Tuberculosis

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Tuberculosis is an infectious disease caused by mycobacterium tuberculosis and characterized by the development of cell allergies, specific granulomas in various organs and tissues, and a polymorphic clinical picture. Damage to the lungs, lymphatic system, bones, joints, genitourinary organs, skin, eyes, nervous system is characteristic. If untreated, the disease progresses and ends fatally.

Etiology

    • Mycobacterium tuberculosis (obsolete. Koch’s bacillus, tuberculosis bacillus) is a type of mycobacteria that causes tuberculosis in humans in 92% of cases; was opened in 1882 by Robert Koch. One of more than 30 members of the genus Mycobacterium. M. tuberculosis is able to multiply both in macrophages and extracellularly in tissues. Under the influence of antibacterial agents, M. tuberculosis is increasingly becoming drug resistant
    • M. bovis is a species of mycobacteria that causes tuberculosis in both cattle and humans when drinking milk from an animal with tuberculous mastitis
    • There are rare cases of tuberculosis in humans in Africa, caused by M. africanum – obligate aerobes, facultative intracellular parasites
    • M. avium and a variety of other mycobacteria cause the less common human disease mycobacteriosis.

 

Risk factors

    • Poor social and living conditions
    • Immunosuppression (especially in AIDS), incl. long-term therapy with high doses of glucocorticoids
    • Close contact with a TB patient
    • Lymphogranulomatosis
    • Lymphomas
    • Diabetes
    • CRF
    • Starvation.

Microbiology. Mycobacteria are classified as acid-resistant microorganisms; their staining requires special treatment (according to ZplkgNielsen). Surface lipids of mycobacteria and water-soluble components of the cell wall show their activity at the first meeting with macrophages. M. tuberculosis is identified in clinical specimens, but the pathogen is traditionally present in low numbers, and a long study of stained products (100 fields) will be needed. Tuberculosis mycobacteria are thin, straight or slightly curved non-spore-forming rods 1–10 µm long and 0.2–0.6 µm wide. homogeneous or granular with slightly rounded ends, located in a smear in pairs or groups. When stained with the fluorescent dye auramine-rho-damine, mycobacteria can be seen at 100x non-immersion magnification. The result is more accurate when stained according to Ziel-Neelsen with carbolfuchsin and immersion microscopy at 1000x magnification. The growth of cultures of M. tuberculosis makes it possible to clarify the diagnosis, more accurately identify the pathogen and determine its susceptibility to drugs. The growth of the first colonies on classical media (Levenshtein-Jensen) is noted after 4-8 weeks. Modern methods using highly selective media make it possible to grow cultures in 1–2 weeks, but identification of the microorganism requires additional time. Modern seeding techniques are highly informative, and it is currently considered unnecessary to conduct biological tests with infection of guinea pigs. M. tuberculosis has the ability to produce niacin, which distinguishes it from other mycobacteria. Nucleic acid hybridization methods have been developed for faster identification of mycobacteria.

Epidemiology

    • The determining factor is that 30% of the world’s population is infected with Mycobacterium tuberculosis; every year 10 million people fall ill with bacillary forms of tuberculosis (presumably the same number – tuberculosis without bacterioexcretion). 60% of cases are in developing countries. 3-4 million people die annually from tuberculosis, which is within 6% of all deaths worldwide
    • In Russia, the incidence of tuberculosis has been declining since the 1950s. XX century until 1991 (34:100,000 population). For 1991-96 the incidence of tuberculosis in Russia increased by 97.4%, reaching 67.5:100,000 of the population, mortality – by 97.4%, reaching 17.0:100,000 (1977 level). The incidence of tuberculosis in children in Russia has increased by more than 60% over 5 years. Annual increase in incidence – 4%
    • With the spread of AIDS, tuberculosis has become the leading cause of morbidity and mortality in these patients.
    • M. tuberculosis is transmitted from person to person by airborne droplets (alimentary, percutaneous and vertical routes of infection are possible, but rare). Each patient with active bacillary tuberculosis is able to infect an average of 10-15 people. Although tuberculosis is not classified as a highly contagious disease, 25-50% of those who come into close and prolonged contact with bacteria-excreting bacteria become infected with M. tuberculosis. Getting infected with tuberculosis does not mean getting sick. Only 5-15% of those infected fall ill, the rest develop non-sterile immunity. Patients with tuberculosis of the larynx, bronchi and destructive forms of pulmonary tuberculosis are especially contagious.
    • Infection with M. bovis tuberculosis may be associated with drinking milk from a cow with tuberculous mastitis
    • The focus of tuberculosis infection is the place of residence of a patient with tuberculosis with bacterioexcretion. Pathogenesis
    • The primary entry of the tuberculosis pathogen into the lungs or other organ of a previously uninfected organism causes an acute nonspecific inflammatory reaction that is not often recognized clinically.
    • Mycobacteria are taken up by macrophages and transported by them to the regional lymph nodes. With local primary infection during the first week, 50% of macrophages contain Mycobacterium tuberculosis, with repeated infection (in the presence of immunity), most bacteria are quickly destroyed, and only 3% of macrophages contain Mycobacterium tuberculosis. M. tuberculosis is found mainly in the phagosome of macrophages. Incomplete phagocytosis is caused by the production of an enzyme by mycobacteria that inhibits the fusion of phagosomes with lysosomes.
    • If the spread of the pathogen is not limited to the lymph nodes, then mycobacteria through the thoracic lymphatic duct enter the bloodstream and spread throughout the body. In most cases, TB infection screening sites, as well as lung damage at the site of the primary lesion, heal on their own, but they are a potential source of late TB reactivation throughout the life of the patient. Dissemination can lead to miliary TB or TB meningitis, with an increased risk of serious illness and death, especially in infants and toddlers
    • Within 2–8 weeks after primary infection, while mycobacteria continue to multiply intracellularly, a delayed-type T-lymphocyte-mediated hypersusceptibility develops in the human body.
    • Immunocompetent lymphocytes enter the zone of penetration of the pathogen, where they produce chemotactic factors, for example, IL and lymphokines. In response to this, monocytes migrate here and transform into macrophages, and then into histiocytic cells, later organized into granulomas.
    • Mycobacteria can persist in macrophages for many years despite increased production of lysozyme by these cells; however, further reproduction and spread of the primary infection is limited precisely by phagocytosis
    • Subsequent healing of the primary affect is often accompanied by calcification seen on chest radiographs. The combination of calcification in the lung with a calcified lymph node in the root of the lung is commonly called Gon’s complex.
    • The development of tuberculosis in individuals without previous primary infection is unlikely. Some people develop tuberculosis within a few weeks of a primary infection, but most often mycobacteria persist latently in the body until they multiply exponentially, leading to the development of the disease.
    • Immunity can be formed by vaccination with BCG (bacillus Calmette-Guerin, BCG) or by infection with another type of mycobacterium. Pathomorphology. Granulomatous process with foci of caseous decay surrounded by epithelioid macrophages and Langhans giant cells surrounded by lymphocytes. Tuberculosis classification used in Russia
    • Tuberculosis intoxication in children and adolescents
    • Primary Tuberculosis Complex (PTK)
    • Tuberculosis of the intrathoracic lymph nodes (TVLNU)
    • Disseminated tuberculosis
    • Miliary tuberculosis
    • Focal pulmonary tuberculosis
    • Infiltrative pulmonary tuberculosis
    • Caseous pneumonia
    • Tuberculoma of the lungs
    • Cavernous pulmonary tuberculosis
    • Fibrous-cavernous pulmonary tuberculosis
    • Cirrhotic pulmonary tuberculosis
    • Tuberculous pleurisy (including empyema)
    • Tuberculosis of the bronchi, trachea, upper respiratory tract, etc. (nose, mouth, pharynx)
    • Tuberculosis of the respiratory organs, combined with dusty occupational lung diseases (coniotuberculosis)
    • Tuberculosis of the meninges and CNS
    • Tuberculosis of the intestines, peritoneum and mesenteric lymph nodes
    • Tuberculosis of bones and joints
    • Tuberculosis of the urinary, genital organs
    • Tuberculosis of the skin and subcutaneous tissue
    • Tuberculosis of peripheral lymph nodes
    • Tuberculosis of the eye
    • Tuberculosis of other organs. Note on classification. The classification provides for an indication in the diagnosis of the localization and extent of the process (in the lungs by lobes and segments, and in other organs – by the localization of the lesion), the phase of the process (infiltration, decay, seeding or resorption, compaction, scarring, calcification), as well as the presence or absence of M. tuberculosis in the material – BK (+) or BK (-).

 

Clinical picture

    • Primary tuberculosis is an infectious disease caused by Mycobacterium tuberculosis during the period of primary infection (7-10% of infected), most typical for infants and persons infected with HIV-1.
    • Characteristic features
    • Lymphotropism
    • Imperfect immune response
    • Paraspecific and extensive perifocal reactions
    • The tendency to generalize the process, and in the future (during the formation of immunity) – the likelihood of self-healing.
    • Clinical forms
    • Tuberculosis intoxication in children

 

and teenagers

    • TVGLU
    • PTK.
    • Clinical picture
    • Usually asymptomatic until complications develop
    • Nonspecific pneumonitis is traditionally found in the middle or lower lungs.
    • Enlarged lymph nodes in the roots of the lungs in childhood can cause bronchial obstruction.
    • Complications
    • Compression of the mediastinal organs by hyperplastic lymph nodes
    • Involvement of the pleura in subpleural localization of the tuberculosis focus.
    • outcomes
    • Lymph node calcifications and/or calcified lung.
    • Disseminated tuberculosis develops when mycobacterium spreads to organs or several organs via the hematogenous or lymphogenous route with the formation of foci of productive inflammation. This form can bear the features of both primary and secondary tuberculosis.
    • Characteristic features
    • The symmetry of the process in terms of localization (traditionally mainly in the upper parts of the lungs)
    • The process is symmetrical in time (changes are isomorphic, a cavity on the one hand and foci on the other make it possible to exclude a disseminated process).
    • Flow
    • Acute disseminated pulmonary tuberculosis has been singled out as a separate form, miliary tuberculosis, which develops as a result of extensive hematogenous spread of tuberculosis infection. Untimely diagnosis of this form of tuberculosis and lack of treatment lead to the death of the patient within a few months (transient consumption).

– Clinical picture (2-6 weeks ahead of the x-ray). There are pulmonary (with a predominance of shortness of breath and other pulmonary symptoms) and typhoid (with a predominance of symptoms of intoxication up to confusion) forms

    • Fever of unknown origin, sometimes with a double-humped temperature curve, often accompanied by anemia and splenomegaly
    • In childhood, miliary tuberculosis can proceed at lightning speed (sudden onset, severe intoxication, tachycardia and shortness of breath)
    • Hematogenous screenings can occur simultaneously in various organs (probably damage to the meninges).

– X-ray diagnostics. Bilateral symmetric total small-focal dissemination. Often this picture is recognized on side pictures or on soft radiographs. – Bacterioscopy and bacteriological examination of sputum are uninformative (sputum is not always and does not often contain mycobacteria). – Tuberculin diagnosis (see below). Tuberculin anergy is typical and therefore negative skin tests have no differential diagnostic value. In vitro observations in the culture of lymphocytes also revealed anergy associated with the suppressor function of monocytes. With successful treatment and stabilization of the condition of a patient with miliary tuberculosis, tuberculin hypersusceptibility is restored. – Transbronchial biopsy or liver biopsy often confirms the diagnosis. – Bone marrow biopsy is positive in 2/3 of the patients.

    • Subacute and chronic Disseminated tuberculosis is a consequence of repeated entry into the blood of mycobacteria from the primary tuberculosis focus, manifested primarily by a symmetrical lesion of the upper sections of both lungs. Differential diagnosis is carried out with sarcoidosis and other granulomatosis, pneumoconiosis, carcinomatosis, fibrosing alveolitis and hemosiderosis.

– Subacute disseminated tuberculosis – stamped or spectacled caverns that form in the upper lobes of both lungs. Symptoms are shortness of breath and progressive pulmonary heart failure.

    • Secondary tuberculosis is an infectious disease caused by mycobacterium tuberculosis when a person encounters M. tuberculosis again (exogenous reactivation of old foci or exogenous superinfection from another source); most often observed in middle-aged and elderly people.
    • Characteristic features
    • The organ nature of the lesion (often with lung involvement) with the formation of a focus, infiltrate or cavity without involvement of the lymph nodes in the process
    • Damage to the apical, posterior apical segments of the upper lobe and the upper segment of the lower lobe (I, II and VI segments)
    • The prevalence of the lesion varies from foci and small infiltrates (not always manifested clinically) to extensive processes with cavitary formations, fibrosis, malnutrition and pulmonary heart failure.
    • The presence of foci-screenings that appear after the main lesion (this sign is used in the differential diagnosis of tuberculosis and tumors).
    • The data of an objective study are informative only with an extensive lesion.
    • Wheezing over the tops, aggravated by coughing
    • Amphoric breathing (in the presence of large caverns)
    • Shortening of percussion sound above the tops of the lungs.
    • Course and forecast
    • The onset of the disease is latent
    • Lung damage develops over several weeks
    • With the natural development of the process, a third of patients note a long course of the disease with periods of remissions and exacerbations.
    • In the process of lung lesion progression, central necrosis is accompanied by the development of caseosis, so named for the outward resemblance of necrotic material to cheesy masses, which can subsequently be partially liquefied.
    • Necrotic material can be torn off through the bronchi with the formation of pulmonary caverns – cavity formations of a tuberculous nature. At the same time, bronchogenic screening is possible with the development of new areas of exudative inflammation. In some patients, the process may capture a segment or lobe
    • Sometimes the bronchogenic spread of tuberculosis occurs due to a breakthrough of the affected peribronchial lymph node into the lumen of the bronchus (adenogenic tuberculosis)
    • With the progression of tuberculosis, the lung loses its normal structure – typical development of fibrosis, a decrease in lung volume and pulling up the roots of the lungs
    • With timely chemotherapy, the newly diagnosed process heals with relatively little loss of lung tissue.
    • On average, 60% of untreated patients die within 2.5 years.
    • Focal pulmonary tuberculosis is a minor clinical form. It can be newly revealed (soft-focal) or involutive (fibrous-focal) as a result of the reverse development of more severe forms. Isolation of mycobacteria by patients, as a rule, is absent. The diagnosis is confirmed by fluorography or x-ray of the chest. Differential diagnosis is carried out with focal pneumonia, early stages of tumors and focal pneumosclerosis.
    • Infiltrative pulmonary tuberculosis is the most common form of secondary tuberculosis, characterized by the presence of an infiltrate in the lungs. It can be asymptomatic with broncholobular infiltrate or occur with fairly pronounced symptoms of tuberculous intoxication, cough and even hemoptysis with lobite. Manifestations of other clinical and radiological forms gradually increase from segmentitis, rounded infiltrate, cloud-like infiltrate and periscissuritis (with involvement of the interlobar sulcus) to caseous pneumonia, currently isolated in a separate clinical form and characterized by damage to the lobe of the lung and more, massive caseous necrosis with its subsequent decay and rejection, suppression of immune responses (despite bacilli excretion, tuberculin tests are hypo- or energetic, see below).
    • Tuberculoma of the lung is a relatively favorable form, characterized by an encapsulated caseous focus with a diameter of more than 1 cm. Most often, it is the result of involution of the exudative-caseous focus in individuals with an increased level of specific immunity (tuberculin tests are more often hyperergic). There are small tuberculomas (up to 2 cm in diameter), medium (2-4 cm) and large (more than 4 cm in diameter). Differential diagnosis is carried out with benign and malignant tumors, vascular aneurysms, echinococcus cyst. Treatment is conservative and operative (lung resection).
    • Cavernous pulmonary tuberculosis is characterized by the presence of a formed cavity, which is displayed on the radiograph as an isolated annular shadow in the lung. This form arose during the introduction of antibiotic therapy, in which the existence of a tuberculous cavity may not be accompanied by seeding or severe infiltration. The formation of a cavity occurs in the presence of infiltrative or disseminated pulmonary tuberculosis. The decay of the cavity is manifested by a cough with sputum, moist rales in the lungs, hemoptysis, and bacterial excretion. The formed cavity is oligosymptomatic. It is clearly visible on a plain radiograph or CT scan of the chest. It is believed that the cavernous form exists up to 2 years, during this period it is either cured (including lung resection), or progresses to fibrous-but-cavernous tuberculosis,
    • Complications – pulmonary hemorrhage, especially with the progression of tuberculosis (the presence of terminal pulmonary arteries inside the cavities creates a risk of profuse pulmonary hemorrhage from the so-called Rasmussen aneurysms; another underlying cause of bleeding is the development of aspergilloma in a chronically existing tuberculous cavity [including sanitized cavities], in this case hemorrhage not associated with the progression of tuberculosis). A breakthrough of the tuberculous cavity into the pleural cavity can lead to tuberculous empyema and bronchopleural fistula.
    • Fibrous-cavernous pulmonary tuberculosis is the most unfavorable hyperchronic form; typical are the presence of thick-walled, infrequently deformed cavities surrounded by fibrous tissue, bronchial deformities, displacement of mediastinal organs, persistent or recurrent bacilli excretion of multiresistant strains of M. tuberculosis, the development of complications such as hemoptysis and pulmonary hemorrhage, amyloidosis, irreversible pulmonary heart failure, spontaneous pneumothorax . Patients with fibro-cavernous pulmonary tuberculosis pose the greatest threat to the healthy population, require isolation

and prolonged chemotherapy. The prognosis for this form of tuberculosis is often poor.

    • Cirrhotic pulmonary tuberculosis is the final form of secondary tuberculosis, resulting from the involution of fibrous-cavernous, chronic disseminated, massive infiltrative tuberculosis, pleural lesions and TVLNU with bronchopulmonary lesions. Growth of coarse connective tissue in the lungs and pleura is characteristic. This is a terminal, but not the most dangerous form of pulmonary tuberculosis (most often patients are oligobacillary). The cure of such patients is problematic, since the diffusion of tuberculostatics into the altered tissue is sharply reduced. Local forms can be cured surgically.
    • Extrapulmonary tuberculosis
    • Pleura lesions in tuberculosis are observed in the form of three options.
    • Allergic pleurisy is a paraspecific reaction from the pleura. In this case, in the pleural fluid, bacterioscopy and bacteriological examination do not detect mycobacteria, and the biopsy material does not reveal tuberculous granulomas.
    • Perifocal pleurisy is a lesion of the pleura, directly adjacent to the area of ​​lung tissue affected by tuberculosis.

+ Tuberculous pleurisy – hematogenous or lymphogenous seeding of the pleura with tuberculosis with the formation of tuberculous tubercles on its sheets. In the United States, this clinical form is often observed in people over 35 years of age (it accompanies pulmonary tuberculosis in about every 30% of its patients). Tuberculous pleurisy, untreated with anti-tuberculosis products, traditionally subsides spontaneously, but 2/3 of the patients develop active pulmonary tuberculosis within 5 years. – Clinical picture. The occurrence of a unilateral (usually) pleural effusion, not often massive, accompanied by pain in the side on the side of the lesion. Most often, symptoms develop quickly. Classically, exudative tuberculous pleurisy occurs in young people who have not previously had tuberculosis. – Severe complications: bronchopleural fistula and tuberculous empyema of the pleura due to a breakthrough of a pulmonary lesion into the pleural cavity. In this case, the diagnosis does not cause problems, since mycobacteria are often present in the pleural fluid. Treatment consists of drainage of the pleural cavity and chemotherapy. – Examination of the pleural fluid. The effusion has the character of an exudate. In the pleural fluid, lymphocytes traditionally predominate, mesothelial cells are not often found. Note. Pleural puncture is necessary for both diagnostic and therapeutic purposes. If the liquid is not quickly evacuated, then fibrin loss with the formation of adhesions is observed. Pumping out the liquid to dryness is unjustified, since there is a high risk of injuring the lung. The need for surgical decortication occurs infrequently. – Puncture biopsy of the parietal pleura reveals granulomas. – Tuberculin diagnostics (see below). The tuberculin skin test is negative in a third of patients because pleurisy often develops before tuberculin hypersensitivity develops.

    • Tuberculous pericarditis is sometimes combined with pleurisy and may be a sign of a generalization of the process. Usually the pericardium is contaminated with mycobacteria from the affected lymph node, i.e. lymphogenically
    • Characteristic symptoms are fever and chest pain. On auscultation of the heart, a pericardial friction rub can be heard. In some cases, cardiac tamponade occurs. The most dangerous chronic stenosing pericarditis
    • Diagnosis of tuberculous pericarditis is often difficult and may require thoracotomy and pericardial biopsy.
    • Tuberculosis of the larynx is most often observed in patients with advanced forms of pulmonary tuberculosis. Rarely, it occurs in individuals with minimal lung involvement. It occurs due to the ingress of mycobacteria on the mucous membrane of the larynx during expectoration of sputum. The process begins with superficial laryngitis, then ulceration and granuloma formation occur. Sometimes the epiglottis is damaged. Dysphonia is the main symptom of tuberculous laryngitis.
    • Tuberculosis of the bronchi traditionally leads to damage to part of the lung. Characteristic symptoms are cough and non-cordinal hemoptysis. At the same time, patients with tuberculosis of the larynx and bronchi are traditionally very contagious. At the same time, these processes quickly respond to chemotherapy, and then the prognosis for the patient is usually favorable.
    • Tuberculosis of the lymph nodes (scrofula). The term scrofula is used to denote chronic tuberculous lymphadenitis of the cervical lymph nodes. Any group of cervical lymph nodes can be affected, but the anterior cervical triangle immediately under the lower jaw is a favorite place for this form of tuberculosis. Tuberculosis-affected lymph nodes have a rubbery consistency and are painless. With progression, they become more dense and soldered. Skin fistulas with chronic lymphorrhea may form, but this phenomenon is not often observed. Diagnosis is usually made by surgical biopsy. The lymph node taken for biopsy should be examined both bacteriologically and histologically. Before the biopsy or immediately after it, chemotherapy will need to be started, avoiding the formation of a postoperative fistula at the site of this operation. Lymph nodes located outside the neck are affected by tuberculosis less often, their involvement is approximately 35% of tuberculous lymphadenitis. Note. In infants, lymph node involvement can be caused by mycobacteria such as M. scrofulaceum and M. in-tracellulare. The process develops traditionally at the age of 5 years. As with tuberculosis, the upper cervical lymph nodes are most often affected. Often only one node is enlarged. Typically, there are no general symptoms, and the inflamed lymph node is not painful. Equally typical is the progression of the process with the development of necrosis of the lymph node and the formation of a fistulous tract. These mycobacteria are not sensitive to tuberculostatics and, if necessary, the node is excised.
    • Tuberculosis of bones and joints is not an uncommon manifestation of tuberculosis. Osteoarticular tuberculosis can occur in the form of primary osteitis with damage to the vertebral body and its destruction, but without the spread of tuberculosis.

process beyond the vertebrae. Pdtt’s disease (tuberculous spondylitis, tuberculosis of the spine) affects its middle part. Mycobacteria enter the spine via the hematogenous route or through the lymphatic vessels from the pleural cavity to the paravertebral lymph nodes. Erosion of the anterior plane of the vertebral bodies leads to their collapse and pronounced kyphosis without scoliosis with the formation of a hump (gibbus). Paraplegia may occur. In the absence of neurological disorders, Pott’s disease is amenable to chemotherapy, although surgical correction is not often necessary. If there is a risk of developing paraparesis, an urgent orthopedic consultation may be necessary. Progressive spondylitis is characterized by the spread of the process beyond the vertebrae with damage to the adjacent vertebrae, curvature of the spinal column, the appearance of cold abscesses, fistulas, spinal disorders. Abscesses do not require drainage if adequate chemotherapy is given and if they do not grow large. Spread through the intermuscular spaces can lead to the development of streaks – new abscesses remote from the main focus. M. tuberculosis also affects the flat bones and joints of the pelvis and chest, bones and joints of the skull and face. Tuberculosis of the joints most often affects large joints – the hip and knee. This type responds well to chemotherapy. Tuberculous synovitis is observed both as an independent pathology and in combination with tuberculous arthritis. Not often in general practice, tuberculosis-allergic synovitis and arthritis as a paraspecific reaction of the synovial membrane of the joint to distant hidden foci of tuberculosis infection are a diagnostic mystery. Abscesses do not require drainage if adequate chemotherapy is given and if they do not grow large. Spread through the intermuscular spaces can lead to the development of streaks – new abscesses remote from the main focus. M. tuberculosis also affects the flat bones and joints of the pelvis and chest, bones and joints of the skull and face. Tuberculosis of the joints most often affects large joints – the hip and knee. This type responds well to chemotherapy. Tuberculous synovitis is observed both as an independent pathology and in combination with tuberculous arthritis. Not often in general practice, tuberculosis-allergic synovitis and arthritis as a paraspecific reaction of the synovial membrane of the joint to distant hidden foci of tuberculosis infection are a diagnostic mystery. Abscesses do not require drainage if adequate chemotherapy is given and if they do not grow large. Spread through the intermuscular spaces can lead to the development of streaks – new abscesses remote from the main focus. M. tuberculosis also affects the flat bones and joints of the pelvis and chest, bones and joints of the skull and face. Tuberculosis of the joints most often affects large joints – the hip and knee. This type responds well to chemotherapy. Tuberculous synovitis is observed both as an independent pathology and in combination with tuberculous arthritis. Not often in general practice, tuberculosis-allergic synovitis and arthritis as a paraspecific reaction of the synovial membrane of the joint to distant hidden foci of tuberculosis infection are a diagnostic mystery. and if they do not reach large sizes. Spread through the intermuscular spaces can lead to the development of streaks – new abscesses remote from the main focus. M. tuberculosis also affects the flat bones and joints of the pelvis and chest, bones and joints of the skull and face. Tuberculosis of the joints most often affects large joints – the hip and knee. This type responds well to chemotherapy. Tuberculous synovitis is observed both as an independent pathology and in combination with tuberculous arthritis. Not often in general practice, tuberculosis-allergic synovitis and arthritis as a paraspecific reaction of the synovial membrane of the joint to distant hidden foci of tuberculosis infection are a diagnostic mystery. and if they do not reach large sizes. Spread through the intermuscular spaces can lead to the development of streaks – new abscesses remote from the main focus. M. tuberculosis also affects the flat bones and joints of the pelvis and chest, bones and joints of the skull and face. Tuberculosis of the joints most often affects large joints – the hip and knee. This type responds well to chemotherapy. Tuberculous synovitis is observed both as an independent pathology and in combination with tuberculous arthritis. Not often in general practice, tuberculosis-allergic synovitis and arthritis as a paraspecific reaction of the synovial membrane of the joint to distant hidden foci of tuberculosis infection are a diagnostic mystery. Spread through the intermuscular spaces can lead to the development of streaks – new abscesses remote from the main focus. M. tuberculosis also affects the flat bones and joints of the pelvis and chest, bones and joints of the skull and face. Tuberculosis of the joints most often affects large joints – the hip and knee. This type responds well to chemotherapy. Tuberculous synovitis is observed both as an independent pathology and in combination with tuberculous arthritis. Not often in general practice, tuberculosis-allergic synovitis and arthritis as a paraspecific reaction of the synovial membrane of the joint to distant hidden foci of tuberculosis infection are a diagnostic mystery. Spread through the intermuscular spaces can lead to the development of streaks – new abscesses remote from the main focus. M. tuberculosis also affects the flat bones and joints of the pelvis and chest, bones and joints of the skull and face. Tuberculosis of the joints most often affects large joints – the hip and knee. This type responds well to chemotherapy. Tuberculous synovitis is observed both as an independent pathology and in combination with tuberculous arthritis. Not often in general practice, tuberculosis-allergic synovitis and arthritis as a paraspecific reaction of the synovial membrane of the joint to distant hidden foci of tuberculosis infection are a diagnostic mystery. Tuberculosis of the joints most often affects large joints – the hip and knee. This type responds well to chemotherapy. Tuberculous synovitis is observed both as an independent pathology and in combination with tuberculous arthritis. Not often in general practice, tuberculosis-allergic synovitis and arthritis as a paraspecific reaction of the synovial membrane of the joint to distant hidden foci of tuberculosis infection are a diagnostic mystery. Tuberculosis of the joints most often affects large joints – the hip and knee. This type responds well to chemotherapy. Tuberculous synovitis is observed both as an independent pathology and in combination with tuberculous arthritis. Not often in general practice, tuberculosis-allergic synovitis and arthritis as a paraspecific reaction of the synovial membrane of the joint to distant hidden foci of tuberculosis infection are a diagnostic mystery.

    • Urogenital tuberculosis can affect any part of the genitourinary system in both men and women, and most often has a hematogenous nature. Symptoms can be subacute, chronic, atypical. Most often, the final diagnosis is made with a positive result of bacteriological examination of urine.
    • Tuberculosis of the kidneys is manifested initially by pyuria and microhematuria with negative results of bacterioscopy. Diagnosis can be made on the basis of bacteriological examination of urine. As the disease progresses, cavities form in the kidneys. The final stage may be pyonephrosis. In the past, the removal of a kidney for its tuberculosis lesion was carried out quite often. When conducting adequate chemotherapy in nephrectomy, most often there will be no need.
    • Tuberculosis of the ureters and bladder is traditionally a consequence of the spread of mycobacteria in the urine. Sometimes ureteral stricture develops.
    • Tuberculosis of the male genital organs is a consequence of hematogenous tuberculosis or a complication of tuberculosis of the kidneys and urinary tract. More often there is a lesion of the prostate, seminal vesicles and epididymis. The process begins with tuberculous epididymitis with subsequent spread to the testicle, prostate and vas deferens. The course can be acute to asymptomatic. Tuberculous prostatitis and epididymitis are characterized by painless nodular seals, which are detected during an objective examination. In the majority of cases, epididymectomy is necessary for the radical cure of tuberculous epididymitis.
    • Tuberculosis of the female genital organs manifests itself in the form of: tuberculosis of the fallopian tubes (salpingitis), progressive tuberculosis of the uterine appendages (salpingoophoritis), widespread tuberculosis of the genital organs with the transition of the process from the appendages to the body of the uterus, tuberculosis of the external genital organs. In sick women, the menstrual cycle is disturbed, primary or secondary infertility develops. Characterized by pain in the lower abdomen and in the lumbar region, aggravated during menstruation. Treatment is conservative and surgical.
    • Tuberculous meningitis is a lesion of mycobacterium tuberculosis of the meninges. The meninges are affected by mycobacteria during the development of primary tuberculosis infection. Currently, this clinical form is most often observed in young children, however, late reactivation of the lesion in the meninges can cause tuberculous meningitis in adults who do not have signs of pulmonary tuberculosis. The clinical picture of meningitis of tuberculous etiology does not have specific signs. It is manifested by meningeal signs, but there may be signs of cranial nerve damage, which reflects the basilar spread of the infection. The lumbar puncture plays a decisive role in the diagnosis – the liquid is clear, flows out in frequent drops (cloudy liquid indicates purulent meningitis), CSF cytosis is 100-600 cells in 1 μl, lymphocytes predominate (normal – up to 3-5 lymphocytes per 1 μl), the protein content is increased to 6-10 g / l and above, the content of sugar and chlorides is reduced. In the resulting CSF, a delicate fibrin film in the form of a grid falls out in a day, in which mycobacteria are detected during bacterioscopic examination. When interpreting the data of CSF studies, the leading place is occupied by the protein-cell dissociation syndrome typical of tuberculous meningitis (congestion comes to the fore compared to inflammatory ones) – a high protein content and a relatively low cytosis, which indicates the so-called. block of liquor pathways. Mortality in tuberculous meningitis in the pre-antibacterial era was 100%, but even now only early diagnosis can radically help the patient. Effective treatment with isoniazid, rifampicin and ethambutol,
    • Tuberculomas of the meninges and brain can be diagnosed in adults many years later after primary infection. The main clinical manifestation is the appearance of seizures. Tuberculoma of the brain is most often formed in its subcortical regions.
    • Tuberculous encephalopathy is manifested by a violation

 

consciousness and coma.

    • Tuberculosis of the eye is observed among extrapulmonary forms relatively often in all age groups. Mycobacterium can affect any part of the eye. There are tuberculous allergic lesions of the eyes, but more often metastatic tuberculosis of the eyes is observed in the form of anterior and

peripheral uveitis, choroiditis, chorioretinitis. Diagnosis of ocular tuberculosis is extremely difficult and most often empirical. Clinical manifestations of eye tuberculosis are practically indistinguishable from sarcoidosis or systemic mycosis, however, phlyctenular keratitis is observed only with tuberculosis. It is customary to call a phlyctenula an infiltrate located in the superficial layers of the cornea or conjunctiva of the eyeball, consisting mainly of lymphoid cells. Flyctenulosis lesions are more likely manifestations of hypersensitivity to tuberculotoxins than mycobacterial infection. Tuberculous tubercles on the choroid of the eye are often observed in patients with miliary tuberculosis. Tuberculosis of the eye responds well to anti-tuberculosis therapy.

    • Gastrointestinal tuberculosis
    • The stomach is a barrier to tuberculosis infection. Ingestion of a large number of virulent bacilli does not lead to the development of the disease. Rarely, traditionally with extensive destructive pulmonary tuberculosis and severe malnutrition, ingested microorganisms reach the ileum and caecum with the development of tuberculous ileitis. Chronic diarrhea and fistula formation are typical but will need to be differentiated from Crohn’s disease. With a stricture of the intestine, partial intestinal obstruction develops. The most severe complication is perforation of the intestinal ulcer with the development of diffuse peritonitis.
    • Tuberculosis of the liver can be observed as an independent clinical form or as a manifestation of miliary tuberculosis.
    • Tuberculous mesadenitis in the infiltrative phase is characterized by a poor clinical picture, while in the caseous-necrotic phase it is manifested by the involvement of the peritoneum in the process.
    • Tuberculous peritonitis – see Tuberculous peritonitis.
    • Tuberculosis of the adrenal gland. Hematogenous infection of the adrenal gland occurs frequently, but the disease therefore develops infrequently and traditionally accompanies extensive pulmonary processes. The adrenal cortex is most frequently involved, resulting in adrenal insufficiency. In differential diagnosis, it should be taken into account that even extensive damage to the adrenal cortex in carcinomatosis does not often lead to adrenal insufficiency.
    • Tuberculosis of the skin and subcutaneous tissue is a rare form of tuberculosis that can manifest as primary or secondary scrofuloderma, acute miliary skin tuberculosis, or chronic progressive skin tuberculosis (lupus vulgaris). The last form is a granulomatous skin lesion that responds well to treatment. Diagnosis is based on the results of a skin biopsy. Tuberculin hypersensitivity is typical. Sometimes erythema nodosum is observed, although this symptom is more characteristic of other granulomatous processes (sarcoidosis, systemic mycosis). Sometimes tuberculides appear – papular lesions of the skin or mucous membranes that occur as a result of specific sensitization to the causative agent of tuberculosis.
    • Silicotuberculosis. Much more often than in the general population, tuberculosis is observed in patients with silicosis and other pneumoconiosis. Most often, focal tuberculosis, disseminated tuberculosis and tuberculoma are combined with pneumoconiosis. Diagnosis is often difficult because X-ray signs of pneumoconiosis mask the manifestations of tuberculosis. A pronounced radiological similarity is observed between tuberculoma and silicoma (a conglomerate of silicotic nodules), as well as in a tuberculous cavity and disintegrated silicoma. The main distinguishing feature of tuberculous changes is the dynamics in the course of chemotherapy. Sometimes with silicotuberculosis, the leading clinical sign may be increasing respiratory failure. Patients with silicotuberculosis require a longer treatment than that provided for in the classical schemes.
    • Tuberculosis in AIDS patients. Tuberculosis is one of the main opportunistic infections in HIV-infected individuals. In patients who are first infected with M. tuberculosis and then with HIV, the risk of developing tuberculosis is 5-10% per year. If these infections develop in reverse chronological order, then their combination is more dramatic: tuberculosis occurs in more than 50% of HIV-infected people traditionally within a few months immediately after the initial infection.
    • Lymphocytes and monocytes, the main cells of defense against tuberculosis infection, are destroyed by HIV. However, the insufficiency of anti-tuberculosis immunity manifests itself early, before a significant decrease in CB4
    • -lymphocytes. In HIV-infected individuals without clinical manifestations of AIDS, skin tuberculin susceptibility may be lost, although 2/3 of HIV-infected patients with tuberculosis have positive tuberculin tests. Despite the fact that tuberculosis can develop in any phase of the course of HIV infection in individuals who are at the same time infected with M. tuberculosis, it is 1–3 months ahead of other opportunistic infections in AIDS. For HIV-seropositive tuberculosis patients, the number of CO4
    • -lymphocytes is traditionally 150-200 cells per 1 ml, although significant individual variations are possible.
    • Approximately half of AIDS patients have extrapulmonary forms of this disease with tuberculous lymphadenitis, predominantly of the anterior cervical lymph nodes. Among patients with AIDS and pulmonary tuberculosis, within half, they have an atypical radiological picture with diffuse tender infiltrates, pulmonary infiltrates, lymphadenopathy of the roots and basal infiltration. Pleural effusion is a fairly common finding. Some AIDS patients with microbiological evidence of mycobacteria in sputum may have a normal chest x-ray.
    • In patients with AIDS, other mycobacterioses are often observed. In the United States, approximately 50% of patients are diagnosed with a disseminated process caused by M. avium, which develops in the later stages of AIDS. At the same time, in Africa (Saharan region), among those with AIDS, there are practically no cases of M. avium lesions.

 

Laboratory research

    • General blood test – moderate anemia, increased ESR, lymphopenia, monocytosis within 8-12%.
    • Bacterioscopy and bacteriological examination of sputum (in most cases), urine or other physiological fluids and tissues can identify the pathogen.
    • The likelihood of a positive smear or culture result is directly related to the extent and nature of lung lesions.
    • Approximately 30% of patients with bacterial excretion can be detected by primary microscopy of a stained sputum smear. With microscopy of smears for several days in a row, the diagnosis of bacterial excretion rises to 2-thirds. No need to use more than five sputum samples
    • With limited forms of pulmonary tuberculosis, approximately 30% of patients will have a positive sputum smear even after multiple examinations.
    • In the absence of pathology on a chest x-ray, the detection of mycobacteria in a smear is unlikely, and there is no indication for further microbiological studies.
    • If a patient with an extensive destructive or infiltrative process in the lungs has a negative sputum smear, the disease is more likely to be non-tuberculous in nature.
    • If there is no sputum or it does not come out well, then provocative inhalations are used or samples are taken by nasotracheal aspiration.
    • An excellent material for a smear and bacteriological examination is an aspirate of gastric contents taken early in the morning. Although non-pathogenic mycobacteria are sometimes found in gastric aspirate, their numbers are extremely small and do not interfere with the diagnosis of tuberculosis.
    • Bronchoscopy is a highly informative method in the diagnosis of tuberculosis, but its use in taking microbiological samples is justified only in case of repeated unsuccessful attempts to obtain material using simpler methods in patients with an unclear diagnosis.
    • New methods for rapid diagnostics
    • Serological studies in tuberculosis are based on the recognition of serum IgG specific for mycobacterial Ag. Note. Solid-phase ELISA (ELISA) – informativeness can be high in infants and in patients with extrapulmonary tuberculosis in regions with a low prevalence of tuberculosis.
    • The DNA polymerase method (PCR) makes it possible to detect a non-cordial (10–1000) number of mycobacteria in the test material by identifying a DNA segment and repeating it multiple times (amplification). The result of the study can be obtained within 2 hours. A distinctive feature of the method is its high specificity. Note. Despite the fact that Amplicor and Genprobe commercial test systems are already in operation, the DNA polymerase method has not yet been widely used. In laboratories with advanced chromatographic techniques, rapid identification of mycobacteria is possible by detecting species-specific lipids.
    • Liver function tests are important at high risk of chemotherapy complications (see below).

 

Special Studies

    • Mass fluorography is a traditional method for detecting tuberculosis in Russia. The advantage is high throughput and mobility. Fluorography is carried out among the population 1 r / 2 g.
    • X-ray and CT of the chest organs are an important method for diagnosing tuberculosis. Usually, a direct survey radiograph, a lateral radiograph from the side of the lesion, and tomograms are performed.
    • Primary changes in the lungs can be represented by calcifications (for example, Gon’s focus). Note. Such changes also leave behind histoplasmosis and coccidioidomycosis, which are extremely difficult to distinguish from post-tuberculous changes. For histoplasmosis, calcification of the right paratracheal lymph nodes is more characteristic.
    • The accumulation of foci and infiltration in the upper posterior segments of the upper lobe and the upper segment of the lower lobe are typical signs of secondary pulmonary tuberculosis. Infiltrates tend to disintegrate with the formation of caverns. Layer-by-layer examination of the lungs often helps to identify foci characteristic of tuberculosis in other parts of the lungs, traditionally not found in carcinoma. Pictures in the position of lordosis allow to recognize changes hidden on a traditional radiograph in direct projection by a combination of shadows of the posterior sections of the 30% and the fourth rib, the anterior part of the second rib and the clavicle. With other localization, this position does not provide additional information. With a decrease in the activity of tuberculosis or its cure, cicatricial changes and fibrosis remain on the radiograph. The affected upper lobes are reduced in volume, typically pulling the roots of the lungs up and medially. Fibrotic changes may undergo calcification. Tuberculosis activity can be assessed by radiographs taken over time.
    • Tuberculin tests are all kinds of ways to introduce tuberculin to detect sensitization of the body to Mycobacterium tuberculosis.
    • The Pirquet test is a skin scarification test performed by applying a drop of old Koch tuberculin (ATK) to the skin of the inner plane of the forearm and scarifying the skin through the applied drop. After 48-72 hours, an assessment of the local reaction is carried out. At present, the test is practically not used due to the low standard in the setting of the test (different drop sizes, different length and depth of the scratch, etc.).
    • Graduated test of Pirke (Karpilbvsky-Grinchara) is a modified test of Pirke. On the skin of the inner plane of the forearm or the anterior plane of the thigh, 4 different tuberculin solutions are applied dropwise: 100%, 25%, 5% and 1%, and as a control, the fifth drop of 0.25% carbolic acid solution in 0.9% p-re NaCl, on which tuberculin solutions are prepared. Skin scarification through the applied drops is carried out, starting with the control solution and ending with 100% tuberculin. Reading the local reaction is carried out after 48-72 hours. Most often, this test is used in pediatric practice.
    • The Mantoux test is an intradermal injection of tuberculin. Usually, 0.1 ml (2 TU) of purified PPD-L tuberculin is administered and the result is evaluated after 48-72 hours. A papule of 5 mm or more is considered a positive test result. A papule with a diameter of 17 mm or more in children and 21 mm or more in adults is regarded as a hyperergic reaction. In differential diagnostic cases, with a negative reaction to 2 TU, a Mantoux test with 100 TU is performed.
    • Koch test – subcutaneous injection of tuberculin. This test requires an assessment of the general and focal reactions to the introduction of tuberculin after 48-72 hours. The general reaction is characterized by a change in the hemogram, proteinogram and other tests. Focal reaction in pulmonary tuberculosis is assessed auscultatively, according to radiographs, according to sputum tests in dynamics.
    • Notes
    • Tuberculin is an incomplete Ar M. tuberculosis (hapten) used for the diagnosis and differential diagnosis of tuberculosis. In Russia and the CIS countries, they are also used to stimulate sluggish tuberculosis. They produce 2 products – the old Koch tuberculin, or alttuberculin (ATK), and the purified protein derivative of MA Linnikova (PPD-L). – ATK, or old tuberculin – autoclaved filtrate of a 6-9-week broth culture of M. tuberculosis, condensed to 1/10 of the original volume. This product is used in Russia only in anti-tuberculosis institutions for individual tuberculin diagnostics when solving questions about the activity of the process or in differential diagnosis. 1 ml of ATK contains approximately 100,000 TU (tuberculin units). Use it in dilutions, multiples of ten.

The first is called a dilution of 1:10, the second – 1:100, etc. Usually IV and VI dilutions are used, in 0.1 ml containing 1 IU and 0.01 IU, respectively. In controversial cases, 100 IU or 0.1 solution of ATK II dilution is administered intradermally. In the bulk of European countries, ATK is not used; it was replaced by purified standard tuberculin Seibert-PPD-S. – Purified tuberculin MA Linnikova (PPD-JI – Purified Protein Derivative – purified protein derivative) is freed from the protein fractions of the nutrient medium, which makes the specificity of allergic reactions to it significantly higher. It is produced in 2 forms: standard solution and dry matter for dilution. For mass tuberculin diagnostics, a standard solution containing 2 TU in 0.1 ml is intended, while standard solutions containing 5 TU and 10 TU in 0.1 ml

    • Tuberculin diagnostics can be mass or individual.

– Mass Tuberculin Diagnosis – staging tuberculin samples to the population (especially annually – to children and adolescents) for early detection of tuberculosis, detection of tuberculosis infection and determination of indications for BCG revaccination. Mass tuberculin diagnosis is carried out using the Mantoux test with 2 TU PPD-L. With mass tuberculin diagnosis, the fact of primary infection or a turn of tuberculin samples is revealed. – Individual Tuberculin diagnosis – staging tuberculin samples in patients or when a disease is suspected for the purpose of differential diagnosis, evaluation of the activity of the process and dynamic monitoring. Depending on the specific situation, a Mantoux test with a different dose of tuberculin, a Koch test, a graduated Pirquet test are used. – Tuberculin test turn – the transition of a negative tuberculin test into a positive one or an increase in the papule by 6 mm or more. Sighted faces are subjected to further examination and, even if tuberculosis is not diagnosed, chemoprophylaxis with isoniazid is carried out. The ratio of the number of those who respond positively to the introduction of tuberculin to all persons with a tuberculin test is called infection and is expressed as a percentage. Hypersusceptibility to tuberculin can also occur upon contact with non-pathogenic environmental mycobacteria, which reduces the information content of this technique. Non-specific susceptibility to tuberculin is not often observed in states with a northern climate, here susceptibility to PPD reflects infection with M. tuberculosis. In countries with a warm and humid climate, including all coastal areas of the southeastern United States, characterized by nonspecific hyperreactivity to tuberculin. In such areas, it is generally accepted to consider a papule with a diameter of less than 10 mm as an unreliable result. However, this approach is not without the risk of missing TB in individuals with low overall reactivity. A papule >5 mm is regarded as a positive reaction in those who have been in contact with patients with tuberculosis, a papule >10 mm in groups of people with an increased risk of developing tuberculosis, a papule >15 mm in groups with a low prevalence and likelihood of tuberculosis, especially in geographic areas with a high incidence nonspecific tuberculin sensitivity. However, this approach is not without the risk of missing TB in individuals with low overall reactivity. A papule >5 mm is regarded as a positive reaction in those who have been in contact with patients with tuberculosis, a papule >10 mm in groups of people with an increased risk of developing tuberculosis, a papule >15 mm in groups with a low prevalence and likelihood of tuberculosis, especially in geographic areas with a high incidence nonspecific tuberculin sensitivity. However, this approach is not without the risk of missing TB in individuals with low overall reactivity. A papule >5 mm is regarded as a positive reaction in those who have been in contact with patients with tuberculosis, a papule >10 mm in groups of people with an increased risk of developing tuberculosis, a papule >15 mm in groups with a low prevalence and likelihood of tuberculosis, especially in geographic areas with a high incidence nonspecific tuberculin sensitivity.

    • Repeating tuberculin tests for a short period of time (1-2 weeks) leads to a booster effect, or an increase in reactivity to tuberculin. This is important for differentiating true sensitivity from non-specific. With repeated administration of tuberculin, the nonspecific reaction does not increase,
    • Anergy is commonly referred to as the paradoxical lack of skin sensitivity to tuberculin in infected individuals. It is observed in patients with a number of diseases and in individuals with immunosuppression.

physitis. It is also characteristic of 15% of patients with newly diagnosed tuberculosis, in whom reactivity is restored as the process stabilizes. Half of the patients with miliary tuberculosis and 30% of patients with newly diagnosed tuberculous pleurisy have negative tuberculin tests.

    • False-negative reactions to tuberculin appear with technical errors, including subcutaneous administration of the product, the end of the expiration date of tuberculin, and others.

 

Treatment:

 

Diet number 11

Classification of anti-tuberculosis products.

    • Depending on the strength of action (classification based on the recommendations of the International Tuberculosis Union)
    • Group I (highest activity) – isoniazid and rifampicin
    • Group II (products of medium efficiency) – streptomycin, kanamycin, florimycin, cycloserine, as well as ethambutol, ethionamide, prothionamide, pyrazinamide
    • Group III (products of moderate efficiency) – PASK, tibon (thioacetazone).
    • Depending on preference
    • First-line drugs are the most effective and are considered an integral part of any short-term course of chemotherapy. The drugs of choice are isoniazid and rifampicin. Additional products – pyrazinamide, ethambutol and streptomycin
    • Second-line drugs are clinically less effective and have more adverse reactions. They are prescribed mainly to patients requiring long-term treatment, or with polyresistance. These include PAS, ethionamide, cycloserine, kanamycin, amikacin, capreomycin, and thioacetazone.

 

Characteristics of individual products

  • Isoniazid (5 mg / kg, children – 10-20 mg / kg, adults and children no more than 0.3 g / day) – the main product
  • Side effects
  • Isoniazid -associated hepatitis is idiosyncratic and increases with age. Up to 35 years old, it is observed no more often than in 0.3% of cases, up to 49 years old – 1.2% and over 50 years old – 2.3%. The risk of hepatitis is increased with alcohol, rifampicin, and slow acetylators. In all cases of the risk of developing hepatitis, biochemical control of liver functions is necessary. To do this, it is advisable to determine the activity of ALT and ACT in the first 2-4 weeks, then monthly
  • Peripheral neuritis (dose-dependent) – in 2-20% of cases. The risk of development can be reduced to 0.2% with prophylactic pyridoxine 10–50 mg/day.
  • Others (rare) – rash (2%), fever (1.2%), anemia, acne, arthralgia, optic nerve atrophy, epileptic seizures and mental disorders.
  • Rifampicin (10 mg/kg/day) is the second most important drug
  • Side effects
  • Hepatotoxicity
  • Flu-like syndrome (20% in first-time intermittently treated patients)
  • Nausea and vomiting (1.5%)
  • Rash (0.8%)Hemolytic anemia (

     

     

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