Diagnosis of tuberculosis of extrapulmonary localization

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Diagnosis of osteoarticular tuberculosis

Radiological diagnostics of bone and joint tuberculosis is aimed at identifying primary bone foci of specific inflammation - isolated or included in the zone of contact destruction of articulating bones, be it vertebrae, articular ends of tubular or articular surfaces of flat bones. The primary focal nature of the tuberculous process determines the depth of contact destruction, which in most cases allows differentiating the specific process from other diseases. At the same time, targeted identification of complications of bone damage is carried out - inflammatory (abscesses, fistulas) and orthopedic (impaired shape and relationships of vertebrae, articular ends).

The depth of examination is determined by the objectives of diagnostics and surgical treatment.

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Diagnosis of spinal tuberculosis

Tuberculous spondylitis is characterized by the destruction of bone tissue of the vertebrae or their processes, secondary involvement of intervertebral discs in the process, and the formation of abscesses in the paravertebral tissues and epidural space.

It is necessary to use radiation diagnostic methods:

• establish the level of spinal damage, the number and number of vertebrae involved;
• determine the characteristics of the affected area:
  • focal, contact or combined type of destruction, its depth (height);
  • the presence of pathological inclusions in destructive cavities;
  • the relationship of cavities/inclusions with paravertebral tissues and the spinal canal;
  • the structure of the bone tissue of the affected vertebrae and the general structural background of the spine;
• determine the condition of the intervertebral space (discs) in the affected area;
• to identify possible involvement of elements of the posterior vertebral column in the process;
• characterize the condition of paravertebral tissues, the presence and prevalence of abscesses or fistulas, their relationship with other anatomical areas and organs;
• determine the presence of epidural abscesses, establish the presence/absence of spinal cord compression (dural sac), its degree, length, compression substrate;
• determine the condition of the spinal cord and its membranes at the level of spinal deficit, especially in case of dissociation of indicators (absence of compression images in spinal cord disorders).

The expansion of the arsenal of methods for radiation diagnostics of tuberculous spondylitis, the advantages and limitations of different methods make it necessary to choose a diagnostic path. Most authors, putting radiography at the first diagnostic stage, then offer their algorithms. Indeed, with the availability of CT and MRI, the examination scheme for patients with tuberculous spondylitis in the hands of specialists could be significantly shortened. After taking overview images, it is ideal to conduct MRI. X-ray techniques, including CT, can then be used if it is necessary to clarify the state of the bone structure in the affected area or the patency of the cerebrospinal fluid pathways. CT, as the second step after overview radiography, is advisable for lesions limited to one or two vertebrae, especially in the cervical and lumbar regions, as well as in the presence of metal structures, when MRI is contraindicated.

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Diagnosis of tuberculosis of the joints

In the diagnosis and monitoring of treatment of tuberculosis of the joints, the most common methods are classical radiological and tomographic methods.

Diagnosis of complications in tuberculosis of bones and joints includes abscessography, fistulography in a survey or tomographic version. Stereoradiography is widely used. In this case, sequential shooting is performed on two identical films (usually 24x30 cm) with an exact repetition of the position of the cassette and the object of shooting, with the tube shifted first to the right of the center, then to the left by 3.5 cm. When these images are viewed simultaneously on a stereoscope, a spatial volumetric image of abscesses, fistula tracts, their relationships with bones and joints is obtained.

Of the new methods of radiation diagnostics, CT is most often used for bone and joint pathology. The resulting image clearly demonstrates destructive cavities in the articular ends, their scale relative to the thickness of the bone; it reveals the extent of contact destruction of the articular ends, sequesters, abscesses, and the condition of the soft tissues of the joint itself.

CT is advisable to use in anatomical areas where radiography in conventional projections provides insufficient information (especially in cases of lesions of the pelvic girdle bones).

MRI is used less frequently in diagnostics of bone and joint pathology, but it is precisely this that facilitates early detection of inflammatory and necrotic changes in bones (bone marrow), visualizes changes in the cartilaginous covering of the articular ends, infiltration near the joint capsule, and effusion in the joint bag. Deep intermuscular abscesses that are not detected by other methods are clearly visible on MRI tomograms.

Diagnosis of tuberculosis of the urinary system

Radiation methods play one of the leading roles in the diagnosis and differentiation of tuberculosis of the urinary system. CT and MRI have now been added to traditional X-ray methods. The tasks of X-ray examination of a patient with kidney pathology include identifying:

• general background (the presence of calcified lymph nodes or abscesses, urinary or biliary tract stones, spinal pathology, calcification of costal cartilage), on which special studies are then carried out;
• functional changes, dynamics of urinary tract emptying;
• early infiltrative and destructive changes in the renal parenchyma (papillitis);
• extensive destructive changes in the kidneys (caverns - isolated or communicating with the cavity system, including those containing calcified caseous);
• non-functioning kidney segments, cystic kidneys or disabled kidneys;
• changes in the cavity system of the kidneys and ureters (primary expansion of the cavities - hydronephrosis, pyelectasis; cicatricial deformations of the cups; rigidity, strictures, expansion of the ureters);
• cicatricial changes, deformations of the bladder, ureteral orifices;
• secondary changes in the kidneys and their cavity system (secondary expansion of the cavities, shrunken kidney); complications of the underlying process, changes in the surrounding soft tissues of the retroperitoneal space.

The condition of the surrounding tissues is determined by plain radiography of the abdominal cavity, preceding excretory urography. The latter, if indicated, is supplemented by tomography of the kidneys under contrast conditions (optimal sections are selected by a regular measurement, most often 7-8-9 cm). The duration (time) of the study depends on the concentration function of the kidneys and other features of the pathology. In case of difficult visualization of the ureters, it is recommended to take a picture with the patient in the prone position. Clarification of structural changes in the parenchyma and cystic system of the kidneys was previously achieved by retrograde pyelography or tomography of the kidneys without the introduction of contrast. Contrast cystography is used to diagnose cicatricial changes in the bladder and adjacent parts of the ureter. An absolute contraindication to all contrast studies is intolerance to iodine preparations.

The method of choice in diagnostics of urinary system pathology is CT, which gives an accurate description of the anatomy and pathology of the kidneys and retroperitoneal organs. The study is initially conducted without the use of contrast agents, then, in the absence of contraindications, supplemented with contrast. An unshaded layered structural image of the kidneys in cross-section provides exceptional diagnostic capabilities, the same applies to bladder pathology. MRI is used in urological diagnostics somewhat less often. Of particular value are frontal sections, allowing one to see the structure of the kidneys along their length, navigate the topography of the retroperitoneal region, paranephric tissues.

Renal angiography retains its importance primarily for solving problems of differential diagnosis with oncopathology.

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Diagnosis of tuberculosis of male genital organs

In the diagnosis of tuberculosis of the male genital organs, a survey radiography of the urinary bladder area is used with a caudal inclination of the tube at an angle of 70° to remove the prostate shadow from under the symphysis, sometimes revealing calcifications in the prostate and seminal vesicles. X-ray examination of the vas deferens is performed using various modifications of spermatography, revealing destructive changes in the sex glands, the patency of the vas deferens, and the transition of the process to the pelvic genital organs.

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Diagnosis of tuberculosis of female genital organs

Tuberculosis of the female genital organs in 80-90% begins with damage to the tubes, especially their ampullar part. Tuberculosis of the ovaries most often occurs through the spread of the process to them from the tubes, the uterus is often affected simultaneously with the tubes. Morphological changes in tuberculosis of the female genital organs are the same as in other localizations of tuberculosis. Their essence is the formation of a specific granuloma, its infiltrating growth in the mucous membrane and underlying layers of the tubes and uterus, in the formation of tuberculous foci in the ovaries. Then there is a caseous-necrotic decay of the granulomas with the formation of cavities, ulcers, adhesive process with the occurrence of obstruction and obliteration of the hollow organs. The next stage is scarring at the site of the transferred inflammation, leading to persistent structural and functional disorders of the entire female genital area. Modern X-ray techniques - static and dynamic hysterosalpingography - reveal pathology according to the outlined scheme of morphological changes.

The objectives of X-ray examinations include:

• determination of the size, shape, and position of the uterine cavity.
• detection of infiltrative changes in the uterine cavity and fallopian tubes (thickening of the endometrium, mucous membrane of the tubes, swelling of folds, rigidity of the tubes):
• identification of niches, jagged contours of the uterine cavity, fistulas - as signs of granuloma disintegration:
• diagnostics of deformations and assessment of pipe patency.

During the period of inflammation attenuation and prevalence of the cicatricial process, deformations, obstruction of the cervical canal, deformations and strictures of the tubes, their fixed position can be detected radiographically. It is possible to detect calcifications in the tubes, ovaries, pelvic lymph nodes. Currently, ultrasonography plays a major role in the diagnosis of tuberculosis of the female genitalia.

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Diagnosis of abdominal forms of tuberculosis

Abdominal forms of tuberculosis include tuberculous mesadenitis, tuberculous peritonitis, intestinal tuberculosis. In case of tuberculous mesadenitis, only the presence of calcified lymph nodes in abdominal images or fluoroscopy can be considered reliable radiological signs. Disturbances in the motor function of the stomach and intestines, symptoms of dynamic obstruction, prolapse of the stomach and transverse colon revealed by fluoroscopy are an insufficient basis for establishing the diagnosis of "mesadenitis", although they can be a reaction to a specific process. Evaluation of the results of radiological examination in such cases is possible only when they are analyzed in combination with other special studies. MRI data, allowing visualization of packages of intra-abdominal lymph nodes, and CT, capable of demonstrating lymph nodes, including those with calcification, can be of significant importance.

X-ray diagnostics of intestinal tuberculosis occupies one of the leading places and is carried out by traditional methods (irrigoscopy, fluoroscopy of the stomach and intestine with oral contrast) in various modifications. The histogenesis of the tuberculous process in the intestine consists of the formation of tuberculous tubercles and infiltrates in the submucosa of the ileum and cecum with subsequent disintegration and scarring of the pathological tissue. Accordingly, an X-ray examination can reveal: rigidity of the walls of the intestinal sections involved in the process, serration of contours, ulcerations and individual deeper ulcer niches, cicatricial changes in the intestinal walls and accompanying deformations, narrowing of the lumen, and the formation of pathological bends. These changes are accompanied by pronounced deviations in the motility of the gastrointestinal tract. The latent forms of the disease may manifest themselves radiologically only by functional disorders: hypermobility of the distal ileum, spasms, accelerated passage of barium suspension, persistent spastic contraction in the affected area (Stierlin's symptom). This may be accompanied by functional disorders in the gastroduodenal zone. The above signs are not pathognomonic, the diagnosis of "tuberculosis" is made on the basis of a set of clinical and radiological data.

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Ultrasound diagnostics of extrapulmonary tuberculosis

Sonography is based on ultrasound localization, i.e. the perception of reflected ultrasound impulses.

This method allows you to obtain:

• echotopographic information: depth of location, localization, number of formations, their sizes, mutual arrangement of internal organs of superficial structures:
• description of the identified pathological changes: the acoustic structure of the formation, its contours, the configuration of the organ and their deviation from the norm.

Fluid and tissue formations (cysts, tumors, abscesses and infiltrates), stones in the renal cavity system and gallbladder are clearly visible.

Ultrasound examination of the genitourinary system

The examination of the kidneys is carried out in the horizontal and vertical position of the patient in the projection of the kidneys along the anterior lateral and posterior surfaces of the body using longitudinal transverse and oblique scans.

Determine:

• size, position, contours of the kidneys:
• the state of the abdominal cavity system, parenchyma;
• the presence of pathological formations, stones;
• developmental anomalies;
• mobility.

Ultrasound diagnostics of kidney tuberculosis

Reliable ultrasound signs of renal parenchyma tuberculosis and tuberculous papillitis have not been identified. Only fibrotic and calcified small foci can be detected in the form of single echo-dense inclusions (2-3 mm in diameter) in the projection of the renal parenchyma. These changes are non-specific and occur as a result of infectious diseases such as malaria, typhoid fever, scarlet fever, etc. When a hydrocalyx is formed, ultrasound reveals a thin-walled cystic formation within the renal pelvic system (RPS).

The diagnostic value of ultrasound increases if there is a cavity of decay in the tuberculous lesion. Tuberculosis of the ureter and bladder. Scanning of the ureter along its entire length is carried out along the anterior and lateral surfaces of the body with longitudinal and transverse scans. Visualization of the bladder is carried out in the suprapubic region in different planes with preliminary preparation (1 hour before the examination, the patient drinks 3 glasses of water).

Normally, the ureter is not visible. In tuberculosis, due to pronounced infiltration, edema, and hypertrophy of the muscular membrane, it can be visualized as a linear hypoechoic structure with a diameter of 6-8 mm.

The diagnostic value of sonography is especially high in the case of a non-functioning kidney, the occurrence of cicatricial changes and strictures of the ureter in places of physiological narrowing, mainly in the lower third, as well as in the formation of hydronephrosis and ureterohydronephrosis.

Tuberculosis of the male genital organs

With the advent of ultrasound, including transrectal ultrasound (TRUS), it has become possible to visualize processes occurring in the prostate gland. Early changes, often not detectable by palpation, are visualized as foci on TRUS (Fig. 15-20).

In the presence of destructive processes in the lesion, an anechoic decay zone (abscess) is formed. These changes, as well as massive calcification, must be differentiated from the tumor process.

Scanning of the seminal vesicles is performed in the suprapubic region with a filled urinary bladder in a cross-section or on a TRUS with a rectal sensor.

The symmetry of the bubbles, their uniform structure, thickness (no more than 1-1.5 cm), and the presence of inclusions are noted.

Ultrasound of the scrotum organs with a superficial high-frequency sensor is performed with longitudinal, transverse and oblique scans alternately from each side along the anterolateral surface of the scrotum. The patient is in a horizontal position, the scrotum is raised and fixed. Scanning of the epididymis and spermatic cord is best performed along the lateral surface of the scrotum closer to the posterior edge.

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Tuberculosis of female genital organs

Ultrasound reveals general signs of inflammation that are not specific. These include:

• accumulation of fluid in the Douglas space (more than 10 mm); observed in 69.7% of cases with a specific process and in 57.1% with a non-specific one:
• accumulation of fluid in the lumen of the fallopian tube (hydrosalpinx): an anechoic formation of oval or retort shape (in the early stages of the inflammatory process - elongated, with a long course - rounded, with compacted walls);
• enlargement of the ovaries, blurred contours, microcystic structure;
• a round, non-uniform tubo-ovarian formation with an unclear outline in the projection of the appendages, containing fluid;
• displacement of the uterus to the side.

Specific to tuberculosis are:

• caseous masses in the projection of the uterus, appendages, parametrium tissue, having an echogenic, heterogeneous structure, sometimes encapsulated;
• calcifications in the projection of the myometrium, fallopian tubes and ovaries. In the basal layer of the endometrium, calcifications are visible as echo-dense inclusions (2-4 mm). Their detection outside the myometrium is usually difficult due to the presence of echo-dense signals from the intestine filled with gases.

Adhesions, parametritis, and pelvic peritonitis are not detected by ultrasound. Tuberculosis of the female genital organs is differentiated from ovarian and paraovarian cysts, ovarian, uterine and tube tumors, calcified endometrial polyps. Dynamic ultrasonography is used in the comprehensive diagnostics of tuberculosis of the female genital organs. It is used to assess the focal reaction against the background of segmental tuberculin tests. A positive focal reaction is characterized by:

• enlargement of the ovaries, the appearance of “blurred” contours and a decrease in the echogenicity of the ovarian tissue:
• the appearance and increase in volume of sactosalpinx;
• the appearance and increase in the amount of free fluid in the Douglas space;
• inhibition of endometrial proliferation (by 0.8 mm or more).

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Ultrasound diagnostics of retroperitoneal abscesses in spinal tuberculosis

Ultrasound scanning of psoas abscesses is performed using longitudinal and transverse scans along the lateral surface of the anterior abdominal wall with the patient in a horizontal position along the iliopsoas muscle from the legs of the diaphragm to the inguinal ligament.

Ultrasound diagnostics of tuberculosis of peripheral lymph nodes

It is performed with a high-frequency surface sensor with the patient lying down or sitting, alternately on both sides with longitudinal and transverse scans. The following parameters are determined:

• localization of nodes, their location relative to the sternocleidomastoid muscle;
• linear dimensions and quantity;
• shape and contours;
• structure (echogenicity, homogeneity, presence of additional inclusions);
• the presence of abscesses and fistulas, their length;
• the severity and thickness of the lymph node capsule, the presence of boundaries between them.

Radionuclide diagnostics of extrapulmonary tuberculosis

Radionuclide methods have a number of advantages, allowing to clarify both the structure and function of an organ.

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