SECONDARY

PULMONARY
TUBERCULOSIS
SECONDARY PULMONARY TUBERCULOSIS

 Occurs more frequently in adults

1) Due to reactivation of latent TB infection
(endogenous reinfection) of a primary
tuberculosis;
2) Due to exogenous infection, showing a
bronchogenic extension, with lung
desctructions and chronic evolution;
Development of secondary TB
DISSEMINATED
PULMONARY
TUBERCULOSIS
DISSEMINATED PULMONARY TUBERCULOSIS
Is a complication of a primary tuberculosis in
children and adolescents and secondary form of
TB in adults.
The morphological substrate are micronodulary
lesions with d = 2 mm (millet-sized in acute
disseminates TB) and different size nodules (in
subacute and chronic pulmonary TB)
symmetrically located in both lungs,
The TB infection is spread through the body by
haematogenous, limphogenous and
bronchogenous ways
Frequence – 10%
 Clinical forms
 The sharpest form
(Sepsis tuberculosis or tifobacilosis
Landuzi)
 Acute (miliary) disseminated
tuberculosis
 Subacute disseminated tuberculosis
 Chronic disseminated tuberculosis
 The sharpest form
 Develops in young adults with severely
compromising immune risk factors: low
social status, homelessness, alcoholism,
imprisonment
 Acute onset with fever up to 39 ° - 40 ° C,
with a highly expressed intoxication
syndrome, cough, dyspnea, with an acute
evolution, generalizing by affecting multiple
organs (liver, spleen, brain etc.)
 Poor prognosis and death
 Is rarely form of TB
 Disseminated acute (miliary)
tuberculosis
 Is an acute, severe form of tuberculosis
caused by the haematogenous spread of
the bacilli, often occurring soon after
primary infection
 Is most often in children and young adults
 Unlike other pulmonary tuberculosis
forms, is highly fatal
 Milliary tuberculosis
 acute onset with fever up to 38 ° - 39°C
 different clinical manifestations
depending on forms:
 Typhoid
 Meningeal

 Pulmonary
 Miliary
tuberculosis
 Typhoid form
 Is similar with abdominal typhus
 Occurs within the first weeks after primary
infection
 Onsets with a severe generalized condition
similar with typhoid, irregular fever (39–40°C),
stupor, vomiting and diarrhea
 Unlike typhoid fever, there are no rose spots
on the abdomen or splenomegaly, the pulse is
elevated (there is no dissociation between the
pulse and the temperature), which enables
this diagnosis to be eliminated.
 Meningeal type
 The clinical signs are similar to meningitis:
 high fever
 headache
 vomiting
 In the meningeal reactions (‘meningismus’)
meningeal signs are less pronounced than in
tuberculosis meningitis - nuchal rigidity,
symptoms Kerning is weak positive
 In the cerebrospinal fluid pressure increases
insignificant (70 drops, rule - 60 drops), slightly
increased protein, cells - 20-25 in cm2 (normal
up to 10 cells).
 Pulmonary type
 Pulmonary symptoms predominate:
 Dyspnea
 Cyanosis
 occasional develops acute respiratory
failure
Miliary tuberculosis
 The distinctive
radiological pattern
are many small and
similar spots of 1-5
mm distributed in
both lungs as millet
seeds—thus the
term "miliary"
tuberculosis
 Aspect in
harmonious
"mirror“ or starry
sky
Miliary tuberculosis
Miliary tuberculosis
Miliary tuberculosis
Miliary tuberculosis
Miliary tuberculosis
 Subacute disseminated
tuberculosis
 Clinically onsets with a prodrome period with
signs of intoxication during 1-2 weeks, then
fever rises up to 38-39 °C, determining the
continuous worsening of the intoxication
syndrome
 Appear bronho-pulmonary syndrome, larynx
events (hoarseness of voice, pain in
swallowing, foreign body sensation)
Radiological sings

 nodular shadows, their size

varies from a micronodule (less
than 3mm in diameter), to a
nodule (more than 3mm and
less than 1cm), with irregular
borders, from small to medium
intensity, symmetrically located
in medium and upper cortical
segments of both lungs,
confluencing and spreading in
all areas in "snowstorm"
 There are not characteristic
cavities,
 but if there are, subclavicular
localisation and thin walls
(stamped cavities in the form of
glasses) are specific.
Subacute disseminated tuberculosis
Subacute disseminated tuberculosis
Subacute disseminated tuberculosis
Subacute disseminated tuberculosis
“Stamped caverna”
in the upper
part of the right lung
 Chronic disseminated tuberculosis
 has a long lasting evolution, with
periods of remission and overheating
 During overheating the t°C raises up to
38 - 39°C, the intoxication syndrome is
characterized by asthenia, headache,
night sweats, anorexia, loss of weight
and work ability;
 Bronho-pulmonary syndrome consists
from cough with mucopurulent
expectoration, dyspnea
Chronic disseminated
lung tuberculosis
 Chronic disseminated
tuberculosis
 During the remission periods
fever decreases until feverish,
patient’s state improves,
the cough and expectoration are
diminishing,
but dyspnea is continuously
worsening
 Physical signs
 Patient looks older, the skin is pale and
moist, the thickness of the skin is reduced,
also the muscular tonus;
 Barrel-shaped chest, retraction of
supraclavicular fossae, dullness in the upper
and interscapular parts.
 Breath sounds are diminished, crepitations
and rhonchi are auscultated.
 Tachycardia, cardiac tone II are pronounced
at a. pulmonalis.
Chronic disseminated
tuberculosis
 Multiple nodulary opacities
of different sizes and
intensities, located
asymmetrically, in the
cortical area of upper and
medium lobes on the
background of a diffuse
fibrosis, pulmonary
emphysema in lower
regions, symptoms of
"weeping willow“
 Hypertransparencies and
stamped cavities
Chronic disseminated
tuberculosis
Chronic disseminated tuberculosis
Chronic disseminated tuberculosis
Chronic disseminated tuberculosis
 Diagnosis
 Sputum smear is positive in most of cases
 The tuberculin skin testation is usually
negative in miliary tuberculosis
 Analysis of blood: anemia, moderate
leukocytosis, eosinophilinopenie,
lymphocitopenie, monocytosis,ESR
accelerated during overheating and the
trend of normalization during remission
 Differential diagnosis
 Metastatic tumors
 Bronchiolitis
 Alveolitis (extrinsic allergic alveolitis,
idiopathic fibrosing alveolitis)
 Occupational disease (silicosis)
 Disease of subcutaneous connective
tissue
 Pulmonary stasis in cardiac pathology
etc.
Carcinomatosis
Papillary thyroid carcinoma with miliary metastases
 Sarcoidosis of the lungs
and intrathorasic limph nodes
sarcoidosis
Bronchopneumonia
Pulmonary nodulary
tuberculosis
 Pulmonary nodulary
tuberculosis
 Is a secondary form of tuberculosis with
morphological substrate of nodular
lesions with size up to 1cm localized in
the apical segments S1, S2, in one or
both lungs, asymmetricaly
 Frequency - below 20%
Secondary TB-pathogenic particularities

 The main role in the development of

secondary TB is the reactivation of the
latent TB infection (localized in
intrathoracic lymph nodes, postTB
sequelas)
 In the postTB sequelas are persisting
dormant/latent mycobacterias which are
maintained in the this phase by the host
cellular immunity
 Secondary TB-
pathogenic particularities

 If the host immunity decreases, the

reactivation of the latent TB infection
localized in postprimary TB sequelas
develops.
Exogenous infection contributes to the
reactivation of latent TB infection from
postprimary TB sequelas old due to delayed
hypersensitivity immune reaction
 Pulmonary nodulary
tuberculosis
 Is a limited form of pulmonary TB,
oligosymptomatic, or asymptomatic form
 The onset is often insidious or
asymptomatic, with asthenia, periodic
feverish in the evening, loss of appetite,
unexplained loss of weight, dry cough or
reduced expectoration
 Physical signs
 positive symptoms:
 Sternberg - the pain at the palpation in the
regions of shoulder belt
 Vorobiov – Pottendjer -rigidity in the same
area
 at the percussion – shortening of the field
Kroening
 in supra- and subclavicular areas is hear dry
rales and rough breath sounds
 These clinical signs mimic myositis, cervical
osteochondrosis
 Nodulary tuberculosis

in segments 1 and
2 in one or both
lungs are localized
asymmetric
nodules, low
intensity, with
unclear borders,
with sizes less
than 1 cm in early
stage
Nodulary tuberculosis
Nodulary tuberculosis
Nodulary tuberculosis

In late stages the

nodules become
with medium and
high intensity with
clearly borders on
background of
pneumofibrosis
(apex decreased in
volume, pleural
adhesions).
 Diagnosis
 AFB - in sputum is rarely found
 IDR Mantoux 2 UT is positive
 Blood count shows moderate changes
 Differential diagnosis
 Bronchopneumonia
 Post inflammatory pneumofibrosis
 Peripheral apical carcinoma
(Pancoast Tobias tumor)
Pancoast –Tobias tumor
 Pulmonary
infiltrative
tuberculosis
 Pulmonary infiltrative
tuberculosis
 is a form of secondary pulmonary
tuberculosis, with a morphological
substrate in the form of a nodulary
lesion with central necrosis, surrounded
by a perifocal inflammation, sized more
than 1 cm, frequently located in the
upper and posterior segments of the
lungs (S1, S2, S6, S10)
 frequency - 70 %
 Diseases and conditions,
which weaken immunity
 Malnutrition
 Alcoholism
 HIV/AIDS
 Diabetes mellitus
 Gastrectomy
 Chronic renal insufficiency
 Silicosis
 Leukemias
 immunosuppressive drug treatment
 malignant tumors (Hodgkin's disease and
lymphomas)
 Clinically signs
 Infiltrative tuberculosis is detected by passive way
through patient’s addressing to general practitioner
 The onset can be insidious, subacute or acute,
depending by the extensibility of the process
 In limited forms the onset is insidious with
moderate asthenia, loss of appetite and weight,
feverish, or can be asymptomatic
 Typically there is gradual worsening of the
onset during weeks or months.
 Subacute onset meets in the middle and
extended forms of pulmonary infiltrative TB.
 Clinically signs
 The clinical picture in these patients often
mimics respiratory diseases:
 influenza
 pneumonia
 bronchitis
 haemoptysis
 Intoxication syndrome expressed through
asthenia, night sweats, fever as well as
bronho-pulmonary syndrome (chest pain,
cough for more than 3 weeks, dyspnea,
haemoptysis) are instaled.
 The onset of disease
 Insidious
 Catarrhal
 Hemoptoic
 Acute
 Insidious onset
 is characterized by gradual
development of asthenia, anorexia,
loss of weight and appetite, and
other vague complains
 Intermittent fever or feverish in the
evening is associated with excessive
night sweats
 Catarrhal onset
 is characterized by gradual increase of
productive cough, expectorations and
haemoptysis
 Fever and night sweats also are noted
 Hemoptoic onset
 the presenting symptom is
haemoptysis either with or without
other symptoms already mentioned
 Acute onset
 Occasionally
 Influenza-like with high fever, chills,
myalgia, and productive cough
 Pleuritic pain, with or without pleural
fluid sometimes appears
 Clinical signs
 In limited infiltrate clinical data are missing.
 In middle extended infiltrate:
 the inspection determines decreased of thoracic
excursion
 the palpation – rigidity of belt scapulars muscles
(symptoms Vorobiov - Pottenger)
 to percussion – dullness
 to auscultation –diminished breathing, moist
rales in the “alarm areas” (suprascapular,
supraclavicular and subclavicular areas)
 In extended forms - breathing lining.
 Clinical presentations
 diurnal fever, with normal temperature early
in the morning, which is gradually rising,
achieving the peak in the late afternoon or
evening
 Night-time decreased temperature is often
accompanied by diaphoresis leading to night
sweats
 Fever and night sweats are more expressed
in severe forms of pulmonary TB.
 Clinical presentations
 Cough may be absent or appears later
 A mild non productive cough commonly occurs
initially in the morning and may be confused with a
“smoker‘s cough“ by clinician and ignored by the
patient
 The morning cough is a result of accumulation of
secretions during the sleeping hours
 During disease progression, cough often becomes
more continuous throughout the day and may
become productive of yellow or yellow-green and
occasionally blood streaked sputum
 Nocturnal coughing is associated with advanced
pulmonary disease, often with cavitations
 Physical examination
 Physical data is usually non specific
 Classic findings are palidity, cachexia, tachycardia,
non specific ausculation signs (coarse crackles in
the corresponding area, wheezing and ronchi,
clinical signs of lung condensation)
 decreased vesicular murmur and broncophony or
tubular blow when pleural effusion is present
 the amphoric breath sounds above/near cavities
The types of Infiltrates

 Limited infiltrate:
 bronho–lobular
 round infiltrate
 ovalar infiltrate

 The middle extended infiltrate

 nebulous infiltrate
 triangle infiltrate (periscisuritis)

 extended infiltrate:
 lobar infiltrate
 caseous pneumonia
Broncho – lobular infiltrate
 an opacity whose
size varies from 1.5
to 2 cm in the upper
segments (S1 S2) of
lung
Broncho – lobular infiltrate
Round infiltrate
 is a round infiltrate
with 2 - 4 cm
diameter,
 homogeneous, low
intensity, irregular
borders localized in
subclavicular space
Ovalar infiltrate
Nebulous infiltrate (cloudy-like)

 Patchy infiltrate, with

irregular borders, located in
the upper lobes with 5-6
cm diameter, with areas of
hypertransparencies
Nebulously (cloudy-like) infiltrate
Triangle infiltrate (periscisuritis)
 Has the form of a triangle,
based on the chest wall
and apex to hilum, bottom
side is formed by interlobar
pleura, situated in the
superior lobe.
 The most common
symptom, which lead
patient to the doctor is
pain in the chest
 Lobar infiltrate (lobit)
 Was described by L.
Bernard, with pronounced
clinical manifestations -
syndrome of intoxication,
cough with sputum,
breathlessness, chest pain,
haemoptysis. Objective -
thoracic excursion is
decreased on the involved
side, tactile vocal fremitus is
increased, dullness, tubular
breathing, reduced râles of
small caliber
Lobar infiltrate (lobit)
Lobar infiltrate (lobit)
 Caseous pneumonia

huge opacity,
heterogeneous,
medium intensity,
with multiple
sectors of lucency
(honeycomb) and
dissemination in
the rest of the
lobes in both
lungs
Caseous pneumonia
 Caseous pneumonia
 The most extensive and severe form of infiltrative
tuberculosis.
 Develops in people with compromised immunity, with
multiple social and medical-biological risk factors
 Pronounced syndrome of intoxication as well as the
bronchopulmonary
 Physical exam is an expressive: observed a habitus
ftizicus - haggard, gleaming eyes, hectic flush
 The rales of different caliber can be heard in the lungs
 The evolution process is rapid progressing, the diagnosis
is unfavorable, often finishes with death or develops of
fibrous-cavernous tuberculosis
 Diagnosis
 AFB in sputum positive
 The Mantoux test is negative
 Analysis of blood for advanced
tuberculosis - anemia, with moderate
leucoccytosis deviation to the left),
eosinophilinopenie, lymphocitopenie,
monocytosis, ESR accelerated
 Differential diagnosis
 Bronchiectasis with episodes of
acute infection
 Chronic bronchitis or chronic
obstructive pulmonary disease
 Asthma

 Lung cancer

 Mitral stenosis
FIBROUS – CAVERNOUS
PULMONARY
TUBERCULOSIS
 Fibrous-cavernous
pulmonary tuberculosis
 is a secondary form of tuberculosis,
 the substrate is a cavity (or more) with hard
walls and massive fibrosis in adjacent tissue,
 with the bronchogenous dissemination in
lower regions and the mediastinum shifted
to the affected side;
 the clinical picture is characterized by a
chronic evolution manifested through
periods of remission and overheating of the
process
 Fibrous-cavernous pulmonary
tuberculosis develops from early
forms of tuberculosis

 infiltrative - 50-60%
 nodulary - 25%

 disseminated - 10-15%
 Causes
of chronization of the cavity
 the incorrect treatment (irregular, one
short of the violations)
 the refuse of the surgical intervention
 the persons who abuse alcohol
 the persons who are in detention
 the patients with comorbidities (diabetes,
gastric ulcer, mental illness)
 Cavity structure
 internal stratum - caseous-
necrosis
 middle stratum - granulation

 external stratum - fibrotic

 Cavities by the sizes
 small up to 2 cm
 medium up to 4 cm

 big up to 6 cm

 giant more than 6 cm

 Fibrous-cavernous pulmonary
tuberculosis

 The process is aggravated via

bronchogenic and lymphogenous
dissemination of TB infection
 Some broncho-lobar shadows with
confluent character appear
 The formation of new cavities and
increasing the old ones is characteristic
for the expanded forms
 Clinical picture

 Limited and relatively stable

 Evolving

 Complicated fibrous-cavernous

pulmonary tuberculosis
 Clinical picture
 limited and relatively stable,
due to treatment when the
process is stable and
the overheating does not appear
for several years
 Clinical picture
 Evolving,
Characterized by the alternation of periods of
overheating and remission with different
duration - short and long, and with the
appearance of new cavities and infiltrates
during the overheating
In some cases lungs is completely destroyed,
and in others, when treatment is ineffective,
develops a caseous pneumonia
 Clinical picture

 Complicated fibrous-cavernous
pulmonary tuberculosis,
often gradually evolving with
development of cardiopulmonary
failure, amyloidosis and other
complications of pulmonary
 Overheating
 marked asthenia
 anorexia
 pronounced weight loss
 night sweats
 remittent fever
 chest pain
 cough with copious/ abundant purulent sputum
(100-200 ml per 24 hours)
 sometimes haemoptysis
 dyspnea
 compensatory tachycardia
 cyanosis
 Physical examination
habitus ftizicus:
 Cachexia with muscular atrophy

 Deformation of the chest by retraction of

the affected party
 Retraction of the intercostals spaces,

supraclavicular fossaes
 Thoracic excursion on the involved side
is decreased
Habitus ftizicus
Habitus ftizicus
 Physical examination
 Palpation:
 belt scapulars muscles atrophy (p. Vorobiov-
Pottenger II)
 trachea moving towards affected lung (s. "fork"
Rubinstein)
 Percussion:
 Dullness
 Tympanitis (giant cavity)
 Auscultation:
 The main findings are medium-sized consonating
crepitations and bronchial breathing of the
cavernous type
 Amphoric breathing is heard above the big cavities
 Remission

 Intoxication signs are weak or

missing
 Sometimes cough with expectoration

and dyspnea (due pneumosclerosis),

nonspecific bronchitis and
bronchiectasis are present
 X-ray picture
 Presence of deformed cavities, with large and thick
wall, surrounded with massive fibrosis
 The inner wall of a tuberculous cavity can be smooth
or irregular
 The cavities usually situated in the upper lung
zones
 The destruction of the lung parenchyma and gradual
fibrosis lead to retraction of the neighbouring
structures: the trachea may be displaced, the hilum
may become elevated, the diaphragm may be pulled
upward and the cardiac silhouette may change the
shape and place, retraction of chest
 The heart shifts to the affected side
 Spread and confluence of the nodules in the rest
areas on both lungs are characteristic
Fibrous-cavernous pulmonary
tuberculosis
Fibrous-cavernous pulmonary tuberculosis
Fibrous-cavernous pulmonary tuberculosis
Fibrous-cavernous pulmonary tuberculosis
 Diagnosis
 Tuberculin test is negative during overheating and
positive in remission
 Analysis of blood: anemia, with moderate
leucoccytosis with shift to the left, eosinopenia,
lymphocytopenia, monocytosis, ESR accelerated.
 Urine analysis: proteinuria, granular cylinders
 FBS - tubercular disease - 10-20%, non-specific
endobronchitis
 Microscopic examination: AFB positive in the
sputum
 Drug-susceptibility testing: drug resistant TB
 Differential Diagnosis
 Lung cancer
 Lung abscess

 Pulmonary fibrosis of different

etiologies
 Actinomycosis
Lung abscess
Actinomycosis
 COMPLICATIONS
 Reversible:
 Spontaneous pneumothorax
 Pulmonary hemorrhage

 Pleurisy

 Empyema

 Bronchial, laryngeal, intestinal

tuberculosis
Lung cancer
Empyema
Pleurisy
PNEUMOTHORAX

the lung is separated from the

chest wall by a homogeneous
jet-black zone
it is best seen above the lung
apex and on X-ray in
exhalation
the lung lies close to the
mediastinum and may show
the underlying disease
the cupola of the diaphragm is
flattened and the mediastinum
is shifted to the opposite side
 Pneumothorax

PNEUMOTHORAX
Pneumothorax
Pneumothorax with chest tube
Spontaneous pneumatorax
Pneumathorax
 COMPLICATIONS
 Irreversible:
 Pulmonary fibrosis

 Bronchiectasis

 Chronic respiratory failure

 Amyloidosis
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