Tuberculosis in elderly and elderly people

The isolation of tuberculosis in elderly and senile people is dictated by the peculiarities of physiological and pathological processes in the elderly. In elderly and elderly people, the diagnostic value of many symptoms often decreases, a combination of several diseases is revealed, which is manifested by the syndrome of mutual burdening of diseases, it becomes necessary to apply non-standard approaches to the treatment of tuberculosis.

In accordance with the modern classification of age groups, the elderly are considered to be 65 to 75 years of age, the elderly from 75 to 85; people older than 85 years are called long-livers.

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

Physiological aging is characterized by a gradual withering of the body and a decrease in its functional and reactive abilities; limiting energy resources, and reducing adaptive capacity.

What causes tuberculosis in the elderly?

In elderly people, the risk factors for developing tuberculosis should be considered as a combination of conditions that reduce immunity:

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

Peculiarities of tuberculosis in older age groups are largely due to structural and functional changes in the bronchopulmonary system, denoted by the term "senile lung", which includes

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

In all elements of the respiratory system - parenchyma, bronchus, blood vessels, lymphatic apparatus, involutive processes are observed.

Reactivation of tuberculosis of the intrathoracic lymph nodes in the elderly usually develops after a long period (several dozen years) after the transferred tuberculosis infection and is associated with exacerbation of the elements of the primary complex. In the studies of A.E. It is shown that lime dissolves in the areas of calcified caseous necrosis, Lizegang rings lose their characteristic structure, lymphoid infiltration sites and epithelial tubercles appear. Sometimes reactivation of a specific process occurs in the zone of radical sclerosis, formed as a result of involution of tuberculous foci and lymphangitis. In posttubercular residual foci persistant agent of tuberculosis persists. With massive and multiple petrificates, as a result of the demineralization processes, which is typical for people of older age groups, calcium salts are resorbed, the L-form of the pathogen reversion to its original form, with restoration of its inherent virulence. These processes often occur in the presence of factors that reduce immunity.

Less common is the exogenous path of secondary tuberculosis development in the elderly, associated with a new (repeated) infection of mycobacterium tuberculosis with massive repeated superinfection.

Tuberculosis, observed in elderly and senile age, it is common to divide into old and senile.

Old tuberculosis

Old tuberculosis usually begins in young or middle age, lasts for years, and sometimes because of the torpid current it is diagnosed only in old age. Such patients are observed for a long time by specialists of the general medical network, where they are diagnosed with various other diseases, most often chronic nonspecific respiratory diseases. Old tuberculosis can also form due to treatment defects. The main clinical forms for old tuberculosis are: fibro-cavernous, cirrhotic, less often - pleural empyema, described in detail in Chapter 18 "Respiratory Tuberculosis."

Fibrous-cavernous tuberculosis, as well as cirrhotic tuberculosis, in persons of older age groups can be mistakenly diagnosed as chronic bronchitis, bronchiectatic disease with the presence of emphysema and pneumosclerosis.

Tuberculosis empyema is accompanied by the accumulation of purulent exudate in the pleural cavity. This disease develops with widespread caseous nemesis of the pleura, due to the breakthrough of the cavity into the pleural cavity with the formation of a bronchopleural fistula or as a complication of the surgical manual for active tuberculosis. This form is found in elderly patients who have undergone such therapeutic measures in the past as artificial pneumothorax, oleotorax and other manipulations, called small surgery elements. At present, the number of such patients has significantly decreased. However, pleural empyema can also be characterized by a "cold" course, leaking without significant intoxication. The leading symptoms are increased dyspnoea, cyanosis and tachycardia. Errors in the diagnosis of this form are most often observed with the development of empyema after a long time after curing active tuberculosis.

X-ray diagnosis of old tuberculosis in the elderly is largely complicated by the presence of post-inflammatory (nonspecific and specific) changes in the lungs in the form of areas of pleural consolidation, cirrhotic darkening areas, stagnant phenomena, age-related physiological changes. So, due to aging of bronchopulmonary and bone structures, their densification, the X-ray picture of tuberculosis in the elderly is masked by deformed and excess pulmonary pattern, emphysema, sharply contrasting walls of bronchi, vessels, bone fragments. The summary image of such changes in the lungs imitates a non-existent focal dissemination on the roentgenogram), or vice versa - it covers small-scale disseminated changes. Due to severe emphysema, tubercle cavities become less contrasting. The features of the old tuberculosis include the following symptoms:

• patients with long-term tuberculosis, as a rule, are asthenicized;
• on the side of the lesion, chest lag in breathing is noted;
• The trachea and the organs of the mediastinum shift towards defeat;
• in the lungs, along with the signs of tuberculosis, characteristic of a particular chronic form, there is pronounced fibrosis, pneumosclerotic changes, emphysema, bronchiectasis;
• in persons treated in the past with artificial pneumothorax, after 20 years or more, pleuropneumocirrhosis may develop, accompanied by pronounced dyspnea:
• in patients with old tuberculosis, there are multiple violations of the liver that potentiate the development of hemoptysis and pulmonary hemorrhage;
• tuberculin tests with old tuberculosis, as a rule, are positive, but this does not have a large differential diagnostic value;
• decisive in the diagnosis is the detection of mycobacterium tuberculosis by microscopy and sowing; the percentage of positive findings of mycobacteria depends on the correctness and duration of sputum collection and the multiple studies conducted (at least 3 times by microscopy and sowing).

The course of old tuberculosis, as a rule, is complicated by the following pathology:

• inadequate function of external respiration and circulation;
• symptoms of a chronic pulmonary heart;
• development of bronchiectasis;
• inclinations to hemoptysis and pulmonary hemorrhage;
• amyloidosis of internal organs.

Old tuberculosis

Under senile it is customary to designate tuberculosis that has developed in individuals of older age groups as a result of reactivation of the process in areas of post-tuberculosis pulmonary changes or foci in the intrathoracic lymph nodes: mediastinal, paratracheal, tracheobronchial and bronchopulmonary. Stary tuberculosis is characterized by the following triad of symptoms: cough with phlegm, shortness of breath, circulatory function. Significantly less frequent hemoptysis and pain in the chest. Not every single sign, nor their totality, makes it possible to diagnose tuberculosis with confidence.

In the elderly and senile age there are the following features:

• there is a general infection of persons of these groups;
• there is a high proportion of people with large post-tuberculosis changes in the bronchopulmonary system (the so-called "children of war");
• reactivation of tuberculosis occurs after a long period (several dozen years);
• reversion in old foci of L-forms of mycobacterium tuberculosis into true mycobacteria takes place with a special clinical picture in the form of previous recurrent, sometimes migratory, pneumonias that are well treatable with broad-spectrum drugs;
• it is possible to isolate typical mycobacterium tuberculosis in the absence of obvious signs of visible bronchial lesions due to bronchonodular microperforations;
• more often a specific bronchial lesion is observed - every second patient develops fistulose endobronchitis;
• dissemination in the lungs is observed 3 times more often than in the young, often has the features of miliary tuberculosis and occurs under the mask of pneumonia, another nonspecific bronchopulmonary pathology or carcinomatosis;
• along with the lungs, simultaneous or sequential lesions of the liver, spleen, bone, urogenital system and other organs are possible;
• more often there is tuberculosis of the larynx, which is sometimes detected much earlier than the tuberculosis lesion of the lungs;
• Pleural exudates are caused by more frequent specific pleurisy. And oncological and cardiac pathology, and differential diagnosis of tuberculosis provides for a wider use of pleural biopsy;
• the prevailing clinical form is tuberculosis of the intrathoracic lymph nodes, defined as secondary tuberculosis genetically related to the primary infection;
• much less often than in young, focal tuberculosis develops, which is the result of endogenous reactivation of old residual changes (Simon's foci);
• over the past decade, increased bacillary forms of tuberculosis with an inconspicuous onset and erased clinical symptoms or rapidly progressive acute forms like caseous pneumonia;
• caseous pneumonia in the elderly can be the result of endogenous reactivation of old tuberculosis foci with reduced immunity, severe concomitant or associated diseases, long-term treatment with corticosteroids, antitumor drugs, X-rays and radiotherapy, as well as severe stressful situations and starvation;
• emphysema, pneumosclerosis, scar changes in the lungs and pleura mask the signs of active tuberculosis and slow down the reparative processes;
• in the formulation of the diagnosis, the significance of endoscopy studies is great;
• Tuberculosis is often associated with a variety of concomitant diseases and often occurs with decompensation of background diseases, which greatly complicates the timely diagnosis of tuberculosis, complicates the treatment of the patient as a whole and worsens the prognosis of the disease.

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

• with severe manifestations of general intoxication, a cough with sputum, sometimes hemoptysis, painful sensations in the chest;
• with poor clinical manifestations in patients with small forms of tuberculosis and even a progressive tuberculosis process, most often combined in such cases with other diseases characterized by the prevalence of symptoms associated with tuberculosis disease.

Drug treatment of tuberculosis in elderly and senile patients

Treatment of elderly tuberculosis requires adherence to conventional approaches to chemotherapy for tuberculosis. However, most patients fail to fully complete the entire course of standard chemotherapy, and at individual stages of treatment, individualized regimens of therapy, including the treatment of co-morbidities, need to be resorted to, and therefore polypharmacy can not be avoided. Concomitant diseases in some cases progress and assume the role of a primary or competing disease.

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

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