Tuberculosis - I.T. Pyatnochka 2005

Primary tuberculosis
Pulmonary tuberculoma

Pulmonary Tuberculoma is an encapsulated caseous lesion of diverse genesis measuring over 1 cm in diameter, characterized by a chronic, torpid clinical course (Fig. 19).

Among newly diagnosed Pulmonary Tuberculosis patients, tuberculomas occur in 0.5–1% of cases, whereas they develop during anti-mycobacterial therapy in 4–5% of cases.

The Pathogenesis of tuberculomas varies, as this form encompasses tuberculosis lesions that differ in Morphology and stage of development. Most frequently, tuberculomas develop from infiltrative, focal, and less commonly disseminated tuberculosis or the Primary tuberculous complex.

The formation of tuberculomas is associated with high host resistance and pronounced anti-tuberculosis Immunity, as well as, to some extent, prolonged Treatment with streptomycin, and BCG Vaccination and revaccination.

Pathomorphology. Based on pathomorphological Structure, several variants of tuberculomas are distinguished:

1. Homogeneous tuberculoma: an encapsulated caseous focus that frequently arises from infiltrative tuberculosis.

2. Layered tuberculoma: consists of concentric layers of necrosis separated by Connective Tissue rings, developing As a result of frequent exacerbations of the tuberculosis focus.

3. Conglomerate tuberculoma: combines a conglomerate of caseous foci surrounded by a common connective tissue capsule, presenting with a round or irregular polycyclic shape.

4. Infiltrative-pneumonic tuberculoma: a round focus of specific Pneumonia with areas of caseation and a tendency toward a productive reaction.

5. Pseudotuberculoma (blocked cavity): forms when the patency of the draining bronchus is impaired and the cavity is blocked; it appears as a round, homogeneous focus with a capsule characteristic of a cavity, while the content consists of thick or liquid caseous necrosis masses.

Small (1–2 cm), medium (2–4 cm), and large (over 4 cm) tuberculomas are distinguished. They are predominantly localized in the I, II, or VI segments of the Lungs.

Clinical Features. The clinical course is asymptomatic or mildly symptomatic. Upon progression, symptoms of intoxication and hemoptysis may occur. Percussion dullness is detected only when the tuberculoma exceeds 4 cm in diameter, and rales appear upon progression and breakdown.

The hemogram shows no deviations from the norm in the vast majority of patients. MBT are detected when the tuberculoma breaks down. Tuberculin sensitivity is high.

Based on the clinical course, progressive, stable, and regressive variants of tuberculoma progression are distinguished.

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Fig. 19. Tuberculoma of the left lung. Overview radiograph

Diagnostics. Important signs of a tuberculoma include an isolated round or oval, intense, though not entirely homogeneous shadow (with eccentric sickle-shaped breakdown, calcification inclusions), measuring from 1 to 8 cm with clear margins, predominantly localized in segments I, II, and VI, and accompanied by intense foci, pneumosclerosis in the surrounding tissue, and calcifications in the ROOT.

Cytology/practical/136.html">Differential Diagnosis OF tuberculomas is performed with peripheral Cancer, solitary metastases of a malignant tumor, aspergilloma, a filled cyst, echinococcosis, benign tumors, arteriovenous aneurysm, nonspecific pneumonia, and encysted Pleurisy.

Treatment of newly diagnosed patients with pulmonary tuberculoma begins with the administration of anti-mycobacterial drugs, primarily those with good tissue penetration (isoniazid, rifampicin, pyrazinamide). If there is no tendency toward regression of the tuberculomas within 2–3 months of initiating treatment, or in cases of large tuberculoma size (over 3–4 cm), presence of breakdown and bacteriodshedding, diagnostic uncertainty (tumor cannot be ruled out), as well as when the patient cannot continue their professional activity due to an active tuberculosis process (teachers, staff of children's institutions, etc.), a conservative lung resection is indicated. Postoperative Chemotherapy is continued for another 4–6 months (isoniazid + rifampicin or ethambutol).

CONTROL QUESTIONS

1. Definition of pulmonary tuberculoma.

2. Pathogenesis of tuberculomas, reasons for their increased frequency among other Clinical forms of tuberculosis.

3. Pathomorphology of tuberculomas, their Classification by size and pathomorphological structure.

4. Clinical features, objective and laboratory findings in tuberculoma.

5. Radiological signs of tuberculoma.

6. Diseases requiring differential diagnosis with tuberculomas.

7. Treatment Methods for patients with pulmonary tuberculoma and their indications.

8. Indications for Surgical treatment of tuberculomas.

9. Prevention of pulmonary tuberculomas.

TESTS

1. In which segments are tuberculomas most commonly localized?

A. I, II, III

B. I, II, VI

C. I, VI, X

D. I, II, VIII

E. II, IV, V

2. Which condition should be considered for the differential diagnosis of tuberculoma:

A. aspergilloma

B. air cyst

C. central cancer

D. eosinophilic infiltrate

E. chronic abscess

3. Patient K., 29 years old, has been experiencing generalized weakness, cough, low-grade fever over the past 5 months; Amenorrhea for 3 months. A chest X-ray reveals a round formation, over 3 cm in diameter, of moderate density in the II segment of the upper lobe of the left lung. Mantoux test with 2 TU shows a 23 mm infiltrate. The most likely diagnosis is:

A. Aspergilloma

B. Peripheral cancer

C. Tuberculoma

D. Retention cyst

E. Chondroma

4. The most rational combination of antimycobacterial drugs in the initial phase for patients with pulmonary tuberculoma, MBT (-).

A. Isoniazid + streptomycin + rifampicin

B. Isoniazid + rifampicin + pyrazinamide

C. Isoniazid + streptomycin + pyrazinamide

D. Rifampicin + pyrazinamide + PAS

E. Rifampicin + ethionamide + kanamycin

5. How many variants of tuberculomas are distinguished by their pathomorphological structure?

A. 1

B. 2

C. 3

D. 4

E. 5

6. How many Variants of the clinical course of tuberculomas are known?

A. 1

B. 2

C. 3

D. 4

E. 5

7. From which clinical form of tuberculosis is a tuberculoma most frequently formed?

A. Disseminated

B. Fibro-cavitary

C. Cirrhotic

D. Focal

E. Infiltrative

8. In the absence of positive treatment dynamics within 2–4 months in patients with pulmonary tuberculoma, the following is used:

A. conservative lung resection

B. pneumonectomy

C. decortication of the affected lung

D. hormone therapy

E. continue antimycobacterial therapy for 6–8 months

9. Frequency of tuberculomas in patients with newly diagnosed pulmonary tuberculosis.

A. 0.5-1 %

B. 3-4 %

C. 5-6 %

D. 7-9 %

E. 10-15 %

PROBLEMS

1. Patient R., 32 years old, has been complaining of a dry cough, general weakness, sweating, and low-grade fever for the last four months. A fluorogram shows a round formation, more than 2 cm in diameter and of medium intensity, In the second segment of the upper lobe of the right lung. At the age of 20, he suffered from Infiltrative pulmonary tuberculosis. General Blood count is within normal limits. Mantoux test with 2 TU shows a 15 mm infiltrate.

a) Preliminary diagnosis.

b) Examination plan.

c) What other disease can be suspected?

Answer: a) Newly diagnosed pulmonary tuberculosis (08.08.2003), segment II of the right lung (tuberculoma), Destr-, MBT0, Hist0, Cat3, Coag3 (2003). b) Plain chest radiograph, tomogram; sputum examination for MBT and cancer Cells (5-6 times), bronchoscopy. c) Peripheral cancer.

2. Patient Z., 35 years old, during a radiological examination, revealed a shadow with blurred contours measuring 4 cm in the right lung (1st segment), MBT (-). After 3 months of antimycobacterial therapy, a round focus with a diameter of 2 cm, a homogeneous structure, and clear contours was formed.

a) Formulate the diagnosis prior to treatment.

b) Diagnosis after 3 months of treatment.

c) Further treatment plan.

3. A 60-year-old man during a fluorographic examination was found to have a round shadow with wavy outer contours in the 3rd segment of the left lung, with single calcifications in the roots. ESR is 62 mm/h.

a) What disease can be suspected?

b) Is trial treatment appropriate?

c) Examination plan.

4. Patient Z., 29 years old, has been bothered by a cough with a small amount of sputum and occasional low-grade fever for 2 years. She did not seek medical help. A week ago, a heterogeneous opacity of 2.5x3.0 cm with clear contours and an area of eccentric lucency was detected in the sixth segment on the left.

a) Preliminary diagnosis.

b) Examination plan.

c) Treatment plan.

5. Patient S., aged 17, suffering from Diabetes Mellitus, underwent fluorography which revealed a round shadow 2.5 cm in diameter of moderate intensity with blurred outer contours and a path leading to the lung root in the VI segment of the right lung. Mantoux test with 2 TU showed an infiltrate of 24 mm.

a) Preliminary diagnosis.

b) Examination plan.

c) Treatment plan.