Tuberculosis - I.T. Piatnochka 2005

Pulmonary tuberculosis complicated by comorbid conditions and pregnancy
Tuberculosis and Motherhood

Pregnancy and Childbirth are high-risk factors for disease, contributing to the exacerbation, relapse, and progression of tuberculosis.

Pathogenesis. The impact of pregnancy on the course of tuberculosis is quite complex: in some cases, pregnancy promotes the progression of the tuberculous process, while in others, it facilitates healing. The course of tuberculosis during pregnancy and childbirth depends on many factors: The Nature of the tuberculous process, the stage of pregnancy, antimycobacterial therapy, as well as social, domestic, and familial circumstances.

Clinical presentation. An inactive tuberculous process during pregnancy does not always exacerbate or relapse. However, tuberculosis that develops during pregnancy predominantly tends to progress. At the same time, it responds well to specific Treatment.

By the way, tuberculosis can occur and progress at any stage of pregnancy and after childbirth; however, about 1/3 of all cases occur in the first three months of pregnancy, and 2/3 in the first 6 months postpartum. In the early months of pregnancy, symptoms of early toxicosis overlap with signs of tuberculous intoxication, making it sometimes difficult to determine whether the deterioration in well-being, low-grade fever, increased sweating, etc., are caused by toxicosis or tuberculosis. In the second half of pregnancy, patients' well-being improves, and they may feel better than before pregnancy. A course of tuberculosis with mild clinical signs may mask the progression of the disease and create an illusion of well-being. Nevertheless, the highest risk of progression arises postpartum.

Diagnosis of tuberculosis, its exacerbations, or relapse is sometimes quite complex. Radiological examination is of particular importance, and if necessary, an X-ray should be taken at any stage of pregnancy, although it is preferably performed after the first month postpartum. Fluoroscopy and mass miniature radiography should be avoided; only standard X-rays should be taken, and even then, provided that the pregnant woman's abdomen and pelvis are reliably protected with a lead apron from unnecessary radiation.

Treatment must be initiated immediately upon the detection of active tuberculosis using adequate anti-tuberculosis drugs and standard WHO regimens. In cases of ineffective treatment or when there is doubt about a positive outcome, a therapeutic abortion can be performed before 12 weeks of pregnancy. Termination of pregnancy after 3 months requires complex interventions that are tolerated worse than physiological childbirth; therefore, it is resorted to only in exceptional cases. Antimycobacterial drugs generally have no teratogenic effect, do not impair intrauterine fetal development, and are not contraindicated during pregnancy. However, it is advisable to avoid The Use of kanamycin, streptomycin (primarily dihydrostreptomycin), viomycin, ethionamide, protionamide, and thioacetazone.

Currently, the most appropriate and safest drugs are isoniazid, ethambutol, and rifampicin.

In general, labor proceeds normally in patients with Pulmonary Tuberculosis; labor stages may be slightly shorter, and children are born healthy. Intrauterine fetal infection occurs only in exceptional cases. Most children are infected by the sick mother after birth, and more rarely during delivery. All newborns are immediately isolated from the mother, and in the absence of contraindications, BCG Vaccination is administered. The child is isolated from the sick mother for at least two months, during the period of Immunity development.

Breastfeeding of newborns by a mother with active tuberculosis is strictly prohibited, although MBT are not transmitted through breast milk. Infection mainly occurs via aerogenic or contact routes.

Breastfeeding of newborns is cautiously permitted only to mothers with an inactive form of pulmonary tuberculosis.

CONTROL QUESTIONS

1. Features of the clinical course, diagnosis, and treatment of Pulmonary tuberculosis combined with COPD.

2. Frequency, pathogenesis, clinical presentation, and treatment of pulmonary tuberculosis in patients with Diabetes Mellitus.

3. The course of pulmonary tuberculosis in patients with gastric and duodenal ulcer disease.

4. Clinical and radiological features of the course and treatment of pulmonary tuberculosis in patients with chronic alcoholism.

5. The relationship between Tuberculosis and AIDS. Clinical presentation, diagnosis, and treatment of patients with these comorbidities.

6. Frequency, pathogenesis, clinical presentation, diagnosis, and treatment of patients with pulmonary tuberculosis combined with bronchocarcinoma.

7. Features of the diagnosis of pulmonary tuberculosis in pregnant women.

8. The impact of pregnancy and childbirth on the development and course of pulmonary tuberculosis.

TESTS

1. Patient K., 35 years old, has had Chronic Bronchitis for the past 4 years. 5 months ago, she developed hemoptysis, and her body Temperature rose to 38 °C. A chest X-ray against the Background of an enhanced pulmonary pattern in the upper lung zones reveals focal shadows of small and medium intensity, with areas of rarefaction beneath the clavicles. Mantue test: 10 mm infiltrate. What is the most likely diagnosis?

A. Carcinomatosis

B. Focal pulmonary tuberculosis

C. Disseminated pulmonary tuberculosis

D. Bilateral Focal Pneumonia

E. Sarcoidosis

2. A 38-year-old female patient has a 6-year history of diabetes mellitus. For the past 4 months, she has been complaining of generalized weakness, thirst, cough, intermittent low-grade fever up to 38 °C, and weight loss. Objective Examination: the left hemithorax lags behind in the respiratory act; Percussion dullness and moist rales are detected near the lower angle of the scapula. X-ray imaging reveals a non-homogeneous shadow with areas of translucency in the lower lobe of the left lung. Mantoux test with 2 TU shows an 11 mm infiltrate. What is the most likely diagnosis?

A. Tuberculosis

B. Central Cancer

C. Eosinophilic infiltrate

D. Exudative Pleurisy

E. Lower lobe pneumonia

3. Patient K., aged 25, suffers from AIDS and mycobacteriosis. Indicate the optimal combination of antimycobacterial drugs.

A. Kanamycin + cycloserine + rifadin

B. Rifampicin + ethambutol + PAS

C. Isoniazid + rifampicin + ethambutol

D. Isoniazid + streptomycin + capreomycin

E. Pyrazinamide + ethambutol + ethionamide

4. X-ray Examination of a female patient with AIDS reveals massive focal-infiltrative shadows in the lower lobes of both Lungs. The Mantoux tuberculin Skin test with 2 TU is negative. What is the most likely diagnosis?

A. Bilateral lower lobe pneumonia

B. Disseminated tuberculosis

C. Carcinomatosis

D. Bronchiectasis

E. Mycobacteriosis

5. The incidence of tuberculosis in patients with diabetes mellitus is significantly higher than that in the general population.

A. 1.5 times

B. 2.5 times

C. 5 times

D. 15 times

Е. 25 times

6. How many times higher is the incidence of tuberculosis in alcoholics compared to the general population?

A. 1.5 times

B. 5 times

C. 0 times

D. 18 times

E. 35 times

7. How many times higher is the incidence of tuberculosis in patients with gastric ulcer compared to the general population?

A. 1.5-2 times

B. 3-5 times

C. 6-9 times

D. 10-15 times

E. 0-25 times

8. Bronchogenic carcinoma in patients with pulmonary tuberculosis is observed significantly more often.

A. 1.5-2 times

B. 3-6 times

C. 7-10 times

D. 12-15 times

E. 17-20 times

9. Patient B., aged 58, previously received successful treatment for infiltrative Tuberculosis of the upper lobe of the right lung in the decay phase, MBT+. Over the past three months, the patient's condition has deteriorated, accompanied by hemoptysis, shortness of breath, and pain in the right hemithorax. Physical examination reveals enlarged, dense Lymph Nodes palpable above the right clavicle. A chest X-ray shows a massive darkening in the upper segment of the right lung. ESR is 65 mm/h. The Mantoux test with 2 TU is negative. What is the most likely diagnosis?

A. Eosinophilic infiltrate

B. Lobar pneumonia

C. Atelectasis of the upper lobe of the right lung

D. Aspergilloma

E. Central Lung Cancer

10. Does pulmonary tuberculosis occur and progress more frequently in women?

A. During the first two months of pregnancy

B. At 3–6 months of pregnancy

C. At 7–9 months of pregnancy

D. During the first 6 months postpartum

E. 1–2 years after childbirth

11. A pregnant woman is suspected of having pulmonary tuberculosis; therefore, the first diagnostic Procedure to perform is:

A. fluoroscopy

B. photofluorography

C. chest X-ray

D. tomography

E. bronchography

12. Artificial termination of pregnancy is not indicated for:

A. focal

B. infiltrative

C. Tuberculoma

D. fibrocavitary

E. miliary pulmonary tuberculosis

13. The most optimal combination of antimycobacterial drugs for the treatment of pregnant women with tuberculosis:

A. Isoniazid + rifampicin + ethambutol

B. Isoniazid + rifampicin + ethionamide

C. Rifampicin + streptomycin + thioacetazone

D. Kanamycin + isoniazid + PAS

E. Cycloserine + rifampicin + prothionamide