Pain in tuberculosis

When infection of Mycobacterium tuberculosis develops primary tuberculosis - the initial, usually asymptomatic stage of the disease. With a weak immune system, the disease can become active, and then with time, there are pains with tuberculosis of various locations.

[1], [2], [3], [4], [5], [6], [7]

Causes of the pain in tuberculosis

The main causes of pain in tuberculosis are inflammation and destruction of tissue sites of certain organs with the formation of necrosis zones. According to phthisiatricians, the primary tuberculosis of the lung in a newly infected person may be manifested by influenza symptoms. Bacilli of M. Tuberculosis slowly multiply in the alveolar macrophages of the lungs, migrating to the intrathoracic lymph nodes, where pathological formations - tuberculosis granulomas appear. They contain the products of casein necrosis of mycobacterial proteins, as well as epithelium and giant cells, lymphocytes and viable mycobacteria.

Infection can spread throughout the tissue with the formation of even more granulomas; lympho- or hematogenous pathogens, bacteria can infect not only the lungs:  tuberculosis of extrapulmonary localization  affects the lymphatic, urogenital, central nervous system, visceral organs, bone tissues and joints. For example, mycobacteria spread through the bloodstream and settle in the bones, usually near the epiphyseal cartilage - in the immediate vicinity of the synovial membrane. And the formation of granulomas damages the structure of bone tissue, causing inflammation and pain.

Periodic paroxysmal or persistent aching pains in the abdomen - of varying intensity and with a wide range of digestive and intestinal disorders - arise from the damage of intraperitoneal (mesenteric) and retroperitoneal lymph nodes, as well as in multiple tuberculous granulomas of the peritoneum and  intestinal tuberculosis.

Due to the development of tuberculosis infection in the organs of the female sexual sphere (ovaries, fallopian tubes, uterus) and in the prostate gland in men, pelvic pain is possible.

[8], [9], [10], [11], [12], [13]

Risk factors

The main risk factors for developing active tuberculosis: contact with patients with tuberculosis; HIV AIDS; early childhood (especially in poor living conditions and malnutrition); alcohol and drug addiction; kidney disease; oncology; radiation therapy; chemotherapy with immunosuppressant drugs; pregnancy; prolonged use of steroids.

In about 5% of people, the immune system can not overcome the infection, and the disease progresses: individual granulomas merge, forming cavities (cavities) filled with bacteria and dead cells; swollen and inflamed nearby tissue, local blood circulation is broken and the functions of the organs, pains occur.

[14], [15], [16], [17], [18], [19], [20]

Pathogenesis

With tuberculosis, the pathogenesis of the pain syndrome is explained in different ways. In cases of diffuse granulomatous inflammation of the tissues and their fibrinous exudation, pain can occur in the usual way: due to the inflammatory reaction, the endings of the nociceptive afferent nerves activate by sensory neuropeptides, kinins, leukotrienes and prostaglandins released by the cells of the inflamed tissue.

And peripheral neuralgic pains, in particular, pain under the shoulder blade with tuberculosis (in the case of tuberculous lesions of the apex of the lungs, the pain irradiates precisely here), as well as neuralgic back pain in spinal tuberculosis - a consequence of damage to sensory neurons, axons or ganglia of vagal, cephalic, diaphragmatic or spinal nerves.

[21], [22]

Epidemiology

Extrapulmonary tuberculosis has become more common with the advent of human immunodeficiency virus and an increase in the number of organ transplants, which also leads to immunosuppression of thousands of people. In Africa, where the prevalence of HIV infection is higher than in other regions of the world, up to one third of adults with osteoarticular tuberculosis are HIV-positive

According to the International Journal of Tuberculosis and Lung Disease, about 10% of the world's population is infected with M. Tuberculosis every year. Approximately in every fourth case, tuberculosis affects the lymph nodes; on urogenital tuberculosis account for about 27% of cases, for tuberculosis of the kidneys - 15-20%, and for tuberculosis of bones and joints - almost 8%, with the most probable foci of infection in the spine, joints of the hips and knees.

Musculoskeletal tuberculosis is more common in children, adolescents and young people. According to British experts, in the UK, tuberculosis of bones and joints is 2.4% of all cases of tuberculosis in children.

At the same time, according to studies by Spanish phthisiatricians, in patients with skeletal tuberculosis, concomitant lung injury is diagnosed on average in 18.6% of cases.

[23], [24], [25], [26], [27], [28], [29]

Symptoms

Early symptoms or the first signs of active pulmonary tuberculosis can include fever, nighttime hyperhidrosis, weight loss, but pain in pulmonary tuberculosis occurs later - with coughing, deep inspiration, during sudden movements - if the inflammation spreads to the pulmonary membrane (pleura). Depending on the place of the lesion, dull pains in the chest can be felt in the shoulder and neck (from the side of the lesion), as well as under the ribs and in the heart.

Pain in pulmonary tuberculosis

Acute retrosternal pains are characteristic of pulmonary tuberculosis complicated by exudative inflammation of the pleura, as well as in the pleural air cavity (pneumothorax).

However, periodic blunt pains of this localization can be not only in the pulmonary form of tuberculosis, but also in tuberculosis of the intrathoracic lymph nodes, as well as in the case of  tuberculous pericarditis.

Sore throat with tuberculosis

Approximately 2% of patients with active pulmonary tuberculosis have tuberculous infiltration of the larynx or  tuberculosis of the upper respiratory tract, trachea and bronchi.

Hoarseness and sore throat in tuberculosis can be in patients with tonsil involvement in the absence of active pulmonary tuberculosis, although such clinical cases are rare. Nevertheless, any oropharyngeal structures can be affected: tongue, mucous membrane of cheeks, sky, tonsils, pharynx.

With active pulmonary tuberculosis and its progression, perspiration and sore throat are most often associated with  tuberculosis of the pharynx, which is characterized by miliary, i.e. Similar to the millet grain granulomatous rashes on mucous membranes, fever, ptyalism (increased secretion of saliva), and dysphagia (impaired swallowing).

Headaches for tuberculosis

Phthisiatricians attribute persistent headaches in tuberculosis to symptoms of hematogenous dissemination of M. Tuberculosis of the meninges, leading to the development of a life-threatening condition known as meningeal tuberculosis or tuberculous meningitis.

The first signs of this type of tuberculosis - deterioration of health, febrile state, headaches; a few weeks later, nausea and vomiting appear, the headache is aggravated, photosensitivity may occur, as well as tension in the neck muscles.

Owing to the increase in the pressure of the cerebrospinal fluid and the accumulation of exudate between the brain envelopes, changes in the mental state are noted: confusion of consciousness, fits of irritability, drowsiness, fainting with loss of consciousness right up to coma.

Some patients with tuberculous meningitis develop a tumor-like formation called tuberculoma, which can cause symptoms similar to a stroke.

Pain in joints with tuberculosis

Articular tuberculosis - peripheral osteoarticular tuberculosis is a slowly progressing chronic disease accounting for approximately 1-3% of all cases of tuberculosis and up to 10% of cases of its extrapulmonary localization. Pain in joints with tuberculosis of this variety is the earliest manifestation of the disease, and fever and systemic symptoms are usually absent. But almost always there is a development of cold abscess - localized caseous necrosis without typical signs of inflammation. As a result of his breakthrough through soft tissues a fistula is formed.

It is believed that tuberculous arthritis is a consequence of the spread of the primary infectious focus in the bone to the joint, and nine cases out of ten suffer from a hip or knee joint. Previous traumatic injury may be a factor that activates persistent tuberculosis infection.

Ribs, sternoclavicular, sacroiliac and ankle joints can be affected. Sometimes one patient is affected by several bones and joints, and then it is a question of multifocal skeletal tuberculosis.

Back pain in tuberculosis

Back pain in tuberculosis is the most common sign of a spinal cord injury - spinal tuberculosis or tuberculosis spondylitis. The grip of the vertebrae is usually the result of the hematogenous spread of M. Tuberculosis into the dense vascular network of the spongy body of the vertebrae. First of all, the pain appears in the lumbar region and in the thoracic spine (against or without typical symptomatology).

The intensity of back pain in spinal tuberculosis is different, it can become stronger during movement and changes in the position of the body due to instability of the vertebrae (caused by their pathological subluxation) and mechanical compression of the nerve roots. Approximately 50% of patients with  spinal tuberculosis  have neurological manifestations.

Thus, neuralgic pain in the back with tuberculosis of the thoracic and cervical spine is accompanied by weakness and numbness of the upper and lower extremities; they can progress to full paraplegia (paralysis of the two extremities) or tetraplegia (paralysis of the lower and upper extremities). Paraplegia can be the result of compression of the spinal cord by a retrofaryngeal (pharyngeal) abscess that causes dysphagia, respiratory distress, or persistent hoarseness.

Also, paralysis can be the result of the destruction of intervertebral discs; edema of the spinal cord and necrosis of areas of its tissue (myelomalacia); tuberculous infiltration of meninges (tuberculous spinal leptomeningitis); infectious thrombosis or endarteritis of cerebrospinal vessels.

Weakness, numbness and pain in muscles with spinal tuberculosis are felt by patients with compression of the horse's tail (rootlets of lumbar and sacral nerves) due to the formation of a cold abscess around the vertebrae of the lumbar and sacral parts.

Tuberculosis of the urinary tract, in particular, ureteral involvement, causes persistent dull pain in the lumbar region. Pain is localized in patients with  kidney tuberculosis. If one kidney is affected, the pain is one-sided. The launched disease with destruction and necrosis of tissues surrounding tuberculosis granulomas, leads to attacks of acute pain.

[30], [31], [32], [33], [34], [35], [36], [37]

Diagnostics of the pain in tuberculosis

Pain as a symptom does not need diagnostics, and the diagnosis of tuberculosis is carried out by administering blood tests (general, biochemical, for antibodies to M. Tuberculosis) and urinalysis, see -  Laboratory diagnosis of tuberculosis

Mantoux test with tuberculin is done, see -  Tuberculosis: detection of mycobacterium tuberculosis

Instrumental diagnostics includes radiography of the chest and any affected organ. Computer and magnetic resonance imaging also help in detecting the disease: CT is more informative for tuberculous meningitis, and for diagnosis of spinal tuberculosis, MRI is a more sensitive imaging technique than X-ray, and more specific than computed tomography. Ultrasound is used in case of damage to the kidneys and urinary tract, mediastinal organs, abdominal cavity and small pelvis. More in the publication -  Diagnosis of extrapulmonary tuberculosis

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Differential diagnosis

Differential diagnosis should distinguish: tuberculosis of the intrathoracic lymph nodes from cysts, malignant neoplasms of the lungs and metastases of carcinoma; tuberculosis of the kidneys - from xanthogranulomatous pyelonephritis and squamous cell carcinoma. Osteoarticular tuberculosis should be differentiated from rheumatic diseases, and vertebral tuberculosis - from oncology or metastases. In such cases, a fine needle aspiration biopsy, including synovial, and a histopathological examination of the sample obtained are performed.

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Treatment of the pain in tuberculosis

Regardless of the localization, tuberculosis is treated for several months with a combination of antibiotics: Isoniazid (other trade names - Isonizide, Tubazid, Tubetol, Ditubin, Eutisone), Rifampicin (Rifadine, Rifaldin, Rifampin, Benemecin, Tubocin), Etambutola (Ebutol, Etambin, Diambutol , Afimotsil, Batakoks), Pyrazinamide and Streptomycin, which are recognized as first-line antituberculous drugs. Amicacin, Ethionamide, Moxifloxacin and para-aminosalicylic acid (sodium para-aminosalicylate) are also used. Full information in the material -  Treatment of tuberculosis

All these drugs are designed to overcome the pathogen - Mycobacterium tuberculosis, but they will not help alleviate the pain. In cases of spinal tuberculosis with neurological symptoms, the patient is recommended strict bed rest for 12-16 weeks. When joint pains, immobilization with fixation bandages and gypsum tires is necessary.

Antituberculosis antibiotics reduce the therapeutic effect of corticosteroids and many analgesic agents, so the treatment of pain in tuberculosis has features, and medications to reduce pain physicians should prescribe, taking into account individual manifestations of the disease, the condition of each patient's organism and possible risks.

Paracetamol can be used (325-500 mg three times daily), but its combination with isoniazid and rifampicin increases the risk of liver damage. Paracetomol is strictly forbidden for children when treated with these antibiotics.

Indomethacin is a non-steroidal anti-inflammatory drug (NSAID) with a pronounced analgesic effect. It is recommended to take 25-50 mg (after meals) two or three times a day; in the form of rectal suppositories - one suppository twice a day; in the form of a solution - intramuscular injection. This drug, like all NSAIDs, can cause side effects in the form of headache and stomach pain, nausea and vomiting, an allergic reaction. And in the presence of an ulcer of the stomach and duodenal ulcer and bronchial asthma, it is contraindicated.

Naproxen (Naxen, Nalixan, Nalgezin, Anaprox, etc.) is taken one tablet (0.5 g) twice a day. Side effects and contraindications are similar to Indomethacin.

For pain in the spine, you can use - by epidural administration - a muscle relaxant with an analgesic effect of Baclofen (Baclosan), but only if patients do not have a history of epilepsy, Parkinson's disease and chronic kidney failure. Side effects of baclofen may manifest as sleep and urination disorders, headache, weakness, seizures, lowering of blood pressure and respiratory depression.

As an anesthetic, the intramuscular administration of Kombilipen, which includes vitamins B1, B6, B12 and anesthetic lidocaine hydrochloride, is practiced. The course of treatment lasts no more than two weeks - two or three injections per week (2 ml each).

Physiotherapeutic treatment for the removal of pain syndrome presupposes sessions of EHF, ultrasound and laser therapy; electrophoresis with lidase or UHF with isonicotinic acid preparations and analgesics (novocaine, analgin); phonophoresis with hydrocortisone or butadione ointment.

Surgery

Surgery may be required to remove damaged tissue and reduce bacterial load. With pulmonary tuberculosis, depending on the extent of the lesion, they can remove the resulting cavern, a separate lobe of the lung, or a significant part of it.

With kidney tuberculosis, surgical treatment includes cavernostomy, partial nephrectomy or unilateral removal of the entire kidney.

You may need surgery for osteoarticular tuberculosis - arthrodesis or arthroplasty of the joint. For example, with tuberculosis of the hip joint, which has a pronounced tendency to relapse, surgical intervention is carried out to remove all necrotic tissues (curettage of the bone).

With spinal tuberculosis, drainage of abscesses or stabilization of the spine is carried out (reconstruction). For reconstruction of the spinal column, bone grafts and artificial materials (steel, titanium, carbon fiber) are used.

Complications and consequences

Tuberculosis of any localization has serious consequences and complications. For example, complications of tuberculosis of the peritoneum (in case of progression of the process) are partial intestinal obstruction, caseous necrotic ulcers on the peritoneum, fistulas in the organs of the abdominal cavity and outward through the abdominal wall.

Generalized or focal hydronephrosis, as well as amorphous dystrophic calcification of tissues - complications of kidney tuberculosis, leading to its dysfunction. Possible complications of intestinal tuberculosis include narrowing of its lumen, obstruction, perforation of ulcerated mucosa with bleeding and peritonitis.

With tuberculous arthritis, the periarticular bone is destroyed, fibrotic or bone ankylosis may develop, and the joint loses mobility.

Orthopedic complications of spinal tuberculosis consist in its deformation (kyphosis) and instability. And among its neurological complications, the radicular syndrome, pyramidal insufficiency syndrome, paralysis, and pelvic organ dysfunction are noted. In the absence of treatment, the tuberculosis of the lumbar spine progresses, which eventually leads to paralysis of the lower extremities and loss of ability to move independently.

The consequences of tuberculous meningitis include stroke, irreversible damage to the brain and death.

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Prevention

Prevention - read the publication  Sanitary and Social Prevention of Tuberculosis

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Forecast

The prognosis depends on many factors, and the key is the early detection of the disease and its proper treatment. According to phthisiatricians, without proper treatment the disease is progressing, and more than half of people with active tuberculosis die within five years.

If osteoarticular tuberculosis is diagnosed and treated at an early stage, the vast majority of patients may recover, but with varying degrees of impairment of musculoskeletal functions. At the same time, in patients with severe deformity, paraplegia can develop in months or years after treatment.

And the prognosis of meningeal tuberculosis depends on the severity of the symptoms in a particular patient, and the most disappointing prospect awaits patients with obvious brain damage.

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