Diagnosis of primary tuberculosis complex

X-ray diagnostics

X-ray diagnostics of the primary tuberculosis complex is based on identifying its main components: primary tuberculous pneumonia, changes in the intrathoracic lymph nodes (usually regional) and the so-called pathway connecting them. The variability of local manifestations is due to the different length of the primary pulmonary lesion, its pathomorphological substrate (the ratio of caseous-exudative changes in the tissue reaction), the prevalence and nature of the process in the intrathoracic lymph nodes, as well as possible complications.

Radiologically, the shadow of primary tuberculous pneumonia during the active phase of the process is uniform, its contours are blurred, it is associated with the pathologically altered root with a "path" in the form of unclearly outlined linear formations. Their morphological substrate is the inflammatory transformation of the lymphatic pathways and interstitial tissue along the bronchi, vessels and lobes of the lung. The intensity of the shadow of the primary focus varies, which is due not only to its size, but also to the severity of caseous necrosis. Changes in the intrathoracic lymph nodes are often regional in nature. In this case, radiologically determines a volumetric increase or expansion of the root of the lung, a violation of the differentiation of its structural elements, in a delimited area in the affected area, blurring and blurring of the contours of the root is possible.

Tomographic examination of the mediastinum allows documenting the enlargement of lymph nodes with their hyperplasia to sizes exceeding the cross-section of the adjacent vascular trunk, with perinodular inflammation and with partial calcification. In addition to damage to the intrathoracic lymph nodes, in the root zone, lymphostasis and lymphangitis are determined in the form of changes in the pulmonary pattern on the affected side. The pattern is displayed in a larger number of elements deformed according to the fine-mesh and linear type with unclear contours. Practical observations in agreement with the literature indicate the inconstancy of this sign. Manifestations of lymphangitis and lymphostasis in tuberculosis in young children are noted in the first 2 months with an acute course of the process in the intrathoracic lymph nodes.

Differential diagnostics. The radiographic picture of changes in specific and non-specific inflammatory processes in children is extremely similar. Differential diagnostics in terms of observations can be carried out by comparing the analysis of a complex of clinical, radiographic, laboratory, bronchoscopic and other data. Primary tuberculosis complex in the infiltration phase with the primary affect, which is a specific segmentitis or lobitus, must be differentiated from non-specific processes of the same extent. When destructive changes occur in the pulmonary component, it is necessary to carry out differential diagnostics with staphylococcal pneumonia, lung abscess, and, less often, with suppurating cysts.

Protracted segmental pneumonias have become quite common in modern conditions. The reverse development of such processes can be delayed up to 3-8 months from the onset of the disease. Protracted segmental nonspecific pneumonias are reversible processes, since inflammatory changes can be eliminated at a later date.

Primary tuberculosis complex in children in modern conditions, due to a number of factors that contribute to the increased reactivity of the child's body, as well as under the influence of intensive tuberculostatic therapy, can have a smooth accelerated course. In this regard, protracted segmental pneumonia and primary tuberculosis complex can have a similar clinical and radiological picture. In both diseases, there are few symptoms, similar segmental localization, and involvement of intrathoracic lymph nodes in the process. In this regard, it is necessary to highlight the distinctive features that can be used for differential diagnosis of these processes.

To diagnose primary tuberculosis complex, one should be guided by the following main criteria.

• Analysis of sensitivity to tuberculin in dynamics in patients with tuberculosis allows to establish infection, and in most cases the early period of infection is diagnosed - virazh. In most patients with pneumonia, sensitivity to tuberculosis indicates post-vaccination allergy, and some children react negatively to tuberculin. However, it should be taken into account that in some cases a child infected with tuberculosis can also suffer from a non-specific protracted bronchopulmonary process. It is in children infected with tuberculosis that differential diagnostics should be carried out to exclude the possible development of tuberculosis. The occurrence of segmental and lobar lesions in a child during the period of virazh of tuberculin reactions in the absence of previous ARI rather indicates a specific infection.

• The primary tuberculosis complex is characterized by a gradual onset of the disease, symptoms of intoxication and respiratory failure are expressed to a lesser extent. With a radiologically determined lobar, segmental process of tuberculous etiology, even with a significant increase in body temperature, a relatively good state of health of the child is noted, he remains active, respiratory disorders are expressed insignificantly. Comparison of clinical manifestations of the primary tuberculosis complex and pneumonia reveals the predominance of general symptoms in tuberculosis, while in pneumonia, cough, chest pain are more pronounced, a small amount of sputum may be separated. During physical examination of a child with a primary complex, percussion changes are expressed, they prevail over auscultatory data. An acute onset is characteristic of a child with protracted segmental pneumonia. In the clinical picture of the acute period of segmental pneumonia, a correspondence is noted between the severity of the condition, the prevalence of the process and the age of the child. In case of lobar polysegmental processes in young children, the severity of intoxication syndrome, respiratory symptoms, and severe condition are detected. In case of pneumonia, auscultatory changes prevail - moist rales of different calibers against the background of weakened, in places, bronchial breathing.
• In tuberculous lesions, the upper parts of the lung tissue are most often affected, the focus is located subpleurally (I-III segments), unilateral lesions are characteristic, more often of the right lung. In non-specific processes, polysegmental lesions with predominant localization in the lower lobes of the lung, a simultaneous combination of lesions of segments of two or more lobes and bilateral changes are characteristic. Streptococcal and staphylococcal pneumonias are also distinguished by multifocality, bilateral spread, variability of the radiographic picture in a short time. A triad of characteristic symptoms is known: foci of infiltration, rounded cavities of decay, pleural exudate.
• Bronchoscopic examination of a patient with tuberculosis reveals localized non-specific catarrhal endobronchitis or (more rarely) tuberculous bronchial lesions. In patients with pneumonia, widespread, diffuse, usually bilateral edema and hyperemia of the mucous membrane are noted, with mucopurulent secretions in the bronchial lumen.
• In difficult cases, for the purpose of differential diagnosis, therapy with broad-spectrum antibiotics is carried out, taking into account bacterial sensitivity.

Considering the pathomorphism of primary tuberculosis in children in modern conditions and the change in clinical manifestations, each case of lung damage and protracted disease requires alertness from general pediatricians and the need for an earlier consultation with a phthisiatrician.

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