Tuberculosis - I.T. Pyatnochka 2005
Primary tuberculosis
Caseous pneumonia
Caseous Pneumonia is an acute specific pneumonia characterized by significant caseous-necrotic Changes in the Lungs, pronounced signs of intoxication, a severe progressive course, and a frequently fatal outcome (Fig. 18). Over the past 5–8 years, its incidence has increased 3–5 fold, accounting for 20–25% of the total Structure of Infiltrative Pulmonary Tuberculosis.
Pathomorphology. Caseous pneumonia occurs in patients with a sharply reduced body resistance caused by various factors, in the presence of high virulence of MBT, as well as their resistance to antimycobacterial drugs.
Caseous pneumonia as a primary independent form of tuberculosis is extremely rare. In recent years, secondary caseous pneumonia has been observed with increasing frequency; it develops on the Background of lobitis, cloud-like infiltrate, following Pulmonary Hemorrhage, against the background of aspiration pneumonia, or severe progressive forms of tuberculosis, such as fibro-cavitary or Subacute Disseminated pulmonary tuberculosis.
Depending on the pattern of pathomorphological changes, lobar and lobular caseous pneumonia are distinguished.
In lobar caseous pneumonia, the process involves an entire lung lobe, and the infiltrative-pneumonic form rapidly transforms into a caseous-destructive one. The cause of such rapid formation of caseous necrosis and the spread of the process to the entire lobe is presumably a sharply reduced body resistance, a high degree of macroorganism sensitization, and high virulence and massiveness of infection. In this form of tuberculosis, In addition to large areas of caseous necrosis, multiple disintegration cavities or a large cavity are invariably formed As a result of purulent melting.
Lobular caseous pneumonia more frequently develops as a result of aspiration pneumonia following hemorrhages, as a complication of disseminated pulmonary tuberculosis, etc.
Clinical Features. A characteristic feature is an acute, sudden onset with high body Temperature, rapidly increasing symptoms of intoxication, profuse sweating, dyspnoea, chest pain, and a cough productive of abundant Blood-tinged sputum. The Skin is pale, and mucous Membranes have a cyanotic tint. Marked tachycardia and hypotension are present. Percussion reveals dullness over the affected areas, and Auscultation reveals numerous moist rales of various calibres.
The radiograph in lobar pneumonia shows a massive opacification of the lung lobe without clear boundaries, containing disintegration cavities, with a large cavity forming subsequently; in lobular caseous pneumonia, large confluent foci of opacification are seen, and as the disease progresses, multiple disintegration cavities appear along with fresh foci of bronchogenic dissemination.
All of this is accompanied by marked changes in the hemogram, specifically hypochromic anaemia, leukocytosis, eosinopenia, an increased number of band neutrophils, lymphopenia, and a sharply accelerated ESR (up to 70 mm/h). MBT are found in the sputum. The tuberculin skin test may be negative (negative anergy).
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Fig. 18. Caseous pneumonia of both lungs. Tomogram
Cytology/practical/136.html">Differential Diagnosis OF caseous pneumonia is carried out with croupous and staphylococcal pneumonia.
Treatment of caseous pneumonia involves the administration of maximally tolerated doses of isoniazid, rifampicin, streptomycin, pyrazinamide, and ethambutol, concurrently with detoxification, symptomatic therapy, and Vitamins, and when necessary, fluoroquinolones (ofloxacin, ciprofloxacin) to suppress secondary infection. However, complete cure is extremely rare; more often, fibro-cavitary or Cirrhotic pulmonary tuberculosis develops. Given all this, the treatment plan for patients with caseous pneumonia should provide for surgical intervention such as resection of the lung or its lobe, followed by continued antimycobacterial therapy for up to 6 months.
CONTROL QUESTIONS
1. Definition of infiltrative pulmonary tuberculosis.
2. Pathogenesis and pathomorphology of infiltrative tuberculosis.
3. Clinical and radiological variants of infiltrates.
4. Radiological signs of tuberculous infiltrate.
5. Diseases with which differential diagnosis of infiltrative pulmonary tuberculosis is most frequently performed.
6. Complications of infiltrative pulmonary tuberculosis.
7. Basic principles of treatment for patients with infiltrative pulmonary tuberculosis.
8. Definition of caseous pneumonia.
9. Causes of caseous pneumonia.
10. Pathomorphology of caseous pneumonia.
11. Clinical features and differential diagnosis of caseous pneumonia.
12. Treatment of patients with caseous pneumonia.
13. Possible outcomes of caseous pneumonia.
TESTS
1. Frequency of infiltrative tuberculosis in the overall structure of newly diagnosed pulmonary tuberculosis patients:
A. 5-10 %
B. 13-24 %
C. 25-35 %
D. 45-55 %
Е. 65-85 %
2. Diseases that are most frequently differentiated from caseous pneumonia:
A. staphylococcal pneumonia
C. eosinophilic pneumonia
3. Against the background of which pulmonary tuberculosis complications does caseous pneumonia most frequently develop?
A. Pulmonary hemorrhage
C. Laryngeal tuberculosis
E. Atelectasis of a lung lobe
4. Predominant segmental localization of tuberculous infiltrate.
A. Segments 1, 2, and 3
B. Segments 1, 3, and 4
C. Segments 1, 4, and 5
D. Segments 1, 2, and 6
E. Segments 2, 6, and 9
5. Under the guise of which diseases does tuberculous infiltrate most frequently present?
A. Peripheral cancer
B. Retention cyst
C. Pneumonia
D. Eosinophilic infiltrate
E. Aspergilloma
6. A 39-year-old female patient, Z., developed Diabetes Mellitus 6 years ago. X-ray Examination revealed an infiltrative shadow with a central lucency in the lower lobe of the left lung. The patient's general condition is satisfactory. Blood test: WBC - 10.5x109/L, ESR - 25 mm/h. Mantoux test with 2 TU is positive. What is the most probable diagnosis?
A. Lung cancer
B. Pneumonia
C. Infiltrative tuberculosis
D. Lung abscess
E. Primary tuberculosis complex
7. A 36-year-old male patient, K., developed acute illness following surgery for a perforated gastric ulcer. The radiograph shows massive infiltration of the lung tissue in the upper lobe of the right lung with multiple destruction cavities. Mantoux test with 2 TU is doubtful. Blood test: WBC - 17.0x109/L, ESR - 52 mm/h. MBT were found in the sputum. What is the most probable clinical form of pulmonary tuberculosis?
A. Infiltrative
B. Focal
C. Fibrocavernous
D. Caseous pneumonia
E. Cirrhotic
8. What is the most characteristic blood test in patients with infiltrative pulmonary tuberculosis?
A. WBC - 25.0x109/L; e - 3, b - 6, s - 51, l - 23, m - 7 %; ESR - 6 mm/h.
B. WBC - 9.8x109/L; e - 5, b - 6, s - 65, l - 13, m - 11 %; ESR - 36 mm/h.
C. WBC - 4.0x109/L; e - 2, b - 2, s - 60, l - 26, m - 9 %; ESR - 6 mm/h.
D. WBC - 16.5x109/L; e - 10, b - 10, s - 64, l - 14, m - 2 %; ESR - 21 mm/h.
E. Лейк. - 6.0×109/L; e - 4, st - 3, seg - 60, l - 26, m - 6 %; ESR - 7 mm/h.
PROBLEMS
1. A 30-year-old female patient with a history of gastric ulcer underwent a routine fluorographic examination (Apr 4, 2005), which revealed a cloud-like opacity in the upper lobe of the right lung with central radiolucency, alongside a paracardial cluster of low-intensity foci.
a) Preliminary diagnosis.
b) Which medical facility should the patient be referred to?
c) Examination plan.
Відповідь: а) ВДТБ (04.04.2005) верхньої частки правої Легені (інфільтративний) (обсіювання), Дестр+, МБТ0, Гіст0, Кат 1 Ког 2 (2004). б) В протитуберкульозний диспансер. в) Оглядова рентгенограма, томограма; 3-х разове бактеріоскопічне і Бактеріологічне дослідження харкотиння на МБТ; загальний аналіз крові та сечі.
2. A 17-year-old girl developed hemoptysis a day after excessive sun exposure. Fluorography performed six months prior showed no pulmonary abnormalities. Moist medium-bubbling rales are auscultated below the right clavicle. Mantoux test with 2 TU reveals a 23 mm infiltrate.
a) Preliminary diagnosis.
b) Emergency care.
c) Examination plan.
3. Patient B., aged 40, was found during a fluorographic examination to have a medium-intensity shadow below the right clavicle with central lucency and a linear marking extending to the lung ROOT. General condition is good.
a) Formulate a preliminary diagnosis.
b) Which medical facility should the patient be referred to?
c) Examination plan.
4. Plan specific treatment for a patient with newly diagnosed pulmonary tuberculosis (June 5, 2004) of the right upper lobe (caseous pneumonia), Dest+, MBT+M+K+, Resist-, Hist0, Cat 1 Coh 2 (2004). Patient's age is 45, weight is 46 kg. General condition is severe. No comorbid pathology.
a) Antimycobacterial drugs.
b) Drug dosages.
c) Average duration of treatment.
5. Patient K., aged 35, was hospitalized in a tuberculosis dispensary for pulmonary hemoptysis that appeared two weeks after childbirth. History of primary tuberculosis complex in childhood.
a) Preliminary diagnosis.
b) Emergency care.
c) Examination plan.
Last update: 10/08/2026
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