Tuberculosis pain

When infected with Mycobacterium tuberculosis, primary tuberculosis develops - the initial, usually asymptomatic stage of the disease. With a weak immune system, the disease can become active, and then over time, pain occurs with tuberculosis of various localizations.

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Causes tuberculosis pain

The main causes of pain in tuberculosis are inflammation and destruction of tissue areas of certain organs with the formation of necrosis zones. According to phthisiologists, primary pulmonary tuberculosis in a recently infected person can manifest itself with flu-like symptoms. M. tuberculosis bacilli slowly multiply in the alveolar macrophages of the lungs, migrating to the intrathoracic lymph nodes, where pathological formations arise - tuberculous granulomas. They contain products of caseous necrosis of mycobacteria proteins, as well as epithelioid and giant cells, lymphocytes and viable mycobacteria.

The infection can spread throughout the tissue, forming even more granulomas; the bacteria can infect not only the lungs via the lymphatic or hematogenous route: extrapulmonary tuberculosis affects the lymphatic, genitourinary, central nervous systems, visceral organs, bone tissue and joints. For example, mycobacteria spread through the bloodstream and settle in the bone, usually near the epiphyseal cartilage - in close proximity to the synovial membrane. And the formation of granulomas damages the structure of the bone tissue, causing inflammation and pain.

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

As a result of the development of tuberculosis infection in the female reproductive organs (ovaries, fallopian tubes, uterus) and in the prostate gland, men may experience pain in the pelvic area.

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Risk factors

The main risk factors for the development of active tuberculosis are: contact with people with tuberculosis; HIV/AIDS; early childhood (especially with poor living conditions and malnutrition); alcohol and drug addiction; kidney disease; oncology; radiation therapy; chemotherapy with immunosuppressive drugs; pregnancy; long-term use of steroids.

In about 5% of people, the immune system cannot fight the infection, and the disease progresses: individual granulomas merge, forming cavities (caverns) filled with bacteria and dead cells; nearby tissues swell and become inflamed, local blood circulation and organ function are impaired, and pain occurs.

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Pathogenesis

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

And peripheral neuralgic pain, in particular, pain under the shoulder blade with tuberculosis (with tuberculous lesions of the apex of the lungs, the pain radiates here), as well as neuralgic pain in the back with tuberculosis of the spine - a consequence of damage to sensory neurons, axons or ganglia of the vagus, thoracoabdominal, phrenic or spinal nerves.

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Epidemiology

Extrapulmonary TB has become more common with the advent of the human immunodeficiency virus and the increase in organ transplants, which also leads to immunosuppression in thousands of people. In Africa, where HIV prevalence is higher than in other parts of the world, up to one-third of adults with osteoarticular TB 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 each year. In about one in four cases, tuberculosis affects the lymph nodes; urogenital tuberculosis accounts for about 27% of cases, renal tuberculosis - 15-20%, and tuberculosis of the bones and joints - almost 8%, with the most likely foci of infection in the spine, hips and knees.

Musculoskeletal tuberculosis is more common in children, adolescents and young adults. According to British experts, bone and joint tuberculosis accounts for 2.4% of all tuberculosis cases in children in the UK.

Moreover, as studies by Spanish phthisiologists show, in patients with skeletal tuberculosis, concomitant lung damage is diagnosed in an average of 18.6% of cases.

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Symptoms

Early symptoms or first signs of active pulmonary tuberculosis may include fever, night hyperhidrosis, weight loss, but pain in pulmonary tuberculosis appears later - when coughing, taking a deep breath, during sudden movements - if the inflammation spreads to the lung membrane (pleura). Depending on the location of the lesion, dull pain in the chest can be felt in the shoulder and neck (on the side of the lesion), as well as under the ribs and in the heart area.

Pain in pulmonary tuberculosis

Acute chest pain is characteristic of pulmonary tuberculosis complicated by exudative inflammation of the pleura, as well as when air enters the pleural cavity (pneumothorax).

However, periodic dull pain in this localization can occur 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 may occur in patients with tonsil damage in the absence of active pulmonary tuberculosis, although such clinical cases are rare. However, any oropharyngeal structures can be affected: tongue, mucous membrane of the cheeks, palate, tonsils, pharynx.

In the presence of active pulmonary tuberculosis and its progression, a sore throat and a sore throat are most often associated with tuberculosis of the pharynx, which is characterized by miliary, i.e. millet-grain-like granulomatous rashes on the mucous membranes, fever, ptyalism (increased secretion of saliva) and dysphagia (difficulty swallowing).

Headaches in tuberculosis

Phthisiatrists classify persistent headaches associated with tuberculosis as 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 are deterioration of health, fever, headaches; after a few weeks, nausea and vomiting appear, the headache intensifies, photosensitivity may occur, as well as tension in the neck muscles.

Due to the increase in cerebrospinal fluid pressure and the accumulation of exudate between the membranes of the brain, changes in mental state are observed: confusion, attacks of irritability, drowsiness, fainting with loss of consciousness up to coma.

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

Joint pain in 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. Joint pain in this type of tuberculosis is the earliest manifestation of the disease, and fever and systemic symptoms are usually absent. But the development of a cold abscess is almost always noted – localized caseous necrosis without typical signs of inflammation. As a result of its breakthrough through soft tissues, a fistula is formed.

Tuberculous arthritis is thought to be the result of the spread of a primary bone infection to a joint, and nine out of ten cases involve the hip or knee joint. A previous traumatic injury may be a trigger for persistent tuberculous infection.

The ribs, sternoclavicular, sacroiliac and ankle joints may be affected. Sometimes several bones and joints are affected in one patient, and then we are talking about multifocal skeletal tuberculosis.

Back pain in tuberculosis

Back pain in tuberculosis is the most common symptom of spinal damage – spinal tuberculosis or tuberculous spondylitis. Spinal involvement is usually the result of hematogenous spread of M. tuberculosis into the dense vascular network of the spongy body of the vertebrae. First of all, pain appears in the lumbar region and in the thoracic spine (with or without typical symptoms).

The intensity of back pain in spinal tuberculosis varies and may become stronger with movement and changes in body position 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 experience neurological manifestations.

Thus, neuralgic back pain in tuberculosis of the thoracic and cervical spine is accompanied by weakness and numbness of the upper and lower extremities; it can progress to complete paraplegia (paralysis of both extremities) or tetraplegia (paralysis of the lower and upper extremities). Paraplegia can result from compression of the spinal cord by a retropharyngeal (retropharyngeal) abscess, causing dysphagia, respiratory distress, or persistent hoarseness.

Paralysis may also be the result of destruction of intervertebral discs; edema of the spinal cord and necrosis of areas of its tissue (myelomalacia); tuberculous infiltration of the meninges (tuberculous spinal leptomeningitis); infectious thrombosis or endarteritis of the spinal vessels.

Weakness, numbness and muscle pain in spinal tuberculosis are felt by patients with compression of the equine tail (roots of the lumbar and sacral nerves) due to the formation of a cold abscess around the vertebrae of the lumbar and sacral regions.

Tuberculosis of the urinary tract, in particular, damage to the ureter, causes constant dull pain in the lumbar region. The localization of pain is similar in patients with tuberculosis of the kidneys. If one kidney is affected, the pain is one-sided. Advanced disease with destruction and necrosis of tissues surrounding tuberculous granulomas leads to attacks of acute pain.

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Diagnostics tuberculosis pain

Pain as a symptom does not require diagnostics, and tuberculosis diagnostics are performed by prescribing blood tests (general, biochemical, for antibodies to M. tuberculosis) and urine analysis, read - Laboratory diagnostics of tuberculosis

The Mantoux test with tuberculin is done, see – Tuberculosis: detection of Mycobacterium tuberculosis

Instrumental diagnostics include chest X-ray and any affected organ. Computer and magnetic resonance imaging also help in identifying the disease: CT is more informative in tuberculous meningitis, and for diagnosing spinal tuberculosis, MRI is a more sensitive imaging technique than X-ray and more specific than CT. Ultrasound is used in cases of damage to the kidneys and urinary tract, mediastinal organs, abdominal cavity and pelvis. More details in the publication - Diagnosis of tuberculosis of extrapulmonary localization

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Differential diagnosis

Differential diagnostics 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 renal cancer. Osteoarticular tuberculosis should be differentiated from rheumatic diseases, and tuberculosis of the vertebrae from oncology or metastases. In such cases, fine-needle aspiration biopsy, including synovial, and histopathological examination of the obtained sample are performed.

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Treatment tuberculosis pain

Regardless of the localization, tuberculosis is treated for several months with a combination of antibiotics: Isoniazid (other trade names are Isoniazid, Tubazid, Tubetol, Ditubin, Eutizon), Rifampicin (Rifadin, Rifaldin, Rifampin, Benemetsin, Tubotsin), Ethambutol (Ebutol, Etambine, Diambutol, Afimocil, Batacox), Pyrazinamide and Streptomycin, which are recognized as first-line anti-tuberculosis drugs. Amikacin, Ethionamide, Moxifloxacin and para-aminosalicylic acid (sodium para-aminosalicylate) are also used. Full information in the material - Tuberculosis Treatment

All of the above medications are designed to combat the pathogen, Mycobacterium tuberculosis, but they will not help relieve pain. In cases of spinal tuberculosis with neurological symptoms, the patient is recommended to stay in bed for 12-16 weeks. In case of joint pain, immobilization is necessary using fixing bandages and plaster splints.

Anti-tuberculosis antibiotics reduce the therapeutic effect of corticosteroids and many analgesics, so the treatment of pain in tuberculosis has its own characteristics, and doctors should prescribe drugs to reduce pain, taking into account the individual manifestations of the disease, the condition of each patient's body and possible risks.

Paracetamol can be used (325-500 mg three times a day), but its combination with Isoniazid and Rifampicin increases the risk of liver damage. And children are strictly prohibited from taking Paracetamol 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 injections. This drug, like all NSAIDs, can cause side effects in the form of headaches and stomach pain, nausea and vomiting, allergic reactions. And in the presence of gastric ulcer and duodenal ulcer and bronchial asthma, its use is contraindicated.

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

For back pain, the muscle relaxant with analgesic effect Baclofen (Baclosan) can be used by epidural administration, but only if patients do not have a history of epilepsy, Parkinson's disease or chronic renal failure. Side effects of Baclofen can include sleep and urination disorders, headache, weakness, convulsions, decreased blood pressure and respiratory depression.

As a pain reliever, intramuscular injection of Combilipen is practiced, which includes vitamins B1, B6, B12 and the anesthetic lidocaine hydrochloride. The course of treatment lasts no more than two weeks - two to three injections per week (2 ml each).

Physiotherapeutic treatment for pain relief includes sessions of UHF, ultrasound and laser therapy; electrophoresis with lidase or UHF with isonicotinic acid preparations and analgesics (novocaine, analgin); phonophoresis with hydrocortisone or butadion ointment.

Surgical treatment

Surgery may be required to remove damaged tissue and reduce the bacterial load. In the case of pulmonary tuberculosis, depending on the extent of the lesion, the resulting cavity, a separate lobe of the lung, or a significant portion of it may be removed.

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

Surgery may be required for osteoarticular tuberculosis - arthrodesis or arthroplasty of the joint. For example, in case of tuberculosis of the hip joint, which has a pronounced tendency to relapse, surgical intervention is performed to remove all necrotic tissue (bone curettage).

In case of spinal tuberculosis, abscess drainage or spinal stabilization (reconstruction) is performed. Bone grafts and artificial materials (steel, titanium, carbon fiber) are used for spinal column reconstruction.

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 into the abdominal organs and outward - through the abdominal wall.

Generalized or focal hydronephrosis, as well as amorphous dystrophic tissue calcification are complications of renal tuberculosis, leading to its dysfunction. Possible complications of intestinal tuberculosis include narrowing of its lumen, obstruction, perforation of ulcerated areas of the mucosa with bleeding and peritonitis.

In tuberculous arthritis, the periarticular bone is destroyed, fibrous or bony ankylosis may develop, and the joint loses mobility.

Orthopedic complications of spinal tuberculosis include its deformation (kyphosis) and instability. And among its neurological complications are radicular syndrome, pyramidal insufficiency syndrome, paralysis, and dysfunction of the pelvic organs. Without treatment, lumbar spine tuberculosis progresses, which ultimately leads to paralysis of the lower extremities and loss of the ability to move independently.

Sequelae of tuberculous meningitis include stroke, permanent brain damage 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 early detection and proper treatment are considered key. Without proper treatment, the disease progresses, and more than half of people with active TB die within five years, according to TB specialists.

If osteoarticular tuberculosis is diagnosed and treated early, recovery is possible for the vast majority of patients, but with varying degrees of musculoskeletal impairment. At the same time, patients with severe deformity may develop paraplegia months or years after treatment.

The prognosis for meningeal tuberculosis depends on the severity of the symptoms in the individual patient, and the worst prospects are for patients with obvious brain damage.

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