Tuberculosis Study Guide - M.M. Savula 2002

Secondary forms of pulmonary tuberculosis
Caseous pneumonia

Caseous Pneumonia is an acute specific pneumonia characterized by rapidly progressing caseous necrotic changes and a severe, progressive course.

Pathogenesis. This form of tuberculosis develops in elderly individuals, chronic alcoholics, patients with Diabetes Mellitus, and against the Background of immunosuppressive therapy. In recent years, it has been encountered more frequently. Most often, caseous pneumonia is the result of rapid caseous Necrosis of a large infiltrate occupying an entire lung lobe (lobar caseous pneumonia). Rapid liquefaction of caseous masses and their expectoration through a draining bronchus leads to The formation of giant cavities. Subacute Disseminated Pulmonary Tuberculosis can also present as caseous pneumonia when rapid caseous necrosis of multiple foci of hematogenous dissemination occurs (lobular caseous pneumonia). Their breakdown lays the groundwork for the formation of multiple cavities in both Lungs.

Clinical presentation and Diagnosis. The disease usually begins acutely, with severe intoxication, and body Temperature rises to 39-40 °C. Patients complain of chest pain, shortness of breath, profuse sweating, and a cough producing sputum that is initially rusty and later greenish. The face is pale with cyanotic Lips, and the pulse is significantly accelerated. This clinical picture closely resembles pneumonia, and patients are often prescribed broad-spectrum Antibiotics.

Over the affected areas of the lungs, dullness to Percussion is noted, and Auscultation reveals harsh or bronchial breathing, along with moist "gurgling" crackles of various sizes.

Peripheral Blood analysis reveals hypochromic anemia, leukocytosis reaching 15-20-10⁹/L, a left shift in the leukocyte formula, and a high ESR (up to 50-70 mm/h). Erythrocytes, protein, and hyaline casts are often found in the urine. Repeated sputum examinations for MTB are necessary. The Mantoux test is positive, but in severe cases, it may become negative.

On the chest X-ray of lobar caseous pneumonia, a massive inhomogeneous opacity of the lung lobe is visible. When destruction occurs, areas of lucency representing one or multiple cavities appear against this background. Foci of bronchogenic dissemination may be present in other areas of the lung. In lobular caseous pneumonia, a typical picture of subacute disseminated tuberculosis is revealed: symmetrical multiple confluent foci (a "falling snow" pattern) with numerous cavities.

The course of the disease is fulminant. Without specific Treatment, the patient's condition deteriorates, and within 4-8 weeks, death occurs due to severe intoxication and cardiopulmonary insufficiency.

With intensive therapy and a favorable course of the disease, partial resolution of inflammatory changes occurs, caseous foci become encapsulated by Connective Tissue, massive fibrotic changes form, and the process transitions into cirrhotic tuberculosis. If large cavities have already formed in the lungs, they do not heal, and the disease progresses to Fibrocavitary pulmonary tuberculosis. With satisfactory functional indicators of vital Organs, the caseously altered lung lobe is sometimes surgically resected, followed by continued Chemotherapy. In elderly individuals, drug addicts, alcoholics, and immunocompromised patients, it is often impossible to halt the progression of the disease, even with intensive treatment using anti-tuberculosis drugs.