Pulmonary Tuberculosis

.

Specific infectious disease with high prevalence , which is produced by bacteria belonging to the genus Mycobacterium .
In humans the etiologic agent is Mycobacterium tuberculosis – the Koch bacillus .
In producing a secondary tuberculosis in humans can have that cause tuberculosis and Mycobacterium bovis in cattle.

Koch bacillus :
– Aerobic bacillus with alcoolo – acid- resistant
– Cultivated on special media in approx. 3-4 wks ( Lowenstein -Jensen )
– The structure containing a specific protein which can be determined due to its presence in the body – tuberculin
– Purified form (PPD ) tuberculin intradermal injection cause a hypersensitivity reaction

Epidemiology :
New case – a person requiring treatment sick with tuberculosis and who never received anti-tuberculosis . will be recorded and statistically said . Do not include those who did chemoprophylaxis for contact with a person with TB.
Case readmitted – relapse , re-injury – sick who have a relapse of TB requiring treatment but which has previously been treated with anti-tuberculosis after which was declared cured. are declared and recorded statistics.

Sources of infection :
1 . main
– Patient intense bacilifer
– Sick with TB but the Koch bacillus can be revealed only in cultures of sputum
– TB patients resistant to chemotherapy that eliminates BK
– Patients with extrapulmonary tuberculosis – open lesions – genital fistulas , osteo -articular ganglion .
2 . secondary
– Diseased animals (cattle) that the milk and manure can transmit TB to humans

The routes of transmission :
– By air – by sputum Flugger that by evaporating water droplets turn into a heavy dust accumulating in the environment bacilifer patient
– Path marrow – open lesions that come in contact with intense bacilifere ( pus , manure )
– transplacental

Factors that increase the severity of infection :
– Extremes of age ( 0-4 years , 12- 16 years , 60 years )
– Females ( associated with pregnancy , breastfeeding , confinement )
– Socio-economic factors : the low level of living, eating Deficiency in vitamins and protein, unsanitary housing , working conditions in damp , cold, low hygienic standards
– Association with other diseases – diabetes mellitus, chronic alcoholism , silicosis , convalescent infectious diseases infectious

Pathogenesis :
Infected particles are inhaled – enter the alveoli – macrophages fagociteaza bacilli – they multiply inside them – cause destruction of macrophages – cause the formation of granulomatous lesions ( tubers ) from adhering monocytes , lymphocyte , activated macrophages .
Tubers center shows a solid mass – which turns solid necrosis necrosis liquid ( caseous ) that may progress to :
1 . fibrosis and calcification – but remain inside sleeping bacilli that can reactivate
2 . invasion of blood vessels and bronchial walls with formation of caverns
Cazeumul bronchus drained to eliminate bacilli cause coughing and sputum – the patient becomes contagious.

Clinical forms:
I. primary TB
1. primo – infection occult – absence of clinical symptoms , IDR + radiograph shows calcification of primary complex formed by the inoculation chancre ( the point where the bacilli in the lungs ) , lymphadenopathy satellite spans that connect lymph sancru and lymphadenopathy
2 . primo – infection occur – this complex primary and clinical symptoms , IDR +
3 . Miliary TB – dissemination about TB infection marrow lymphocytes from both primary and complex from extrapulmonary focus can be localized only to the lungs or the whole body , is characterized by the presence of numerous very small nodules dispersed both lungs or other organs – brain, liver , spleen , kidney, prognosis
4. tracheobronchial adenopathy TB – tuberculosis ganglionic
5 . Pleural TB – TB pleurisy – sero- fibrinous

II . Secondary TB – phthisis – occurs on land already a primoinfectie allergy after months or years in altering immune
1 . infiltrative – can type onset pneumonia, flu , pleuretic may be asymptomatic was discovered by chance, diagnosis is based on pulmonary or highlighting Rx BK in sputum
2 . tuberculomul – circumscribed caseous tuberculosis – perfectly circumscribed form of tuberculosis that is cazeumul -progressive , secluded , fibrous
3 . Fibro – cavitary TB – phthisis adult – comes from infiltrative forms that shows a process of soft-mindedness eviction cazeificare and content – resulting caverns
types of cavities :
– The degree – small , irregular contour appears infiltrative pulmonary mass
– Tier II – bordered by a wall made ​​up of 3 layers:
– internal (active) or the multiplication occurs BK
– middle ( fibrous ) delineates cave lung parenchyma
– External ( atelectatic ) lung parenchyma consists of jet
inflammatory
– Level III – large fibrous wall , thick -liquid containing
4 . TB fibrous – caused by nodular or diffuse pulmonary fibrotic lesions that cause deformities and decreased pulmonary alveolar surface , an entire lung fibrosis – fibrotorax
5 . Bronchial TB – lesions are localized to the bronchial tree – persistent cough and painful ulceration due to infiltration and bronchial wall

Clinical picture :
1 . signs subjective
General (fever or low grade fever , fatigue , weight loss , anorexia , sweating )
Signs lung – can be irritating cough , productive emetizanta , expectoration more common forms hollow , with muco – purulent sputum greenish
Chest pain – caused by damage to the pleura in the vicinity of the inflammatory process
Exertional dyspnoea
Hemoptysis – minimal – ribbed , lightning , medium
2 . signs objectives
Inspection – facies pale – gray , signs of impregnation bacillary (melting subcutaneous tissue , muscle atrophy , deepening pits over and subclavian )
palpation – increased transmission of voice vibrations
Percussion – dullness
auscultation – hollow breath , breathing blower , rales crepitation

Laboratory picture :
1 . Sputum collected by spontaneous emission or bronchial lavage
a) direct smear colored Ziehl -Nielsen – exam + to> 10,000 bacilli / ml
b) Lowenstein Jensen medium culture – late result
2 . Tuberculin test
0.1 ml of purified protein derivative of tuberculin PPD is injected on the front of the forearm by intra dermal injection . reading is made at 72 hours by measuring the transverse diameter of erythema altebrat obtained .
< 10mm – normal result
> 10mm – positive test
can appreciate after dermal swelling – Palmer Scale :
1 . + edema blisters hard
2 . hard swelling
3 . edema elastic small
4 . rash

False negative reactions may occur in the following cases:
– corticosteroids
– Alcohol
– Irradiated with X-rays
– cachectic
– After infectious diseases – measles , rubella , influenza, whooping cough
3 . Rx exam chest
– Hilarious or mediastinal lymphadenopathy
– Outbreaks of pneumonic -type condensation , homogeneous
– Pleural reaction
– Micro- nodular images
– Skin milestones ( small nodules , disseminated over the entire lung )
– Primary complex – typical primo -infection – the inoculation chancre , lymphadenopathy satellite lymphangitis
4 . Bronchoscopy
– Allowing histopathologic , harvesting secretions , identifying fistulous tract , local therapeutic interventions

Treatment:
A. Prevention:
– Isolation of infectious patients
– Epidemiological investigation to identify contacts: 0-24 years – is tested by TST with PPD , 24 years – Lung Rx , suspected disease – examination of sputum
– Disinfection outbreak
– BCG vaccine – vaccine live attenuated , freeze-dried , suspended in 2 ml of solvent
administered intradermally in third upper left arm – it forms a papule 6-7 mm diameter.
within 2-4 weeks after inoculation and then forms a lump purplish scar – pearly white – who must have diameter > 3mm
Mandatory vaccination program in Romania :
1 . in the first 3-4 days of life to read from the 6th month of the 10th month , if scar < 3mm – testing and revaccination
2 . 7 years
3 . 15 years
4 . 18 years
5 . recruitment for men
– Contacts with intense sources bacilifere mostly < 24 years are required chemoprophylaxis , as well as those immunocompromised by IDR with PPD > 10mm immunoprophylaxis is 5mg/kgc isoniazid and vitamin B6 25mg/zi
Clean the
Principles:
1 . specific ( specific antibiotic called tuberculostatics )
2 . precocious
3 . appropriate clinical form
4 . prolonged ( more than 6 months)
5 . standardized ( standard scheme developed by MS )
6 . combined ( combining several tuberculostatics )
7 . supervised
8 . Morning administered as a single dose , fasting

Objectives:
1 . healing , socio-professional reintegration , restoration work capacity
2. protect the community by decreasing the risk of infection

Essential antituberculosis :
a) increased
– Isoniazid ( HIN )
– rifampicin
b ) minor
– streptomycin
– pyrazinamide
– ETAM – BUTOL
c ) reserve
– cycloserine
– Ciprofloxacin

Side effects: – toxic hepatitis
Types of drug regimens :
I 2 months ago – 4 tuberculostatics then 4 months – 2 tuberculostatics
II 2 months ago – 3tuberculostatice then 4 months – 2 tuberculostatics

The rate of administration :
7 days of seven ( 7/7 )
3 days of 7 ( 3/7 )
2 Days 7 ( 2/7)

Criteria for cure:
1 . bacteriological negativity
2 . disappearance of radiological image
3 . fair treatment led
4l . test of time – six months strictly supervised

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