Tuberculosis of extrapulmonary localization: causes, symptoms, diagnosis, treatment

Extrapulmonary tuberculosis is a name that unites forms of tuberculosis of various localizations, except for tuberculosis of the respiratory organs, since it differs not only in the localization of the process, but also in the features of pathogenesis, clinical manifestations, diagnosis and treatment. The incidence of tuberculosis in general has increased significantly in recent decades, and extrapulmonary tuberculosis accounts for 17-19% of cases.

Tuberculosis of extrapulmonary localization, in addition to ICD-10, uses the Clinical Classification of Tuberculosis of Extrapulmonary Localizations. It more fully reflects the clinical and morphological aspects of the problem, is the basis for choosing the optimal method of treatment (taking into account the leading role of surgical treatment of many forms of tuberculosis of extrapulmonary localization) and provides for the registration of combined tuberculosis lesions.

By localization, tuberculosis is divided into urogenital, peripheral lymph nodes, skin and subcutaneous tissue, bones and joints, eyes, meninges, abdominal, and other organs. By prevalence, it is divided into limited and generalized forms. By morphological manifestations, granulation and destructive (cavernous) tuberculosis are distinguished. By severity, early and advanced forms are determined.

Section 1 of the Clinical Classification of Extrapulmonary Tuberculosis systematizes the general classification features of tuberculosis of various organs and systems:

• Etiology.
• Prevalence:
  • local (limited) tuberculosis - the presence of one lesion in the affected organ [for the spine - in one spinal motor segment (SMS)];
  • a widespread process - a lesion in which there are several foci (zones) of tuberculous inflammation in one organ (for the spine - damage to two or more adjacent PDS);
  • multiple system damage - damage by tuberculosis to several organs of one system (for the spine - two or more non-adjacent PDS);
  • combined tuberculosis - damage to two or more organs belonging to different systems.
• Activity is determined based on a combination of clinical, radiological, laboratory and morphological data; the process is characterized as active, inactive (quiescent, stabilized) or as a consequence of TVL.
  • Active tuberculosis:
    • type of course: progressive, remitting and chronic (recurrent or torpid);
    • The stages of the process characterize the evolution of the primary focus by morphological and functional disorders of the affected organ; if they do not coincide, the overall indicator is determined by the highest stage.
  • Inactive tuberculosis (quiescent, stabilized); in patients with extrapulmonary tuberculosis, residual organ-specific changes persist in the absence of clinical and laboratory signs of their activity; residual changes include scars and limited small calcified foci or abscesses.
  • The consequences of extrapulmonary tuberculosis are established in individuals with clinical cure of a specific process in the presence of pronounced anatomical and functional disorders. This diagnosis can be established both in those who have undergone a course of anti-tuberculosis treatment and in patients with newly identified disorders, which, based on the totality of data, can be determined with a high probability as a consequence of transferred extrapulmonary tuberculosis.
  • Complications of extrapulmonary tuberculosis are divided into:
    • general (toxic-allergic organ damage, amyloidosis, secondary immunodeficiency, etc.);
    • local, directly related to damage to a specific organ or system.

The nature of bacterial excretion and drug resistance of mycobacteria are determined by general principles. Clinical cure of extrapulmonary tuberculosis is confirmed by the elimination of all signs of active tuberculosis - clinical, radiation and laboratory - after the main course of complex treatment, including surgical treatment. This diagnosis is established no earlier than 24 months after the start of treatment, and in case of surgical treatment - 24 months after the operation (in children - no earlier than 12 months after the operation).

Section 2 of the Clinical Classification of Extrapulmonary Tuberculosis reflects the clinical forms and characteristics of the tuberculosis process in different organs and systems.

It allows formulating a clinical diagnosis taking into account the etiological features, distribution, localization of the process, the nature of its course and stage, severity of complications. This not only systematizes the ideas about extrapulmonary tuberculosis, but also plays a positive role in determining the optimal treatment tactics for such patients.

Tuberculosis of bones and joints of the extremities

Tuberculosis of bones and joints is a chronic infectious disease of the musculoskeletal system caused by mycobacteria M. tuberculosis, characterized by the formation of a specific granuloma and progressive destruction of bone, leading to pronounced anatomical and functional disorders of the affected part of the skeleton.

Over the past 10 years, the proportion of patients in older age categories has increased by 3.9 times. Active forms of a specific process in the joints have become 34.2% more common, in 38.5% of cases the disease is accompanied by specific damage to other organs and systems, including various forms of pulmonary tuberculosis in 23.7% of cases. Tuberculous arthritis is complicated by contractures in 83.0% of cases, paraarticular abscesses and fistulas - in 11.9% of patients. The time of diagnosis is on average 12.3 months from the moment the first symptoms of the disease appear. The proportion of progressive arthritis, subtotal and total forms of joint damage has increased (33.3 and 8.9% of cases, respectively). The overall drug resistance of the pathogen to the main antibacterial drugs has reached 64.3%. 72.6% of patients have concomitant somatic pathology.

Tuberculosis of bones and joints is a specific inflammatory disease of the skeleton that occurs in conditions of hematogenous dissemination of the tuberculosis process.

Over the past decades, there has been a steady trend towards a decrease in the incidence of this pathology, and the majority of patients are elderly and senile people.

Osteoarticular tuberculosis accounts for 3% of all cases of tuberculosis. The main localization of the tuberculosis process is the spine (more than 60%). Disability of patients is 100%. The concept of osteoarticular tuberculosis does not include allergic arthritis and polyarthritis caused by tuberculosis of other localizations.

In practice, tuberculous spondylitis, gonitis and coxitis are most often encountered. Other localizations of the process are also very rare. In most cases, the process develops slowly and imperceptibly, and is detected during the formation of skeletal deformations, abscesses, fistulas and neurological disorders: The process is covered by existing pulmonary tuberculosis.

In the prearthritic phase of the process, complaints of pain in the spine or joint, limited movement are noted. Palpation reveals swelling and soreness of soft tissues, soreness and thickening of the bone diaphyses. The symptoms are transient, disappear spontaneously, but reappear. At this stage, the process may stop, but more often it moves on to the next one.

The arthritic phase is characterized by a triad of symptoms: pain, dysfunction of the affected area, and muscle atrophy. The disease develops gradually. The pain, initially diffuse, is localized in the affected area. Light tapping on the tuberculous vertebra causes pain; compression of the iliac wings causes pain in the affected areas of the spine or hip joint (Erichson's symptom).

Mobility is initially limited by muscle rigidity (the spine is characterized by Kornev's symptom - "reins"), then, as the bone and cartilage of the joint are destroyed, due to changes in the congruence of the articular surfaces. In spondylitis, due to the wedge-shaped deformation of the vertebrae, an angular deformation is formed, initially determined by palpation, then in the form of a "button-like" protrusion of the process, then signs of the development of a hump appear, which, unlike chondropathic (Kohler's disease; Scheuermann-May, etc.), has a wedge-shaped form. Other joints thicken due to cartilage proliferation. In combination with muscle atrophy, the joint acquires a spindle-shaped form. The skin fold is thickened (Aleksandrov's symptom) not only above the joint, but also along the limb. There is no hyperemia - "cold inflammation". In children, bone growth stops, the limb shortens, muscle hypotrophy turns into atrophy, and the so-called "tabs" develops. "Cold" abscesses (sags) can form, sometimes significantly distant from the main focus.

The post-arthritic phase is characterized by a combination of skeletal deformation and functional disorders.

Neurological disorders are usually associated with compression of the spinal cord due to its deformation, which requires surgical correction. In this phase, residual foci of tuberculosis, abscesses, which often give a relapse of the process, may remain.

Diagnosis of the disease is quite complicated due to the erased clinical manifestations, in the initial periods it resembles the clinical picture of common inflammatory and degenerative diseases, the presence of active tuberculosis in the patient or in the anamnesis should be alarming. The patient is examined completely naked, changes in the skin, posture disorders, painful points during palpation, muscle tone, Aleksandrov and Kornev symptoms are identified. Movements in the joints and the length of the limb are determined using a centimeter tape and a goniometer.

The main goal of diagnostics is to identify the process in the prearthritic phase: radiography or large-frame fluorography of the affected skeletal section, magnetic resonance imaging. In the prearthritic phase, foci of bone osteoporosis are determined, sometimes with inclusions of bone sequesters, calcifications, and disruption of bone architecture. In the arthritic phase, radiographic changes are caused by the transition of the process to the joint: narrowing of the joint space or intervertebral space (expands with effusion), destruction of the articular ends of the bone and vertebrae, wedge-shaped deformation of the vertebrae, restructuring of the beams along the line of force loads (reparative osteoporosis).

In the postarthritic phase, the picture is varied, combining gross destruction with recovery processes. Joint lesions are characterized by the development of post-tuberculous arthrosis: deformation of the articular surfaces, sometimes with complete destruction, the formation of fibrous ankylosis in a vicious position of the limb. Kyphoscoliosis is manifested by pronounced wedge-shaped deformation of the vertebrae. Spills are detected as vague shadows. The main goal of diagnostics in this phase is to identify residual foci.

Differential diagnostics are carried out: with other inflammatory and degenerative diseases (with a bright inflammatory picture of the process); primary tumors and metastases (a puncture biopsy is performed, which is mandatory in both cases); syphilis of bones and joints (positive serological on radiographs - the presence of syphilitic periostitis and gummatous ostitis).

Treatment is carried out in special medical institutions, dispensaries or sanatoriums. Tuberculosis of the skin and subcutaneous tissue develops with hematogenous or lymphogenous spread from other foci, more often from the lymph nodes, although this issue has not yet been studied, since the connection with tuberculosis of other localizations is not traced. There is only an assumption that this is an exacerbation of cold foci in the basal layer arising from neuroendocrine disorders or the addition of secondary infections. Several forms of tuberculosis of the skin and subcutaneous tissue are noted.

Tuberculosis of the peripheral lymph nodes

Tuberculosis of peripheral lymph nodes represents 43% of various types of lymphadenopathies and accounts for 50% of the incidence of extrapulmonary tuberculosis. The relevance of the problem is that in 31.6% of observations, a combination of tuberculosis of peripheral lymph nodes with other localizations of the specific process is noted, including tuberculosis of the respiratory organs and intrathoracic lymph nodes.

Tuberculous lymphadenitis - tuberculosis of the peripheral lymph nodes is an independent disease or is combined with other forms of tuberculosis. Local and generalized forms are distinguished. Locally, the submandibular and cervical lymph nodes are most often affected - 70-80%, less often the axillary and inguinal - 12-15%. The generalized form is considered to be the defeat of at least three groups of lymph nodes, they make up 15-16% of cases.

The clinical picture is determined by an increase in lymph nodes up to 5-10 mm: they are soft, elastic, mobile; have an undulating course; their increase is not associated with ENT pathology and diseases of the oral cavity; the course is slow. Subsequently, due to the perifocal reaction characteristic of tuberculous lymphadenitis, the surrounding tissues and neighboring lymph nodes are involved in the process. Large "packets" are formed, the so-called tumor-like tuberculosis. In the center, softening and fluctuation appear due to the disintegration of caseous masses. The skin above them is cyanotic hyperemic, thinned, opens with a fistula with the formation of an ulcer. Granulations around the fistula are pale, the discharge is "cheesy". The openings of the fistulas and ulcers have characteristic bridges, subsequently, as they heal, rough scars are formed in the form of cords and papillae. The fistulas close for a very short period, after which a relapse occurs again.

Differential diagnostics with non-specific inflammation, lymphogranulomatosis, tumor metastasis, dermoid cyst, syphilis is carried out on the basis of biopsy; the worst result is given by puncture with cytological examination of the puncture.

Pathogenesis of tuberculosis of peripheral lymph nodes

According to the Evolutionary-Pathogenetic Classification, there are 4 stages of tuberculosis of the peripheral lymph nodes:

• Stage I - initial proliferative;
• Stage II - caseous:
• Stage III - abscessing;
• Stage IV - fistulous (ulcerative).

Complications of tuberculosis of the peripheral lymph nodes

The main complications of peripheral lymph node tuberculosis are the formation of abscesses and fistulas (29.7%), bleeding, and generalization of the process. Of the patients observed in the clinic, complicated forms of tuberculous lymphadenitis were detected in 20.4% of patients, including abscesses in 17.4% and fistulas in 3.0%. Most patients were admitted to hospital 3-4 months after the onset of the disease.

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Tuberculosis of the meninges

Tuberculosis of the meninges, or tuberculous meningitis, is the most severe form of tuberculosis. A remarkable achievement of 20th century medicine was the successful treatment of tuberculous meningitis, which was an absolutely fatal disease before the use of streptomycin.

In the pre-antibacterial period, tuberculous meningitis was predominantly a childhood disease. Its proportion among children newly diagnosed with tuberculosis reached 26-37%. Currently, it is 0.86% among children with newly diagnosed tuberculosis, 0.13% among adults, and the overall incidence of tuberculous meningitis in 1997-2001 was 0.05-0.02 per 100,000 population.

The reduction in the incidence of tuberculous meningitis in our country has been achieved through the use of BCG vaccination and revaccination in children and adolescents, chemoprophylaxis in individuals at risk of tuberculosis, and the success of chemotherapy for all forms of tuberculosis in children and adults.

Currently, tuberculous meningitis mainly affects young children who are not vaccinated with BCG, those from family contacts, and those from asocial families. In adults, tuberculous meningitis most often affects those who lead an asocial lifestyle, migrants, and patients with progressive forms of pulmonary and extrapulmonary tuberculosis. The most severe course of the disease and the worst outcomes are observed in these same categories of patients. Tuberculous meningitis often presents great difficulties in diagnosis, especially in individuals with unclear localization of tuberculosis in other organs. In addition, late treatment, atypical course of meningitis, its combination with progressive forms of pulmonary and extrapulmonary tuberculosis, and the presence of drug resistance of mycobacteria lead to a decrease in the effectiveness of treatment. Therefore, improving the methods of diagnosis and treatment of tuberculous meningitis and improving anti-tuberculosis work in general remain urgent tasks of phthisiology.

Urogenital tuberculosis

Urogenital tuberculosis accounts for 37% of all forms of extrapulmonary tuberculosis. In 80% of cases, it is combined with other forms of tuberculosis, most often pulmonary. In men, in half of the cases, both the urinary and genital organs are affected simultaneously; in women, such a combination is observed only in 5-12% of cases.

The kidneys are most often affected; men aged 30-55 are slightly more likely to get sick than women. The following forms are distinguished: tuberculosis of the renal parenchyma, tuberculous papillitis, cavernous tuberculosis, fibrous-cavernous tuberculosis of the kidney, renal caseomas or tuberculomas, tuberculous pyonephrosis.

Clinical symptoms are scanty, often the only manifestation is the detection of mycobacteria in the urine. Only some patients experience general malaise; subfebrile temperature, aching back pain. Indirect signs include an unreasonable increase in blood pressure, increased pain in the lumbar region after colds, and a history of tuberculosis! Ultrasound examination and excretory urography allow to detect changes in the parenchyma and cavity of the kidneys quite early, before the development of fibrosis and hydronephrosis. But the same picture is observed in other renal pathologies. Only repeated urine tests for mycobacteria, taken under sterile conditions, can confirm the diagnosis of tuberculosis of the urinary system. In all cases, a consultation with a urologist is mandatory, ideally a phthisiourologist, since there is often a combination of renal tuberculosis with pathology of other parts of the urinary system and genitals.

In case of tuberculosis of male genital organs, the prostate is affected first, then the epididymis, testicle, seminal vesicles and vas deferens. On palpation: the prostate is dense, lumpy, areas of depression and softening are noted. Subsequently, the prostate shrinks, becomes flat, the groove is smoothed out, individual calcifications are palpated. All these changes in the form of destruction or calcifications are determined by ultrasound of the prostate. When examining the bladder for residual urine, dysuria is detected. In the analysis of prostate juice, caseosis and tuberculosis mycobacteria are found, but multiple studies are necessary.

Conventional anti-tuberculosis treatment by a phthisiourologist usually ends in impotence and infertility.

Tuberculous chancre

This is compaction, suppuration and opening of the lymph nodes with the formation of a fistula; it differs from hard chancre in syphilis by the absence of compaction at the base and negative serological reactions. Tuberculous lupus is localized on the face with the formation of lumps (dense nodules up to 1 cm), which merge with each other to form a flat infiltrate, often ulcerate or open with a fistula, differentiated from atheroma (dermoscopy: press with a glass slide - an infiltrate in the form of a yellowish jelly is visible against the background of blanching), furuncle and carbuncle (there is no sharp pain characteristic of them). Colliquative tuberculosis of the skin: initially, a slightly painful node of 1-3 cm appears in the thickness of the skin, which increases in size, opens with one or more fistulas with the separation of caseosis and the formation of a flat ulcer; differentiated from hidradenitis and pyoderma (no pain), skin cancer (smear-imprint cytoscopy). Verrucous tuberculosis of the skin occurs in patients with open forms of pulmonary tuberculosis with constant contact of sputum with the skin or in dissectors and veterinarians, when puncturing gloves and skin during work with tuberculosis patients or animals, differs from a wart by the presence of an infiltration rim of cyanotic color around it and an inflammatory rim along the periphery of cyanotic-pink color. Miliary and miliary-ulcerative tuberculosis of the skin is characterized by a rash on the skin or around natural openings of papules of pinkish-cyanotic color, in the center of which ulcers are formed, covered with a bloody crust, necrosis may form.

Disseminated forms include acute miliary tuberculosis of the skin, miliary tuberculosis of the face, rosacea-like tuberculosis, papulonecrotic tuberculosis of the skin, compacted erythema and scrofulous lichen. All these forms are characterized by slow development, chronic course, absence of acute inflammatory changes and pronounced pain, wave-like course with remissions and exacerbations in autumn and spring. All patients with cutaneous forms of tuberculosis or suspicion! For it for differential diagnosis and examination should be referred to a dermatologist.

Abdominal tuberculosis

Tuberculosis of the intestine, peritoneum and mesentery is very rare - less than 2-3% of all extrapulmonary forms of tuberculosis. The lymph nodes of the mesentery and retroperitoneal space are most often affected - up to 70% of cases, with them all abdominal forms begin, less often tuberculosis of the digestive organs - about 18% and peritoneum - up to 12%. The disease is observed in children, but adult patients predominate.

In the gastrointestinal tract, the following are most frequently affected: the esophagus in the form of multiple ulcers that end in stenosis; the stomach with multiple slightly painful ulcers along the greater curvature and in the pyloric section, which leads to its stenosis; the ileocecal section, sometimes with the inclusion of the vermiform appendix, which is accompanied by the development of a picture of chronic enterocolitis and chronic appendicitis (in general, such a diagnosis indicates a secondary process that must be differentiated from typhlitis or Meckel's diverticulitis); the small intestine with multiple ulcers of the mucosa and clinical picture of chronic enteritis. Mesadenitis - damage to the lymphatic vessels and peritoneum is accompanied by contact involvement of the ovaries and uterus in the fibrous inflammatory process, which is one of the causes of female infertility. There are no symptoms typical of tuberculosis; The clinical picture fits into the usual inflammatory diseases, but is distinguished by the low severity of manifestations, a long and persistent course of the process, somewhat reminiscent of oncological processes.

Diagnosis is based on a comprehensive X-ray, endoscopic, laboratory examination and biopsy cytology, tuberculin diagnostics with the Koch reaction.

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