Hematogenous disseminated pulmonary tuberculosis in children

Currently, due to increased resistance of the human body to tuberculosis, widespread specific vaccination and revaccination of BCG, timely diagnosis of primary infection with tuberculosis in childhood and adolescence, hematogenously disseminated tuberculosis is rarely met.

With this form of tuberculosis, a large number of tubercular foci of hematogenous origin appear in various organs and tissues. The symmetry of focal changes in the lungs, the absence of caverns in the pulmonary tissue for a long time and the high frequency (in comparison with other forms) of extrapulmonary tuberculosis localization are characteristic. The development of disseminated forms of tuberculosis is preceded by the period of primary tuberculosis infection and the breakthrough of the tuberculosis focus into the bloodstream while simultaneously sensitizing the vascular system. For the onset of the disease, it is important to reduce immunity under the influence of adverse effects (insolation, eating disorders, intercurrent infections during the bending period, etc.). The source of bacteremia in primary tuberculosis is, as a rule, the intrathoracic lymph nodes, among them MW through the lymphatic duct enter the jugular vein, the right heart, small and then a large circle of circulation. A.I. Apricot named this path lymphohematogenous. If MW fall into a large circle of blood circulation, conditions are created for the emergence of a generalization of the process with the formation of multiple tubercular tubercles in almost all organs and tissues. In young children, the disease often occurs in the form of common miliary tuberculosis, when other organs are affected along with the lungs. The source of dissemination in secondary forms of tuberculosis can be lungs, bones, kidneys and other organs.

The prevalence of clinical symptoms and the course of the disease distinguish acute, subacute and chronic forms of disseminated tuberculosis. To acute leaking forms include disseminated tuberculosis and acute tuberculosis sepsis or typhobacillosis of the Landusi.

[1], [2], [3], [4], [5], [6], [7], [8]

Tuberculous sepsis

Tuberculosis sepsis (typhoid form) begins acutely, with a high body temperature, dyspeptic disorders, proceeds violently, at times with lightning speed and terminates lethal within 10-20 days, with general intoxication coming to the fore. In case of death of the patient, small foci of necrosis with a large number of mycobacteria in them are found in all organs.

For acute dissemination is characterized by seeding of all organs in small, prosovidnyh, the same shape and anatomical structure of tubercles. Histologically fresh foci are mainly lobular-pneumonic with the presence of caseous changes. The older productive tubercles consist of lymphoid, epithelioid and giant cells, mostly with necrosis in the center.

Symptoms of hematogenous disseminated tuberculosis in children

The disease begins suddenly, the body temperature immediately rises to 39-40 C. The sleep is disturbed, the appetite disappears, diarrhea disorders are possible, dry cough, sometimes in the form of seizures, etc. One of the most constant and most painful symptoms for the patient is pronounced dyspnea. , up to 50-70 per minute.The face is pale, pronounced cyanosis, especially the lips and cheeks.The discrepancy between dyspnea and cyanosis, on the one hand, and the absence of objective changes in the lungs, on the other, should always give rise to suspicion of try disseminirovannyi tuberculosis. The general condition of the child's heavy, quickened pulse, possible delirium, clouding of consciousness. Nutritional status and turgor in children is significantly reduced detect peripheral lymphadenitis, palpated slightly enlarged liver and spleen. Sometimes the skin appear rozeoloznye rashes.

Diagnosis of hematogenous disseminated tuberculosis in children

From the lungs reveal a boxed percussion sound, a slightly weakened or hard breathing and in a large number of small moist subcorporeal rales that are better heard in the paravertebral areas. MW in sputum is not determined. Tuberculin tests are often negative. In the anamnesis, there are often signs of contact with patients with tuberculosis. The true nature of the disease, if X-ray examination is not performed, clears up after the appearance of meningeal symptoms or is established only at autopsy. When the process spreads to the meningeal membranes (meningeal form), the symptoms characteristic of serous meningitis come to the fore. Therefore, a diagnostic spinal puncture should be carried out according to extended indications.

At X-ray examination, acute disseminated forms of tuberculosis can be divided into groups depending on the size of tuberculosis foci. In addition to miliary, medium and large focal forms are distinguished, and sometimes mixed acute disseminations with unequal amounts of tuberculosis foci are identified. Large-focal and mixed disseminations in acute course are a manifestation of complicated forms of primary tuberculosis. Often they have complex mechanisms of formation involving lymphogematogenic and bronchogenic pathways. The latter are more common in disseminated subacute or chronic course. At X-ray examination, first the intensification of the pulmonary pattern and additional shadows of inflammatory-altered interstitial tissue are detected, then - total dissemination along the course of the blood vessels. Their size, as a rule, no more than 2-3 mm or even less. They are figuratively compared to semolina or pinhead. The greatest density of foci is found in the lower and middle parts of the lungs. An important sign is the depletion of the lungs pattern with the possible manifestation of the fine-meshed elements. Only large pulmonary trunks near the roots can be traced in the form of limited fragments, regardless of the size of the foci. The roots of the lungs in young children are usually expanded from one or both sides, the outer contours are vague, the structure is lowered, and in adolescents, the roots are unchanged or contain calcinates. In the lungs, fibrosis is defined, calcified foci in the apexes.

For chronic disseminated tuberculosis the following symptoms are characteristic:

• symmetrical lesion mainly of the upper parts of the lungs;
• mainly corticopleural and dorsal localization of changes:
• propensity to productive character of lesions;
• development of small-sclerosis;
• small tendency to cavities;
• development of emphysema;
• thin-walled symmetric cavities;
• hypertrophy of the right heart;
• presence of extrapulmonary localization of the process.

Variety of morphological changes causes a variety of clinical symptoms. The disease can begin to be acute, under the mask of the flu. However, more often the disease creeps up gradually, subjective complaints are not characteristic and very different. The abundance of complaints is due to various violations from the vegetative and endocrine systems. Children complain of fatigue, headaches, palpitation, chest pain, lack of appetite and sleep, cough, mostly dry, sometimes with a small amount of sputum. A child is thin, pale, irritable, he must have shortness of breath, which increases with any physical exertion. Body temperature is often subfebrile, but can be febrile. Tuberculin tests are positive, sometimes hyperergic. MBT is detected not more often than in 25% of cases and only periodically. Hemoptysis is rare. In the initial phases of the development of the disease, physical changes in the lungs are very scarce. They grow as the process progresses. Percutary sound can be shortened in the upper parts of the lungs and boxed in the lower ones. Breath is not uniform, sometimes bronchial or hard, sometimes weakened. On both sides, listen to small wet rattles, and with the formation of caverns - medium or large bubbles. Moderately expressed leukocytosis with a shift of the leukocyte formula to the left, lymphopenia, monocytosis and an increase in ESR. With chronic disseminated tuberculosis, the process acquires features of fibrous-cavernous tuberculosis with exacerbation in the spring-autumn period and an unfavorable outcome.

[9], [10], [11], [12], [13], [14]

Differential diagnostics

In most cases, the picture of disseminated tuberculosis is very typical and does not present special difficulties for diagnosis. However, in pediatric practice, there are cases when disseminated tuberculosis is very difficult to distinguish from a number of diseases: inflammatory nonspecific character (focal bronchopneumonia, bronchiolitis, cystic fibrosis).

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

Focal pneumonia

Differential diagnosis of disseminated tuberculosis is carried out primarily with nonspecific pneumonia. Tuberculin reactions in patients with pneumonia either remain normal or become negative. For a common focal pneumonia is characterized by a more acute onset, a greater severity of the general condition, a sharp manifestation of symptoms of intoxication. In the physical examination of the lungs with pneumonia, more pronounced auscultatory data are revealed (in comparison with tuberculosis). Hemogram changes in nonspecific inflammation are characterized by high leukocytosis, expressed by shifting the leukocyte formula to the left, high ESR. Focal changes in one lung more indicate a nonspecific process, with pneumonia, focal changes are located in the middle and lower parts of the lungs, and the tips are usually not changed. With nonspecific pneumonia, the nature of the foci on the radiograph is more or less the same, their magnitude is somewhat greater than in tuberculosis, the contours are more vague, they are determined against a background of pronounced interstitial inflammation. In subacute and chronic dissemination, cavities in the lungs are often detected. With an uncomplicated course of pneumonia, focal-like shadows dissolve without leaving traces. Radiological picture with nonspecific inflammation is more dynamic (in comparison with tuberculosis). With timely treatment, focal shadows dissolve in a short time (7-10 days). With pneumonia, the roots of the lungs expand frequently on both sides along the pathway of reactive adenitis, their contours are blurred. In the study of sputum in patients with subacute and chronic dissemination, in some cases it is possible to detect MBT.

[21], [22], [23], [24], [25], [26]

Bronchiolitis

Bronchiolitis often occurs in ARVI, but it can also be caused by other viruses. By bronchiolitis is understood as the widespread defeat of the smallest bronchi and bronchioles, leading to the development of severe airway obstruction, usually with the development of significant respiratory failure. Bronchiolitis is more common in children under 2 years of age in the spring and winter months in the form of outbreaks, sporadic cases recorded during the cold season.

Unlike acute disseminated tuberculosis, the occurrence of bronchiolitis is preceded by a respiratory viral infection. Body temperature in children with bronchiolitis often drops to normal in a few days, while in severe dissemination, a high fever persists for a long time. When auscultation of the lungs in a child with bronchiolitis, abundant finely bubbly and dry wheezing are determined, radiologically predominantly in the basal area and below are seen small, sometimes merging nesting sites of infiltration. The pathological anatomy for them is created by a part of fibrinous-cell plugs that block the clearance of bronchioles and cause limited atelectasis, partly lobular-pneumonic changes, often accompanying bronchiolitis. It is also possible to infiltrate the walls of bronchioles. Radiographic changes and auscultatory data in bronchiolitis are marked by pronounced dynamism.

[27], [28]

Cystic Fibrosis

Cystic fibrosis is a disease inherited by an autosomal recessive type. It is characterized by cystic degeneration of the pancreas, total defeat of the glands of the intestine, respiratory tract and other glands (sweat, tear, salivary, etc.) because of blockage of their excretory ducts with a viscous secret. When conducting differential diagnostics with disseminated tuberculosis, it is necessary to take into account that children with cystic fibrosis start to get sick from the first months of life. In the pulmonary form of the disease in young children appears cough, it can be similar to a cough with whooping cough or have a rough metallic shade. Because of the increased viscosity of the bronchial secretion, it is difficult to expectorate sputum, and in this connection the cough often ends in vomiting. A similar character of cough with disseminated forms of tuberculosis is not noted. The lungs are listened to by variously moist wet and dry wheezing caused by obstruction of the bronchi, mucus, pus, and infection process. The phenomena of chronic bronchopulmonary pathology are steadily progressing. There are shortness of breath, cyanosis, symptoms of pulmonary heart failure, thickening of the nail phalanges of the fingers. When X-ray examination, in contrast to disseminated forms of tuberculosis, with cystic fibrosis, the localization of changes may be different, the process often has a diffuse character. Most often, the upper lobe of the right lung suffers. The dominant picture of bronchitis in the form of an intensified and deformed pattern with coarse cellular-linear structures is the background for the formation of heterogeneous local (focal) changes.

[29], [30], [31], [32], [33], [34]