Tuberculosis in the elderly and seniors

The isolation of tuberculosis in elderly and senile persons is dictated by the peculiarities of physiological and pathological processes in the elderly. In elderly and senile persons, the diagnostic value of many symptoms often decreases, a combination of several diseases is detected, which is manifested by a syndrome of mutual aggravation of diseases, and the need arises to use non-standard approaches to the treatment of tuberculosis.

According to the modern classification of age groups of the population, the elderly are considered to be those aged 65 to 75 years, the senile are those aged 75 to 85 years; people over 85 years old are called long-livers.

In developed countries, tuberculosis is seen mainly in the elderly. In developing countries, tuberculosis affects all age groups equally.

Physiological old age is characterized by the gradual withering of the body and a decrease in its functional and reactive abilities; limitation of energy resources, and a decrease in adaptive capabilities.

What causes tuberculosis in the elderly and senile?

In older people, risk factors for the development of tuberculosis should be considered a combination of conditions that reduce immunity:

• severe chronic diseases,
• stressful situations.
• the influence of radiation,
• long-term use of medications with immunosuppressive action.

The characteristics of tuberculosis in older people are largely determined by structural and functional changes in the bronchopulmonary system, referred to as “senile lung”, which includes

• impaired mucociliary clearance;
• decrease in the number of elastic fibers;
• decreased surfactant activity;
• decreased activity of alveolar macrophages.

In all elements of the respiratory organs - the parenchyma, bronchi, blood vessels, and lymphatic apparatus - involutional processes are observed.

Reactivation of tuberculosis of the intrathoracic lymph nodes in elderly people usually develops after a long period (several decades) after a tuberculosis infection and is associated with an exacerbation of the elements of the primary complex. In the studies of A.E. Rabukhin, it was shown that in areas of calcified caseous necrosis, the lime is absorbed, Liesegang's rings lose their characteristic structure, and areas of lymphoid infiltration and epithelial tubercles appear. Sometimes reactivation of a specific process occurs in the area of hilar sclerosis formed as a result of involution of tuberculous foci and lymphangitis. In post-tuberculous residual foci, the persistent causative agent of tuberculosis remains. In case of massive and multiple petrifications, as a result of demineralization processes, which is typical for older age groups, calcium salts are resorbed, L-forms of the pathogen are reverted to their original form with restoration of its inherent virulence. These processes often occur in the presence of factors that reduce immunity.

Less frequently observed is the exogenous pathway of secondary tuberculosis development in elderly people, associated with new (repeated) infection with Mycobacterium tuberculosis during massive repeated superinfection.

Tuberculosis observed in the elderly and old age is usually divided into old and senile.

Old tuberculosis

Old tuberculosis usually begins in young or middle age, lasts for years, and sometimes, due to its sluggish course, it is diagnosed only in old age. Such patients are observed for a long time by specialists in the general medical network, where they are diagnosed with various other diseases, most often chronic non-specific diseases of the respiratory system. Old tuberculosis can also develop as a result of treatment defects. The main clinical forms of old tuberculosis are the following: fibrous-cavernous, cirrhotic, less often - empyema of the pleura, described in detail in Chapter 18 "Tuberculosis of the respiratory system".

Fibrocavernous tuberculosis, as well as cirrhotic tuberculosis, in older people can be mistakenly diagnosed as chronic bronchitis, bronchiectasis with emphysema and pneumosclerosis.

Tuberculous empyema is accompanied by the accumulation of purulent exudate in the pleural cavity. This disease develops with widespread caseous necrosis of the pleura, due to a rupture of a cavity into the pleural cavity with the formation of a bronchopleural fistula, or as a complication of surgery for active tuberculosis. This form occurs in elderly patients who have undergone such treatment in the past as artificial pneumothorax, oleothorax, and other manipulations called elements of minor surgery. Currently, the number of such patients has significantly decreased. However, pleural empyema can also be characterized by a "cold" course, occurring without pronounced intoxication. The leading symptoms are increasing dyspnea, cyanosis, and tachycardia. Errors in the diagnosis of this form are most often observed when empyema develops a long time after the cure of active tuberculosis.

X-ray diagnostics of old tuberculosis in the elderly is significantly complicated by the presence of post-inflammatory (non-specific and specific) changes in the lungs in the form of areas of pleural compaction, cirrhotic areas of darkening, congestion, age-related physiological changes. Thus, due to the aging of bronchopulmonary and bone structures, their compaction, the X-ray picture of tuberculosis in the elderly is masked by a deformed and excessive pulmonary pattern, emphysema, sharply contrasting walls of the bronchi, vessels, bone fragments. The summation image of such changes in the lungs imitates non-existent focal dissemination on the X-ray), or vice versa - covers small focal disseminated changes. Due to severe emphysema, tuberculous cavities become less contrasting. The following signs can be attributed to the features of old tuberculosis:

• patients with long-term tuberculosis are usually asthenic;
• on the affected side, there is a lag in the chest in breathing;
• the trachea and mediastinal organs are displaced towards the affected side;
• in the lungs, along with signs of tuberculosis characteristic of one or another chronic form, there is pronounced fibrosis, pneumosclerotic changes, emphysema, bronchiectasis;
• In individuals who were treated in the past with artificial pneumothorax, pleuropneumocirrhosis may develop after 20 years or more, accompanied by severe shortness of breath:
• patients with old tuberculosis have a variety of liver dysfunctions that potentiate the development of hemoptysis and pulmonary hemorrhage;
• tuberculin tests in old tuberculosis are usually positive, but this does not have much differential diagnostic value;
• The detection of mycobacteria tuberculosis by microscopy and culture is decisive in establishing a diagnosis; the percentage of positive mycobacteria findings depends on the correctness and duration of sputum collection and the frequency of studies (at least 3 times by microscopy and culture).

The course of old tuberculosis is usually complicated by the following pathology:

• insufficiency of external respiration and blood circulation;
• symptoms of chronic pulmonary heart disease;
• development of bronchiectasis;
• tendency to hemoptysis and pulmonary hemorrhage;
• amyloidosis of internal organs.

Senile tuberculosis

Senile tuberculosis is usually defined as tuberculosis that develops in older people as a result of reactivation of the process in areas of post-tuberculous pulmonary changes or foci in the intrathoracic lymph nodes: mediastinal, paratracheal, tracheobronchial and bronchopulmonary. Senile tuberculosis is characterized by the following triad of symptoms: cough with sputum, shortness of breath, and circulatory dysfunction. Hemoptysis and chest pain are observed much less frequently. Neither each symptom separately nor their combination allows one to confidently diagnose tuberculosis.

In old and senile age there are the following features:

• there is a general infection of people in these groups;
• a high proportion of individuals with major post-tuberculosis changes in the bronchopulmonary system (the so-called “children of war”) is noted;
• reactivation of tuberculosis occurs after a long period of time (several decades);
• reversion of L-forms of mycobacterium tuberculosis into true mycobacteria in old foci occurs with a special clinical picture in the form of preceding recurrent, sometimes migrating, pneumonias that respond well to treatment with broad-spectrum drugs;
• it is possible to isolate typical mycobacteria of tuberculosis in the absence of obvious signs of damage to the visible bronchi, caused by bronchonodular microperforations;
• More often, a specific lesion of the bronchi is observed - every second patient develops fistulous endobronchitis;
• dissemination in the lungs is observed 3 times more often than in young people, often has features of miliary tuberculosis and occurs under the guise of pneumonia, other non-specific bronchopulmonary pathology or carcinomatosis;
• Along with the lungs, simultaneous or sequential damage to the liver, spleen, bone, genitourinary system and other organs is possible;
• More often, tuberculosis of the larynx is observed, which is sometimes detected much earlier than tuberculosis of the lungs;
• pleural exudates are caused by both more frequent specific pleurisy and oncological and cardiac pathology, and differential diagnosis of tuberculosis involves a wider use of pleural biopsy;
• the predominant clinical form is tuberculosis of the intrathoracic lymph nodes, defined as secondary tuberculosis, genetically related to the primary infection;
• significantly less frequently than in young people, focal tuberculosis develops, which is a consequence of the endogenous reactivation of old residual changes (Simon foci);
• Over the last decade, there has been an increase in widespread bacillary forms of tuberculosis with an imperceptible onset and erased clinical symptoms or rapidly progressing acute forms such as caseous pneumonia;
• caseous pneumonia in the elderly may be the result of endogenous reactivation of old tuberculosis foci with reduced immunity, severe concomitant or combined diseases, long-term treatment with corticosteroids, antitumor chemotherapy, X-ray and radiotherapy, as well as in severe stressful situations and starvation;
• emphysema, pneumosclerosis, cicatricial changes in the lungs and pleura mask the signs of active tuberculosis and slow down the reparative processes;
• Endoscopic examinations are of great importance in making a diagnosis;
• Tuberculosis is often associated with a variety of concomitant diseases and often occurs with decompensation of underlying diseases, which significantly complicates the timely diagnosis of tuberculosis, complicates the treatment of the patient as a whole and worsens the prognosis of the disease.

A.G. Khomenko (1996) conditionally divides clinical manifestations of tuberculosis in older age groups into 2 main variants of the course of the disease:

• with pronounced manifestations of general intoxication, cough with sputum production, sometimes hemoptysis, pain in the chest;
• with scanty clinical manifestations in patients with minor forms of tuberculosis and even a progressive tuberculosis process, most often combined in such cases with other diseases characterized by the dominance of symptoms of the disease combined with tuberculosis.

Drug treatment of tuberculosis in elderly and senile people

Treatment of tuberculosis in the elderly requires adherence to generally accepted approaches to tuberculosis chemotherapy. However, most patients fail to complete the entire course of standard chemotherapy, and at different stages of treatment, individualized therapy regimens must be used, including the treatment of concomitant diseases, which is why polypharmacy cannot be avoided. Concomitant diseases in some cases progress and acquire the role of the primary or competing disease.

It is necessary to take into account changes in the pharmacokinetics and pharmacodynamics of drugs. In elderly patients, the absorption of most antibacterial agents does not change, but with age, the metabolism of drugs mainly metabolized in the liver decreases: isoniazid, ethionamide, pyrazinamide, rifampicin. Doses of antibacterial drugs that have a predominantly renal elimination pathway (for example, aminoglycosides) must be adjusted, since the level of glomerular filtration decreases with age.

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