Methods of clinical examination of patients with tuberculosis. What methods are used to diagnose tuberculosis

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Who is a phthisiatrician?

Phthisiatrician is a doctor who has received a professional specialization in a field such as phthisiology. As a rule, TB education is received after completion of training in one of the disciplines of general medicine.

Phthisiology is a science that studies tuberculosis, namely the symptoms, causes and mechanism of development of this disease. Also, this industry is studying various methods of diagnosis, therapy and prevention of this disease. Accordingly, a doctor trained in this specialty must possess the knowledge and skills that will help provide competent medical care to patients with tuberculosis. In addition, the TB doctor should develop and implement preventive measures both within a single case ( for example, for relatives of a patient already infected with tuberculosis), and for the population as a whole.

Where does the phthisiatrician take?

A phthisiatrician, can take in medical institutions of a general type ( hospitals, clinics) or in specialized dispensaries. Also, this specialist may be on the staff of a tuberculosis sanatorium. The nature of professional duties largely depends on the type of institution where the TB specialist works.

Phthisiatrician at a hospital or clinic
As a rule, within the framework of these medical institutions, primary medical care is provided to patients with suspected tuberculosis. Primary care consists in conducting various studies to clarify the diagnosis, determine the form of the disease, the type of pathogen. The doctor's office is located in the TB department at the hospital/polyclinic. In the absence of a phthisiatric cabinet, primary medical care can be provided by a family doctor, a pulmonologist ( doctor who deals with lung diseases).

Phthisiatrician at tuberculosis dispensary
As soon as a patient is diagnosed with tuberculosis, he must be registered with a tuberculosis dispensary. The key specialist of this institution is the TB specialist, who develops a treatment plan, considers the need for hospitalization, and monitors the patient after the cure. Also, the staff of the dispensary may include such doctors as a dentist, surgeon, radiologist, gynecologist.

In addition to working with patients of the dispensary, the phthisiatrician conducts educational work ( lectures, seminars) with adults and children. The purpose of such events is to inform people about ways to prevent tuberculosis, the first symptoms of the disease, and safety measures when dealing with infected patients.

Phthisiatrician at the sanatorium
A phthisiatrician working at a tuberculosis sanatorium prescribes health procedures for patients who are undergoing treatment or rehabilitation. On the basis of any sanatorium-resort institution there is a wide range of various procedures ( inhalations, mud, physiotherapy exercises). The phthisiatrician must choose the procedures that are optimal for a particular patient, determine the sequence and duration of their implementation. In the process of treatment, the doctor monitors the patient's well-being, adjusting the developed plan if necessary.

What is the job of a phthisiatrician?

The work of a phthisiatrician is to diagnose, treat and prevent diseases such as tuberculosis and sarcoidosis. Most often, a phthisiatrician encounters tuberculosis. Sarcoidosis is a relatively rare disease, as a result of which it is rarely encountered in the practice of a TB doctor. Many people have heard about tuberculosis. This disease has become epidemic in many countries, for example, in India and Pakistan.

Physiotherapist Skills and Abilities

Tuberculosis is an epidemic infection, which means that the disease is characterized by sudden outbreaks that affect a large number of people. Therefore, a phthisiatrician should know the principles of organizing and conducting anti-epidemic measures in case of a threat of mass spread of tuberculosis in the region. In the case of a particular patient, this doctor must carry out the necessary diagnostics and, upon confirming the diagnosis, provide the patient with competent medical care. Very important in the work of this doctor are measures that help prevent infection of people in contact with an infected person. Also of great importance is the provision of a three-year dispensary observation of the patient after recovery, since there is a possibility of reactivation ( renewal) infectious process. In order to cope with the listed responsibilities at the appropriate level, the phthisiatrician must have certain knowledge.

The TB doctor should be trained in the following areas:

• incidence statistics in the region and factors that increase the risk of an epidemic;
• classification of causative agents of tuberculosis, their properties and distinctive features;
• forms and stages of development of the disease, concomitant symptoms;
• features of the manifestation of tuberculosis in different age groups;
• diseases of the respiratory tract and other body systems similar to tuberculosis;
• existing methods for examining infected patients;
• indications/contraindications for bronchoscopy, biopsy ( sampling of biological material) and other diagnostic methods;
• complications of tuberculosis from the lungs and other organs, measures to prevent complications;
• main and auxiliary methods of treatment of the disease;
• mechanism of action, rules of use and possible side effects of drugs used in the treatment of tuberculosis;
• rules for conducting emergency medical measures if the patient is in serious condition;
• indications/contraindications for chemotherapy, surgical treatment;
• determination of the severity of consequences after treatment and assessment of the threat of reactivation of the disease;
• carrying out educational work and preventive measures;
• security measures in case of a threat of infection with tuberculosis;
• rules for medical examination of infected patients;
• determining the patient's ability to work and providing documentation if necessary ( e.g. for sick leave or a change of working conditions after recovery).

In addition to theoretical training, a phthisiatrician must also have some practical skills in order to provide the patient with emergency assistance if necessary. Also, this doctor should be able to carry out some diagnostic manipulations.

The physician must have the following skills:

• conducting skin tests to detect tuberculosis;
• pneumothorax ( introduction of air into the pleural space) for therapeutic or diagnostic purposes;
• the introduction of drugs through the larynx using a syringe and catheter;
• puncture of the pleural cavity aspiration of contents through a puncture in the chest wall);
• collection of bronchial swabs the introduction of saline into the bronchi with its subsequent suction for research);
• artificial ventilation and indirect ( through the chest) massage of the heart and lungs by various methods.

What heals ( does) phthisiatrician?

The main activity of a phthisiatrician is focused on the diagnosis and treatment of various forms of tuberculosis. However, the competence of a phthisiatrician also includes diseases such as sarcoidosis and leprosy ( among the people leprosy).

Diseases treated by a phthisiatrician include:

• pulmonary tuberculosis and extrapulmonary tuberculosis;
• sarcoidosis;
• leprosy.

Tuberculosis
It is generally accepted that tuberculosis is a disease that affects exclusively the respiratory system. However, this is not the case. Tuberculosis is an infectious disease that can affect any organs and systems. The most common form in adults is pulmonary tuberculosis, in children - tuberculosis of the lymph nodes.

According to the World Health Organization, more than 10 million people suffer from TB today, and more than 2 million died from it in 2016. Thus, this disease becomes one of the leading causes of death in the world ( in 10th place). More than 1 million people, including children, fall ill every year.
Tuberculosis is caused by mycobacteria ( mycobacterium tuberculosis), commonly known as Koch sticks.

Mycobacterial infections are divided into 2 main groups - pulmonary and extrapulmonary tuberculosis.

Pulmonary tuberculosis
It is the main form of tuberculosis and, in turn, can take various forms. Regardless of the form, the main symptoms of the disease are cough, subfebrile temperature ( 37.2 degrees), weakness, night sweats.

Forms of pulmonary tuberculosis are:

• Miliary pulmonary tuberculosis. Despite the fact that this is a pulmonary form of tuberculosis, this disease proceeds with frequent damage to the liver, spleen and other internal organs. This form is characterized by the formation of multiple small foci in the lungs and internal organs. The focus is a localized infection, inside which are Koch's sticks. The disease is acute, often fatal.
• Focal pulmonary tuberculosis. This form of tuberculosis differs from the previous one in that it proceeds with the formation of a few limited foci. The sizes of the foci are from 10 millimeters or more. On x-ray, these foci are not pronounced and are characterized by blurred contours.
• Caseous pneumonia. One of the most severe forms of pulmonary tuberculosis. It is characterized by an inflammatory reaction that involves more than one segment in the lungs. This reaction proceeds according to the type of caseous decay, which means necrosis ( necrosis) lung tissue, as a result of which it acquires a curdled consistency. From the Latin "caseosus" means curdled, which reflects the essence of the name. Caseous pneumonia occurs with severe symptoms of intoxication.
• Infiltrative tuberculosis. This form of tuberculosis is also characterized by the development of caseous necrosis. In fact, infiltrative tuberculosis is a variant of caseous pneumonia. The difference is that with pneumonia, several segments are affected simultaneously, while with infiltrative tuberculosis, infiltrates form in isolation.
• Cavernous tuberculosis. With this form of tuberculosis, a cavity is formed in the lungs ( she is a cavern), surrounded by a small inflammatory response. A variant of cavernous tuberculosis is the fibrous-cavernous form. The difference of this form is fibrotic changes around the cavity ( lung cavity). With these changes, connective tissue grows around the cavity, which deforms the lungs.
• Cirrhotic pulmonary tuberculosis. This form is characterized by diffuse growth of the connective tissue of the lungs, which leads to a complete change in the structure of the lungs. A similar picture occurs in liver cirrhosis, when there is a total restructuring of the architectonics of the liver. Hence the name of the form.

Extrapulmonary tuberculosis
Extrapulmonary tuberculosis can affect any organs and organ systems in the human body. The most common tuberculosis of the digestive system and the genitourinary system. In the first case, as a rule, the small intestine and caecum are affected, in the second case, the kidneys and urinary tract. These forms can be either primary or secondary. The primary form is when Mycobacterium tuberculosis initially enters the digestive tract ( or other system) and begin to multiply. The secondary form develops when Koch's sticks from the lungs ( primary focus) with a current of lymph or blood are carried to other systems.

Extrapulmonary forms of tuberculosis include:

• skin tuberculosis;
• tuberculosis of bones and joints;
• tuberculosis of the genitourinary system;
• tuberculosis of the central nervous system;
• tuberculosis of the digestive system.

With extrapulmonary tuberculosis, the clinical picture of the disease consists of a syndrome of general intoxication and symptoms of the affected organ. As with pulmonary tuberculosis, subfebrile temperature, increased sweating at night, and weight loss are important signs. In 9 cases out of 10, there is an increase in lymph nodes - lymphadenopathy. It can be local or generalized. Local lymphadenopathy is characterized by an increase in one group of lymph nodes localized around an organ. For example, with tuberculosis of the small intestine, the mesenteric lymph nodes increase. Generalized lymphadenopathy is characterized by a simultaneous increase in several anatomically distant lymph nodes.

Sarcoidosis
This is a systemic disease of still unknown etiology, which occurs with the involvement of many organs and systems. The key point in sarcoidosis is the formation of small granulomas in organs and tissues ( tubercles). The lymph nodes, lungs, liver, and spleen are most commonly affected by sarcoidosis. Thus, sarcoidosis of the lymph nodes, lungs, liver is distinguished. Unlike tuberculosis, sarcoidosis is not an infectious disease. However, the clinical and radiological pictures of these diseases are very similar.

There are several stages in the clinical picture of sarcoidosis. In the first stage, there is an increase in the lymph nodes located inside the chest ( i.e. intrathoracic nodes). At the second stage, the lungs are involved in the pathological process. Inflammatory infiltration is noted in the lower parts of the lungs. At the third stage, connective tissue grows in the lungs, pulmonary fibrosis develops.

Leprosy ( leprosy)
Few people know that leprosy or leprosy is a chronic disease also caused by mycobacteria. However, in this case, these are not mycobacteria of tuberculosis, but of leprosy. Mycobacterium leprosy primarily affects the skin, peripheral nervous system, and upper respiratory tract.

Phthisiatrician-gynecologist

A phthisiatrician-gynecologist is a doctor who deals with the genital form of tuberculosis. In most cases, infection of the genital organs is a consequence of the pulmonary or intestinal ( less often) forms of tuberculosis. Tuberculosis of the reproductive system is one of the most common extrapulmonary forms of this disease. In about 90 percent of cases, the infection affects the fallopian tubes, much less often - the ovaries and uterus. Most often, women aged 20 to 30 turn to a phthisiatrician-gynecologist.

Manifestations of genital tuberculosis

The key and often the only symptom of this form of tuberculosis is infertility, which occurs as a result of damage to the fallopian tubes. Violation of menstrual function can also be a sign of this disease. Patients note scanty menstrual flow or their complete absence, severe pain during menstruation. In some, more rare cases, on the contrary, menstrual bleeding becomes profuse, and their duration increases by several days.

Progressing, genital tuberculosis provokes an adhesive process ( pipe splicing), which is accompanied by aching pain in the lower abdomen. There are also common symptoms of tuberculosis infection - increased sweating at night, loss of appetite, weight loss. Often the abdominal cavity is involved in the tuberculous process, which is accompanied by symptoms of an acute abdomen ( tense abs, severe abdominal pain, fever). Often in such cases, patients are referred for surgery with suspected appendicitis, ectopic pregnancy.

Diagnosis of genital tuberculosis

To confirm the diagnosis, the phthisiatrician-gynecologist prescribes a series of studies. The most accurate method for detecting this form of tuberculosis is bacteriological examination. For this, the biomaterial of a woman ( vaginal discharge, scraping of the genital mucosa) is tested for the presence of tuberculosis pathogens using various methods.

Also, a phthisiatrician-gynecologist can prescribe a study of the genital organs using an endoscope, which is inserted through a puncture in the abdominal wall, X-ray or ultrasound ( ultrasound) fallopian tubes.

Children's phthisiatrician

A pediatric phthisiatrician is a specialist in the field of prevention, diagnosis and treatment of tuberculosis in children. In addition to training in phthisiology, this doctor must have knowledge in such a branch of medicine as pediatrics. A pediatric phthisiatrician needs to know what differences the symptoms of this disease have in young patients.
All diagnostic and therapeutic procedures should be carried out in accordance with the age of the sick child.

A crucial moment in the work of a pediatric phthisiatrician is vaccination against tuberculosis. Tuberculosis vaccine ( BCG) is placed in children 3 to 5 days after birth. Re-vaccination ( revaccination) is shown when the child reaches 7 years. The pediatric phthisiatrician must ensure that all small patients assigned to his site undergo primary and re-vaccination. Since BCG has a number of contraindications, the doctor must examine the child before vaccinating.

Mantoux reaction in children

The skin test, also called the Mantoux test, is a procedure that detects tuberculosis at an early stage. Such diagnostics are carried out every year for children ( with parental consent), in order to exclude the possibility of infection of the child. Given the regularity of this manipulation, there is an opinion that the Mantoux reaction is a vaccination. This assumption is erroneous, since the skin test does not allow the development of immunity ( like a vaccine), but only shows whether tuberculosis pathogens are present in the body.

The principle of this procedure is that a certain amount of tuberculosis pathogens is injected under the skin. After 3 days, a bubble appears at the injection site ( papule), according to which the doctor decides whether the patient is infected.

There are the following criteria for evaluating the Mantoux reaction:

• If there is a slight swelling of no more than a millimeter on the skin, then the person is healthy. Such a reaction is called negative.
• If a vesicle of 2 to 4 millimeters appears at the injection site or just redness without a papule, such a reaction is called doubtful and means that additional tests are necessary in order to make a final verdict.
• When a papule of 5 to 9 millimeters in size appears on the skin, the reaction is called weakly positive, which may mean that the tuberculous process is in its initial stage. If the bubble reaches 14 millimeters, the result is medium positive, if it is more than 15 millimeters, then the reaction is called pronounced positive.

It should be noted that the Mantoux reaction will also be positive if the patient has been vaccinated against tuberculosis. Therefore, if in the anamnesis ( medical history) the patient has anti-tuberculosis vaccinations, other methods are used to diagnose the disease.

Phthisiologist-pulmonologist

A phthisiatrician-pulmonologist is a doctor who has theoretical and practical training not only in the field of phthisiology, but also in the field of pulmonology. Pulmonology is a segment of medicine that deals with the detection and treatment of diseases of the respiratory system, which is formed by the lungs, bronchi, trachea and larynx. That is, a phthisiatrician-pulmonologist specializes not only in tuberculosis, but also in other pathologies of the respiratory tract.

There are the following pathologies that a phthisiatrician-pulmonologist treats:

• various forms of pneumonia ( pneumonia);
• all types of inflammation of the bronchi ( bronchitis);

• different types of inflammation of the larynx, trachea ( laryngitis, tracheitis);
• narrowing of the bronchial lumen bronchial asthma);
• formation in the lungs of cavities filled with pus ( abscesses);
• pathologies provoked by toxic substances ( e.g. industrial dust);
• expansion of the chest emphysema);
• scarring in the lungs fibrosis);
• increased viscosity of lung mucus ( cystic fibrosis);
• narrowing of the lumen of the larynx stenosis).

The main causes of respiratory diseases include viral, bacterial and fungal infections. Not the last role in the development of respiratory pathologies is played by air polluted with chemicals ( fumes from industrial enterprises, vehicle exhausts). Smoking also often serves as a trigger for the occurrence of these diseases. Given these factors, the reason for the recent increase in the number of diseases of the respiratory system becomes clear.

When is it necessary to contact a phthisiatrician-pulmonologist?

Diseases of the respiratory department have a number of common symptoms, among which the most common is shortness of breath ( a condition in which the patient has difficulty breathing). As a rule, with problems with the larynx or trachea, problems arise when inhaling air. With diseases of the bronchi, the process of exhalation becomes more complicated, with pulmonary pathologies, problems arise both with inhalation and exhalation.
Another common sign of respiratory disease is a cough that can be dry or wet ( with mucus secretion). Increasing cough in the morning may indicate chronic bronchitis, in the evenings it may be a symptom of pneumonia. Coughing at night is often a sign of tuberculosis. Various pain sensations in the chest can also be a symptom of diseases of the respiratory system. Cough and shortness of breath are specific signs of diseases of the respiratory department, but in addition to them, there are also non-specific symptoms.

There are the following nonspecific signs of respiratory diseases:

• headaches of various types;
• sleep problems;
• feeling of heaviness in the forehead, in the nasal cavity;
• swelling of the eyelids and / or cheeks;
• discharge of mucus or pus from the nose;
• problems with nasal breathing;
• poor appetite, weight loss.

In the treatment of diseases of the respiratory tract, it is important to detect the disease in time and start treatment. Therefore, if one or more symptoms are present, it is necessary to visit a phthisiatrician-pulmonologist.

reception ( consultation) at the phthisiatrician

A consultation with a phthisiatrician is mandatory when applying for a job, when registering a child in a kindergarten, and so on. It is also necessary if a diagnosis of tuberculosis or sarcoidosis is suspected. The consultation involves questioning the patient, identifying his complaints, as well as his examination. The appointment with the phthisiatrician ends with the fact that the doctor gives a referral for fluorography or x-rays ( computed tomography is much less recommended).

The symptoms of tuberculosis are very similar to other diseases such as sarcoidosis, aspergillosis and others. That is why it is important to carefully collect an anamnesis, that is, a history of the disease. An important point in the history of tuberculosis is the duration of symptoms. So, if the cough is observed for several weeks and does not respond to drug treatment, this speaks in favor of a mycobacterial infection. It is also very important to ask if the patient has not been in contact with people with tuberculosis. Even a minor contact in time can cause a disease, especially if it is a weakened organism.

The phthisiatrician should clarify whether there was a high temperature, to what level it rose and how long it persisted. It is also important to ask if the patient sweats at night, and if he has lost weight in the last month.

When is a TB examination necessary?

It is important to remember that tuberculosis is a disease that can be treated. However, the success of treatment depends on the stage of the disease. Therefore, it is important to consult a doctor in time. To do this, you need to know the first signal symptoms of tuberculosis, with the appearance of which it is necessary to urgently contact a phthisiatrician.

The following symptoms are distinguished, upon detection of which, an examination by a phthisiatrician is necessary:

• cough for 2 weeks or more, which may be dry or wet;
• subfebrile temperature ( 37.2 degrees) for several weeks;
• may have a fever;
• increased sweating at night;
• losing more than a few pounds.

Examination at the phthisiatrician

The phthisiatrician begins his examination with an examination of the skin and mucous membranes, after which he proceeds to palpation of the lymph nodes. As already mentioned, in most cases, tuberculosis is accompanied by an increase in lymph nodes. At the same time, the lymph nodes increase even in the early stages, preceding the detailed clinical picture.

Without fail, the phthisiatrician listens to the patient's lungs, but it is worth noting that tuberculosis is not accompanied by specific symptoms that could be auscultated ( listen with a phonendoscope). Therefore, to clarify the diagnosis, the doctor recommends additional examinations.

Fluorography and X-ray of the lungs from a phthisiatrician

Fluorography or RFG for short is a screening method for diagnosing pulmonary tuberculosis. RFG is a mandatory item in the annual planned medical examination. The method is based on the use of X-rays, as a result of which the picture of the lung pattern is projected onto the film. Today, however, film fluorography is increasingly being replaced by digital. The advantage of this method over X-ray is that it takes three times less time. Therefore, it can be used in mass surveys.

What tuberculosis looks like on fluorography depends on the form of the disease. A sign of tuberculosis of the intrathoracic nodes is the expansion of the root of the lungs and calcifications. Multiple, diffusely scattered, small foci are characteristic of disseminated pulmonary tuberculosis. Darkening of an entire lobe of the lung is characteristic of one of the most severe forms of pulmonary tuberculosis - caseous pneumonia. With focal tuberculosis, the picture shows several scattered darkened foci ranging in size from 1 to 2 centimeters. Focal blackout with clear contours and a clear enlightenment inside is a sign of a cavity, which is characteristic of cavernous pulmonary tuberculosis.

Sometimes, for a clearer visualization of the picture, the phthisiatrician may advise you to take an x-ray or a CT scan. These studies also help to make a differential diagnosis with sarcoidosis and other diseases.

Tests at the phthisiatrician

To confirm or deny the presence of tuberculosis in a patient, the phthisiatrician prescribes tests. All types of studies that are used in the diagnosis of this disease are divided into specific and non-specific. Specific tests include a skin test ( Mantoux test) and microbiological cultures. Non-specific studies include those manipulations that are used in the diagnosis of not only tuberculosis, but also other diseases. The Mantoux reaction has the greatest value among all phthisiatric tests.

Microbiological cultures
Microbiological culture is the cultivation of microorganisms removed from the body fluids or tissues of a patient in order to determine their type. The most common procedure for tuberculosis is culture of bronchial washings. To obtain a flush, the doctor inserts a special probe into the patient's bronchi, through which he infuses approximately 50 milliliters of saline ( sodium chloride). After that, the phthisiatrician sucks the liquid back with a probe and sends it to the laboratory. Initially, a bacteriological analysis of swabs is carried out, and if pathogenic microorganisms are detected, they are placed in a favorable environment for reproduction. After a certain time, after the microbes have passed the stage of reproduction, they are studied in detail.

The patient's urine may also be sent for microbiological culture ( with suspected renal form of tuberculosis), cal ( with intestinal tuberculosis), sputum and other biomaterials related to the focus of infection.

Nonspecific tests at the phthisiatrician

This group includes those studies that are used to diagnose not only tuberculosis, but also a large number of other diseases. As a rule, such tests are prescribed for suspicion or detection of extrapulmonary forms of tuberculosis. For example, with the likelihood of tuberculosis

Perelman M. I., Koryakin V. A.

Clinical symptoms of pulmonary tuberculosis are diverse and have no specific signs.

This must be taken into account, especially in the conditions of modern pathomorphosis of tuberculosis, due to changes in the environment, repeated exposure to the human body of various vaccines, sera, antibiotics, as well as a change in the properties of the causative agent of tuberculosis.

Questioning, physical methods of examination (examination, percussion, etc.) only allow one to suspect tuberculosis of the respiratory system. For early and timely detection of tuberculosis of the lungs and other organs, special research methods are needed.

The main special research methods that are of decisive importance in the diagnosis of tuberculosis, differential diagnosis and evaluation of the course of the disease are microbiological methods, tuberculin diagnostics and the so-called intrascopic methods, which include all radiological methods, tracheobronchoscopy, as well as ultrasound examination.

All of these methods are non-invasive and generally well tolerated by patients. Sometimes they are insufficient to verify the diagnosis. In these cases, it is necessary to use invasive, in fact, surgical methods of diagnosis. The general goal of these methods is to obtain biopsy material for cytological, histological, microbiological studies.

Questioning, physical methods

questioning. Patients with pulmonary tuberculosis often do not complain and subjectively consider themselves healthy. Sometimes even a widespread lesion of the lungs with destruction of the lung tissue is an accidental finding during a fluorographic or x-ray examination. This course of tuberculosis is called inapperceptive - latent. However, even in these cases, patients with careful questioning can usually reveal some complaints.

In patients with tuberculosis of the respiratory organs, the most typical complaints are weakness, fatigue, sleep disturbance, loss of appetite, weight loss, fever, sweating, shortness of breath, cough, hemoptysis, chest pain. These symptoms can be expressed in different ways and occur in different combinations. Most often, patients are concerned about weakness, loss of appetite, chest pain, fever.

The disease of pulmonary tuberculosis can begin asymptomatically, gradually or acutely. In children, more often than in adults, there are signs of a common infectious disease with symptoms of intoxication. In adults, local symptoms of lung damage predominate.

Tuberculosis often occurs under the guise of influenza, pneumonia, and against the background of treatment with broad-spectrum antibiotics, the patient's condition may improve. The further course of pulmonary tuberculosis in such patients is usually undulating: periods of exacerbation of the disease are replaced by periods of remission and relative well-being.

In extrapulmonary forms of tuberculosis, along with the general symptoms caused by tuberculosis intoxication, patients also have local manifestations of the disease.

Patients indicate a headache with tuberculous meningitis, sore throat and hoarseness with laryngeal tuberculosis, fatigue and weakness in the limbs, change and stiffness in gait with osteoarticular tuberculosis, pain in the lower abdomen, menstrual dysfunction with genital tuberculosis, dysuric disorders with tuberculosis of the ureters and bladder, dull or sharp pains in the lumbar region with tuberculosis of the kidneys, abdominal pain and dysfunction of the gastrointestinal tract with tuberculosis of the mesenteric lymph nodes and intestines.

However, often patients with extrapulmonary tuberculosis, especially in the initial stage of the disease, do not complain, and to identify it, the use of special research methods is required.

When determining the anamnesis of the disease, it is necessary to establish how it was detected: when contacting a doctor about any complaints or during a fluorographic study. The patient should be asked about the time of appearance of changes in the state of his health and their dynamics, previous operations, injuries, diseases.

It is especially necessary to pay attention to the symptoms of tuberculosis that occurs with the clinical picture of influenza, pneumonia, rheumatism, typhoid fever, such manifestations of tuberculosis as pleurisy, lymphadenitis, erythema nodosum. It is also important to find out if the patient has diseases that could be complicated by tuberculosis (diabetes mellitus, silicosis, peptic ulcer of the stomach and duodenum, alcoholism, drug addiction, HIV infection).

Information about the place of residence of the patient (village, city), his profession and the nature of work, material and living conditions, lifestyle and level of culture are important. When questioning children and adolescents, they find out data on previous anti-tuberculosis vaccinations, the results of tuberculin tests.

It is necessary to obtain information about the health status of the patient's family members, possible contact with tuberculosis patients at home, at the place of study, at work and its duration, about the presence of animals with tuberculosis.

Inspection. Not only in medical literature, but also in fiction, the appearance of a patient with progressive pulmonary tuberculosis, which is known as habitus phthisicus, is described. This is usually a thin young man with a blush on a pale face, with a long and narrow chest, wide intercostal spaces, a sharp epigastric angle and lagging behind (pterygoid) shoulder blades. At present, such external signs are rarely observed in a patient with tuberculosis.

Examination often reveals no pathology. However, inspection is necessary and should be carried out in full. At the same time, attention is paid to the physical development of the patient, the color of the skin and mucous membranes. When examining the chest, the severity of the subclavian fossae, the symmetry of the right and left halves are compared, their mobility during deep breathing, participation in breathing of the abdominal muscles, auxiliary respiratory muscles are evaluated.

Narrowing or expansion of the intercostal spaces, postoperative scars, fistulas or scars after their healing are noted.

Examining the fingers and toes, pay attention to the deformation of the terminal phalanges in the form of drumsticks and changes in the shape of the nails in the form of convex watch glasses. In children, adolescents and young people, scars on the shoulder are examined after the administration of the BCG vaccine.

Palpation. Using this method, the degree of moisture or dryness of the skin, its turgor, and the severity of the subcutaneous fat layer are determined. Carefully palpate the peripheral lymph nodes in the neck, in the armpits and inguinal regions.

In acute inflammatory processes in the lungs involving the pleura, soreness of the chest muscles caused by inflammation of the pleural sheets is often noted.

In patients with chronic tuberculosis and after major operations, atrophy of the muscles of the shoulder girdle and chest can be observed. The displacement of the mediastinal organs can be determined by palpation by the position of the trachea.

In patients with pulmonary tuberculosis, voice trembling may be intensified or weakened. It is better carried out over areas of compacted lung in patients with focal, infiltrative, cirrhotic tuberculosis, over a large cavity with a wide draining bronchus.

Percussion. Percussion can reveal relatively gross changes in the lungs and chest. In connection with the use of radiological methods, percussion has lost its former importance in the diagnosis of lung diseases. However, it plays an important role in the diagnosis of such emergency conditions as spontaneous pneumothorax, acute exudative pleurisy, atelectasis of the lung.

The presence of a box or shortening of the pulmonary sound detected during percussion allows you to quickly assess the clinical situation and conduct the necessary studies.

Auscultation. Many diseases of the respiratory system, in particular tuberculosis, may not be accompanied by a change in the nature of breathing and the appearance of additional noise in the lungs.

The weakening of breathing is characteristic of pleurisy, pleural adhesions, pneumothorax. Hard or bronchial breathing can be heard over the infiltrated lung tissue, amphoric breathing - over a giant cavity with a wide draining bronchus.

It is important to listen to wheezing in the lungs and pleural friction noise, which often make it possible to diagnose a pathology that is not detected by other research methods, including X-ray and bronchoscopic.

Small bubbling wet rales in a limited area are a sign of the beginning destruction of the lung tissue, medium and large bubbling rales are a sign of a cavity.

To detect moist rales, it is necessary to ask the patient to cough after a deep breath, exhale and a short pause, and then take a deep breath again. At the height of a deep breath, wheezing appears or their number increases.

Dry wheezing occurs with bronchitis, whistling - with bronchitis with bronchospasm. With dry pleurisy, a pleural friction rub is heard, with pericarditis, a pericardial friction rub.

Methods for examining patients with suspected respiratory TB:

1) mandatory diagnostic minimum (ODM):

a) purposefully collected anamnesis, analysis of patient complaints

b) stetoacoustic and other physical methods for studying the respiratory organs

c) X-ray examinations of the respiratory organs: large-frame fluorography, plain radiography of the chest organs in 2 projections, computed tomography

d) examination of sputum (bronchial lavage) for MBT using 3-fold immersion or luminescent (better) bacterioscopy (Ziehl-Neelsen stain, MBT - red, surrounding background and non-acid-resistant bacteria - blue) and bakposev (Levenshtein's egg medium - Jensen).

e) Mantoux tuberculin test with 2 TU PPD-L - staging technique: 0.2 ml of tuberculin is drawn into the tuberculin syringe, then 0.1 ml of the solution is released from the syringe through the needle so that the volume of the administered drug is 0.1 ml - 2 THOSE; on the inner surface of the middle third of the forearm, a skin area is treated with 70% ethyl alcohol and dried with cotton wool; a needle with a cut up is inserted into the upper layers of the skin parallel to its surface and 0.1 ml of tuberculin is injected; with the correct injection, a white papule 7-8 mm in diameter forms on the skin

By measuring the infiltrate (papule) with a transparent ruler perpendicular to the axis of the forearm, after 72 hours, the Mantoux reaction is evaluated according to the following criteria: negative- no infiltration and hyperemia, Doubtful- infiltrate 2-4 mm or only hyperemia of any size, Positive- the presence of an infiltrate with a diameter of 5 mm or more, hyperergic- infiltration with a diameter of 17 mm or more in children and adolescents and 21 mm or more in adults or the appearance of vesicles, lymphangitis, regional lymphadenitis, regardless of the size of the infiltrate.

With a negative reaction of the Mantoux test, the state of anergy can be both positive (in non-infected persons with MBT) and negative (in patients with severe progressive TB, with concomitant oncopathology or severe immunodeficiency due to various infections). To differentiate these conditions, they put a Mantoux test with 100 TU PPD-L - if the result is negative, the body is not infected.

e) clinical blood and urine tests

2) additional research methods (DMI):

A. 1st group - non-invasive additional research methods:

a) re-examination of sputum (bronchial washings) for MBT using the flotation method (after shaking an aqueous suspension with hydrocarbon, the MBT float to the surface together with the resulting foam, the resulting creamy ring serves as materials for microscopy) followed by determination of the virulence of the MBT, their sensitivity to antibacterial agents.

Methods for determining the virulence (i.e., the degree of pathogenicity) of MBT:

1. According to the type of colonies during bacteriological cultures: R-colonies (rough) are highly virulent, S-colonies (smooth) are low-virulent

2. By the presence of the cord factor - it is determined in highly virulent strains

3. According to catalase activity - the higher it is, the more virulent the strain

4. According to the life expectancy of experimental animals in a biological sample - the guinea pig dies the faster, the more virulent the MBT

b) tomography of the lungs and mediastinum

c) in-depth tuberculin diagnostics (determination of the threshold of sensitivity to tuberculin, etc.)

d) immunogram

e) BAC: proteinogram, C-reactive protein

A summary assessment of the data of ODM and DMI of the 1st group allows you to make a diagnosis or get a deeper understanding of the nature of the detected disease, however, in a number of patients the diagnosis remains unclear and its morphological verification using DMI of the 2nd group is necessary.

B. 2nd group - invasive additional research methods:

a) bronchoscopy - survey or in combination with catheterbiopsy, brushbiopsy, direct biopsy of the bronchial mucosa and pathological formations in them

b) transthoracic aspiration or open lung biopsy with various biopsy studies

c) puncture biopsy of the pleura

d) puncture of peripheral l. y.

e) biopsy of precalcified tissue

f) mediastinoscopy, pleuroscopy, etc.

The main methods of imaging in the examination of patients with TB:

A) fluorography: film and digital (digital)

B) plain radiography of the lungs

B) X-ray

D) computed tomography

D) magnetic resonance imaging

E) general and selective angiopulmonography, bronchial arteriography

G) non-directional and directional bronchography

H) pleurography, fistulography

I) Ultrasound (to determine the level of fluid in the pleural cavity, the state of L. at.)

K) radioisotope research

E) positron emission tomography

Anamnesis. Examination of a patient with tuberculosis begins with an anamnesis. It is necessary to find out all the factors that contributed to infection and the development of the disease. Very important for infection and disease is the contact of the subject with a patient with tuberculosis. If there is a history of such contact, it is recommended to clarify the duration and nature of it. Contact can be household and industrial, short and long, periodic and permanent. Long-term family contact is of particular importance. In this case, contact can be constant - with the closest relatives living with the sick person, or periodic - with relatives and friends who often visited the sick person. It is necessary, if possible, to find out the nature and severity of the illness of the person with whom the subject was in contact. To clarify the role of contact in the development of the disease of the subject, the age of the latter, his state of health and living and working conditions during the period of contact play a role. Clarification of all these circumstances is important for determining the moment of infection and the duration of the disease.

In order to identify factors that could have an adverse effect on the body, the living conditions of the patient, the family budget, the quality and regularity of nutrition, working conditions, and the presence of occupational hazards should be clarified. In addition to these factors, mental and physical injuries, as well as bad habits (smoking, alcohol abuse) are important for the development of tuberculosis.

For a correct understanding of the influence of the tuberculosis process on the body, it is very important to identify deviations in physical development in childhood, which may be due to the presence of tuberculosis intoxication.

Particular attention should be paid to childhood diseases (pneumonia, pleurisy, lymphadenitis, chronic otitis media, conjunctivitis, etc.).

Inspection. During the external examination of the patient, especially with the initial forms of tuberculosis, there are often no data indicating the presence of an active tuberculosis process. This determined the mandatory use of the X-ray method of research for the diagnosis of tuberculosis. Only chronic, progressive processes with prolonged tuberculous intoxication leave a sharp imprint on the entire appearance of the patient. There are emaciation, pallor of the skin, flattening and deformity of the chest, acrocyanosis, changes in the nail phalanges, etc.

When examining the chest in a number of patients, an asymmetry of its shape and a limited excursion of one side during breathing are revealed. Retraction over and subclavian space is observed when wrinkling the apex of the lung. Significant retraction of one half of the chest and its lagging during breathing are the result of pneumosclerosis, pleural changes, etc. Weight loss, pale skin color, long and thin neck, flat chest with a sharp epigastric angle and narrowed intercostal spaces are considered a characteristic appearance of a typical tuberculosis patient (habitus phthisicus). This type is observed in a small part of patients with long-term TB.

Palpation. Important signs of an active tuberculous process are soreness and muscle tension in the chest and shoulder girdle, detected by palpation. The symptom of functional protection [Pottenger (Pottenger), V. A. Vorobyov] arises as a result of a reflex from the inflamed pleura to the corresponding muscle groups. In chronic progressive processes, the muscles of the shoulder girdle noticeably atrophy. Often pain points are noted in the supraclavicular areas with inflammation of the apical pleura. Severe pain is observed along the intercostal nerves with pleurisy. Soreness of the sternum on palpation can be detected with mediastinitis.

Percussion. It is very important to compare the height of the percussion tone at both tops. In this case, strictly symmetrical places should be compared and, in addition, it should be observed that the patient avoids any tension in the muscles of the neck. With some difference in percussion tone at the tops, attention should be paid to a slightly greater development of the musculature on one side, which may be the reason for the muffled tone. If the difference in sound is not clear enough, the patient is asked to take a deep breath and hold the breath for 5-6 seconds. With a free apex, a clearing of the percussion sound is detected during inspiration, while over the affected apex it will be shortened.

With cicatricial processes and pleural changes, a lower standing of the tops of the lungs, a shortening of the Krenig fields, and a decrease in the mobility of the lower lung edges are noted. Over a massive compaction of the lung tissue or pleural effusion, intense dullness is determined, and over the air bubble in the pleural cavity with pneumothorax, the percussion sound will be tympanic.

Auscultation. Weakened breathing is diagnostic if it is noted or more pronounced on one side. Bilateral uniform weakening of breathing is observed simply with weakness of breathing. It is necessary to carefully listen to the patient's chest in the "zones of anxiety": in the supraclavicular and subclavian spaces, axillary fossae, suprascapular areas, interscapular space at the lower angle of the scapula, where catarrhal phenomena are most often determined. Vesicular breathing is heard over unchanged areas of the lung tissue. It can be normal, enhanced or weakened. The weakening of breathing occurs reflexively when the lung tissue is compressed by exudate, gas (with therapeutic or spontaneous pneumothorax), pleurisy, etc. When the bronchial mucosa changes, vesicular breathing can become hard (hard breathing). Bronchial breathing is normally heard in front of the trachea, behind the VII cervical vertebra and in the interscapular region, respectively, of the bifurcation of the trachea. In other areas of the chest surface, bronchial breathing can be heard in the zone of massive infiltration of the lung, which creates conditions for sound transmission from large bronchi. Amphoric breathing occurs when there are large and giant cavities in the lung (not less than 6 cm in diameter) with smooth tense walls and a free outlet bronchus.

Of great diagnostic importance is the detection of wheezing - dry and wet, of different caliber and different sonority. Wheezing occurs in the bronchi when a jet of air passes through a liquid or viscous secretion and inflammatory exudate. For the early diagnosis of tuberculosis, the detection of moist rales is of particular importance. In the presence of an active tuberculous process and the beginning of the collapse of the lung tissue, moist fine bubbling rales can sometimes be heard only when coughing in a limited area. Medium and large bubbling sonorous rales in patients with tuberculosis are a sign of a cavity.

Crepitus in tuberculosis is very rare.

Dry rales are heard due to complications of pulmonary tuberculosis by an inflammatory process in the bronchi.

Blood study. The amount of hemoglobin, the number of red blood cells in tuberculosis rarely decrease. Only in patients with long-term fibro-cavernous tuberculosis, there is a slight anemia; severe anemia develops mainly due to bleeding and intestinal tuberculosis. The number of leukocytes can remain normal or slightly increased with active tuberculosis - 10-109 / l - 11-109 / l (10,000-11,000 per 1 mm3 of blood). High leukocytosis 12-109 / l-14-109 / l (12,000-14,000 in 1 mm3) is noted only in cases of acute tuberculosis or when non-specific inflammation is attached to tuberculosis, for example, in patients with fibrous-cavernous pulmonary tuberculosis.

The change in the active tuberculous process is determined mainly in the leukocyte formula due to an increase in the number of stab neutrophils; in some cases, young forms of neutrophils and even myelocytes appear in the peripheral blood. Patients with active tuberculosis have eosinopenia, lymphopenia, and monocytosis.

The more active the process, the more pronounced these changes in the blood.

When assessing the clinical condition of the patient, not only the nuclear shift index is taken into account, but also changes in the protoplasm of neutrophils, noting the appearance of pathological granularity in it.

Of great importance for determining the activity of tuberculosis is the erythrocyte sedimentation rate (ESR). In acute and active forms of tuberculosis, the ESR is increased. When determined by the Panchenkov method, it is considered to be a normal erythrocyte sedimentation rate of 6-8 mm/h in 60 minutes; An ESR equal to 15-18 mm/h is considered slightly increased, up to 30 mm/h - moderately high, up to 40 mm/h and above - sharply increased.

The study of protein fractions of blood serum. In persons with active forms of tuberculosis, along with a decrease in the absorption of proteins in the gastrointestinal tract, the biosynthesis of protein substances in various tissues also changes, which leads to a violation of the protein composition of the blood - dysproteinemia. A decrease in the total protein content in the blood is observed in severe forms of tuberculosis, accompanied by severe intoxication. Changes in the metabolism of blood serum proteins are detected by electrophoretic study, which makes it possible to isolate several protein fractions.

Of major importance in tuberculosis are shifts in the concentration of albumin and y-globulins. As for p-globulins, their content in patients with tuberculosis does not undergo significant changes.

In active, especially progressive, forms of pulmonary tuberculosis, an increase in the content of y-globulins and a decrease in the concentration of albumins are observed. The severity of these disorders depends on the degree of tuberculous intoxication and dysfunction of the organs and systems involved in the synthesis of protein substances. The increase in the fraction of ag-globulins is especially noticeable in patients with acute forms of tuberculosis, in which the phenomena of alteration and exudation predominate. These forms include infiltrative pulmonary tuberculosis and caseous pneumonia. The resorption of inflammatory changes is accompanied by a decrease in the content of ag-globulins.

With the transition of an acute tuberculous process into a chronic one, as well as in forms that occur without severe toxemia, globulin indicators become important. An increase in the content of this fraction of blood serum indicates the productive nature of inflammation.

Despite the non-specificity of changes in the protein fractions of blood serum in patients with tuberculosis, their study makes it possible to control the course of the disease and evaluate the effectiveness of treatment. The longer severe dysproteinemia persists, the worse the prognosis.

It is important for absolutely all residents to know the symptoms and methods of diagnosing tuberculosis, as well as to have an idea about the treatment. An overwhelming percentage of residents believe that tuberculosis is a rare disease that affects disadvantaged people. However, it is not. The prevalence of the causative agents of this disease - mycobacteria - is currently growing and affecting new segments of the population.

The main symptoms of the disease

Examination for tuberculosis consists not only in conducting instrumental research methods. First of all, the doctor should conduct a thorough conversation with the patient, find out his complaints, the dynamics of their development. The main symptoms necessary to determine the presence of a tuberculous process:

• Prolonged cough: dry or with sputum;
• Impurities of blood in the sputum (hemoptysis);
• Dyspnea;
• An increase in body temperature, most often to subfebrile (37 - 37.5 0 C);
• Violation of the general condition: increased fatigue, followed by weakness;
• Sweating during a rise in temperature.

Diseases that are taken into account when making a diagnosis

To determine the presence of tuberculosis, a number of other pathologies of the respiratory organs, the symptoms of which are similar to tuberculosis, should be taken into account:

• Pneumonia (inflammation of the lungs);
• Bronchial asthma;
• Chronic obstructive bronchitis;
• Neoplasm in the lungs: benign or malignant.

Above is a list of only the most common diseases, in reality there are many more. Therefore, instrumental and laboratory diagnosis of tuberculosis play such an important role.

The value of the Mantoux test in the detection of the tuberculous process

Tuberculosis is a dangerous disease that can remain dormant in the body for a long time. The symptoms listed above often appear already in advanced cases. Therefore, early diagnosis of tuberculosis is especially important in order to prevent late initiation of treatment.

One of the ways to determine the disease in the early stages and prevent the spread of tuberculosis is the Mantoux test. It consists in the subcutaneous injection of tuberculin, which causes the activation of the body's immune system and the corresponding reactions on the skin. The Mantoux test is performed in schools once a year for students at the same time. The following reaction results are distinguished:

• Negative - a trace from an injection;
• Doubtful - a spot or papule with a diameter of 2-4 mm;
• Weakly positive - diameter from 5 to 9 mm;
• Moderate result - 10-14 mm;
• Pronounced - 15 mm;
• Hyperergic - diameter greater than 17 mm for children, adolescents and adults.

The Mantoux test also gives false results. But this method has a low cost, availability and ease of implementation, which made it so common in educational institutions.

What other method is used for the early detection of tuberculosis

In addition to traditional methods for diagnosing the presence of a tuberculous process in the body, there are more highly effective, but at the same time more expensive research methods.

Use such a diagnostic method as "Diaskintest". Its main difference from the already traditional Mantoux is that here, for a subcutaneous reaction, not a weakened tubercle bacillus is used, as in tuberculin, but a protein with an antigen of the pathogen.

It is also excellent that "Diaskintest" shows only the infection in an active form, and with the introduction of tuberculin, the detection of a positive reaction is also characteristic in the presence of inactive mycobacteria.

Interpretation of the results of the diagnosis of the tuberculosis process using Diaskintest is carried out as follows:

• Negative result - there is only a point from an injection or a bruise up to 2 mm;
• Doubtful reaction - redness of the skin;
• A positive result is 2 mm or more.

Doubtful results of the study should alert the doctor, the child is left under observation. With a positive reaction, a chest x-ray and laboratory diagnostics are done to confirm the diagnosis.

Detection of tuberculosis with a blood test

Diagnosis of pulmonary tuberculosis using the X-ray method is considered more traditional, but it is informative only in the later stages of the disease. Blood is currently most often used as a material for early diagnosis in adults.

There are several research methods by which you can determine the presence of a tuberculous process:

1. General blood analysis;
2. Immunoenzymatic analysis (ELISA) of blood;
3. Polymerase chain reaction (PCR) of blood or other fluids;
4. quantiferon test.

Complete blood count is not highly specific. Its results allow only to suspect the diagnosis. The probability of infection with tuberculosis is indicated by such changes in the diagnostic material as an increase in the erythrocyte sedimentation rate (ESR) and an increase in the level of leukocytes (leukocytosis), mainly due to lymphocytes and monocytes. More specific methods are ELISA and PCR.

ELISA and PCR - modern methods of diagnosis

The essence of enzyme immunoassay is to detect specific antibodies to tuberculosis. There are two groups of antibodies in the body: IgG and IgM. The discovery of the first group indicates a chronic infection or that a person has had tuberculosis in the past. If the results show an increase in IgM, acute active tuberculosis is present in the body.

The PCR method has a high sensitivity. This means that PCR analysis can detect even the smallest amount of Mycobacterium tuberculosis.

Diagnosis of tuberculosis in adults using blood PCR is the most effective method for early diagnosis. It belongs to molecular genetic research methods and is used to detect the DNA of Mycobacterium tuberculosis. The analysis involves the use of material such as blood, urine, cerebrospinal fluid, lymph.

In addition to direct diagnosis, PCR is used to determine the sensitivity of mycobacteria to drugs. Traditionally, this method is used for seeding on nutrient media, but this analysis has a drawback - the result comes after a long time. PCR gives fast results. The sensitivity of tubercle bacilli to drugs using PCR is detected by determining mutations in certain genes.

Instrumental diagnostic methods used in phthisiology

Compared to PCR and ELISA, hardware diagnostics of pulmonary tuberculosis in adults has become more widespread in our time. These are diagnostic methods such as:

• Fluorography;
• X-ray of the chest organs;
• CT scan.

All of the above studies belong to the group of radiological methods. This means that imaging is based on the passage of X-rays through the internal organs and reflection of these rays.

Although the essence of these methods is the same, each of them has its own nuances. Fluorography is the cheapest way of hardware diagnostics of pulmonary tuberculosis. It requires less material for development and does not need special tools. The image is displayed immediately on the computer.

The fluorography method has become widespread for preventive purposes, for the mass detection of tuberculosis in the early stages.

Benefits of x-rays and computed tomography

X-ray is a more informative method of hardware research than fluorography. If, after performing fluorography, the doctor suspected the presence of tuberculosis, he should refer such patients to a plain chest x-ray.

X-ray is performed in two projections: lateral and direct. This is another of its advantages, because in the lateral projection you can see the pathology, which in the direct projection is not visible due to the shadow of the heart.

But the most effective method in diagnosing the tuberculous process in our time is computed tomography. This examination method not only makes it possible to clearly see the localization of tuberculosis, but also has the lowest radiation exposure to organ systems. But this analysis has a significant drawback - this is its high cost. Therefore, tomography is prescribed only in controversial situations, when the data of fluorography and x-rays do not make it possible to make an accurate diagnosis.

X-ray forms of tuberculosis

Forms of the tuberculous process are distinguished in order to be able to predict the further course of the disease, to find out whether this process is chronic or acute, primary or secondary infection of patients. There are the following forms of the disease:

• primary tuberculosis;
• Infiltrative form;
• Focal;
• disseminated;
• Cavernous;
• Fibrous-cavernous;
• Cirrhotic.

Primary tuberculosis occurs in children and the elderly. This form is favorable for the restoration of the respiratory system. It passes without significant residual effects in the lungs, the formation of calcium accumulation foci (Gon's foci) is possible, which are visible on the x-ray as bright white dots.

Features of focal, infiltrative and disseminated forms

These types of the disease are found in adult patients and indicate the acute stage of the tuberculosis process. The most common infiltrative form, which occurs in 65% of cases. On the x-ray, it is visible as a darkening with unequal contours with a diameter of more than 1 cm. If the diameter of the shadow is smaller, such tuberculosis is called focal.

Disseminated tuberculosis is also manifested by the formation of small shadows. The main difference between these forms is that focal tuberculosis is characterized by single foci located on one side in the upper sections of the lung. They have different shapes and densities. With the disseminated type, the foci occupy the entire surface of the respiratory system, have almost the same round shape.

Features of cavernous, fibrous-cavernous and cirrhotic forms

These types of disease are determined on x-rays in the chronic course of the tuberculosis process. Clinically, such forms are manifested by alternating exacerbation and remission, when nothing bothers patients.

The picture of X-ray examination in cavernous and fibrous-cavernous tuberculous process is similar to each other. They are characterized by the presence of cavities in the upper parts of the lungs, and the cavity in the fibrous-cavernous form has a thicker wall. This is due to a longer course of the disease and the growth of connective tissue around the decayed lung tissue. The cirrhotic form is manifested by a massive darkening, which occupies most of the respiratory system.

The prognosis for patients with these forms of the disease is unfavorable. They require longer treatment than acute forms. Diagnosed tuberculosis may require therapy for up to two years.

Methods for examining sputum for making a final diagnosis

Sputum analysis for pulmonary tuberculosis is one of the most informative and accessible methods for diagnosing tuberculosis. These methods should be used to determine the causative agents of tuberculosis - Koch's bacilli. There are two main methods of sputum examination:

1. Microbiological method;
2. Sputum microscopy.

The microbiological definition of tuberculosis consists in the culture of sputum on nutrient media, where the growth of mycobacteria is observed. Depending on the outcome of the microbiological response, a TB patient may or may not shed bacteria. The diagnosis revealed in this way helps to establish the contagiousness of patients to others. According to statistics, 70% of patients are active excretors of mycobacteria.

The main disadvantage of the microbiological diagnostic method is the duration of bacterial growth on nutrient media. This may take more than one week.

Therefore, along with sowing, sputum microscopy analysis is used. This is an affordable method that does not require a lot of time and money.

What can distort the results of sowing and how to avoid it

The diagnostic value of growing bacteria on nutrient media depends on the correct collection of material for the reaction, its storage and transportation.

Sputum should be collected in a specially equipped room, packed in a sterile bottle with a tight lid, made of impact-resistant material to avoid reaction with dust.

In addition, in order for the results of determining the pathogen to be as truthful as possible, a certain system should be followed:

• Collect material before the prescribed treatment;
• Do the examination on an empty stomach in the morning;
• At least 3 sputum samples should be collected;
• Sputum examination is carried out for 3 consecutive days;
• If it is not possible to immediately deliver the sputum to the laboratory, it should be stored in a refrigerator at 4 degrees C for up to 2 days.

Features of the collection of material for tuberculosis of extrapulmonary localization

The study of sputum of patients is effective only in the pulmonary form, but if tuberculosis has a different localization, sowing on nutrient media of the following material is possible:

• urine, semen and prostate secretion in men, menstrual blood in women - with urogenital tuberculosis;
• pus from bone abscesses - with bone tuberculosis;
• pus from the lymph nodes - with tuberculosis of the lymphatic system.

Urine collection is the least problematic for sowing on nutrient media for urogenital tuberculosis. Before collecting the material, the external genitalia should be washed. Best results can be obtained when using a mid-morning urine sample. In women, it is collected with a catheter, in men - in a natural way.

The rules for collecting pus for analysis from abscesses of bones and lymph nodes are the same. A puncture is made using a sterile system for blood sampling. It should immediately be analyzed in the laboratory. There, using a pipette, 2-5 ml of pus is collected, mixed with a 0.9% solution of sodium chloride in an amount of 2-3 ml. The mixture is moved into a vial, shaken in a special apparatus and amenable to research.

Principles of treatment and the most effective drugs

For successful treatment of Mycobacterium tuberculosis, a number of the following principles should be followed:

• therapy should be started as early as possible;
• treatment should be long - the minimum duration of therapy is 6 months and, if necessary, can be extended up to several years;
• continuity - taking drugs every day or with an intermittent regimen - every other day, 2-3 times a week;
• complexity - 4 drugs are prescribed simultaneously;
• the correctness of the therapy should be monitored by a doctor.

The most effective drugs for the treatment of tuberculosis are presented below:

• "Isoniazid;
• "Pyrazinamide";
• "Rifampicin";
• "Ethambutol";
• "Ethionamide".

These medications are also called first-line treatment drugs. Taking these drugs according to the principles listed above gives the best results and increases the chances of patients to completely get rid of mycobacteria.

Conditions that complicate the course of the disease

From the previous section, it can be seen that one of the principles of the treatment of tuberculosis is early initiation of therapy. After all, with an untimely start, the condition of patients worsens, and such complications may occur:

• Pulmonary bleeding;
• Insufficiency of the cardiovascular system - failure of the heart and blood vessels, which leads to a decrease in the supply of oxygen to organs and a deterioration in their function;
• Spontaneous pneumothorax - a condition in which air enters the pleural cavity around the lungs;
• Atelectasis of the lung - the collapse of the alveoli (breathing sacs), which leads to a deterioration in the function of the respiratory system;
• Pleurisy is inflammation of the pleura (the membrane that covers the lungs).

Actions to be taken to prevent TB infection

All preventive measures can be divided into two subgroups:

1. specific;
2. Nonspecific.

Specific prevention means vaccination. According to the "National Immunization Calendar", it is carried out on the 3rd-7th day of a child's life. Revaccination is done at 7 years.

Non-specific prophylaxis for children consists in regular Mantoux test, and for adults - fluorography once a year.

For people who have been in contact with a patient with tuberculosis or for patients in the past, chemoprophylaxis is of particular importance. The anti-tuberculosis drug Isoniazid is taken for 6 months.

We hope you enjoyed the article about the methods of diagnosing tuberculosis. If you know what other ways you can detect the presence of mycobacteria, tell us about it in the comments. Share this article on social networks, because tuberculosis is a dangerous disease that everyone should know about.