Extrapulmonary tuberculosis: causes, symptoms, diagnosis, treatment

Extrapulmonary tuberculosis is the name that unites the forms of tuberculosis of different localization, except for respiratory tuberculosis, as 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 in recent decades has increased significantly, and extrapulmonary cases account for 17-19% of cases.

Tuberculosis extrapulmonary localization, in addition to ICD-10, uses the Clinical classification of tuberculosis extrapulmonary localization. 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 registration of combined tuberculosis lesions.

Localization distinguishes tuberculosis urogenital, peripheral lymph nodes, skin and subcutaneous tissue, bones and joints, eyes, meninges, abdominal, other organs. The prevalence is divided into a limited and generalized form. According to morphological manifestations, granulation and destructive (cavernous) tuberculosis is isolated. The gravity of the current determines the early and neglected forms.

Section 1 Clinical classification of tuberculosis extrapulmonary localization systematizes the general classification of tuberculosis of various organs and systems:

• Etiology.
• Prevalence:
  • local (limited) tuberculosis - the presence of one focus in the affected organ [for the spine - in one vertebral-motor segment (PDS)];
  • a common process is a lesion in which there are several foci of tuberculous inflammation in one organ (for the spine, the defeat of two or more adjacent PDS);
  • Multiple defeat of the system - the defeat of tuberculosis by several organs of the same system (for the spine - two or more non-adjacent PDS);
  • combined tuberculosis - the defeat of two or more organs belonging to different systems.
• Activity is determined by a combination of clinical, radiation, laboratory and morphological data; the process is characterized as active, inactive (quiescent, stabilized) or as a consequence of TVL.
  • Active tuberculosis:
    • type of flow: progressive, subsiding and chronic (recurrent or torpid);
    • the stages of the process characterize the evolution of the primary focus according to the morphological and functional disorders of the affected organ; If they do not coincide, the overall indicator is determined at the highest stage.
  • Inactive tuberculosis (silent, stabilized); in patients with extrapulmonary tuberculosis, residual organ specific changes persist in the absence of clinical and laboratory signs of their activity; to the residual changes include scars and limited small calcified foci or abscesses.
  • The consequences of tuberculosis of extrapulmonary localization are established in persons with clinical cure of a specific process in the presence of pronounced anatomical and functional disorders. This diagnosis can be established both in the past course of antituberculous treatment, and in patients with newly diagnosed disorders, which, according to the totality of the data, can be identified with a high probability as a consequence of the tuberculosis of extrapulmonary localization.
  • Complications of extrapulmonary tuberculosis are divided into:
    • general (toxic and allergic organ damage, amyloidosis, secondary immunodeficiency, etc.);
    • Local, directly related to the defeat of a particular body or system.

The nature of bacterial release and drug resistance of mycobacteria is determined by general principles. Clinical cure of extrapulmonary tuberculosis is ascertained when all signs of active tuberculosis - clinical, radiation and laboratory - are eliminated after the main course of complex, including surgical, treatment. This diagnosis is established not earlier than 24 months after the start of treatment, and in surgical treatment - 24 months after the operation (in children - not earlier than 12 months after the operation).

Section 2 Clinical classification of tuberculosis extrapulmonary localization reflects the clinical forms and features of the tuberculosis process in different organs and systems.

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

Tuberculosis of bones and joints of 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 skeleton.

Over the past 10 years, the proportion of patients in older age groups has increased 3.9 times. The active forms of a specific process in the joints were registered at 34.2%, in 38.5% of cases the disease was accompanied by a specific lesion of other organs and systems, including various forms of pulmonary tuberculosis in 23.7% of cases. Tuberculosis 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 time when the first symptoms of the disease appear . The specific gravity of progressive arthritis, subtotal and total joint lesions increased (33.3 and 8.9% of observations, respectively). The total drug resistance of the pathogen to the main antibacterial drugs reached 64.3%. 72.6% of patients have concomitant somatic pathology.

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

In recent decades, there has been a steady trend towards a decrease in the incidence of this pathology and the bulk of patients are among the elderly and elderly.

Bone and joint tuberculosis accounts for 3% of all cases of tuberculosis. The main localization of the tuberculosis process is the spine (more than 60%). Invalidation of patients is 100%. In the concept; osteoarticular tuberculosis does not include allergic arthritis and polyarthritis caused by tuberculosis of another localization.

In practice, the most common are tubercular spondylitis, gonitis and coxitis. Very rare and other localization of the process. In most cases, the process develops slowly and imperceptibly, is revealed when deformations of the skeleton, abscesses, fistulas and neurological disorders are formed: The available pulmonary tuberculosis covers the process.

In the preartritic phase of the process, complaints of pain in the spine or joint, restriction of movements are noted. When palpation, there is swelling and tenderness of the soft tissues, tenderness and thickening of the diaphysis of the bones. Symptoms are transient, disappear spontaneously, but reappear. At this phase, the process can stop, but more often it goes into the next one.

The arthritic phase is characterized by a triad of symptoms: pain, impaired function of the affected area and muscle atrophy. The development of the disease is progressing gradually. Pain, initially spilled, is localized in the affected area. Easy tapping on the tubercular vertebra causes pain; compression of the wings of the iliac bones causes pain in the affected parts of the spine or the hip joint (Erichsen's symptom).

Mobility is initially limited by the stiffness of the muscles (for the spine is characteristic of the symptom of Kornev - "reins"), then, as the bone and cartilage of the joint are destroyed, by changing the congruence of the joint surfaces. In spondylitis, due to the wedge-shaped deformation of the vertebrae, an angular deformity is formed, initially determined palpation, then in the form of a "frightened" outgrowth of the appendage, then there are signs of development of the hump, which, unlike the chondropathic (Koehler's disease, Sheyerman-May, etc.) has a wedge shape. Other joints thicken due to proliferation of cartilage. In combination with muscle atrophy, the joint acquires a spindle shape. The skin fold is thickened (Alexandrov's symptom) not only over the joint, but also over the limb. There is no hyperemia - "cold inflammation". In children, bone growth stops, the limb shortens, muscle hypotrophy passes into atrophy, so-called "dry" develops. Cold abscesses (natechnict), sometimes considerably removed from the main focus, can form.

The postartritic phase is characterized by a combination of deformation of the skeleton with functional disorders.

Neurological disorders are usually associated with compression of the spinal cord due to its deformation, which requires prompt correction. In this phase, residual foci of tuberculosis, insects, which often give rise to a recurrence of the process, may persist.

Diagnosis of the disease is rather complicated due to the erosion of clinical manifestations, in the initial periods it resembles the clinical picture of usual inflammatory and degenerative diseases, the patient should be alert to the presence of an active tuberculosis in the patient or in an anamnesis. The patient is examined completely naked, reveals skin changes, posture disorders, painful points during palpation, muscle tone, symptoms of Alexandrov and Kornev. The movements in the joints and the length of the limb are determined using a centimeter tape and a protractor.

The main purpose of the diagnosis is the detection of the process in the prearticular phase: radiography or large-frame fluorography of the affected skeleton, magnetic resonance imaging. In the prearthritic phase, foci of bone osteoporosis are determined, sometimes with inclusions of bone sequesters, calcifications, and violation of bone architecture. In the arthritic phase, the radiologic change is caused by the transition of the process to the joint: narrowing of the joint gap or intervertebral space (with widening expands), destruction of the joint ends of the bone and vertebrae, wedge-shaped deformity of the vertebrae, repositioning of the beams along the line of force loads (reparative osteoporosis).

In the postartritic phase the picture is variegated, it combines crude destruction with restorative processes. Joint lesions are characterized by the development of metatuberculous arthrosis: the deformation of articular surfaces, sometimes with complete destruction, the formation of fibrous ankylosis in the vicious position of the limb. Kifoskolioz manifests itself as a pronounced wedge-shaped deformation of the vertebrae. The insects are revealed in the form of diffuse shadows. The main purpose of diagnosis in this phase is the identification of residual foci.

Differential diagnosis is carried out: with other inflammatory and degenerative diseases (with a bright inflammatory picture of the process); primary tumors and metastases (puncture biopsy, which is mandatory in either case); syphilis of bones and joints (positive serology on radiographs - presence of syphilitic periostitis and gummy ostites).

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 lymph nodes, although this issue is still not known, since the connection with tuberculosis of other localizations can not be traced .. There is only: the assumption that this is an exacerbation of cold foci in the basal layer arising from neuroendocrine disorders or attachment of secondary infections. There are several forms of tuberculosis of the skin and subcutaneous tissue.

Tuberculosis of peripheral lymph nodes

Tuberculosis of the peripheral lymph nodes represents 43% of the various types of lymphadenopathy and in the structure of the incidence of extrapulmonary tuberculosis is 50%. The actuality of the problem lies in the fact. That in 31,6% of cases a combination of tuberculosis of peripheral lymph nodes with other localizations of a specific process is noted, including tuberculosis of the respiratory organs and intrathoracic lymph nodes.

Tuberculous lymphadenitis - tuberculosis of peripheral lymph nodes is an independent disease or is combined with other forms of tuberculosis. There are local and generalized forms. Locally more often submaxillary and cervical lymph nodes are affected - 70-80%, less often axillary and inguinal - 12-15%. The generalized form is considered to affect at least three groups of lymph nodes, they constitute 15-16% of cases.

The clinic is defined by an increase in the lymph nodes to 5- ^ 10 mm: they are soft, elastic, mobile; have an undulating current; their increase is not associated with ENT pathology and oral diseases; the flow is slow. Subsequently, due to the perifocal reaction, characteristic of tuberculous lymphadenitis, the surrounding tissues and adjacent lymph nodes are involved in the process. Large "packages" are formed, so-called tumor-like tuberculosis. At the center of them there is a softening and fluctuation due to the decay of the caseous masses. The skin over them is cyanotically hyperemic, thinned, opened with a fistula with the formation of an ulcer. Granulation around the fistulous course is pale, separated by "curdled". Holes of fistula and ulcers have characteristic bridges, subsequently, as healing progresses, rough scars are formed in the form of cords and papillae. Fistulas close for a very short period, after which a relapse occurs again.

Differential diagnosis with nonspecific inflammation, lymphogranulomatosis, tumor metastasis, dermoid cyst, syphilis is performed on the basis of biopsy; The worst result is a puncture with a cytological examination of the punctate.

Pathogenesis of tuberculosis of peripheral lymph nodes

According to the Evolutionary-pathogenetic classification, 4 stages of tuberculosis of peripheral lymph nodes are distinguished:

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

Complications of tuberculosis of peripheral lymph nodes

The main complications of tuberculosis of peripheral lymph nodes are the formation of abscesses and fistulas (29.7%), bleeding, 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 fistula in 3.0%. The majority of patients entered the hospital 3-4 months after the onset of the disease.

[1], [2], [3]

Tuberculosis of meninges

Tuberculosis of meninges, or tuberculous meningitis, is the most severe form of tuberculosis. A remarkable achievement of medicine in the XX century. Became a successful treatment of tuberculosis meningitis, before the use of streptomycin was a completely deadly disease.

In the preantibacterial period, tubercular meningitis was predominantly a childhood disease. The share of it among the first-time children with tuberculosis reached 26-37%. Currently, children with newly diagnosed tuberculosis are 0.86%, in adults 0.13%, and the total incidence of tuberculous meningitis in 1997-2001. Was 0.05-0.02 per 100 thousand of the population.

Reducing the incidence of tuberculous meningitis in our country was achieved through the use of vaccination and revaccination of BCG in children and adolescents, the provision of chemoprophylaxis in persons at risk of tuberculosis and the success of chemotherapy of all forms of tuberculosis in children and adults.

Currently, tuberculosis meningitis is mainly caused by unvaccinated BCG children of an early age, from family contact, from antisocial families. In adults, the leading antisocial lifestyle, migrants, patients with progressive forms of pulmonary and extrapulmonary tuberculosis most often develop tuberculous meningitis. In these same categories of patients, the most severe course and worst outcomes are noted. Often, tubercular meningitis presents great difficulties in diagnosis, especially in persons with unclear localization of tuberculosis in other organs. In addition, later treatment to the doctor, atypical course of meningitis, its combination with progressive forms of pulmonary and extrapulmonary tuberculosis, the presence of drug resistance of mycobacteria leads to a decrease in the effectiveness of treatment. Therefore, improving the methods of diagnosis and treatment of tuberculosis meningitis, and improving TB work in general remain topical tasks of phthisiology.

Urogenital tuberculosis

Tuberculosis of the genitourinary system is 37% of all forms of extrapulmonary tuberculosis. In 80% it is combined with other forms of tuberculosis, more often lungs. In men, in half of the cases both urinary and genital organs are affected simultaneously, in women this combination is noted only in 5-12% of cases.

The most commonly affected kidneys are men of 30-55 years sick a little more often than women. Distinguish the following forms: tuberculosis of the renal parenchyma, tuberculous papillitis, cavernous tuberculosis, fibro-cavernous tuberculosis of the kidney, kidney casei or tuberculomas, tuberculosis pionephrosis.

Clinical symptoms are meager, often the only manifestation is the detection in the urine of mycobacteria. Only some patients experience general malaise; low-grade fever, aching back pain. An indirect sign is the causeless increase in blood pressure, increased pain in the lumbar region after colds, the presence of a history of tuberculosis! Ultrasound examination, excretory urography allow early, before the development of fibrosis and hydronephrosis, to reveal changes in the parenchyma and renal cavity. But the same picture is noted in other renal pathology. Confirm the diagnosis of tuberculosis of the urinary system allows only a multiple study of urine on mycobacteria taken under sterile conditions. In all cases, a consultation of a urologist is obligatory, ideally - a phthisiourologist, since there is often a combination of kidney tuberculosis with the pathology of other parts of the urinary system and genital organs.

In tuberculosis of male genital organs, the prostate is primarily affected, later on the epididymis, testis, seminal vesicles and the vas deferens. At palpation: the prostate is dense, bumpy, the areas of mastication and softening are noted. Subsequently, the prostate shrinks, becomes flat, the groove is smoothed, and individual calcifications are palpated. All these changes in the form of destruction or calcifications are determined by ultrasound of the prostate. When the bladder is examined for residual urine, dysuria is detected. In analyzes of prostate juice, caseosis and mycobacteria tuberculosis, but a multiple study is necessary.

Treatment usual antituberculous, phthisiourologic, ends, as a rule, impotence and infertility.

Tuberculous chancre

This compaction, suppuration and opening of lymph nodes with the formation of a fistula; from a solid chancre in syphilis is distinguished by the absence of compaction at the base and negative serological responses. Lupus tuberculosis - localized on the face with lupus formation (dense nodules up to 1 cm) that merge with each other to form a flat infiltrate, often ulcerate or open with a fistula, differentiate with atheroma (dermoscopy: press with a slide glass - against a blanching, the infiltration is seen as yellowish jelly), furuncle and carbuncle (there is no characteristic sharp pain for them). Collicative skin tuberculosis: initially a 1-3 cm thick, painless knot appears in the thickness of the skin, which increases in size, is opened by one or more fistulas with the separation of caseous and the formation of a flat ulcer; differentiate with hydroadenitis and pyoderma (no pain), skin cancer (cytoscopy of the smear-print). Warty tuberculosis of the skin occurs in patients with open forms of pulmonary tuberculosis with constant contact of sputum with the skin or in prosektorov and veterinarians, when piercing gloves and skin while working with tuberculosis patients or animals, differs from the wart by the presence around it of an infiltrative corolla of cyanotic color and an inflammatory rim on the periphery of cyanotic pink color. Miliary and miliary-ulcerous tuberculosis of the skin is characterized by a rash on the skin or around the natural openings of papules of pinkish-cyanotic color, in the center of which jaundices are formed, covered with bloody crust, necroses can form.

Disseminated forms include acute miliary tuberculosis of the skin, miliary tuberculosis of the face, rosaceo-like tuberculosis, papulo-necrotic tuberculosis of the skin, compacted erythema and lichen scrotal. All these forms are characterized by slow development, chronic course, absence of acute inflammatory changes and pronounced soreness, undulating course with remissions and exacerbations in autumn and spring. All patients with cutaneous tuberculosis or suspected! On him for differential diagnosis and examination should be directed to the 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, all abdominal forms begin, with tuberculosis of the digestive organs - about 18% and peritoneum - up to 12%. The disease is noted in children, but adult patients predominate.

In the gastrointestinal tract, the most commonly affected are: the esophagus in the form of multiple ulcers, which result in stenosis; stomach with multiple painless ulcers along the large curvature and in the pyloric department, which leads to its stenosis; ileocecal section, sometimes with the inclusion of a vermiform appendage, which is accompanied by the development of a picture of chronic enterocolitis and chronic appendicitis (generally such a diagnosis indicates the secondary nature of the process, which must be differentiated with Meckel's tiflite or diverticulitis); a small intestine with multiple ulcers of the mucosa and a clinic of chronic enteritis. Mesadenitis - damage to the lymphatic vessels and peritoneum is accompanied by a contact involving fibrotic inflammatory process of the ovaries and uterus, which is one of the causes of female infertility. Symptoms typical for tuberculosis are not; the clinic fits into the usual inflammatory diseases, but it is characterized by a low degree of manifestation, a long and persistent course of the process, somewhat reminiscent of oncology processes.

Diagnosis is based on complex radiographic, endoscopic, laboratory and biopsy cytology, tuberculin diagnostics with Koch reaction.

[4], [5], [6], [7], [8]