Principles of treating destructive pulmonary tuberculosis. III. Destructive shapes of tuberculosis. The mechanism of formation of the cavity

Given the fact that tuberculosis often proceeds without visible clinical manifestations, it is most often possible to identify it only with the planned passage of the chest radiological study. For this disease, the presence of many forms, which differ from each other not only on the x-ray picture, but also on tactics of treatment with a further forecast. As a rule, destructive forms of tuberculosis may occur from any other form without the necessary treatment, even in a short period of time (during the year).

Destructive pulmonary tuberculosis develops against the background of the progression of other forms of tuberculous lesion, most often infiltrative. As a result of this transformation, caverns are formed - cavities of decay without signs of inflammatory foci.

This formation is concluded in a capsule consisting of three layers:

Upper casomic.
Medium - granulation (contains a large number of cells).
Nizhny - fibrous.

Caverns may occur different sizes, which depends on the area of \u200b\u200bdamaged tissue, its elasticity and the state of draining bronchi.

The formation of the cavity on the background of infiltrative tuberculosis is as follows: with the death of the protective cells, which surrounded the infiltrative focus of inflammation, the release of proteolytic enzymes occurs, the lung tissue is destroyed, which leads to the release of caseous mass through the drainage bronchus.

All this characterizes the decay phase at which the inflammatory focus is preserved around the formed cavity. As the hearth disappears and the fibrosis of the surrounding lung tissue, you can talk about the formed cavity. A factor predisposing to decay may serve as superinfection in the body and its reduced resistance.

This degradation of pulmonary tissue leads to a deterioration in the patient's condition, it makes it difficult to heal in the place of the defeat and reflects the prognosis of the disease.

Symptomatics

Usually, the defeat affects only one side of the lung. Destructive tuberculosis during its development has a complex of clinical manifestations, which are characteristic precisely for the decay phase. At this time, the patient begins to bother with a strong cough with a sputum of sputum, the episodes of hemoptia are possible. When examined by the attending physician, the patient often manages to reveal the presence of mid-sized and large-scale wet wheezing.

With the already formed cavity, the above symptoms disappear, and the overall health of the patient worsens at the expense of:

Pronounced general weakness and reduced performance.
The absence of appetite, a pronounced decline in weight.
The preserving lifting of the total body temperature to subfebrile numbers (up to 37.8).

These features are often not alarmed by the patient himself regarding their condition, which explains the late referred by specialized medical care.

Diagnostics

The standard method for detecting tuberculosis is today a radiological study. The pulmonary x-ray is characterized by the appearance of an enlightenment zone in the form of a circle with a clear boundary. It is very rarely visualized against the background of unchanged pulmonary fabric, since the place of occurrence is closely related to the previous form of the tuberculosis process. It is usually possible to see the seamation around the focus, the presence of a liquid level, as well as the clearance of drainage bronchi.

Since the sick cavernous tuberculosis is distinguished by infected wet, it is necessary to carry out its study for the presence of mycobacterium tuberculosis.

Sometimes the attending physician may face certain diagnostic difficulties in diagnosis, most often this is due to the lack of signs of decay on X-ray, and in the clinic - a characteristic auscultation picture. In such a situation, the patient is shown to conduct a CT study.

Types of destructive tuberculosis

Destructive processes in the lungs are chronized and proceed to several forms:

The cavernous type is an isolated lesion of lung tissue, for which the presence of a cavity in the absence of changes from the surrounding pulmonary fabric. The top layer of its capsule is weakly expressed, the lower (fibrous) is completely absent, and the main share of the cavity occupies an average (granular) layer. The clinically picture of this form of tuberculosis is scanty, and the cure is achieved only with the help of surgical intervention.
The fibrous-cavernous view of the disease is significantly different from the previous one. For it, the formation of a cavern in conjunction with the presence of fibrous changes in the structure of the pulmonary fabric.
Cavern capsule fibrous layer prevails over the others, and there are multiple foci next to it, which are perforated with bronchins. These foci are clearly separated from healthy lung tissue. For symptoms of the disease, a wave-like long-term course, with periods of exacerbation and remission. During the exacerbation, the clinical picture of the pulmonary lesion is pronounced, often an inxication syndrome is connected. On the radiograph, a round hearth is visualized with a thick wall, the pulmonary fabric is reduced in volume. It is important to know that people suffering from this form of tuberculosis are very strong bacteria. The disease is poorly amenable to therapy and has an extremely unfavorable forecast.
The cirrhotic form is represented by the common sclerotic damage to the lung tissue while preserving the foci of tuberculosis lesion. The clinically period of exacerbations occurs extremely rarely, and the symptomatics is weakly noticeable. X-ray signs of this form are pronounced: the volume of affected lung is reduced, its airiness is reduced, there is a sharp deformation of the bronchi.

The healing process usually occurs only with cavernous form and flows along the type of scarring to the formation of false tuberculos or cysts. The remaining forms have an unfavorable forecast. At them, most often there are complications in the form of an empieme of pleural cavity and bronchoploral fistula, as well as caseometric pneumonia and hematogenic dish, which most often leads to a fatal outcome.

Methods of combating destructive tuberculosis

To pass the required course of treatment, the patient must be hospitalized in the hospital. The main direction in therapy is the appointment of anti-tuberculosis drugs. In addition to them, for greater efficiency, hereditary gymnastics are often prescribed.

With a high risk of the formation of the resistance of the pathogen to the preparations of specific therapy, antibacterial agents from the fluoroquinolone group are added to the treatment.

The effectiveness of therapy with the cavernous form of tuberculosis confirms the absence of a patient with a spacing of mycobacteria of tuberculosis six months from the beginning of therapy. Otherwise, the patient is prescribed a surgical treatment method.

It is important to remember that only timely detection (in the early stages) and on time began treatment may result in complete recovery. To do this, each person needs to undergo fluorographic research of the chest organs in a planned manner once a year.

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Any form of tuberculosis can be complicated by the melting of caseosa, the release of caseometric masses through bronchi and the formation of the cavity, i.e., the transition of the process into a destructive form. When moltening caseosa along the edge of the tuberculous focus, caseometric masses can be separated by the type of sequestration. Such a cavern is called sequest. When moltening masses of caseosa by type of autolysis, the cavern has the nature of the autolytic. The formed cavern is characterized by a three-layer structure of the walls: the inner case-necrotic layer is facing the lumen of the cavity; It goes a layer of specific granulation containing epithelioid, lymphoid and giant Pirogov-Langhance cells; The outer fibrous layer is bordered by the surrounding pulmonary cloth and consists of fibers of the connective tissue infiltrated by lymphoid cells and containing blood and lymphatic vessels in a larger or smaller number. Caseous-necrotic masses and tuberculous granulations from the walls of the Kaverne are moving on the walls of drainage bronchi. The intensity of inflammatory changes in bronchi decreases as they remove them from the lumen of the cavity, and in the region of equity and main bronchi, only lymphoid infiltration in epithelioid-gianta carcakers in the sublifted layer are observed.

According to the genesis, the caverns can be pneumonogenic, formed on the site of the focus of tuberculous pneumonia, bronchogen, forming in place of bronchi-affected tuberculosis, hematogenic, arising from hematogenic-disseminated tuberculosis. Depending on the structure of the walls, the severity of the fibrous layer of the cavern may be elastic, easily accumulated, with poorly developed fibrosis, and rigid with dense fibrous walls. Largely distinguished cavities with small - diameter up to 2 cm, medium - from 2 to 4 cm, large - from 4 to 6 cm and gigantic - more than 6 cm. When healing the cavern, the casomino-nerdy layer is brazed, the lumen of the cavity decreases due to wrinkling the walls, as well as the growth of granulation and fibrosis. Ultimately, a scar, in the center of which, sometimes there is a small residual cavity, lined with epithelium and containing transparent liquid can be formed.

In the process of healing, the cavity clearance of drainage bronchi may refuse; In this case, there is an encapsulated focus of a casosis type of Tubercul (see above) at the site of the cavity. Under adverse conditions, caseosis in such a focus can again be melted with the discovery; The lumen of the bronchus and the cavity is formed again, so such a type. Healing is defective.

Rigid cavities during healing are most often transformed into a cystic cavity. In these cases, the rejection of the case-necrotic layer is observed and the substitution of the layer of specific granulation of non-specific connecting tissue. Kavern turns into a cystic cavity. This process is long, and in the walls of this kind of kaverne a long time can be maintained sections of a specific granulation tissue.

In the dynamics of the cavity in the development of healing processes, the state of blood and lymph circulation in its walls is of great importance. Another V. G. Stefko (1938) emphasized the role, lymphottock in removing the decay products and the purification of the cavity. Much attention is paid to the processes of microcirculation in the wall of the cavity during its progressive or healing.

Around the cavity is often formed by the zone of peripocal and inflammation, expressed with different intensity. This zone is a portion of polymorphic pneumonia and lymphocytic infiltration. When deliberate the cavity, stabilization of the pathological process, especially when the use of specific anti-tuberculosis drugs, pneumonic sections are absorbed. At the same time, fibrous changes in the form of seewing of collagen fibers stretching from the fibrous layer of the cavity wall in the surrounding pulmonary fabric. In such a cavern, a large number of lymphocytic clusters and nodules are usually revealed until the appearance of typical lymphoid follicles, located both between the connective tissue fibers of the capsule, and especially on the border of the fibrous wall of the cavity and the surrounding pulmonary fabric. These lymphocytic nodules and infiltrates are currently, as already mentioned, are considered as manifestations of immune responses of the body, which seems to be a large role in the healing processes.

The progression of destructive tuberculosis is expressed in an increase in the case-necrotic layer, which can move on a layer of specific granulation and fibrosis. In the surrounding pulmonary fabric, perifocal inflammation is observed, foci of specific pneumonia are formed. Progress changes and in bronchi with the emergence of centers of acute bronchogenic dissemination.

Cavernous pulmonary tuberculosis is characterized by the presence of an isolated formed cavity without pronounced fibrous changes in its walls and the surrounding pulmonary fabric. Most often, the cavern is located in the same broncho-pulmonary segment, directly under the pleura or in deeper lungs. The casomino-necrotic layer in its walls is thin. The bulk of the wall is a granulation layer, richly infiltrated lymphoid cells; It is well represented by vessels, often penetrating the entire thickness of granulations and reaching the inner surface. It is possible a small dissemination of the process of bronchoms, limited, as a rule, the limits of the affected segment (Fig. 13). Such a cavity due to the lack of pronounced fibrosis in its walls may under the influence of treatment-fall and to heal by the scar. If a cavity is located directly under the pleura, with which its outer "wall grips, healing can occur by the type of cleansing the inner surface of the cavity and transition to a cystic cavity.

Fibrozno-cavernous tuberculosis. Typical for this form is the presence in one (more often) or in both lightweight cavity or cavities located among fibrous modified pulmonary fabric. In the walls of Kavern, in contrast to the cavernous tuberculosis, the fibrous layer is pronounced and prevails over case-necrotic and granular (Fig. 14). Cavern shape is different. Multiple disintegration cavities can form a regulatory cavern system. The inner surface of the kavern is usually uneven due to an unevenly pronounced casomino-necrotic layer. Sometimes "beams" are found on it, which are the basics of oblique blood vessels going through the "cavity. Near the Kaverne, acinquic or lobular foci of bronchogenous dissemination, encapsulated or fresh, not having capsules are usually located. When the process, an exudative-necrotic reaction was progressed in the wall of the Kavern and the bronchogenous dissemination, which has an apico-caudal distribution, is most intense in medium and decreasing lungs. A distinctive feature of the bronchiogenic dissemination of the present time is their clearly separation from the surrounding tissue, which prevents the transition of the process to the alveoli. However, in modern conditions, the process can take an acutely progressive character with the advent of the foci of a peculiar polymorphic pneumonia, the encaser of the walls of the bronchi, the formation of sharp decay cavities with thin, poorly formed walls and a large perifocal reaction.

Fibrozno-cavernous tuberculosis It is distinguished by the wave-like flow, and in the period of stabilization or sinking the process, the phenomena of fibrosis and deformation of the pulmonary fabric are increasing. Fibrozno-cavernous tuberculosis is much worse being healing than cavernous. Fibrosis prevents the circulation of blood and lymph in the walls of such a cavity, with the increase in fibrosis in tuberculosis granulations, the Mac-roofhageal reaction is reduced, and fibrous changes in the root of the lungs, pleura and surrounding pulmonary fabric prevent the decay and scarring of cavities. Therefore, only fibrous cavity small sizes can be healing with the development of the scar. Large fibrous cavities are more often healing by the type of purification of their walls and the formation of a cystic cavity.

Cyrrotic lung tuberculosis It is characterized by developing in the pulmonary tissue of a coarse, deforming organ of sclerosis (cirrhosis), bronchiectatic, check-for-piece types of cysts of cavities, emphysematous bulls or a cavity without signs of pro-trarsing. Between the scars can be determined by different sizes and the structure of the foci. Cyrrotic changes in the lungs are single and bilateral, segmental, lobar or all easy. Cyrrotically modified light sharply deformed, reduced in volume, dense. Pleverra is thickened, sometimes significantly, armor covers everything easy, in it may occur in it. Due to massive fibroids, the airiness of the pulmonary fabric is dramatically reduced, the sections of the atelectasis alternate with the sections of emphysema. The bronchial tree is sharply deformed, there are bronchide basins of various sizes and shapes. In the blood vessels there is a restructuring with recalibration of their lumen, the appearance of a closure type vessels, a plurality of gaping art-rival anastomoses (Fig. 15).

Among the sharply pronounced fibrosis, tuberculous foci can be determined with different signs of the activity of the process. Often they are formed in the walls of the exhazic bronchi or form on the site of the cavern when obliterated drainage bronchi. In the walls of extended bronchi, bronchiectatic cavities and purified cavities are usually expressed by nonspecific inflammation. With significant sclerosis and the absence of active tuberculosis changes in it, cirrhosis is lung as the consequence of transferred tuberculosis.

Postatuberculosis pneumosclerosis Refers to residual changes after cured tuberculosis. Residual changes are characterized by the presence in organs affected by the previous tuberculosis, scars of various lengths, calcined foci, cystal cavities. Healing of tuberculosis foci or cavern, in any organs that they do not localize, leads to an increased development of connective tissue, replacing tuberculous granulations. In this case, the deformation of the affected body is observed. Evaluating the scar changes in the lungs, it is necessary to distinguish fibrosis, sclerosis and cirrhosis. Pneumophybosis is the general concept of the development of connective tissue in light. Under sclerosis, the development of collagen fibers, limited in length, but not leading to greater deformation of the bronchi and lung tissue. Under cirrhosis, pronounced sclerotic changes with the deformation of bronchi and lung tissue, decreasing its size.

Tuberculosis forms

The purpose of the classification is to combine the entire variety of forms of tuberculosis according to its clinical, pathogenetic and morphological features. The classification of forms of tuberculosis is improved as the accumulation and systematization of scientific and practical information about the nature of the disease. Currently, in addition to the clinical classification of tuberculosis developed in our country, there is an international, which is used in medical statistics for disease registration, including tuberculosis.

The clinical classification adopted on the VIII congress of phthisiators in 1973 consists of 4 sections:

BUT - clinical forms of tuberculosis;

B. - forms of tuberculosis according to the characteristics of the tuberculous process on localization and the volume of lesion;

IN - Complications of tuberculosis.

G. - residual phenomena of cured tuberculosis

Section A. Combines 3 groups of clinical forms of tuberculosis:

The form of tuberculosis of the I-th group is morphologically characterized by the presence of minor pathological changes in the lymphatic system. With these tuberculosis forms, sometimes foci of primary infection are located in almonds, bones or other organs. This diagnosis can be made only to persons under 18, since in more mature age, the diagnosis is extremely difficult.

The forms of tuberculosis of the II group include both the primary shape of tuberculosis, so other diseases of the lungs and upper respiratory tract of primary and secondary genesis.

The primary form of tuberculosis is characterized mainly by the development of tuberculosis bronchotenitis: tumor, infiltrative or with a minor lesion of intragenuous lymph nodes. The primary form of tuberculosis is rarely observed, and the frequency of its detection testifies mainly about insufficient measures of specific prophylaxis of tuberculosis. Such tuberculosis forms Occasionally meets in adult young people, more often women aged 18 to 22 years, while the reactivation of the lymph nodes of the mediastinum is sometimes observed in the elderly as a result of the imminent immunity.

Disseminated form of tuberculosis can be primary and secondary genes and takes acute, subacute or chronic current.

Such a form of tuberculosis, as focal tuberculosis of the lungs, can develop as a result of the endogenous reactivation of old foci, superinfection, as well as the involution of the infiltration or cavernous process. The infiltrative form of the pulmonary tuberculosis with inflammation predominantly exudative nature is peculiar to the relatively fast dynamics of the process both towards the resorption and in the direction of progression. Possible complications, therefore, these forms of tuberculosis require the rapid hospitalization of patient and intensive therapy.

Lung tuberculosis is a form of tuberculosis, which is often distinguished by a torpid flow and is almost not amenable to conservative treatment due to the lack of a vascular network in this zone, which prevents the penetration of drugs into the lesion focus.

Cavernous tuberculosis, being a transitional form of tuberculosis between the phase of decay and fibrous-cavernous tuberculosis of the lungs, is characterized by the presence of an formed cavern with a relatively erased clinical picture of intoxication.

In the fibrous-cavernous form of tuberculosis, basically develops fibrosis around the cavity and the disease is difficult to cure. In the cirrotic form of tuberculosis, foci, bronchiectases and cavities are observed in a cirrotically modified light, while focal and cavernous structures can occur periodically.

Tuberculosis pleurisy and empieme make up separate clinical forms of tuberculosis. The features of their flow determine the need to use active treatment methods (puncture, drainage of the pleural cavity, etc.).

Tuberculosis of the upper respiratory tract, as a separate clinical form of tuberculosis, is rare. It often coexists with infiltrative, disseminated and cavernous tuberculosis forms. The mucous membrane of the bronchus as a result of the endogenous hit of the IBT is amazed extremely rarely.

Tuberculosis of respiratory organs, combined with professional diseases of the lungs, is a special form of tuberculosis, which is distinguished by a number of clinical and radiological signs; It is found in industrial areas in individuals with industrial contact with inorganic dust.

In the third group, all forms of tuberculosis of extrapilence localization are included.

Section B. Includes the characteristic of the tuberculosis process on localization and the volume of the lesion, its phase, which makes it possible to estimate the degree of activity of this process. Infiltration, the disintegration and disintegration indicate the active progressive form of tuberculosis, resorption and seal - about its sinking, scarring and occasion - about the occurring cure. The bacterial excretion is denoted by BC (+), with this bacteria model is considered to be only the one who has been identified by MBT (tuberculosis microbacteria).

Section B. Includes complications of tuberculosis, which are a mandatory part of the diagnosis, among which, with pulmonary tuberculosis, pulmonary bleeding and hemopoly are most often found.

Section G. It is the last, fourth section of the classification and characterizes the residual phenomena of cured tuberculosis forms in the form of fibrous, fibrous focal calcinates, pneumosclerosis, cirrhosis and bronchiectasis, as well as conditions after surgical interventions. This section reflects the success of the cure of various forms of tuberculosis and is the innovation, which contributed to the classification of the VIII Congress of phthisiators in 1973. Persons with residual changes to a certain extent make up the risk of recurrence of tuberculosis, especially in adverse situations (after reducing the stomach, at pneumonia, Complicated flu, etc.), and need annual dispensary observation, and in some cases - both in the conduct of chemoprophylaxis, since the incidence of pulmonary tuberculosis among them is observed in tens of times more often than among people who do not have morphological changes in the lungs.

For the characteristics of the tuberculosis process in the classification, besides the name of the clinical form of tuberculosis, localization, phase of the process and the state of bacilloscience are provided.

Being one of the best in the world, this classification at the same time does not reflect the pathogenesis pathogenesis; It has no separation for the first time for the first time sick and persons with relapses and an outbreak of the disease, there is no assessment of the typification of MBT and their sensitivity to antibacterial drugs, dividing into small, common and destructive forms of tuberculosis, which makes it difficult to evaluate therapeutic activities.

Any form of tuberculosis can be complicated by the melting of caseosa, the release of caseometric masses through bronchi and the formation of the cavity, i.e., the transition of the process into a destructive form. The formed cavern is characterized by a three-layer wall structure: an inner case-necrotic layer; a layer of specific granulation containing macrophages, epithelium, lymphoid and giant Pirogov-Langhance cells; The outer fibrous layer, bordering the surrounding pulmonary tissue, consisting of fibers of the connective tissue infiltrated by lymphoid cells, and containing blood and or smaller quantities and lymphatic vessels. Caseous-necrotic masses and tuberculous granulations from the walls of the Kaverne are moving on the walls of drainage bronchi.

On the genesis of the cavity can be pneumonogenic, formed on the site of the focus of tuberculous pneumonia, bronchogenic, formed on the site of bronchial tuberculosis, hematogenic, arising from hematogenic-disseminated tuberculosis [Stefko V. G., 1938; Storm. I., 1948; Puzik V. I. et al., 1973]. The magnitude of the diameter of the cavity is distinguished: small - up to 2 cm, medium - from 2 to 4 cm, large - from 4 to 6 cm, giant - more than 6 cm [Strukov A. I., 1959]. When healing, the cavron is observed rejection of the case-necrotic layer, reducing the lumen of the cavity by wrinkling the walls, the growth of granulation tissue and fibrosis. Ultimately, a scar, in the center of which, sometimes there is a small residual cavity, lined with epithelium and containing transparent liquid can be formed.

In the process of healing, the cavity clearance of drainage bronchi may refuse, and in this case there is an encapsulated focus of a casosis type of tuberculus in place of the cavity. When healing the cavity can be transformed into a cystic cavity.

This process is long, and in the walls of such a cavern for a long time, areas of specific granulation tissue can be maintained. In the development of healing processes, the state of blood and lymphorage is of great importance, especially in the microcirculation system - both in the walls of the cavity and its surrounding pulmonary fabric [Stefko V. G., 1938; Puzik V. I. et al., 1973; Strasov A. I., Soloviev I. P., 1976; Erokhin V. V., 1987, and others].

When deliberateing the cavity, stabilizing the pathological process (especially when using anti-tuberculosis drugs) polymorphic, pneumonic areas around the cavity are absorbed, fibrous changes are growing, "stretching" from the fibrous layer of the cavity wall into the surrounding pulmonary fabric. In such a cavern, a large number of different variance of lymphocytic clusters and nodules located between the connective tissue capsule fibers are revealed.

The progression of destructive tuberculosis is expressed in an increase in the case-necrotic layer, which can move on a layer of specific granulation tissue and fibrosis. In the surrounding pulmonary fabric, peripocal inflammation is observed, foci of specific pneumonia are formed. Progress changes and in bronchi with the emergence of centers of acute bronchogenic dissemination.

Cavernous pulmonary tuberculosis is highlighted in a separate shape. It is characterized by the presence of an isolated formed cavity without pronounced fibrous changes in its walls and the surrounding pulmonary fabric. Most often, the cavern is located in the same bronchopulmonary segment. The case-necrotic layer in its walls is thin, and the bulk of the wall is a granular layer, rich in lymphoid cells and microshogs. Due to the lack of pronounced fibrosis in the walls of such a cavity, it can under the influence of treatment to fall and hesitate by the scar. Healing can also

(Including the modified forms of mycobacterium tuberculosis), morphofunctional inferiority of macrophages and the incompleteness of phagocytosis, violation of the processes of fibril formation, insufficiency of the surfactant lung system, etc. [Erokhin V. V., Yelshanskaya M. P., 1986].

Cyrrotic pulmonary tuberculosis is characterized by developing in the pulmonary tissue of a coarse, deforming organ of sclerosis (cirrhosis), bronchiectatic, nostcavernous (cyst) cavities, Emphic Bull or Kavern without signs of cavity. Between

proceed by the type of purification of the inner surface of the cavity and transition it into a cystic cavity (Fig. 1.9).

Fibrozno-cavernous tuberculosis is characterized by the presence in one or both lightweight cavity or cavities located among fibrous modified pulmonary fabric. In the walls of the Kavern, in contrast to the cavernous tuberculosis, the fibrous layer is usually sharply pronounced and prevails over case-necrotic and granular (Fig. 1.10). Near Kaverne, there are usually foci of bronchogenous dissemination, encapsulated or fresh.

A distinctive feature of bronchogenous disseminations is currently their clear separation from the surrounding tissue, which prevents the transition to the process to the alveoli. However, under the conditions of insufficiency of immunity, the process may take an urgentrogressive nature. At the same time, the foci of the peculiar polymorphic pneumonia, caseosis, are formed by sharp decay cavities with thin, poorly formed walls and a large period of focal reaction

Fibrozno-cavernous tuberculosis is distinguished by a wave-like flow, in the period of stabilization or sinking the process, the phenomena of fibrosis and deformation of the pulmonary fabric are increasing. Fibrosis prevents blood circulation and lymph, destroys the microcircuit vessels

the latorine degrades the conditions of microenvironment of granulation tissue cells, the functional activity of macrophages decreases with fibrosis. Changes in the root of the lungs, pleura and surrounding pulmonary fabric prevent the decay and scarring of cavities. Therefore, only small-sized cavities can be healing with the development of a scar. Large fibrous cavities are more often healing by the type of purification of their walls and the formation of a cystic cavity. The main reasons for the development of healing processes in the wall of the cavity are established: the presence of an antigenic stimulus by scars can be determined by tuberculous foci of different sizes and buildings. Cyrrotically modified light sharply deformed, reduced in volume, dense. The pleura is thickened, sometimes significantly, the shell covers everything easy, it may occur in it. Due to the presence of massive fibroids, the airiness of the pulmonary fabric is dramatically reduced, the sections of the atelectasis alternate with the sections of emphysema. The bronchial wood is sharply deformed, there are bronchiectases of various sizes and shapes. In the blood vessels there are perestroika with recalibration of their lumen, the appearance of the vessels of the closure type and the set of gaping arteriovenous anastomoses.

In the walls of extended bronchi, bronchiectatic cavities and purified cavities are usually expressed by nonspecific inflammation. With significant sclerosis and the absence of active tuberculosis changes, there is cirrhosis of the lung as the consequence of the transferred tuberculosis (Fig. 1.11).

Destructive pulmonary tuberculosis

The destructive tuberculosis of the lungs is a disease, the main difference of which is considered the presence in the tissues of the light isolated decay cavity. The clinical picture of such a form of the disease usually does not cause the appearance of a large number of symptoms and the patient complains only on increased fatigue, decrease in appetite and a rare appearance of cough with a mocroid. In addition, to testify to progression in the human body of such an agell may be the emergence of unless hemloration or bleeding. The diagnosis of the cavernous form of tuberculosis is carried out using X-ray diagnostics, and tuberculinidiagnosis, also by detecting mycobacteria in the patient's studied discharge.

Causes of the development of ailment

Mostly the main cause of the development of the destructive form of pathology becomes infiltrative tuberculosis. At the very beginning of the development of the disease, infiltrate includes focus of inflammation and in its very center there is obstructed lung fabric. In the event that peripocal infiltrate occurs, the increased concentration of lymphocytes, leukocytes and macrophages is revealed.

After moving such cells, the formation of a large concentration of proteases occurs, which is possible to melt caseosis without any problems. The resulting case of caseosis becomes through drainage bronchus, which causes the appearance of the breakdown cavity. During the diagnosis, the patient is made such a diagnosis as infiltrative tuberculosis, which is in the decay stage. In case of non-effective drug therapy, peripocal infiltration is resorved around the decay focus. As a result, the cavity remains, around which all the time there are inflammation elements converted into a caseous tissue.

Another reason for the development of the destructive form of pathology is considered to be the transformation of tuberculosis in a cavnet.

In a situation, if a cavity occurs, this is significantly aggravated by the characteristics of the tuberculosis disease, and increases the risk of adverse outcome. This is explained by the fact that there are ideal conditions for entering infected discharge from the cavity into a healthy pulmonary tissue. The process of healing of the cavity becomes too difficult, since inflammation of the body tissue creates obstacles to its healing.

Symptomatics of pathology

Medical practice shows that its one-sided localization is considered a feature of the destructive form of the alend. Most often, pathology begins its development for about 3-4 months after the start of inefficient drug therapy for other forms of tuberculosis. Special brightness clinical picture reaches precisely during the decay period and there is a strong cough with a sputum. In addition, wet wipes are found during listening, the location of which becomes the cavity of the decay. After the process of forming a cavity ends, signs of the disease decrease significantly and become lowraged.

In this phase, for such a form of tuberculosis, the appearance of the following symptoms is characterized by:

constant feeling of weakness and fatigue;
reducing appetite or its complete absence;
severe slimming of the patient;
development of asthenia;
periodic subfebelitet.

In fact, patients with cavernous tuberculosis are considered a source of infection and a disseminator of mycobacteria. In the event that such a disease goes into a hidden form, then evidence of it can bleeding from the lungs, which can occur without any causes and in an externally healthy person.

In the transition of the destructive form of the disease to complicated, a breakthrough of the cavity into the pleural cavity is possible, and the development of the following pathologies:

empiama pleura;
bronchoploral fistula.

Depending on the size of the cavity, experts allocate cavities of small, medium and large sizes. Typically, the course of the cavernous form of tuberculosis is about two years, after which the cavern is healing. Most often, this process proceeds in the form of the scarring of fabric, the formation of tuberculosis and tuberculosis focus.

Features of the treatment of pathology

The diagnosis of cavernous tuberculosis is carried out using bacteriological methods and clinical and radiological studies. Patients with cavernous tuberculosis require premises in the hospital of the anti-tuberculous dispensary. This is due to the fact that such patients are a source of active discharge of bacteria, which represents a serious danger to others.

In the primary identification of the cavernous process, drug treatment is prescribed using the following anti-tuberculosis drugs:

In order to the high concentration of such chemotherapeutic drugs, intravenous and intrabrochetic administration of them into the patient's body, as well as in the cavity of the vein are prescribed. Medical therapy with drug use is complemented by the treatment of gymnastics for respiratory organs and tuberculinotherapy.

In addition, the following physiotherapy procedures are appointed:

In fact, the cavernous form of tuberculosis is quite successfully amenable to medication treatment. When diagnosing a small-sized caution in a patient, using anti-tuberculosis treatment, it is possible to achieve their closure and scarring of the tissue.

The cavities are gradually filled again with caseous masses, and the result of pseudotuberkuli becomes the result.

In some cases, various complications may develop, but this is diagnosed extremely rarely. In some patients, despite drug therapy, the pulmonary tissue is observed and the further progression of the tuberculosis process is observed.

Destructive shapes of tuberculosis lungs

By the beginning of the 1990s, an unfavorable epidemic situation on tuberculosis was developed in the world. This applies to both developed and developing countries. Tuberculosis is recognized by WHO with a global problem that appreciates the tremendous economic and biological damage. In 1993, the World Health Organization was announced that tuberculosis was out of control and is "in critical position all over the world."

In Russia, this was due to interference with the epidemic process with a tuberculosis of three powerful destabilizing factors: the socio-economic crisis, reducing the activity of conducting tuberculosis measures and the spread of HIV infection. In subsequent years, negative trends began to increase - preventive inspections decreased to 63-65% and in this background the proportion of destructive forms of tuberculosis increased.

According to R.Sh. Valiev (1987) among patients taken registered for the first time revealed tuberculosis, the decay of the pulmonary fabric was discovered in 35.8%, bacterial excretion - 67.1%.

Over the ten-year period, the incidence of destructive forms of tuberculosis increased almost 2-2.5 times - from 12.3 per 100 thousand population in 1992 to 35.2 in 2004 and the incidence of tuberculosis with bacterial excretion from 14.0 in 1992 . up to 35.2 per 100 thousand population in 2004

The effectiveness of treatment for the first time identified patients according to the criterion for the closure of disintegration cavities in 1998 was 63.4%, according to the criterion of discontinuation of bacteries - 73.2%, which is 15% lower than 1992 values.

The reduction in these indicators is due to a whole group of factors of both an objective and subjective nature, starting with a deficit of drugs to changes in the social composition of patients towards the predominance of non-working persons, their negative attitude towards treatment, the increasing number of patients with sharply progressive forms of tuberculosis, case-like pneumonia with abundant bacterial excretion .

The initial massiveness of the bacteria creates serious difficulties in curing tuberculosis changes, as it fully reflects the prevalence of pulmonary tuberculosis with multiple destruction and slow-to-inclination of the specific process. The insufficient effectiveness of the treatment of patients with various forms of destructive tuberculosis of the lungs is directly related to the impairment of immunity indicators due to various endogenous and exogenous factors and the lack of their positive dynamics in the process of chemotherapy, as well as medicinal resistance of the mycobacterium tuberculosis (MBT).

The problem of the destructive tuberculosis of the lungs.

The epidemiological situation on tuberculosis in any region depends on the reservoir of tuberculosis infection, circulating in an environment surrounding man and environmental factors. The reservoir of infection is associated with the number of patients excretion of tuberculosis mycobacteria, i.e. Precious, primarily destructive forms of lung tuberculosis. The possibilities for reducing the infection reservoir depend on the cure of such patients. Therefore, the study of the epidemiology of destructive tuberculosis of the lungs, its clinical flow, depending on the immunological and psychological state of the body, the medicinal stability of mycobacterium tuberculosis (MBT), as well as environmental and geochemical factors affecting them in modern socio-economic conditions and the improvement of the methods of its treatment seems to be relevant The task of phthisiology.

In order to differentiated the treatment of pulmonary tuberculosis in a qualitative characteristic for a long time, it was customary to divide into small shapes without decay, common without decay and destructive.

All the destructive tuberculosis of the lungs with this separation of processes in a qualitative characteristic is assigned to one category and, accordingly, it is recommended a uniform method of its treatment. Meanwhile, destructive processes in the lungs are extremely heterogeneous. In existing literature, criteria are not given to the distinction of the described categories of processes or criteria are extremely inhomogeneous and without relevant justifications, sometimes not so much the number and sizes of the cavern, how much the prevalence of infiltrative and focal changes.

Thus, the question of separating the destructive tuberculosis of the lungs into groups in a qualitative and quantitative characteristic prior to the beginning of its study by the staff of our department was only at the stage of problem formulation. Meanwhile, this is important not only for differentiated treatment, but also for a comparative assessment of the effectiveness of various schemes of comprehensive therapy proposed by different authors for introducing evidence-based medicine. However, a detailed analysis of the literature of that time did not allow them to evaluate them in a comparative plan and identify among them the most effective.

The destruction of pulmonary fabric is not just a complication of the disease, this is an indicator of a qualitatively different form of a tuberculosis process, the emergence and course of which is apparently determined by the primary immunodeficiency. The implementation of the latter into the disease tuberculosis depends on various reasons known as risk factors. The non-defective forms of the disease occurring rarely progress and detected in preventive fluorographic surveys of the population. Destructive tuberculosis is formed in a short time between two fluorographic inspections, showing itself symptoms. It is more often diagnosed in clinics when contacting the doctor. Among the destructive forms there are options that differ in the speed of progression. Therefore, the concept of small and initial (early) tuberculosis is not identical. The incidence rate of the destructive tuberculosis of the lungs per 100,000 population, as well as the number of patients who died during the year after the onset of the disease, and the number of patients again ill bacteriologically positive tuberculosis are basic to assess the epidemiological situation on tuberculosis. The indicator of the total incidence of tuberculosis should be regarded as an additional, and not the main one.

The analysis showed that the frequency of detection of destructive tuberculosis in the frequency of fluorographic surveys is 1 time per year, for example, was in 1994. - 33.1%, gradually decreased and amounted to in 1998. - 32.2%. This suggests that even when conducting regular annual inspections of the population in each third case destructive tuberculosis is detected, i.e. This is not the neglence of the case, as it was considered earlier, but the originality of the flow of tuberculosis. In assessing the passage of fluorography among patients identified by treatment, it was established that among those who have the term of the last fluorographic examination was less than 1 year the frequency of detection of destructive tuberculosis was 41.1% -53.4%, which once again confirms the possibility of the formation of destruction for a small period. At the same time, among those who have not been examined for more than 5 years or did not undergo a fluorographic examination of the frequency of destruction amounted to 66.7% -73.8%. The results of the data we received formed the basis of the regulatory documents to determine the frequency of prophylactic examinations on tuberculosis, depending on the risk factors and professional affiliation, approved by the Decree of the Government of the Russian Federation No. 892 dated December 25, 2001.

Conducted studies suggest that the use of the incidence of the incidence of lungs with a destructive tuberculosis per 100 thousand population helped objectification of data on the epidemiological situation on tuberculosis both in the Republic of Tatarstan and Russia, because Since 2005 It is included in the official statistics of the Ministry of Health and the Russian Federation.

We tried to divide the destructive tuberculosis of the lungs into groups, based on the main sign - the timing of the healing of the decay cavities in conventional chemotherapy and some other treatment regimens. The other signs of the clinical course of the disease also appreciated, which confirmed the existence of qualitative differences in groups allocated on the main basis (Table 1).

Terms of closure of disintegration cavities in percents with various variants of destructive pulmonary tuberculosis

12 months and more

with one cavity 2-4 cm

In brackets - intensive comprehensive treatment

A detailed analysis of the results of treatment made it possible to allocate the following variants of the destructive tuberculosis of the lungs, which clearly differed in terms of the timing of healing of the decay cavities:

1. Lung tuberculosis with minimal destruction (MDT). There are cases where the decay phase was diagnosed on indirect features (47 observations) and cases where there were decay cavities less than 2 cm (as a rule, up to 1.5 cm) single (135 observations) or multiple (73 observations). The analysis showed that the timing of closing the decay cavities, including multiple, in all these cases, is approximately the same and sharply different from the timing of lightening of a larger kaverne. After 2 months, the treatment of the breakdown cavity was ceased to be determined from the third part, and after 4 months - in two thirds of patients. In most cases, where the cavities have ceased to be determined, in a later dates, it was possible to state that there were caseometric tricks in the field of infiltration of pulmonary tissue with partial melting them, from which slow dynamics depended. In some of these patients, typical tuberculle was formed in the treatment process.

2. Limited destructive pulmonary tuberculosis (DTT). At first, here we delivered only the processes with single medium-sized decay cavities (2-4 cm). In this case, it turned out that the cavity with a diameter of 2 cm in terms of closure occupy an intermediate position between the cavities up to 1.5 cm and the cavities with a size of 3-4 cm, by location closer to the latter. Therefore, we attributed processes with such caverns to the category of limited destructive tuberculosis of the lungs.

Further analysis showed that in cases where there are 2 cavities with a diameter of 2-4 cm or (rarely) a combination of one such a cavity with one or more small cavities (up to 1.5 cm) closing time with ordinary chemotherapy the same as single cavities And they differ sharply from the time of healing of multiple (system) cavities of the same size. This forced to combine both groups of processes in one category of limited destructive pulmonary tuberculosis. The closure of the cavern in such diseases occurs for 2-4 months later than with tuberculosis with minimal destruction.

3. Common destructive pulmonary tuberculosis (RDT). Based on the performance of the terms and frequency of the tavern healing, we assigned to this group, firstly, the processes with multiple disintegration cavities. In isolated cases, there were 3 cavities, and most patients had a decay cavity system, the number of which was often not calculated. Secondly, this category includes processes with large and giant cavins. Approximately half of these cases, such cavities were solitary, in the rest of the patients at the same time with large cavins in the lungs there were one or more medium-sized cavities (2-4 cm). Although the healing of the latter was observed earlier, the closure of large cavities was also late and rarely, as in cases where they were solitary.

From the table, it can be seen that the frequency and timing of the closure of the cavern with a common destructive tuberculosis of the lungs differ sharply from limited processes. And although these indicators in the presence of large cavities are significantly worse than with multiple medium cavities, we attributed them to one category, because In both cases, equally intensive therapy is necessary. With ordinary chemotherapy only after 8-12 months. The closure frequency of the cavern reaches the same level that with limited destructive tuberculosis after 4 months.

The hopping decrease in the effectiveness of the treatment of the group to the frequency group and the closing time of the Kavern itself is in itself seemed to be quite convincing evidence of the need to separate the destructive tuberculosis of the lungs with infiltrative and disseminated processes by 3 dedicated categories. They differ in other indicators of the clinical course of the disease. In particular, the prevalence of infiltrative and focal changes in the lungs in most cases corresponded to the number and size of the cavern. In cases of inconsistencies, the timing of the closure of the cavity depended more on their size than from infiltrative and focal changes. Therefore, we concluded that the separation of destructive processes into categories is advisable to carry out the main attribute - the number and size of the decay cavities.

This indicator usually corresponded to the degree of severity of intoxication syndrome and the deadlines for improving the condition of patients, as well as the massiveness of the bacillomodes and the deadlines for its termination.

Due to the peculiarities of the dynamics of disintegration cavities and differences in therapy methods during the division of the first diagnosed destructive tuberculosis of the lungs in the category for a qualitative characteristic, it is necessary to allocate in individual groups of lung tuberculos with decay and fibrous-cavernous processes.

4. We observed tuberculos with decay in 75 patients. In less than half of the cases, they were diagnosed immediately when identifying patients. In the remaining observations, they were formed from infiltrative processes with decay during chemotherapy. Patients received a variety of treatment, but it was not possible to estimate the effectiveness of its individual schemes. When separated by groups, each turned out to be a very small number of observations. The overall efficacy of conservative therapy is presented in the table. It can be seen that the closure of decay cavities, sometimes as a result of their filling occurs in late terms.

5. Fibrozno-cavernous process We observed in 32 for the first time identified patients. As the cavity in this disease cease to be determined very rarely, the results of treatment are not presented in Table 1.

The outcomes of the pulmonary tuberculosis are another essential indicator of the quality characteristics of the destructive tuberculosis of the lungs. Observations for patients for 2 years and more showed that the final results depend on many factors: the age of patients concomitant diseases, tolerability of chemotherapy, drug resistance of the pathogen, etc. But most of all, its severity and prevalence, the methodology and duration of treatment in the hospital, the discipline of patients with treatment on the outpatient stage were influenced. Under all circumstances, Table 1 shows clear differences in the outcomes of the disease, respectively, the dedicated categories of destructive tuberculosis of the lungs, which once again confirms the validity of such division and the accuracy of the criteria developed.

Thus, it has been proven that the destructive tuberculosis of the lungs in for the first time sick people in high-quality and quantitative characteristic in order to develop differentiated treatment methods is advisable to divide into 5 categories. This made it possible to carry out differentiated treatment of patients, increase the effectiveness of the treatment of severe forms of the disease, including caseometric pneumonia and reduce the drug load of patients with relatively small tuberculous processes in the lungs. Development of the principles of differentiated treatment of patients depending on the qualitative and quantitative characteristics of the destructive process in the lungs is a new direction in the development of tuberculosis chemotherapy.

When testing new methods of treatment in order to develop indications for them, and in order for the results of studies of different authors are comparable, it is advisable to conduct an efficiency assessment at each category of lungs destructive tuberculosis.

Based on the long observation of patients with destructive tuberculosis of the lungs, new approaches to the evaluation of the timeliness of their identification are proposed.

We, based on the comparative effectiveness of the stationary and outpatient treatment of patients with destructive tuberculosis of the lungs, is shown that a significant part of them can be translated into outpatient treatment or in a daytime hospital without waiting for the closure of decay cavities, shortly after the cessation of bacterial excretion and significant resorption of inflammatory changes in the lungs, which significantly reduces financial expenses.

R.Sh. Valiev.

Honored Doctor of the Russian Federation, Honored Doctor of the Republic of Tatarstan,

Head of the Department of Fthisiaria and Pulmonology of KGM,

doctor of Medical Sciences, Professor

From the acts of speech on April 22, 2009 at an expanded meeting of the Academic Council of the GOU DPO "Kazan State Medical Academy of Roszdrava"

"Improving the methods of diagnosis, treatment and prevention of pulmonary tuberculosis in the conditions of socio-economic transformations and distribution of HIV infection"

Another reason for the development of the destructive form of pathology is considered to be the transformation of tuberculosis in a cavnet.

Symptomatics of pathology

In this phase, for such a form of tuberculosis, the appearance of the following symptoms is characterized by:

constant feeling of weakness and fatigue;
reducing appetite or its complete absence;
severe slimming of the patient;
development of asthenia;
periodic subfebelitet.

In the transition of the destructive form of the disease to complicated, a breakthrough of the cavity into the pleural cavity is possible, and the development of the following pathologies:

empiama pleura;
bronchoploral fistula.

Features of the treatment of pathology

In the primary identification of the cavernous process, drug treatment is prescribed using the following anti-tuberculosis drugs:

Rifamycin.
Streptomycin.
Etcutol.
Isoniazid.

In addition, the following physiotherapy procedures are appointed:

laser;
ultrasound;
industothermia.

With the unanimous course of the destructive form of the disease, after 5-6 months, the patient notes positive results of treatment. The patient stops the selection of mycobacteria, the cavity decreases, and even its complete closure occurs. In the event that after a certain time it is impossible to achieve the healing of the cavity, then the specialists decide on the conduct of surgical intervention. Doctors are performed by such types of operation as resection of the tissue of the lungs and the imposition of artificial pneumothorax.

The cavities are gradually filled again with caseous masses, and the result of pseudotuberkuli becomes the result.

Destructive called
Tuberculosis accompanied by
Phase decay.
Frequency among for the first time
identified patients
Tuberculosis - about 50%
(mostly adults and
adolescents).

Cavern formation mechanism:

Caseous masses are diluted under
action enzymes
The wall of the drainage bronchus is destroyed,
Expectress Kazosa
Fresh destruction is formed - 2 layers
(pyrogen and granular)
Forming a fibrous wall transformation into a true cavity.

Continued

The decay phase occurs with any
Clinical form of tuberculosis.
It rarely happens with primary tuberculosis,
Focal, not often with tuberculle.
Often accompanied by a decay phase:
Infiltrative tuberculosis (70%),
Disseminated (70%).
Always, in 100% of cases, cavities are available at
cavernous and fibrous cavernous TB.

Caverne sizes:
* Small - up to 2 cm in diameter;
* average - 2-4 cm;
* Large - 4 - 6 cm;
* Giant -\u003e 6 cm.

Syndrome of the decay phase (cavity)
Includes clinical I.
Radiographic signs
Clinical signs:
cough with sputum;
pulmonary bleeding;
wet medium and large-tie
wheezing (localized)

Radiographic signs

Straight
- Enlightenment against the background of blackout or ring-shaped
shadow with closed contours defined when
Two types of radiothetgen examination.
- no pulmonary pattern in the area
Enlightenment.
- incongruence of contours.
Indirect
- Observing around
- Level of fluid
- clearance of drainage bronchi

Laboratory sign

Massive
bactering.

MBT with simple microscopy

Difficulties in the diagnosis of cavern

Lack of wheezing ("Silent
cavity ";
lack of signs of decay on
Review radiograph.
Need tomography, CT.

Types of involution of the breakdown cavity

Formation of a linear scar.
Star scar.
False tuberculus.
Postatuberculosis cyst
(Sanitary cavity).

Chronic destructive forms of tuberculosis

Cavernous.
Fibrozno-cavernous.
Cyrrotic

Cavernous tuberculosis

Thin-walled breakdown cavity without
pronounced infiltration I.
fibrous changes in the surrounding
Pulmonary fabric.
Clinic Poor.
MBT +.
Treatment predominantly
Operative.

Fibrozno-cavernous tuberculosis

Characterized by several less frequently
Cavern with thick fibrous walls
and pronounced fibrous changes
In the surrounding pulmonary fabric.
Prevalence varieties:
limited process- no more shares;
Common - more shares.

Histotopographic
th section of the lung with
Fibroznochermino
Tuberculosis: 1 -
Chronic
cavity; 2 -
Pneumocirrosis; 3 -
Thickening and sclerosis
pleura; Color
Hematoxylin I.
Eosin.

Frequency FTT.
Among the first identified patients -
2,5%.
Among all the contingents of the patients -
17%.
Causes of FCT formation:
- later identification of the process;
- Failure of patients from enough
long-term treatment.

Clinic

Long-term with exacerbations and
remissions.
Inxication syndrome increasing with
exacerbations.
DN syndrome, later LSN.
Pulmonary symptoms: cough with sputum,
Often painful, adsady (due to
Bronchial lesions TB). Hemlochy I.
pulmonary bleeding, pain in
chest.

Objective data

General condition from satisfactory to
medium gravity and heavy;
- Habitus phtisicus - asthenic physique,
reduced nutrition, swim over and
subclavian spaces, pale leather, often
with acricyanosis, muscle hypotrophy;
- affected half of the chest (or more
affected) lags behind in breathing;

Continued

-
-
Percussion- dull due to rough
fibrosis; in unaffected departments -
box sound (compensatory
emphysema);
Auscultative - hard breath,
bronchial, sometimes amphoric,
wet medium or large-tangible
wheezing, sometimes localized dry
wheezing.

Laboratory data

Massive bacterial excretion;
Often multiple medicinal
stability (MDU);
significantly increased ESO;
lymphopenia;
hypochromic anemia;
Possible pathology in the analysis of urine (due to
toxic nephropathy, amyloidosis).

X-ray signs FTTL

Round-shaped shadow S.
Thick walls,
defined in 2nd
Projections on background
Negomogenic dimming.
Reduced volume
pulmonary fabric due to
replacing it fibrous
hustles.
The presence of bronchogenic
Observing in the same or
More easy.

Radiograph
Breasts
Cells for
Fibroznochermino
Lung tuberculosis:
Right pulmonary field
narrowed, mediastinum
shifted to the right, in
Top right
Lung is determined
Giant Kaverna S.
Tolstoy dense
walls (indicated
arrow) in the middle
and lower departments
left lung -
Multiple
merging
Shadensions
(Foci dropout).

Top share of the right lung
Reduced in volume, small intercole
Plevra at the level of P.O. 2 ribs. In S1-S2
right lung on the background of local
Rough pneumophybosis is determined
cavity 2.5 * 3.5 cm incorrect
Forms, with different wall thickness (0.5 -
1.5 cm), with uneven inner
contour and the presence of a "track" to
root (drainage armor); around
Multiple polymorphic foci
different sizes. In S1-2 left lung
and S9 right lung foci with fuzzy
contours, small and medium
Intensities are prone to merger.
Right outdoor sinus homogeneously
shaded to the level of the dome of the diaphragm with
Clear upper contour.
Treverpoapical layers on the right.
The roots of the lungs are not expanded,
nestaurants, right -
Deformed and pulled up.
The trachea is somewhat shifted to the right.
Conclusion: Fibrozno-cavernous
Tuberculosis of the top share of the right
Easy with a s1-2 left
lung and S9 right lung
Complicated by exdivalent pleuritis
on right.

Tomogram organs
chest in straight
Projections of the patient
Fibrozno-cavernous
Tuberculosis right
Lung and left-sided
Casomic pneumonia:
left lung reduced into
volume, diffuse
shaded in his upper
Departments are determined
Multiple cavities
decay (1); Right light
increased in volume, in
Medium its departments
Definition of the flooring
(2) at the second level
intercostal interval
- Kavern (3); shadow
Mediterranean is shifted
Left.

Other types of surveys

Reaction to tuberculin test Mantu -
normergic;
FBS- N or Signs of Specific
Bronchi damage;
FVD - DN;
ECG - Possible Signs of HLS.

Epidemic Danger

Due to the constant massive
bactering and frequent MLU
patients with fibrous cavernous
Tuberculosis represent
The greatest epidemic
Danger.

Treatment and outcomes

Chemotherapy (HT) is little effective. For
Limited formas - surgical
treatment.
Possible transition to circyrotic
Tuberculosis on the background of HT.
More often the forecast is unfavorable.
The causes of lethal outcomes are
complications.

Complications FTT.

Specific
Casomic pneumonia
Hematogenic
Observing
TB bronchi, trachea,
Language
Purritish, Empiama,
pneumothorax
Nonspecific
DN
Hls.
Lonantic bleeding
amyloidosis
Absoing cavity
DVS syndrome

To death leads
predominantly
Process progression
Specific complications.
Masters are often so
Complications are:
Casomic pneumonia (70%),
Hematogenic virgin (20%).

Conclusion in FTT.

Fibrozno-cavernous TB - chronically current
Destructive process developing in
The result of the progression of other forms
tuberculosis.
This process is poorly treatable and
is the main cause of death
with tuberculosis.
Leading directions of preventing this
Tuberculosis forms: timely detection and
Adequate treatment of its other forms.

Cyrrotic tuberculosis

Arrangement of rough connective tissue in lungs and pleura
With the preservation of the activity of the process: foci, tuberculos,
Live formations, (bronchiectases, bulls and
Sanished cavity), emphysema
Clinic
Tuberculosis intoxication, moderately pronounced;
Picture of non-specific inflammation (CHNZL);
recurrent hemopling;
LSN (shortness of breath, hls, nk);
Currently wavy with rare or frequent
exacerbations.

The right light is shaded and reduced in the amount of fibrosis and massive pleural layers, calcinates are determined in the ribratra (

the right light shaded and is reduced in the amount due to fibrosis and massive
Pleural layers, calcinates are defined in the ribratra (1),
At the level of the clavicle in the right light, a chronic cavity (2) is visible,
Pulmonary pattern sharply deformed on both sides, in the left lung
There are scattered high-intensity shadows of old foci (3), shadow
The trachea is shifted to the right, the median shadow is deformed.