Tuberculosis - I.T. Pyatnochka 2005

Extrapulmonary tuberculosis
Miliary tuberculosis

Acute disseminated tuberculosis of haematogenous origin most commonly manifests as miliary tuberculosis (from the Latin milium, meaning millet seed) with diverse clinical presentations, and has been classified as a distinct clinical entity due to its increasing incidence in modern practice (Fig. 31).

Miliary tuberculosis is typically generalized, with The formation of lesions in the Lungs, Liver, Spleen, intestines, and Meninges. Less commonly, this form affects only the lungs. Miliary tuberculosis is characterized by an acute course and the appearance of tubercles or their conglomerates—small tuberculous foci—in the interstitial tissue of various Organs. It develops As a result of the haematogenous dissemination of MTB against the Background of severely compromised host resistance, most frequently in children and adolescents.

Based on its clinical course, miliary tuberculosis is conventionally divided into pulmonary, typhoid, meningeal, and septic (Landouzy's disease) forms.

In the pulmonary form of miliary tuberculosis, tubercle eruptions occur predominantly in the lungs; alongside pronounced intoxication, symptoms such as dyspnoea, dry cough, and cyanosis predominate. The respiratory rate exceeds 40 breaths per minute, accompanied by marked tachycardia.

Physical examination findings are minimal. Percussion reveals a pulmonary note with a tympanitic tinge due to acute emphysema. Breath sounds may be diminished or harsh, accompanied by dry and fine rales.

During the first days of the disease, chest radiographs may show no pathological changes or may reveal a delicate reticular pattern resulting from increased pulmonary vascular engorgement; only after 7–14 days does a bilateral, diffuse, millet-like dissemination appear throughout the lungs.

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Fig. 31. Miliary tuberculosis. Plain chest radiograph

Typhoid form of miliary tuberculosis. Microfocal dissemination is observed across all organs and Tissues. The clinical course resembles that of typhoid fever. However, typhoid fever has an insidious onset, whereas miliary tuberculosis begins acutely. The body Temperature in typhoid fever tends to be sustained, whereas in tuberculosis it is irregular and remittent. Patients with typhoid fever may exhibit bradycardia, meteorism, and diarrhoea, which are atypical for miliary tuberculosis. Furthermore, typhoid fever is accompanied by leucopenia and relative lymphocytosis, whereas miliary tuberculosis presents with mild leucocytosis and lymphopenia. Mental apathy is characteristic of typhoid fever, as is relative bradycardia, a positive Widal reaction, and roseolous rashes on the abdominal Skin.

In the meningeal form of miliary tuberculosis, the Brain AND SPINAL cord, and particularly their meninges, are affected. This form of tuberculosis is diagnosed primarily on The basis of meningeal symptoms, with involvement of other sites becoming apparent subsequently.

Acute miliary Sepsis, like the preceding forms, is characterized by the haematogenous spread of highly virulent MTB, resulting in generalized microfocal involvement of all organs and tissues in an immunocompromised host. Furthermore, from the very onset of the disease, specific small tubercles rapidly undergo purulent-caseous necrosis, where A large number of Mycobacterium tuberculosis organisms can be detected. The patient's general condition is extremely critical. The disease is difficult to differentiate from non-tuberculous sepsis, which accounts for its high mortality rate. Typically, sepsis is associated with purulent processes in other organs, a sudden onset, high septic body temperatures, and chills. There is significant leucocytosis (exceeding 20 x 10⁹/L with a marked left shift). The Diagnosis is confirmed by Blood cultures for sterility; staphylococcal or streptococcal growth is detected on days 2–3, whereas MTB grow slowly on culture media, taking an average of 3–4 weeks.

The Treatment of patients with miliary tuberculosis involves the administration of four anti-tuberculosis drugs at optimal doses: isoniazid and rifampicin at 0.6 g daily, streptomycin at 1.0 g intramuscularly, and pyrazinamide at 1.0 g twice daily or ethambutol at 1.0 g once daily, for a duration of 2–3 months. Thereafter (after 2 months), streptomycin is discontinued. The total duration of continuous Chemotherapy is 8–12 months. Concurrently with anti-tuberculosis drugs, Vitamins B₁, B₆, and C are prescribed, along with desensitizing and general strengthening agents, and a course of glucocorticoids (1.5–2 months) during the initial months of treatment.

Review Questions

1. Pathomorphological forms of Peripheral Lymph Node tuberculosis.

2. Clinical presentation and diagnosis of tuberculous lymphadenitis.

3. Treatment of patients with peripheral lymph node tuberculosis.

4. Tuberculosis of mesenteric Lymph Nodes: Clinical Features, diagnosis, and treatment.

5. Intestinal tuberculosis: pathological anatomy, clinical presentation, diagnosis, and treatment.

6. Peritoneal tuberculosis: forms, clinical presentation, diagnosis, and treatment.

7. Bone and joint Tuberculosis. Clinical presentation, diagnosis, and treatment.

8. Urogenital Tuberculosis.

9. Pathomorphology of Renal tuberculosis. Clinical presentation, diagnosis, and treatment.

10. Tuberculosis of the FEMALE REPRODUCTIVE ORGANS. Clinical presentation, diagnosis, and treatment.

11. Cutaneous tuberculosis. Forms of skin tuberculosis. Treatment.

12. Ocular tuberculosis. Pathogenesis. Clinical presentation, diagnosis, and treatment.

13. Tuberculosis of the ear. Clinical presentation, diagnosis, and treatment.

14. Tuberculosis of The Heart and Blood Vessels. Features of the clinical course, diagnosis, and treatment.

TESTS

1. Which of the urogenital organs is most frequently affected by tuberculosis?

A. Kidneys

B. Ureter

C. Urinary Bladder

D. Seminal Vesicles

E. Fallopian tubes

2. The primary method for confirming the Etiology of urinary bladder tuberculosis is:

A. Ultrasound

B. Excretory urography

C. Detection of MBT in urine

D. X-ray Examination

E. Radioisotope scanning

3. Patient V., aged 36, has a history of Pulmonary Tuberculosis. Three months ago, he developed a fever, along with pain, Swelling, and redness of the Scrotum. Palpation reveals induration and enlargement of the right Epididymis, with a subtle cutaneous fistula on the upper pole of the Testis. What is the most likely diagnosis?

A. Syphilis

B. Cancer

C. Actinomycosis

D. Tuberculous epididymitis

E. Purulent (non-infectious) epididymitis

4. Predominant localization of Genital Tuberculosis in women.

A. Fallopian tubes

B. Endometrium

C. Cervix

D. Vagina

E. Ovaries

5. At what age is genital tuberculosis most commonly diagnosed in women?

A. 16-30 years

B. 30-35 years

C. 36-40 years

D. 41-45 years

E. 46-60 years

6. In active genital tuberculosis, subcutaneous tuberculin injection causes:

A. calcification

B. scar formation

C. encapsulation

D. resolution of the specific process

E. exacerbation of the specific process

7. Infection with Mycobacterium bovis most frequently affects which lymph nodes:

A. cervical

B. supraclavicular

C. paratracheal

D. mesenteric

E. axillary

8. In complex diagnostic cases, to confirm the tuberculous etiology of lymphadenitis, the decisive role belongs to:

A. clinical blood test

B. Mantoux test with 2 TU

C. Koch's test

D. histological examination of the biopsy specimen

E. trial therapy

9. Predominant localization of abdominal tuberculosis:

A. colon

B. Small Intestine

C. Appendix

D. Pancreas

E. mesenteric lymph nodes

10. A 15-year-old girl has been complaining of abdominal pain, decreased appetite, weight loss, low-grade fever, and irregular menstruation over the past two years. She frequently consumed raw cow's milk. The Mantoux test with 2 TU shows an 18 mm infiltrate. Abdominal palpation reveals a relatively fixed tumor-like mass below the umbilicus. What is your provisional diagnosis?

A. Tumor

B. Chronic appendicitis

C. Tuberculous mesenteric lymphadenitis

D. Chronic cholecystitis

E. Partial intestinal obstruction

11. Duration of antimycobacterial therapy for patients with tuberculosis of the mesenteric lymph nodes.

A. 3-4 weeks

B. 1-2 months

C. 3-6 months

D. 6-8 months

E. 1.5-2 years

12. Predominant localization of tuberculosis of the alimentary tract.

A. Esophagus

B. Stomach

C. Duodenum

D. Cecum

E. Sigmoid colon

13. Most frequent localization of bone and joint tuberculosis.

A. Hip joint

B. Knee joint

C. Spine

D. Ankle joint

E. Shoulder joint

14. An 8-year-old boy (patient Z.) has been experiencing pain in his right knee joint for the past two months following an injury. Body temperature is low-grade (subfebrile), the joint is enlarged, hot to the Touch, the skin is hyperemic, and joint mobility is limited. The Mantou test with 2 TU shows a 19 mm infiltrate. ESR is 30 mm/h. Alexandrov's sign is positive. The most likely diagnosis is:

A. Joint tumor

B. Infectious Arthritis

C. Rheumatic monoarthritis

D. Tuberculous gonitis

E. Post-traumatic Arthritis