Symptoms of tuberculosis

The clinical symptoms of pulmonary tuberculosis are varied, but the disease has no specific signs. This is especially important to consider in modern conditions, characterized by an unfavorable environmental situation, frequent use of various vaccines, serums and antibiotics, as well as changes in the properties of the tuberculosis pathogen.

In this case, it is necessary to keep three circumstances in mind:

• When symptoms of the disease appear, patients with tuberculosis consult a general practitioner, therapist, pulmonologist, infectious disease specialist, neurologist, and less often, other medical workers, rather than a tuberculosis specialist,
• Tuberculosis is an infectious disease, and patients can pose a serious danger to others;
• Treatment of patients with tuberculosis requires the use of specific anti-tuberculosis drugs and should be carried out under the supervision of a TB specialist who has the necessary knowledge and skills.

Questioning and physical examination only allow one to suspect tuberculosis. Special research methods are necessary for timely diagnosis: immunological, microbiological, radiation, endoscopic and morphological. They are of decisive importance in the diagnosis and differential diagnosis of tuberculosis, assessment of the course of the disease and treatment results.

Study of complaints and anamnesis

When reviewing the anamnesis, it is necessary to establish when and how tuberculosis was detected: when visiting a doctor about some complaints or during an examination (preventive or for another disease). The patient is asked about the time of onset of symptoms and their dynamics, previously suffered diseases, injuries, operations. Attention is paid to such possible symptoms of tuberculosis as pleurisy and lymphadenitis, concomitant diseases are identified: diabetes mellitus, silicosis, gastric ulcer and duodenal ulcer, alcoholism, drug addiction, HIV infection, chronic obstructive pulmonary disease (COPD), bronchial asthma. It is clarified whether he received drugs that suppress cellular immunity (glucocorticosteroids, cytostatics, antibodies to tumor necrosis factor).

Important information is about stay in regions with high tuberculosis incidence, in penitentiary institutions, participation in military operations, place and living conditions of the patient, presence of children in the family. Profession and type of work, material and living conditions, lifestyle, presence of bad habits (smoking, alcohol, drugs) are important. The patient's level of culture is assessed. Parents of sick children and adolescents are asked about anti-tuberculosis vaccinations and results of tuberculin tests. It is also necessary to obtain information about the health of family members, possible contact with patients with tuberculosis and its duration, presence of animals with tuberculosis.

When contact with a patient with tuberculosis is detected, it is important to clarify (request from another medical and preventive institution) the form of the disease, bacterial excretion, the presence of mycobacterial resistance to anti-tuberculosis drugs, the treatment administered and its success.

Typical symptoms of tuberculosis of the respiratory organs: weakness, increased fatigue, loss of appetite, weight loss, increased body temperature, sweating. cough, shortness of breath, chest pain, hemoptysis. The severity of tuberculosis symptoms varies, they occur in various combinations.

Early manifestations of tuberculosis intoxication may include such symptoms of tuberculosis as weakness, increased fatigue, loss of appetite, weight loss, irritability, and decreased performance. Patients often do not associate these symptoms of tuberculosis with the disease, believing that their appearance is due to excessive physical or mental stress. Symptoms of tuberculosis and intoxication require increased attention, especially in people at risk for tuberculosis. In-depth examination of such patients may reveal early forms of tuberculosis.

An increase in body temperature (fever) is a typical clinical symptom of infectious and many non-infectious diseases.

In tuberculosis, body temperature can be normal, subfebrile, and febrile. It is often characterized by significant lability and can increase after physical or mental stress. Patients usually tolerate an increase in body temperature quite easily and often hardly feel it.

In children with tuberculosis intoxication, body temperature rises in the afternoon for a short time to 37.3-37.5 °C. Such increases are observed periodically, sometimes no more than twice a week, and alternate with long periods of normal temperature. Less often, body temperature remains within 37.0 °C with a difference between morning and evening temperatures of approximately one degree.

A persistent subfebrile temperature with minor fluctuations in temperature during the day is not typical for tuberculosis and is more common in chronic nonspecific inflammation in the nasopharynx, paranasal sinuses, bile ducts or genitals. An increase in body temperature to subfebrile may also be caused by endocrine disorders, rheumatism, sarcoidosis, lymphogranulomatosis, and kidney cancer.

Hectic fever is characteristic of acutely progressive and severe tuberculosis lesions (miliary tuberculosis, caseous pneumonia, pleural empyema). Intermittent hectic fever is one of the diagnostic signs that allows one to distinguish the typhoid form of miliary tuberculosis from typhoid fever. Unlike tuberculosis, with typhoid fever the body temperature has a steady tendency to increase, and then remains stably high for a long time.

In rare cases, patients with pulmonary tuberculosis have a perverted type of fever, when the morning temperature exceeds the evening temperature. Such fever indicates severe intoxication.

Excessive sweating is a common symptom of tuberculosis. Patients with tuberculosis in the early stages of the disease often note increased sweating on the head and chest at night or in the morning. Pronounced sweating (the "wet pillow" symptom) in the form of profuse sweat occurs with caseous pneumonia, miliary tuberculosis, other severe and complicated forms of tuberculosis, as well as with non-specific acute infectious diseases and exacerbations of chronic inflammatory processes.

Cough very often accompanies inflammatory, tumor and other diseases of the lungs, respiratory tract, pleura, mediastinum.

In the early stages of tuberculosis, there may be no cough, sometimes patients report a periodic cough. As tuberculosis progresses, the cough intensifies. It can be dry (unproductive) or with sputum production (productive). Dry paroxysmal cough appears when the bronchus is compressed by enlarged lymph nodes or displaced mediastinal organs, for example, in a patient with exudative pleurisy. Dry paroxysmal cough occurs especially often with bronchial tuberculosis. Productive cough appears in patients with pulmonary tuberculosis with destruction of lung tissue, formation of a lymphobronchial fistula, or a breakthrough of fluid from the pleural cavity into the bronchial tree. Cough in tuberculosis can also be caused by chronic nonspecific bronchitis or bronchiectasis accompanying tuberculosis.

Sputum in patients with early stages of tuberculosis is often absent or its secretion is associated with concomitant chronic bronchitis. After the disintegration of lung tissue, the amount of sputum increases. In uncomplicated pulmonary tuberculosis, sputum is usually colorless, homogeneous and odorless. The addition of nonspecific inflammation leads to increased coughing and a significant increase in the amount of sputum, which can become purulent.

Dyspnea is a clinical symptom of respiratory or cardiovascular failure. In lung diseases, it is caused by a decrease in the respiratory surface, impaired bronchial patency, limited chest excursion, and impaired gas exchange in the alveoli. Of particular importance is the effect on the respiratory center of toxic waste products of pathogenic microorganisms and substances formed during tissue breakdown.

Severe shortness of breath - in acute pulmonary tuberculosis, as well as in chronic disseminated, fibrous-cavernous, cirrhotic pulmonary tuberculosis.

Progression of tuberculosis can lead to the development of chronic pulmonary heart disease (CPHD) and pulmonary heart failure. In these cases, dyspnea increases significantly.

The high proportion of smokers among patients with tuberculosis determines the prevalence of concomitant COPD, which can affect the frequency and severity of expiratory dyspnea and requires differential diagnosis.

Dyspnea is often the first and main symptom of complications of pulmonary tuberculosis such as spontaneous pneumothorax, atelectasis of a lobe or the entire lung, and pulmonary embolism. With rapid accumulation of a significant amount of exudate in the pleural cavity, severe inspiratory dyspnea may suddenly occur.

Chest pain is a symptom of diseases of various organs: trachea, lungs, pleura, heart, aorta, pericardium, chest wall, spine, esophagus, and sometimes abdominal organs.

In pulmonary tuberculosis, chest pain usually occurs due to the spread of the inflammatory process to the parietal pleura and the occurrence of perifocal adhesive pleurisy. The pain occurs and intensifies with breathing, coughing, and sudden movements. The localization of pain usually corresponds to the projection of the affected part of the lung on the chest wall. However, with inflammation of the diaphragmatic and mediastinal pleura, the pain radiates to the epigastric region, neck, shoulder, and heart region. Weakening and disappearance of pain in tuberculosis is possible even without regression of the underlying disease.

With dry tuberculous pleurisy, pain occurs gradually and persists for a long time. It intensifies with coughing and deep breathing, pressing on the chest wall and, depending on the localization of inflammation, can radiate to the epigastric or lumbar region. This complicates diagnosis. In patients with exudative tuberculous pleurisy, chest pain occurs acutely, but decreases with the accumulation of exudate and remains dull until it is absorbed.

In cases of acute pericarditis, which sometimes occurs with tuberculosis, the pain is often dull and intermittent. It is relieved by sitting and leaning forward. After the pericardial effusion appears, the pain subsides, but may recur when it disappears.

Sudden sharp chest pain occurs when tuberculosis is complicated by spontaneous pneumothorax. Unlike the pain of angina and myocardial infarction, the pain of pneumothorax increases during talking and coughing and does not radiate to the left arm.

With intercostal neuralgia, the pain is limited to the area of the intercostal nerve and increases with pressure on the area of the intercostal space. Unlike the pain with tuberculous pleurisy, it increases when the body is tilted to the affected side.

With lung tumors, chest pain is constant and can gradually increase.

Hemoptysis (pulmonary hemorrhage) is more often observed in infiltrative, fibro-cavernous and cirrhotic pulmonary tuberculosis. It usually gradually stops, and after the release of fresh blood, the patient continues to cough up dark clots for several more days. In cases of blood aspiration and the development of aspiration pneumonia after hemoptysis, an increase in body temperature is possible.

Hemoptysis is also observed in chronic bronchitis, non-specific inflammatory, tumor and other diseases of the chest organs. Unlike tuberculosis, patients with pneumonia usually first experience chills and fever, followed by hemoptysis and stabbing pain in the chest. In pulmonary infarction, chest pain often appears first, followed by fever and hemoptysis. Long-term hemoptysis is typical for patients with lung cancer.

Massive pulmonary hemorrhages most often occur in patients with fibro-cavernous, cirrhotic tuberculosis and pulmonary gangrene.

In general, it should be borne in mind that tuberculosis of the respiratory organs often begins as a general infectious disease with symptoms of intoxication and often proceeds under the masks of flu or pneumonia, and against the background of treatment with broad-spectrum antibiotics (especially fluoroquinolones, aminoglycosides, rifampicins) the patient's condition may improve. The further course of tuberculosis in such patients is usually wave-like: periods of exacerbation of the disease are replaced by periods of relative well-being. In extrapulmonary forms of tuberculosis, along with symptoms caused by tuberculosis intoxication, patients experience local manifestations of the disease. Thus, headache is typical for tuberculous meningitis, sore throat and hoarseness are observed in tuberculosis of the larynx, back or joint pain, changes and stiffness of gait are observed in bone and joint tuberculosis, lower abdominal pain, menstrual dysfunction are observed in tuberculosis of the female genital organs, pain in the lumbar region, dysuric disorders are observed in tuberculosis of the kidneys, ureters and bladder, pain in the lumbar region, dysuric disorders, and abdominal pain and gastrointestinal dysfunction are observed in tuberculosis of the mesenteric lymph nodes and intestines. However, patients with extrapulmonary forms of tuberculosis, especially in the early stages, do not present any complaints, and the disease is detected only by special research methods.

Physical examination methods for patients with tuberculosis

Inspection

The appearance of patients with progressive pulmonary tuberculosis, known as habitus phtisicus, is described not only in medical literature but also in fiction. Patients are characterized by a lack of body weight, a blush on a pale face, shiny eyes and wide pupils, dystrophic changes in the skin, a long and narrow chest, widened intercostal spaces, an acute epigastric angle, and lagging (winged) scapulae. Such external signs are usually observed in patients with late stages of the tuberculosis process. When examining patients with initial manifestations of tuberculosis, sometimes no pathological changes are detected at all. However, an examination is always necessary. It often allows you to identify various important symptoms of tuberculosis and should be carried out in full.

Pay attention to the patient's physical development, skin color, and mucous membranes. Compare the severity of the supraclavicular and subclavian fossae, the symmetry of the right and left halves of the chest, evaluate their mobility during deep breathing, and the participation of accessory muscles in the act of breathing. Note the narrowing or widening of the intercostal spaces, postoperative scars, fistulas, or scars after their healing. On 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 watch glasses). In children, adolescents, and young people, examine the scars on the shoulder after BCG vaccination.

Palpation

Palpation allows determining the degree of skin moisture, its turgor, and the severity of the subcutaneous fat layer. The cervical, axillary, and inguinal lymph nodes are carefully palpated. In inflammatory processes in the lungs involving the pleura, a lag in the affected half of the chest during breathing and soreness of the pectoral muscles are often noted. In patients with chronic tuberculosis, atrophy of the muscles of the shoulder girdle and chest may be detected. Significant displacement of the mediastinal organs can be determined by palpation of the position of the trachea.

Vocal fremitus in patients with pulmonary tuberculosis may be normal, increased or decreased. It is better performed over areas of compacted lung in infiltrative and cirrhotic tuberculosis, over a large cavity with a wide draining bronchus. Weakening of vocal fremitus up to its disappearance is observed in the presence of air or fluid in the pleural cavity, atelectasis, massive pneumonia with bronchial obstruction.

Percussion

Percussion allows to detect relatively gross changes in the lungs and chest in case of infiltrative or cirrhotic lesions of lobar nature, pleural fibrosis. Percussion plays an important role in diagnostics of such emergency conditions as spontaneous pneumothorax, acute exudative pleurisy, pulmonary atelectasis. The presence of a box or shortened pulmonary sound allows to quickly assess the clinical situation and conduct the necessary studies.

Auscultation

Tuberculosis may not be accompanied by a change in the nature of breathing and the appearance of additional noises in the lungs. One of the reasons for this is the obstruction of the bronchi draining the affected area by dense caseous-necrotic masses.

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

Wheezing in the lungs and pleural friction rub often allow diagnosing a pathology that is not always detected by X-ray and endoscopic examinations. Small-bubble moist rales in a limited area are a sign of the predominance of the exudative component in the inflammation zone, and medium- and large-bubble rales are a sign of a cavity or cavern. To listen to moist rales, ask the patient to cough after a deep breath, exhalation, a short pause, and then another deep breath. In this case, wheezing appears or increases in number at the height of a deep breath. Dry wheezing occurs with bronchitis, whistling - with bronchitis with bronchospasm. With dry pleurisy, pleural friction rub is heard, with pericarditis - pericardial friction rub.

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