Diagnosis of extrapulmonary tuberculosis

[1], [2], [3], [4], [5], [6],

Diagnosis of osteo-articular tuberculosis

Radiological diagnosis of osteo-articular tuberculosis is aimed at identifying the primary bone foci of specific inflammation - isolated or within the contact destruction zone of the articulated bones, be it vertebrae, the articular ends of the tubular or articular surfaces of the flat bones. The primary focal nature of the tuberculous process determines the depth of contact destruction, which in most cases allows us to differentiate a specific process from other diseases. At the same time carry out a targeted identification of complications of bone lesions - inflammatory (abscesses, fistulas) and orthopedic (violations of the shape and ratio of the vertebrae, articular ends).

The depth of the examination is determined by the tasks of diagnosis and surgical treatment.

[7], [8], [9], [10], [11]

Diagnosis of spinal tuberculosis

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

Methods of radiation diagnosis is necessary:

• establish the level of spinal lesions, numbers and the 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 ratio of cavities / inclusions with paravertebral tissues and the spinal canal;
  • bone structure of the affected vertebrae and the general structural background of the spine;
• determine the state of the intervertebral space (discs) in the affected area;
• identify possible involvement in the process of elements of the posterior vertebral column;
• characterize the state of the paravertebral tissues, the presence and extent of abscesses or fistulous passages, their connection with other anatomical areas and organs;
• to determine the presence of zpidural abscesses, to establish the presence / absence of compression of the spinal cord (dural sac), its degree, length, compression substrate;
• to determine the state of the spinal cord and its membranes at the level of the spinal deficit, especially during the dissociation of the indices (the absence of a compression image for spinal disorders).

The expansion of the arsenal of methods for radiological diagnosis of tuberculous spondylitis, the advantages and limitations of various methods make it necessary to choose the diagnostic path. Most authors, putting on the first diagnostic stage radiography. Further offer their algorithms. Indeed, with the availability of CT and MRI, a scheme for examining patients with tuberculous spondylitis in the hands of specialists could be significantly reduced. After performing the survey images, ideally, an MRI scan is advisable. X-ray techniques, including CT. Can then be used if 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 a review X-ray, is appropriate 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.

[12], [13], [14], [15]

Diagnosis of joint tuberculosis

In diagnosing and monitoring the treatment of joint tuberculosis, classical radiographic and tomographic techniques are most common.

Diagnosis of complications of tuberculosis of the bones and joints includes abscessography, fistulography in the survey or tomographic version. Stereo-radiography is widely used. At the same time, they take consecutive shots on two identical films (usually 24x30 cm) with exact repetition of the position of the cassette and the subject, with the displacement of the tube first to the right from the center, then to the left by 3.5 cm. When you simultaneously view these images on a stereoscope, a spatial volume image is obtained abscesses, fistulous passages, their relationships with bones and joints.

Of the new methods of radiation diagnosis in the pathology of bones and joints, CT is most often used. The resulting image demonstrates well the destructive cavities and the articular ends, their scale relative to the thickness of the bone; reveals the degree of prevalence of contact destruction of the articular ends, sequesters, abscesses, and the state of the soft tissues of the joint itself.

It is advisable to use CT in anatomical areas, where radiography in normal projections gives insufficient information (especially in case of damage to the bones of the pelvic girdle).

MRI in the diagnosis of pathology of bones and joints are used less frequently, but it promotes the early detection of inflammatory and necrotic changes in the bones (bone marrow), visualizes changes in the cartilage cover of the articular ends, infiltration near the joint capsule, effusion in the articular bag. On MR-tomograms, deep intermuscular abscesses are not visible, not detected in other ways.

Diagnosis of urinary system tuberculosis

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

• general background (presence of calcified lymph nodes or abscesses, urinary or biliary tract stones, pathology of the spine, calcification of the cartilage cartilage), which further conduct special studies;
• functional changes, urinary tract emptying dynamics;
• early infiltrative and destructive changes in the kidney parenchyma (papillitis);
• extensive destructive changes in the kidneys (caverns - isolated or communicating with the abdominal system, including those containing calcified caseosis);
• non-functioning segments of the kidneys, chilled or disconnected kidneys;
• changes in the abdominal system of the kidneys and ureters (primary cavity dilations - hydrocalycosis, pyeloectasia; cicatricial deformities of the cups; rigidity, strictures, ureteral expansions);
• cicatricial changes, deformities of the bladder, the mouth of the ureter;
• secondary changes of the kidneys and their abdominal system (secondary expansion of the cavities, wrinkled kidney); complications of the main process, changes in the surrounding soft tissues of the retroperitoneal space.

The state of the surrounding tissues is determined by a survey radiography of the abdominal cavity, which precedes the excretory urography. The latter, according to indications, is supplemented with tomography of the kidneys in contrast conditions (the optimal sections are chosen by the usual measurement, more often it is 7-8-9 cm). The duration (time) of the study depends on the concentration function of the kidneys and other features of the pathology. When obstructed visualization of the ureters recommend taking the picture in the position of the patient on his stomach. The refinement of structural changes in the parenchyma and lacrimal system of the kidneys was previously achieved by retrograde pyelography or tomography of the kidneys without contrast. Contrast cystography is used to diagnose cicatricial changes in the bladder and adjacent parts of the ureter. Absolute contraindication to all contrast studies is an intolerance to iodine preparations.

The method of choice in the diagnosis of pathology of the urinary system is CT. Giving an accurate description of the anatomy and pathology of the kidneys and organs of the retroperitoneal space. The study is carried out initially without the use of contrast agents, then, in the absence of contraindications, complement the contrast. Nothing obscured layered structural image of the kidneys in cross section provides exceptional diagnostic capabilities, the same applies to the pathology of the bladder. MRI is used in urological diagnosis a little less. Of particular value are the frontal sections, which make it possible to see the structure of the kidneys along their length, orient themselves in the topography of the retroperitoneal region, and perirenal tissues.

Angiography of the kidneys retains its value primarily for solving problems of differential diagnosis with cancer.

[16], [17]

Diagnosis of male genital tuberculosis

In the diagnosis of tuberculosis of the male genital organs, an x-ray of the bladder with a caudal angle of 70 ° of the tube is used to remove the prostate shadow from under the symphysis, and sometimes calcifications in the prostate and seminal vesicles are detected. X-ray examination of the vas deferens is performed using various modifications of spermatography, revealing destructive changes in the gonads, the permeability of the sperm glands, the transition process to the pelvic genitals.

[18], [19], [20]

Diagnosis of female genital tuberculosis

Tuberculosis of the female genital organs in 80-90% begins with the defeat of the tubes, especially their ampullary part. Ovarian tuberculosis occurs more often by spreading the process to them from the side of the tubes, the uterus is often affected simultaneously with the tubes. The morphological changes in female genital tuberculosis are the same. As with other sites of tuberculosis. Their essence is in 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 tubercular foci in the ovaries. Further, caseous necrotic disintegration of granulomas occurs with the formation of cavities, ulcerations, adhesions with the occurrence of obstruction and obliteration of 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 the pathology of the morphological changes, as described.

The tasks of X-ray studies include:

• determining the size, shape, position of the uterus.
• identification 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):
• niche identification serrations of the contours of the uterus, fistulas - as signs of disintegration of the granuloma:
• diagnostics of deformations and assessment of pipe maneuverability.

During the period of subsidence of inflammation and the prevalence of the cicatricial process, radiographically, deformations, obstruction of the cervical canal, deformations and strictures of the pipes, their fixed position can be identified. Detection of calcifications in the tubes, ovaries, pelvic lymph nodes. Currently, ultrasonography has a large role in the diagnosis of female genital tuberculosis.

[21], [22], [23], [24], [25]

Diagnosis of abdominal tuberculosis

To abdominal forms of tuberculosis include tubercular mesadenitis. Tuberculosis peritonitis, intestinal tuberculosis. In tuberculous mesadenitis, only the presence of calcified lymph nodes in the images of the abdominal cavity or during fluoroscopy can be considered as reliable radiological signs. The disturbances in the motor function of the stomach and intestines detected by fluoroscopy, the symptoms of dynamic obstruction, the omission of the stomach and the transverse colon are an insufficient basis for establishing the diagnosis of "mesadenitis", although they may be a reaction to a specific process. Evaluation of the results of X-ray studies in such cases is possible only when they are analyzed in conjunction with other special studies. MRI data, which allow visualization of packages of intra-abdominal lymph nodes, and CT, which can demonstrate lymph nodes, including calcification, can be significant.

Radiodiagnosis in intestinal tuberculosis is one of the leading places and is carried out by traditional methods (irrigoscopy, fluoroscopy of the stomach and intestines with oral contrast) in various modifications. The histogenesis of the tuberculosis process in the intestine consists in the formation of tuberculosis tubercles and infiltrates in the submucosal membrane of the ileum and cecum with the subsequent disintegration and scarring of the pathological tissue. Accordingly, X-ray examination can reveal: the rigidity of the walls of the intestinal sections involved in the process, the jagged contours, ulcerations and some deeper ulcerative niches, cicatricial changes of the intestinal walls and the accompanying deformities, narrowing of the lumen, the formation of pathological curves. These changes are accompanied by pronounced deviations in the motility of the gastrointestinal tract. The erased forms of the disease can appear radiographically only by functional disorders: hypermobility of the distal ileum, spasms, and accelerated passage of a barium suspension. Persistent spastic contraction in the affected area (Stirlin symptom). This may be accompanied by functional disorders in the gastroduodenal zone. These signs are not pathognomonic, the diagnosis of "tuberculosis" is made on the basis of a complex of clinical and radiological data.

[26], [27], [28], [29], [30], [31]

Ultrasound diagnosis of extrapulmonary tuberculosis

Sonography is based on ultrasound location, i.e. The perception of reflected ultrasound pulses.

This method allows you to get:

• echotopographic information: depth, location, number of formations, their size, relative position of the internal organs of the surface 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.

Clearly visible fluid and tissue formations (cysts, tumors, abscesses and infiltrates), stones in the abdominal system of the kidneys and gall bladder.

Ultrasound examination of the urogenital system

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

Determine:

• size, position, contours of the kidneys:
• condition of the abdominal system, parenchyma;
• the presence of pathological formations, calculus;
• developmental abnormalities;
• mobility.

Ultrasound diagnosis of kidney tuberculosis

No reliable ultrasonic signs of tuberculosis of the renal parenchyma and tuberculous papillitis were found. You can only detect fibrosing and calcified small foci in the form of single echo-dense inclusions (2-3 mm in diameter) in the projection of the renal parenchyma. These changes are nonspecific and occur in the outcome of such infectious diseases as malaria, typhoid fever, scarlet fever, etc. When forming hydrocalix with ultrasound, a thin-walled cystic formation within the cup and pelvis canal system (CLS) is detected.

The diagnostic value of ultrasound increases if there is a decay cavity in the tubercular focus. Tuberculosis of the ureter and bladder. The entire ureter is scanned along the anterior and lateral surfaces of the body with longitudinal and transverse scans. The bladder is visualized in the suprapubic area 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 case of tuberculosis, due to a pronounced infiltration, edema, hypertrophy of the muscle 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 with a non-functioning kidney, the occurrence of cicatricial changes and ureteral strictures in places of physiological narrowing, mainly in the lower third, as well as during hydronephrosis and ureterohydronephrosis formation.

Male Genital Tuberculosis

In connection with the advent of ultrasound, including transrectal ultrasound (TRUS), it became possible to visualize the processes occurring in the prostate gland. Early changes, often not detected by palpation, are visualized on TRUS in the form of foci (Fig. 15-20).

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

Scanning of seminal vesicles is performed in the suprapubic area with a filled bladder in a transverse section or with a rectal transducer on TRUS.

The symmetry of the bubbles, their homogeneous structure, thickness (not more than 1-1.5 cm), and the presence of inclusions are noted.

Ultrasound of the scrotal organs with a high-frequency surface transducer is performed by longitudinal, transverse and oblique scans alternately on each side along the anterior side of the scrotum. The patient is in a horizontal position, the scrotum is raised and fixed. Scanning the epididymis and spermatic cord is best done along the lateral surface of the scrotum closer to the posterior margin.

[32], [33], [34]

Female Genital Tuberculosis

Ultrasound detects common signs of inflammation that are not specific. These include;

• fluid accumulation in Douglas space (more than 10 mm); observed in 69.7% of cases with a specific process and in 57.1% with non-specific:
• accumulation of fluid in the lumen of the fallopian tube (hydrosalpinx): anechoic formation of an oval or retort-shaped form (at the early stages of the inflammatory process - extended, with a long flow - rounded, with compacted walls);
• ovarian enlargement, fuzziness of their contours, small cystic structure;
• rounded shape with a fuzzy contour inhomogeneous tubo-ovarian formation in the projection of appendages containing fluid;
• displacement of the uterus to the side.

Specific to tuberculosis are:

• Caseous masses in the projection of the uterus, appendages, parametric fiber, having an echotic, heterogeneous structure, sometimes encapsulated;
• calcinates in the projection of myometrium, fallopian tubes and ovaries. In the basal layer of the endometrium, calcinates are seen in the form of echo-dense inclusions (2-4 mm each). Their identification outside the myometrium is usually difficult due to the presence of echo-dense signals from the intestine filled with gases.

Adhesions, the phenomenon of parametritis, pelvioperitonitis with ultrasound are not detected. Tuberculosis of the female genital organs is differentiated with ovarian cysts and para-varial cysts, ovarian tumors, uterus and tubes, calcified endometrial polyps. In the integrated diagnosis of female genital tuberculosis, dynamic ultrasonography is used. It serves to assess the focal reaction on the background of segmental tuberculin samples. Positive focal reaction is characterized by:

• an increase in the ovaries, the appearance of "blurring" of the contours and a decrease in the echogenicity of the ovarian tissue:
• the appearance and increase in the volume of the saktosalpinx;
• the appearance and increase in the amount of free fluid in Douglas space;
• inhibition of proliferation of the endometrium (0.8 mm or more).

[35], [36]

Ultrasound diagnosis of retroperitoneal abscesses in spinal tuberculosis

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

Ultrasound diagnosis of peripheral lymph node tuberculosis

It is carried out by a superficial high-frequency sensor in the position of a patient lying or sitting alternately on both sides with longitudinal and transverse scans. The following parameters are determined:

• the location of the nodes, their location relative to the sore muscles;
• linear dimensions and quantity;
• shape and contours;
• structure (echogenicity, homogeneity, presence of additional inclusions);
• the presence of abscesses and fistulous passages, their length;
• the severity and thickness of the capsule of the lymph nodes, the presence of boundaries between them.

Radionuclide diagnosis of extrapulmonary tuberculosis localization

Radionuclide methods have several advantages, allowing you to specify both the structure and the function of an organ.

[37], [38], [39], [40], [41]