes more compact. To 96 h its wrinkling begins, to 120 h involution is already considerably expressed. The papule as it is correct, disappears for 5-7 days, pigmentation – a test trace – can remain about one month and even more depending on the nature of the former reaction and specific features of skin.
Repeated tests should be carried out in other places because on site old test reaction is more expressed, arises quicker and dies away that complicates comparability and assessment of reaction.
Reaction can arise on site once carried out tests at repeated administration of tuberculine on the new place. The phenomenon of "ignition" of reaction is connected with fixing by tuberculine fabrics in the place of old tests or cell-bound immune complexes in a cell. Fixing comes in 5-10 minutes and lasts for many weeks.

External factors and features of internal environment of an organism influence results of tuberkulinovy tests. A certain impact on results of a tuberculinodiagnosis is exerted by age and sexual distinctions. A little big sensitivity of skin to tuberculine at healthy women, and also less expressed, than at men is noted, the tendency to easing is reactions with age.  Weakening of tuberkulinovy reactions at the healthy contingents infected with tuberculosis in process of increase in their age is connected usually with two factors: decrease in a role of the supporting antigenic influence of superinfection and age changes of reactivity of skin.
A number of authors note change of sensitivity to tuberculine seasonally. There are data on strengthening in the spring and reduction in the fall.
Professional factors take place. Strengthening of reaction is noted during the long work with lead or chrome, at the working factories producing synthetic rubber at textile workers and chemists.
Some authors point to decrease in intensity of reactions during the periods of periods, pregnancy and childbirth, and its strengthening in a puerperal period. Oppression of tuberkulinovy reaction (false-negative Mantoux reaction) is observed at a number of the factors weakening an organism: alcoholism, defective food, burns, avitaminosis With, a rengenooblucheniya, long fervescence. Influence of a number of medicines on tuberkulinovy reaction is established: its false positive result is observed at use of drugs of iodine, penicillin, Norsulfazolum. The false-negative Mantoux test is possible at use of antihistaminic drugs, pyrogenal, iron-ascorbic acid, a pyridoxine, Butadionum, Rutinum and drugs of bromine. Weakening of reaction on the inflamed skin, on the sites of skin affected with nonspecific diseases is noted (eels, psoriasis). Reaction at a xeroderma decreases, a venous hyperemia. Radiation of skin small doses of X-ray leads to strengthening of tuberkulinovy reaction, use of averages and high doses – to easing.
False-negative Mantoux reaction is noted at use of glucocorticosteroid drugs, and reaction strengthening – at a thyrotoxicosis. The hypothyroidism promotes weakening of reaction. The expressed reactions are noted at the women inclined to completeness.
According to some authors, giperergichesky Mantoux tests decide 5 times more often at persons on mental disorders, and negative tests – at measles.

Treatment of the Pulmonary tuberculosis:

Treatment of tuberculosis assumes a complex medicamentous, and at not need and surgical treatment. The therapy of tuberculosis which is carried out in a tubstatsionara  sanatoria, carried out against the background of rational and individual the mode of maintaining the patient allows to achieve high effect. The regime moments include rest, clinical nutrition, natural and hardware physical therapy. It is necessary to take a form and a phase of tubercular process, existence of associated diseases into account. There are 3 options of the motive mode: the mode of absolute rest sparing and training options. The leading role is assigned to use of chemotherapy. Use of antituberculous remedies provides tuberculostatic effect, i.e. suppression of reproduction of mycobacteria, decrease in their virulence and activity. It is especially important to use chemotherapeutic drugs rationally to avoid transition of acute process in chronic, and to prevent
The pulmonary tuberculosis is the indication for carrying out specific chemotherapy. Treatment of tuberculosis assumes a complex medicamentous, and at not need and surgical treatment. The therapy of tuberculosis which is carried out in a tubstatsionara  sanatoria, carried out against the background of rational and individual the mode of maintaining the patient allows to achieve high effect. The regime moments include rest, clinical nutrition, natural and hardware physical therapy. It is necessary to take a form and a phase of tubercular process, existence of associated diseases into account. There are 3 options of the motive mode: the mode of absolute rest sparing and training options.
The pulmonary tuberculosis is the indication for carrying out specific chemotherapy. Antitubercular drugs divide into the main and reserve groups.
Drugs of the 1st row are the following medicines: an isoniazid (Tubazidum) and its derivatives (Saluzidum, Ftivazidum and others), PASK  and streptomycin, and also streptomycin combinations with pantothenic and ascorbic acid. There is a separate group of the combined antitubercular drugs – Pasomycinum and стрептосалюзид.
Antitubercular drugs divide into the main and reserve groups.
Drugs of the 1st row are the following medicines: an isoniazid (Tubazidum) and its derivatives (Saluzidum, Ftivazidum and others), PASK  and streptomycin, and also streptomycin combinations with pantothenic and ascorbic acid. There is a separate group of the combined antitubercular drugs – Pasomycinum and стрептосалюзид.
Tuberkulostatiki of the reserve choice are drugs of the 2nd row. Kanamycinum, Etioniamidum, Cycloserinum and others concern to them. New antitubercular drugs which began to apply recently differ in bigger efficiency (rifampicin and Ethambutolum).
Isoniazid (Tubazidum) drug-tubostatik of the first row of the choice. Course duration an isoniazid depends on a condition of the patient, his weight, portability of this drug and other factors. The daily dose of an isoniazid makes 0,6 g. Elderly patients, and also patients weighing less than 55 kg should appoint minimum effective doses – 0,3 g a day. Purpose of an isoniazid demands a combination with other antitubercular drugs. Monotherapy by an isoniazid is admissible only in couples a polyvalent allergy to other tubulostatik, or in case of an aftercare after active therapy.
Streptomycin as antitubercular drug, is known long ago. Now streptomycin salts – sulfate or a calcium chloride complex are used. Bigger distribution complex drugs of streptomycin – стрептодимицин, dihydrostreptomycin bought ascorbas and dihydrostreptomycin pantothenate.  Streptomycin sulfate is applied not only at pulmonary tuberculosis, but also at extra pulmonary defeats. A form of administration of sulfate of streptomycin – intramuscular injections. A dose – 1.0 g a day. It is necessary to reduce a drug dose to 0,5 g with a small weight or advanced age of the patient. It is necessary to appoint an aerosol way of administration of this drug at endobronchial tuberculosis, for this purpose 200 000 PIECES of drug dissolve in 2 ml of physical solution and carry out inhalations.
Drugs PASK  do not use as independent treatment of a pulmonary tuberculosis, and apply in a combination with streptomitsidy or an isoniazid.
Simultaneous uses of drugs of various therapeutic groups promotes delay of development of medicinal stability of sticks of Koch that increases efficiency of antitubercular treatment. Besides, at such scheme of treatment it is simpler to control administration of drug. Special value of a combination therapy of tuberculosis has at the undisciplined patients evading from treatment. стрептосалюзид and пасомоцин are choice drugs at the combined scheme of therapy.
Pasomycinum shows tuberculostatic action after the first injection. The dose for adults reaches 1 g a day. To children drug is appointed adequate doses depending on age of the diseased. It is vnutriplevralno possible to apply Pasomycinum (a dose of 0,25-0,5 g).
Streptosalyuzid is a combination of streptomycin and Saluzidum in the ratio 1,13: 1. Intramuscular, inhalation or introrakheobronkhialny ways of introduction are possible. Streptosalyuzid it is not necessary to apply in a combination with others with other antitubercular drugs, t. to in itself it is highly active medicine.
High performance in relation to human type of mycobacteria the semi-synthetic antibiotic rifampicin has. Rifampicin oppresses activity and life activity of mycobacteria. As drug is removed generally with urine, rifampicin can be used not only at a pulmonary tuberculosis, but also at its urogenital form. The daily dose of rifampicin makes 10 mg on 1 kg of weight.