Diagnostic minimums are mandatory additional and optional. Clinical minimum examination of patients for tuberculosis (Main course of chemotherapy II). ❝ Mandatory diagnostic minimum of examinations for tuberculosis ❞

BASIC PRINCIPLES OF TUBERCULOSIS DIAGNOSIS

The diagnostic process consists of several stages. The first stage is the selection of persons with various lung diseases among patients who sought medical help. This selection is usually carried out in clinics by doctors of the general medical network.

In different countries, the selection of individuals for research is carried out using different methods. For example, in developing countries in Africa and Asia, such individuals are selected from among those who sought medical help by asking about the presence of cough with sputum, which is collected and subjected to laboratory testing. Most patients with pulmonary tuberculosis in developing countries are identified by the presence of pulmonary symptoms.

In our country, the selection of patients with lung diseases is made by a doctor based on a set of data obtained from the study of complaints, anamnesis, and physical examination. When studying the stetoacoustic picture, it is sometimes very difficult to even suspect pulmonary tuberculosis, especially focal and even more widespread forms, therefore fluorography is currently proposed as a selection method. Fluorography allows you to identify even minor changes in extent, both fresh and old; It is recommended to use fluorography for all persons who visited the clinic this year for any reason. In order for all patients who come to the clinic to undergo fluorography, it is necessary to equip each clinic with fluorographs. In the absence of fluorographs, the selection of patients with lung diseases can be carried out using fluoroscopy. This is a large load for the doctor, for the X-ray equipment and, most importantly, not a very desirable radiation exposure for the subjects.

These methods are not applied after a clinical examination, but on the contrary, first, using fluorography, individuals with pulmonary pathology are selected, and then other research methods are prescribed. Patients with pulmonary tuberculosis can be identified by testing sputum for mycobacteria.

The task of phthisiatricians is to organize the correct selection of patients with lung diseases, including tuberculosis, among all patients who applied to the clinic and were admitted to the hospital. Currently, as the prevalence of tuberculosis decreases, the role of mass preventive examinations, including mass fluorography of the population, and, in relation to children and adolescents, tuberculin diagnostics, is increasing.

Stages of the diagnostic process:

1) application of research methods to the patient and accumulation of the information obtained;
2) analysis of the information received from the point of view of reliability, information content and specificity;
3) construction of a diagnostic symptom complex based on selected signs;
4) formulation of a presumptive diagnosis of a disease or a number of diseases;
5) differential diagnosis;
6) formulation of a clinical diagnosis (in expanded form);
7) checking the correctness of the established disease in the process of monitoring the patient and his treatment.

In a number of territories, up to 70% of all newly diagnosed tuberculosis patients are detected during mass preventive examinations, and the rest are found among people who seek medical help. Selection of patients with suspected pulmonary pathology is an important stage in the diagnosis of tuberculosis. Then selected patients with pulmonary pathology are examined in more depth, the results obtained are studied (analysis), and a preliminary or final diagnosis is formulated. The subsequent stages of diagnosis are the formulation of a clinical diagnosis and verification of the correctness of the established diagnosis in the process of observation and treatment.

Each clinician must choose from a large number of methods for examining pulmonary patients those that are necessary for a given patient. We proposed dividing all methods for examining pulmonary patients into three groups. The first group is mandatory methods (ODM is a mandatory diagnostic minimum). You can not use any method included in ODM if there are contraindications to its use. First of all, this is a clinical examination of the patient: a targeted study of the anamnesis, complaints, stetoacoustic picture, identifying not only bright, but also less pronounced symptoms of lung disease.

Clinical diagnosis of tuberculosis

V.Yu. Mishin

Diagnosis of tuberculosis includes several successive stages. In this case, all research methods are divided into 3 groups: mandatory diagnostic minimum (ODM), additional methods of non-invasive research (DMI-1) And invasive (DMI-2) character and, finally, optional methods (FMI).

ODM includes the study of complaints, medical and life history, clinical blood and urine tests, Ziehl-Neelsen sputum microscopy of at least three samples with quantitative assessment of the massiveness of bacterial excretion, x-ray of the chest organs in frontal and lateral projections and Mantoux test with 2 TE PPD-L .

TO DMI-1 include advanced microbiological diagnostics with sputum examination by PCR and sputum culture on nutrient media with determination of MBT drug resistance to anti-tuberculosis drugs, as well as sputum culture for nonspecific microflora and fungi; in-depth radiation diagnostics using CT of the lungs and mediastinum, ultrasound for pleurisy and subpleurally located round formations; in-depth immunodiagnostics using enzyme-linked immunosorbent assay (ELISA) to detect anti-tuberculosis antibodies (AT) and antigens (AG) in the blood.

In addition to microscopy of sputum and other pathological material as a mandatory diagnostic minimum, it is possible to study using fluorescent microscopy, PCR and the bacteriological (cultural) method of inoculation on nutrient media, which are carried out in specialized laboratories of anti-tuberculosis institutions.

Detection of MBT allows you to establish an etiological diagnosis without much difficulty. The most difficult situation in diagnosing tuberculosis occurs in patients with clinical symptoms in the absence of sputum, and also when MBT is not detected in the sputum. In these cases, the diagnosis of pulmonary tuberculosis is largely based on radiation methods for examining the chest organs.

These methods complement the results of clinical examination of patients, while their combined analysis makes it possible to increase sensitivity and specificity, and in case of negative data from microbiological and morphological studies, they are of decisive importance. X-ray CT of the lungs is the leading diagnostic method.

X-ray tomographic picture of pulmonary tuberculosis differs in polymorphism both in the nature of infiltrative changes and in the localization of specific changes, and requires targeted differential diagnosis.

Specific tuberculous inflammation has a variety of radiological manifestations - from single or multiple confluent foci, round infiltrates and recissuritis to lobar tuberculous pneumonia. However, most manifestations are characterized by localization of the process in the apical [C1], posterior [C2] and upper segments of the lungs.

All variants of pulmonary tuberculosis are characterized not only by the presence of focal and infiltrative shadows, but also quite often by cavities, which, as a rule, are accompanied by bronchogenic contamination, which has certain patterns, which can serve as a diagnostic sign.

In the presence of a cavity in the upper lobe of the left lung, the presence of foci of contamination along the periphery and in the anterior [C3], superior lingular, inferior lingular segments, as well as the basal medial, anterior basal, lateral basal [C9] and posterior basal [C10] segments of the lower lobe of the left lung is typical .

In right-sided cavities, foci of contamination spread to the underlying parts of the upper lobe with a predominant lesion of the anterior [C3] segment, and cross-metastasis also occurs in the left lung, mainly in the upper lingular and lower lingular segments.

In clinical practice diagnostic value of the Mantoux test with 2 TE PPD-L in adult patients with radiologically detectable changes in the lungs is determined by its negative or hyperergic reaction. If the patient has a negative Mantoux reaction (puncture reaction at the injection site), changes in the lungs are more likely to be non-tuberculous processes.

In the presence of a hyperergic reaction (papule size 21 mm or more in diameter or vesiculonecrotic reactions regardless of the size of the papule), changes in the lungs are more likely to be tuberculous.

A positive Mantoux 2 TE PPD-L reaction with a papule size of 5 to 20 mm in diameter has no diagnostic value, since more than 70% of the adult population by the age of 30 are already infected.

Currently used laboratory and immunological methods for diagnosing pulmonary tuberculosis are mainly indirect in nature and are used comprehensively to increase the significance of diagnosis verification.

In cases of doubtful activity of tuberculous changes in the lungs, exjuvantibus therapy can be used. In this case, chemotherapy is prescribed with four anti-tuberculosis drugs (isoniazid, rifampicin, pyrazinamide and ethambutol). In such cases, a repeat X-ray examination is necessary after 2 months.

In cases of tuberculous etiology, partial or complete resorption of inflammatory changes is observed - this is the so-called delayed diagnosis. By this time, it is possible to obtain the results of sputum culture on nutrient media, done before the start of chemotherapy. Culture growth in the presence of MBT in the material is usually observed after 4-8 weeks, which confirms the diagnosis.

DMI-2 include bronchoscopy with various types of biopsies (aspiration, brush, etc.) and BAL; puncture of the pleural cavity and pleurobiopsy; transthoracic lung biopsy; thoracoscopy, mediastinoscopy and, finally, open lung biopsy with subsequent cytological, histological and microbiological studies of the obtained material.

Detection of specific elements of tuberculous granuloma (caseosis, epithelioid and multinucleated cells) in a biopsy specimen allows morphological verification of pulmonary tuberculosis and timely initiation of anti-tuberculosis treatment.

FMI are very numerous and are aimed not so much at diagnosing tuberculosis, but at determining the functional state of various internal organs and metabolic processes. They examine the level of glucose in the blood, liver function, cardiovascular system, external respiration function, blood gas composition, pulmonary blood flow, etc.

Correct and timely diagnosis of respiratory tuberculosis makes it possible to identify patients in the early stages of disease development, and timely initiation of chemotherapy will prevent the development of common progressive forms with the release of MBT.

ODM should be carried out, as the name itself suggests, in full. DMI/FMI optional methods are used according to indications.

Phthisiatrician's notebook - tuberculosis

Everything you want to know about tuberculosis

Mandatory diagnostic minimum (MDM) for patients who applied to the general medical network (GPN) for suspected tuberculosis

Skachkova E. I.

The successful solution of diagnostic problems in identifying tuberculosis by a doctor of a general medical network, the correct collection of sputum by medical staff of health care facilities and high-quality laboratory diagnosis of tuberculosis showed the importance of such a section of work as training of health care facility personnel involved in the process of identifying and diagnosing tuberculosis among the assigned population. The level of knowledge identified before the training and at the time of its completion actually determines the results of the event and allows you to plan further methodological work with personnel.

In case of suspicion of tuberculosis, patients who apply to general medical institutions are prescribed targeted tests (mandatory diagnostic minimum) according to the scheme presented below:

Anamnesis;
Inspection;
General analysis of blood, sputum and urine;
3-fold bacterioscopic examination of the material for MBT according to Ziehl-Neelsen or using a fluorescent microscope (sputum, urine, cerebrospinal fluid, punctate, pus, fistula discharge, effusion);
Radiation diagnostics (radiography of the chest and affected organs, tomography, CT, MRI if necessary);
Tuberculin diagnostics in children using the Mantoux test with 2 TE PPD-L.

The issue of actively attracting the population to a medical institution to carry out activities to identify tuberculosis, as one of the socially significant diseases, can also be successfully resolved by opening a “trust” telephone in the office of a phthisiatrician. Coverage of the helpline in the media allows the population to find out the phone number and take advantage of telephone consultation to resolve issues that concern them regarding the detection, treatment and prevention of tuberculosis.

Diagnostic minimum for tuberculosis

DIAGNOSIS OF TUBERCULOSIS IN CHILDREN

Bogdanova E.V., Kiselevich O.K.

Department of Phthisiopulmonology, Russian State Medical University

The lack of specific clinical symptoms and the variety of clinical manifestations of tuberculosis in children creates significant difficulties in diagnosing the disease. Therefore, the main condition for timely diagnosis of tuberculosis is a comprehensive examination of the patient, which is carried out by a phthisiatrician.

Identification of children in need of consultation with a phthisiatrician is carried out by pediatricians of the general medical network at sites and in hospitals. The pediatrician needs to know the risk groups for tuberculosis among children and adolescents. Children and adolescents from these groups should be promptly referred for consultation to a phthisiatrician. In addition, the pediatrician has to resolve issues of differential diagnosis of tuberculosis and other diseases.

Diagnosis of tuberculosis in children is difficult. Clinical manifestations are varied, but do not have strictly specific features. Tuberculosis in children often occurs under the guise of various diseases - ARVI, bronchitis, etc.

To diagnose tuberculosis, a phthisiatrician uses a set of mandatory examination methods - Mandatory Diagnostic Minimum (MDM) which includes:

1. Taking an anamnesis: identifying the source and route of infection of the child with MTB, identifying unfavorable medical and social factors, assessing the dynamics of tuberculin sensitivity using the Mantoux test with 2TE PPD-L;

2. Identification of complaints. Close attention is paid to complaints of loss of appetite, restless sleep, fatigue, irritability; in schoolchildren – decreased memory, attention, deterioration in academic performance, headaches; increase in temperature, etc.;

3. Examination and physical examination methods;

1) X-ray examination allows you to visualize changes in the lungs and/or intrathoracic lymph nodes, characteristic of various forms of tuberculosis. For this purpose, a survey radiography of the chest organs is performed in direct and lateral projections, tomography of the affected area;

2) A clinical blood test allows you to identify certain changes. With active tuberculosis, a combination of anemia and lymphopenia is often found, with complicated tuberculosis - leukocytosis, shift to the left, monocytosis, acceleration of ESR.

3) General urine analysis. Changes in tests are not specific, but in combination with other signs confirm the activity of the tuberculosis process.

4) Examination of sputum, a smear from the back of the throat in order to detect MBT is carried out at least 3 times within 3 days;

5) Individual tuberculin diagnostics (skin prick test, Mantoux test with tuberculin dilutions; Koch test in a hospital setting) - according to indications.

There are 2 pathognomonic criteria tuberculosis process:

I. The causative agent of tuberculosis is Mycobacterium tuberculosis (MBT).

Detection of MBT in material from a patient indicates the specificity of the pathological process in the patient’s body.

The choice of material for research depends on the clinical form of tuberculosis, the phase of the tuberculosis process, and the age of the patient. Most often, sputum, bronchial and gastric lavages, feces, urine, biopsy and surgical material, pleural exudate, etc. are examined.

The following microbiological research methods are used:

1) Bacterioscopic method :

Bacterioscopic examination is the fastest, simplest and cheapest method for identifying acid-fast mycobacteria. However, the bacterioscopic method makes it possible to detect mycobacteria with a content of at least 5000-10000 in 1 ml of the test material. Microscopic detection of acid-fast mycobacteria does not allow differentiating the causative agent of tuberculosis from atypical and saprophytic mycobacteria.

2) Culture method(inoculation on nutrient media) makes it possible to detect MBT in the presence of several tens of microbial cells in 1 ml of the test material.

However, the growth of MBT culture on a solid nutrient medium occurs over a long period of time - 2-3 months. Currently, liquid nutrient media have been obtained on which MBT grow for 10-14 days. Of great importance is the quantitative assessment of the contamination of the studied material, which makes it possible to assess the severity of the process, its prognosis and determine treatment methods. The cultural method makes it possible to differentiate MBT from other types of mycobacteria and determine the drug sensitivity/resistance of MBT to anti-tuberculosis drugs.

3) Biological method — infection of laboratory animals (especially sensitive guinea pigs). The method is highly sensitive, because allows you to get a positive result if the test material contains even single (1-5) mycobacteria. The duration of the study is 1.5-2 months. This method can only be used in laboratories of Federal Research Institutes.

Each of the methods used has its positive aspects and certain limitations.

Additional diagnostic and differential diagnostic tests for tuberculosis are immunological studies and molecular biological methods. These methods make it possible to identify the causative agent of tuberculosis when its viability decreases. Immunological methods make it possible to assess the reactivity of the patient’s body, identify the activity of the tuberculosis process, monitor the effectiveness of treatment, determine the need for surgical treatment, and predict the further dynamics of a specific process.

§ determination of MBT antigens and antibodies to the causative agent of tuberculosis using enzyme-linked immunosorbent assay (ELISA);

§ determination of the DNA of Mycobacterium tuberculosis using the polymerase chain reaction (PCR).

II . Elements of tuberculous granuloma, detected by histocytological methods in the studied material.

A protective inflammatory reaction is formed around the focus of necrosis caused by MBT: a shaft of epithelioid cells, Pirogov-Langhans giant cells, and an accumulation of lymphocytes.

The possibility of morphological research is associated with certain difficulties, because in various clinical cases of tuberculosis in children, pathological material for research may not be available.

Therefore, for early and correct diagnosis of the disease in children, the main role is played by the assessment of a complex of clinical, x-ray and laboratory data.

Basic methods for detecting tuberculosis in children and adolescents

Currently, detection of tuberculosis among children and adolescents is possible using the following methods:

o Mass tuberculin diagnostics. The Mantoux test with 2 TE PPD-L is used as a mass screening test.

Mass tuberculin diagnostics is aimed at:

— early detection of tuberculosis in children and adolescents;

— study of MBT infection and the annual risk of primary infection.

Tuberculin tests do not allow one to judge the strength of anti-tuberculosis immunity.

Children from risk groups on the development of tuberculosis. Risk groups include:

1. Newly infected with MBT. The fact of primary infection is established by the “turn” of the tuberculin reaction.

2. Infected individuals with hyperergic sensitivity to tuberculin, which is determined by the size of the infiltrate of 17 mm or more, the presence of vesicular-necrotic reactions at the site of intradermal injection of tuberculin.

3. MBT-infected persons with an increase in tuberculin sensitivity. An increase in sensitivity to tuberculin is determined by an increase in the size of the infiltrate by 6 mm or more compared to the previous year.

4. Persons with an unclear etiology of allergy to tuberculin - if at this time it is not possible to resolve the issue of the cause of a positive reaction to tuberculin (post-vaccination? infectious?). There are no absolute criteria for the differential diagnosis of post-vaccination and infectious tuberculin allergies. Often the question of the nature of the reaction is decided by a phthisiatrician during dynamic observation. In addition to the size of the infiltrate, an assessment of its qualitative characteristics is also taken into account: color intensity, clarity of contours, period of preservation of pigmentation after the infiltrate fades.

5. MBT-infected persons, if the Mantoux test with 2 TE PPD-L was performed irregularly. In this group, special attention should be paid to frequently ill children and adolescents and those with concomitant diseases.

o Timely examination of children in contact with the patient tuberculosis.

Much attention should be paid to identifying the source of infection of children with Mycobacterium tuberculosis. The routes of infection of children and adolescents depend on the nature of the source of infection.

1. Aerogenic route – contact with a person suffering from tuberculosis, especially a bacteria-excreting person. In this case, infection occurs with M. tuberculosis.

2. Alimentary route – consumption of infected milk and thermally untreated dairy products from animals with tuberculosis. Infection occurs with M. bovis.

3. Contact route - when MBT penetrates through damaged skin and mucous membranes, primary local damage to these organs occurs.

4. The transplacental route is rare. Damage to the placenta, both tuberculosis and damage during childbirth, plays an important role. MBT penetrate through the umbilical vein into the fetus, remain mainly in the liver, and damage to the portal lymph nodes is possible. Primary damage can occur in the lungs and other organs when the fetus aspirates and ingests infected amniotic fluid.

In most cases, children, especially of early and preschool age, are infected with MTB in the family. The danger of a family focus of tuberculosis infection is determined not only by the massiveness of the infestation, but also by its duration. In most cases, a child being in contact with a patient with tuberculosis from the first months of life leads to the development of the disease. As a rule, in these cases, children develop generalized, complicated forms of tuberculosis.

When a tuberculosis patient is identified in a family, contacts are immediately disconnected. The child is sent for consultation to a phthisiatrician for examination within 7-10 days (ODM). For children, the most essential preventive measure is to prevent contact with a person with tuberculosis.

o Examination when presenting with symptoms of the disease.

The initial manifestations of the tuberculosis process are scanty: loss of appetite, body weight, fatigue, irritability, periodic rises in temperature to low-grade levels, etc.

Young children become whiny, capricious, and sleep restlessly. In children of this age group, loss of appetite and weight loss are especially noticeable.

Children of preschool age quickly get tired when playing, sweating appears, periodically - dyspepsia, abdominal pain.

Schoolchildren's performance declines, memory and attention deteriorate. Children complain of rapid fatigue, frequent headaches, and sometimes fleeting pain in muscles and joints.

Symptoms of intoxication reflect dysfunction of the nervous system caused by the toxic effects of Mycobacterium tuberculosis on the nervous system.

Temperature changes during tuberculosis in children are highly variable. Most often it is low-grade fever. At the same time, active tuberculosis can occur with normal or febrile temperature. Sometimes there are significant temperature fluctuations in the morning and evening.

Cough appears during complicated tuberculosis in children. At the onset of the disease, cough is not the leading symptom.

Vivid clinical manifestations of the disease are observed in patients with common forms and complicated course of tuberculosis. But there are no pathognomonic clinical symptoms of tuberculosis. Therefore, timely diagnosis of the tuberculosis process is possible only with a comprehensive assessment of anamnestic data, objective examination data, tuberculin diagnostics, data from instrumental and laboratory research methods.

o Preventive fluorographic examination.

Preventive fluorographic medical examinations are carried out for adolescents aged 15 and 17 years. In the absence of data on preventive examinations at these ages, an extraordinary fluorographic examination is carried out.

If changes are found on the fluorogram, the patient is examined in depth by a TB specialist. For this purpose, the mandatory diagnostic minimum (MDM) is used.

Features of the course of tuberculosis in young children

are determined by the reactivity and resistance of the child’s body, as well as its anatomical and physiological characteristics.

Mechanisms of natural resistance the newborn child is in a state of physiological failure. In newborns it was noted:

- low phagocytic activity of leukocytes;

- low migration activity of mononuclear cells and leukocytes. The reason for this is the reduced formation of chemotactic factors in the blood serum and the increased release of the inhibitory factor by blood lymphocytes. These factors are associated with the weak ability of the skin of newborns to develop an inflammatory reaction;

— the absorption phase of phagocytosis is well expressed, the digestive phase lags significantly behind the absorption phase;

— deficiency of humoral factors of natural resistance. Humoral factors of natural resistance (complement, lysozyme, properdin, etc.) lead to extracellular destruction of mycobacteria. Deficiency of the main components of complement (C3 and C5) contributes to insufficient formation of chemotactic factors in the blood serum and insufficient bactericidal activity. Lysozyme has the property of lysing bacteria. Its level in the blood serum of newborns is higher than in adults, but after 7 days it decreases to the level in the mother's blood serum. The bactericidal activity of properdin appears only in combination with complement and magnesium ions.

Nonspecific protective factors play the main protective role until the period of maturation of specific immune mechanisms.

Development of immunological reactivity the child’s body occurs at different times:

- functional immaturity of the T- and B-lymphocyte systems. The functioning of T-lymphocytes begins in the fetus by 9-15 weeks, however, delayed-type hypersensitivity reactions reach full development by the end of the 1st year of life. Thus, T-lymphocytes of the fetus and newborn are not yet functionally mature enough. The number of B lymphocytes in newborns approaches the value in adults, but antibody production is minimal or absent. The functioning of B lymphocytes begins and improves further in the postnatal period. During intrauterine infection, IgM is formed by fetal cells. There is no IgA in the blood serum of newborns, its amount increases by the end of 1 year of life and reaches the level of adults only by 8-15 years. IgG in a newborn child is maternal, and in the first 6 months of the child’s life their catabolism and decrease in level occur. IgG appears only at the 6th week of a child’s life and its amount increases by 5-15 years. Thus, the newborn child is incapable of a full specific humoral response.

A newborn child has a deficiency in the functions of the T- and B-lymphocyte systems, and a decrease in nonspecific resistance. These factors play a role in the formation of anti-tuberculosis immunity mechanisms. Tuberculosis infection, in turn, changes the functioning of the immune system as the disease develops.

Premature babies have a significant deficiency of natural resistance factors. Immunodeficiency in premature infants is long-term and lasts until the 5th year of life.

The unfavorable course of tuberculosis infection is facilitated by the characteristics of the respiratory system in young children, due to anatomical and physiological structure:

— the relative narrowness, small size and insufficient functional differentiation of the air-conducting system lead to deterioration of lung ventilation and contribute to the settling of microorganisms;

— features of the lymphatic system;

- insufficient number of mucous glands in the bronchial mucosa, which leads to its relative dryness and complicates the evacuation of foreign substances, including microorganisms;

— acini have a primitive structure, poor in elastic fibers, which reduces the speed of air flow and favors the settling of microorganisms;

— an insufficient amount of surfactant creates conditions for the development of specific and nonspecific inflammatory changes in the lungs, promotes the development of atelectasis;

The consequence of these features in young children is massive damage to lymphoid tissue, a tendency to generalize the tuberculosis process, and a tendency to caseous necrosis in the affected organs.

Features of the course of tuberculosis in adolescence are determined:

- increased activity of metabolic processes, which leads to a pronounced picture of the morphological and clinical course of the tuberculosis process;

— uneven maturation of individual organs and systems, which can determine the selectivity of the localization of the lesion;

- rapid development and restructuring of the neuroendocrine system: in adolescents, the function of the thyroid gland and gonads increases, the ratio of excitation and inhibition processes in the nervous system changes (the predominance of the excitation process).

These factors affect the protective and adaptive capabilities of the adolescent’s body, the nature of the course of immunological, inflammatory reactions and regeneration, and, consequently, the clinical manifestations and outcomes of the disease.

❝ Mandatory diagnostic minimum of examinations for tuberculosis ❞

Clinical manifestations of respiratory tuberculosis are very diverse. Along with pronounced symptoms: cough with profuse sputum, pulmonary hemorrhage or hemoptysis, specific tuberculosis intoxication and exhaustion, there are variants of inaperceptive, i.e. asymptomatic course of the disease.

For timely, correct diagnosis of tuberculosis and characterization of its course, a comprehensive examination is used. Its arsenal includes a mandatory diagnostic minimum (MDM), additional research methods (ADM) and optional research methods (FMI).

ODM examinations for tuberculosis include the following activities: studying the patient’s complaints; careful history taking; conducting an objective examination: inspection, palpation, percussion, auscultation; performing radiographs or fluorograms in frontal and lateral projections; conducting laboratory tests of blood and urine; examination of sputum and other biological fluids for MVT; Carrying out tuberculin diagnostics for the submitted reaction to the Mantoux test with 2TE.

Doctors of all specialties are well aware of the saying: “Quo bene diagnostic - bene curat” (He who diagnoses well, treats well). In phthisiopulmonology, it should be used with the amendment - “He treats well who detects tuberculosis well and early.”

Subjective research is the first step in fulfilling the requirements of ODM. With respiratory tuberculosis, people can contact doctors with various complaints, and, first of all, general practitioners. In such cases, it is important not to forget about tuberculosis, have phthisiatric alertness, remember its main manifestations and, if necessary, refer the patient for a screening fluorographic (x-ray) study.

In most cases, a general practitioner is the doctor whom a first-time patient with tuberculosis encounters. Not only the health of one person, but also the fate of entire teams depends on the results of this meeting. If the patient remains undetected, he is in the team and continues to work. His tuberculosis process is gradually progressing. Such a patient contaminates the community with mycobacteria (MBT), which contributes to the emergence of new cases of the disease - from sporadic, isolated, to group diseases and even epidemic outbreaks. In this regard, it should be recalled once again that tuberculosis can occur with or without clinical manifestations.

Knowledge of the above is necessary for early diagnosis of tuberculosis, for timely isolation, hospitalization and organization of a complex of anti-tuberculosis measures.

When a patient first contacts a doctor, they first identify complaints, collect an anamnesis of the disease, an anamnesis of life, clarify data on contact with tuberculosis patients, epidemiological anamnesis and bad habits. After this, an objective examination is carried out. Correct interpretation by a doctor of the results of subjective and objective research can contribute to the correct diagnosis.

Complaints. There are no specific complaints characteristic only of pulmonary tuberculosis. Complaints associated with respiratory disease include the following: chest pain, cough, shortness of breath, pulmonary hemorrhage or hemoptysis. In addition to these complaints, there may also be complaints associated with damage to the body by specific tuberculosis endotoxin.

Clinical manifestations tuberculosis respiratory organs are very diverse. Along with pronounced symptoms - cough with copious sputum, pulmonary hemorrhage or hemoptysis, specific tuberculosis intoxication and exhaustion - there are variants of inapperceptive, i.e. asymptomatic, course of the disease.

For timely correct diagnosis tuberculosis and the characteristics of its course, a comprehensive examination is used, accepted in the clinic of internal diseases.

Its arsenal includes (ODM), additional research methods (ADM) and optional research methods (FMI). ODM provides:
- study of patient complaints;
- careful collection of anamnesis;
- conducting an objective study (inspection, palpation, percussion, auscultation);
- performing radiographs or fluorograms in frontal and lateral projections;
- carrying out laboratory tests of blood and urine;
- examination of sputum and other biological substrates for MBT;
- carrying out tuberculin diagnostics according to the reaction to the Mantoux test with 2 TE.

To doctors of all specialties The saying is well known: “Quo bene diagnostit - bene curat” (“He who diagnoses well, treats well”). In phthisiopulmonology, it should be used with the amendment: “He treats well who detects tuberculosis well and early.”

At clinical manifestations of tuberculosis people can address various complaints to doctors and, first of all, to therapists. In such cases, it is important not to forget about tuberculosis, to have phthisiatric alertness, to remember its main manifestations and, if necessary, to refer the patient for a screening fluorographic (x-ray) examination after evaluating such generally available medical methods as examination, palpation, percussion and auscultation.

General practitioner in most cases, he is the doctor with whom a patient with tuberculosis first encounters. Not only the health of one person, but also the fate of entire teams depends on the results of this meeting. If the patient remains undetected, he is in the team and continues to work. His tuberculosis process is gradually progressing. Such a patient infects the MBT community, which contributes to the emergence of new cases of the disease - from sporadic, isolated, to group diseases and even epidemic outbreaks.

In this regard, it should once again remind that tuberculosis can occur with or without clinical manifestations. Knowledge of this is necessary for early diagnosis of tuberculosis, for timely isolation, hospitalization and for organizing a set of anti-tuberculosis measures.

When contacting sick When visiting a doctor, first of all, they identify complaints, collect an anamnesis of the disease, an anamnesis of life, clarify data on contact with tuberculosis patients, epidemiological anamnesis and bad habits. After this, an objective examination is carried out.

Correct doctor's interpretation the results of subjective and objective studies can contribute to the correct diagnosis. When compiling a medical history of a patient with respiratory tuberculosis, it is necessary to be guided by the plan for writing it.

source

PHTISIOPULMONOLOGY / Method materials for lesson 1_8 / Method materials for lesson 1_7 / ODM for tuberculosis

MANDATORY DIAGNOSTIC MINIMUM (DMM)

conducting an objective examination: inspection, palpation, percussion, auscultation;

conducting laboratory tests of blood and urine;

examination of sputum and other biological fluids for MBT (3-fold bacterioscopy);

Carrying out tuberculin diagnostics based on the reaction to the Mantoux test with 2TE.

Questioning a patient for suspected tuberculosis

A doctor of any specialty must remember the prevalence of tuberculosis among certain groups of the population and the possibility of this disease in a given patient; in this regard, he must ask the patient the following control questions:

1. Has this patient previously suffered from tuberculosis?

2. Did his (her) relatives have tuberculosis?

3. Has the patient had contact with tuberculosis patients or animals (household, professional contact)?

4. Is the patient registered with a tuberculosis institution for any reason, for example, due to the presence of a hyperergic reaction to tuberculin, contact with tuberculosis patients, or suspected tuberculosis?

5. Has the patient undergone fluorographic examination?

6. Was the patient invited for additional research after fluorography?

7. Has the patient been in prison or living with people previously in prison?

8. Is this patient homeless, refugee, migrant, or otherwise disadvantaged?

Collecting anamnesis It is necessary to pay attention to repeated respiratory infections. This phenomenon is usually considered by patients as a cold.

If a patient who has had the flu has a low-grade fever for a long time, cough and malaise persist, it is necessary to think that it was not the flu, but one of the manifestations of tuberculosis.

If the patient has suffered exudative or dry pleurisy, this may indicate the presence of primary tuberculosis.

When studying the history of adolescents, adults and elderly people, it is extremely important to determine the presence of tuberculosis, to establish whether they had chronic conjunctivitis, erythema nodosum, and other signs of latent tuberculosis intoxication.

When collecting anamnesis, it is necessary to find out when the results of the tuberculin test became positive.

A well-collected anamnesis facilitates diagnosis.

ABOUT landmarks to establish the diagnosis of pulmonary tuberculosis

Limited wheezing in the lungs

(The more “+” symbols, the more significant the symptom seems)

It is important to remember that all signs could be caused by other diseases.

One of the most important signs that should make you think about the possibility of tuberculosis is that Symptoms developed gradually over weeks and months.

If the patient has any of the following symptoms, consider it – “ patient with suspected tuberculosis»:

1. Cough for more than 3 weeks;

3. Chest pain for more than 3 weeks;

4. Fever for more than 3 weeks.

All of the above symptoms may be associated with other diseases, therefore, if any of the above symptoms are present, it is necessary to examine sputum for the presence of MBT.

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Mandatory diagnostic minimum (MDM) for patients who applied to the general medical network (GPN) for suspected tuberculosis

Skachkova E. I.

In case of suspicion of tuberculosis, patients who apply to general medical institutions are prescribed targeted tests (mandatory diagnostic minimum) according to the scheme presented below:

Anamnesis;
Inspection;
General analysis of blood, sputum and urine;
3-fold bacterioscopic examination of the material for MBT according to Ziehl-Neelsen or using a fluorescent microscope (sputum, urine, cerebrospinal fluid, punctate, pus, fistula discharge, effusion);
Radiation diagnostics (radiography of the chest and affected organs, tomography, CT, MRI if necessary);
Tuberculin diagnostics in children using the Mantoux test with 2 TE PPD-L.

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18) Modern methods of examining a patient with tuberculosis. Diagnostic minimum for examining a patient with tuberculosis. (ODM)

ODM (mandatory diagnostic minimum when examining persons with respiratory pathologies):

1. Purposefully collected anamnesis.

2. Stetoacoustic examination of the respiratory organs.

3. X-ray examination of the respiratory organs (large-frame fluorography, plain radiography of the chest organs, computed radiograph).

4.General blood test. 5.General urine analysis.

6. Examination of sputum (bronchial lavage water) for MBT (3-fold bacterioscopy).

19. Instrumental examination methods and their role in the diagnosis and differential diagnosis of tuberculosis. Instrumental methods of diagnostic surgical interventions (invasive):

1. Diagnostic bronchoscopy.

2. Transthoracic lung aspiration biopsy.

3. Puncture of the peripheral lymph node.

7. Videothoracoscopy with biopsy.

8. Biopsy of pre-calcified tissue.

10. Open lung biopsy.

METHODS OF BACTERIOLOGICAL DIAGNOSIS OF TUBERCULOSIS The bacteriological laboratory plays a significant role in identifying and diagnosing tuberculosis, choosing rational chemotherapy regimens and assessing their effectiveness. Bacteriological diagnostics includes processing of clinical material, microscopic examination, isolation of a microorganism using cultural methods, identification of mycobacteria using bacteriological and biochemical gests, as well as determination of drug sensitivity of mycobacteria.

There are several groups of methods used to detect MBT in various diagnostic materials: routine (microscopy, cultural examination), biological (bioassay, determination of the virulence of MBT strains). automatic systems (MGIT, VASTES, MV/VasT, ESP Culture System, etc.), molecular genetic techniques (PCR. I.CR, NASBA, Q-Bela, etc.). Each of these methods has a certain sensitivity and specificity, which must be taken into account when clinically interpreting the results obtained.

Bacterioscopic examination of sputum with Ziehl-Neelsen smear staining to detect acid-fast mycobacteria (AFB) is the fastest, most accessible and cost-effective existing method for identifying patients with tuberculosis. It can be carried out in any clinical diagnostic laboratory (CDL) of medical institutions of all levels and departments. Sputum bacterioscopy seems to be extremely informative for determining the epidemiological danger of the patient to others, which correlates with the number of mycobacteria in the sample. Properly performed bacterioscopic examination has a positive predictive value for pulmonary tuberculosis of more than 90%. The resolution of this method is 50-100 thousand mycobacteria in 1 milliliter of sputum and significantly depends on a number of factors: the correctness of sputum collection, the preparedness of laboratory personnel and the resolution of the microscopes used. When microscopying smears prepared from samples taken over three consecutive days, the effectiveness of the method increases by 20-30%. However, there is no need to use more than 4-5 sputum samples.

The Ziehl-Neelsen staining method is most often used for bacterial detection of mycobacteria. It consists of the following: sputum smears are stained with fuchsin when heated, then decolorized with hydrochloric acid alcohol and counterstained with methylene blue. As a result, mycobacteria are painted crimson, and the background is blue. This specific staining is due to the ability of mycobacteria to retain the dye when treated with acid or alcohol.

In bacteriological laboratories that perform a large number of studies (100 or more daily), fluorescence microscopy is used. This method is based on the ability of mycobacterial lipids to perceive luminescent dyes (acridine orange, auramine, rhodamine, etc.) and then glow when irradiated with ultraviolet rays. Depending on the dyes, Mycobacterium tuberculosis produces a clear bright red glow on a green background or a golden yellow glow on a dark green background. The fluorescent microscopy method is more sensitive than light microscopy, especially in combination with the method of enriching diagnostic material (sediment microscopy), since fluorescent microscopy allows the detection of altered mycobacteria that have lost acid resistance. therefore, they are not detected by Ziehl-Neelsen bacterioscopy. Smears for fluorescent microscopy are prepared from the sediment obtained after treating the diagnostic material with a detergent, followed by washing or neutralization. If the result of bacterioscopy of smears stained with fluorochromes is positive, confirmatory microscopy of smears stained with Ziehl-Neelsen should be performed

Bacterioscopic examination must be carried out very carefully. Typically, the sample is examined for 15 minutes (corresponding to viewing 300 fields of view) to make a conclusion about the absence or presence of AFB in the preparation. When stained with fluorochromes, it takes less time to examine one smear.

The main diagnostic material for bacterioscopy for AFB is sputum. The results of bacterioscopic examination of other biological materials (various fluids, tissues, pus, urine, etc.) for AFB are of limited value for the diagnosis of tuberculosis. So. study 9

Smears from centrifuged urine sediment do not always provide reliable results, since non-tuberculous mycobacteria may be present in the urine. Therefore, detection of AFB in urine does not always indicate the presence of a specific process. Smears from gastric lavage sediment and other materials may contain acid-resistant sa-prophytes, which can easily be confused with MBT.

The result of a microscopic examination allows us to draw a conclusion only about the presence or absence of acid-fast bacteria in the preparation. A reliable diagnosis of tuberculosis can be established only after the isolation of the MBT culture from clinical material using the cultural method and its identification. A negative result of a bacterioscopic examination does not exclude the diagnosis of tuberculosis, since the sputum of some patients may contain fewer mycobacteria than bacterioscopy can detect.

The number of detected AFB determines the severity of the disease and the patient’s danger to others. Therefore, the research should be not only qualitative, but also quantitative. In modern epidemiological and economic conditions, bacterioscopic examination of sputum in persons with clinical symptoms suspicious of tuberculosis who applied to health care facilities for medical care is a priority in the tactics of early detection of this disease. The increasing role of this method is also associated with the emergence in recent years of acutely progressive forms of the disease, accompanied by pronounced clinical manifestations and abundant

Cultural (bacteriological) study. From the time of Koch's work until 1924, the efforts of scientists aimed at finding methods for isolating pure cultures of Mycobacterium tuberculosis did not have much success. In 1924, Levenshtein and Sumioshi established that acids and alkalis in known concentrations and at certain exposures kill the accompanying microflora without affecting the viability of MBT. With continuous improvement, this method began to acquire practical significance. Currently, bacteriological (cultural) examination of biological material for MBT, due to its high sensitivity (from 10 to 100 viable microbial cells in 1 ml of the test material) and specificity in combination with the microscopic method, is the “gold standard” in the diagnosis of tuberculosis. Bacteriological testing for tuberculosis is carried out in specialized bacteriological laboratories of anti-tuberculosis dispensaries or culture centers.

Material for bacteriological examination is collected aseptically. Before carrying out bacteriological examination, samples received in the laboratory are treated with solutions of acids or alkalis, followed by centrifugation. This is necessary to liquefy and concentrate the sample, as well as to prevent contamination, since sputum samples are viscous in consistency and contain a large amount of microflora. About 1 ml of the liquefied and decontaminated clinical sample is inoculated into tubes containing media and incubated at 37°C for 10 weeks.

For the cultivation of mycobacteria, solid (egg, agar) and liquid nutrient media are used. Egg media containing! whole eggs or egg yolk, as well as phospholipids, proteins and other ingredients. To prevent contamination, some dyes, such as malachite green, as well as antibiotics are added to the medium. Therefore, egg media (Levenschein-Jensen, Finn), on which mycobacteria are cultivated. have a blue-green color. The use of egg media makes it possible to obtain visible growth of M tuberculosis colonies after 18-24 days in the form of a dry, wrinkled, cream-colored coating. However, the quality of the ingredients used to prepare the media sometimes varies significantly, which can affect the reproducibility of the results. Compared to egg agar media, they have a number of advantages: they are prepared from semi-synthetic bases, which ensures more stable quality and reproducibility of results. Detection of MBT growth on agar media is possible after 10-14 days. However, agar media are more expensive, require the presence of CO2 in the atmosphere and are incubated in a thermostat for no more than 1 month. As a rule, a set of two different nutrient media is used to isolate mycobacteria.

Automatic systems. The development of the VASTES 460 radiometric system (Becton Dickinson) marked a qualitative breakthrough in the rapid detection of mycobacteria and determination of their drug sensitivity

Automatic systems designed to detect mycobacterium tuberculosis allow detection of mycobacterial growth 2-3 times faster than classical methods. A positive test result must be confirmed bacterioscopically. In the practice of bacteriological laboratories, research using automatic systems is necessarily carried out in parallel with research on solid nutrient media

Identification of mycobacteria. Although the morphology of the colonies, the presence of pigment and growth characteristics give some

with C. Thus, the two DNA strands remain in solution in a state unbound to each other until. until the temperature drops. At the next stage, called the primer annealing stage, which takes place at 40-60°C, primers bind to sections of single-stranded DNA molecules flanking the target sequence. These are short sections of RNA about 20 nucleotides long. Each primer binds to only one DNA strand. The next step of PCR is multiplication of the target sequence using polymerase. Since the incubation system at the denaturation stage is heated to 90-95°C, thermostable Taq polymerase isolated from Thermus aquaticus is used in PCR. The stage of completion of the seeds takes place at 70-75°C. This ends the first amplification cycle. Then all stages are repeated 20-25 times. As a result, the amount of target DNA increases in the geometric profession.

In practice, DNA is isolated from pathological material taken from patients using special methods. A reaction buffer, a mixture of nucleoside triphosphates, primers, polymerase and 1 12 are added to it.

amplification is carried out in a programmable thermostat (thermal cycler). The result is taken into account using electrophoresis in an agarose gel or using immobilized DNA fragments. The presence of the target sequence in the sample indicates the presence of MBT in the sample under study. PCR allows you to detect 1-10 bacterial cells in 1 ml of biological material. The specificity of the reaction is 97-98%.

Sputum, bronchial secretions, pleural and other fluids, urine, peripheral and menstrual blood, scrapings of epithelial cells of the cervical canal are subject to study by PCR.

It should be noted that PCR cannot determine the activity of the tuberculosis process, so the result must be interpreted taking into account clinical and radiological data. The PCR method can be used as an additional diagnostic method in differential diagnosis in combination with other methods of laboratory diagnosis of tuberculosis and cannot be used as a screening method for identifying patients with tuberculosis due to the possibility of false-positive results. Except yu10. An obstacle to the widespread use of this method is the need to use expensive equipment and diagnostic kits.

PCR is not the only amplification method for detecting mycobacteria. The use of amplification techniques to identify differences in the genetic structure of sensitive and resistant strains is another new approach to determining the drug sensitivity of mycobacteria. Conducting these studies was made possible by determining the nucleotide sequences of genes in which mutations lead to resistance to anti-tuberculosis drugs. When using amplification methods, the research time is significantly reduced. The main limitation to their use is the existence of other resistance mechanisms. Using amplification techniques, about 10% of cases of resistance to rifampicin, 20% to isoniazid and 40% to streptomycin are not detected. Therefore, molecular methods will never be able to completely replace classical cultural methods for determining the drug resistance of MBT.

Research into the epidemiology of tuberculosis has long been hampered by the lack of an accurate and reproducible method for subtitrating clinical isolates to study the distribution of MB'H strains. Improvement of molecular genetic methods has made it possible to develop highly specific markers for typing MBT strains.

MBG strains cannot be distinguished using routine biochemical tests or serological methods. Resistance to anti-TB drugs is a reproducible marker in some cases, but this marker is not universally accepted. Until recently, the only suitable method for typing MVT strains was the phage optimization method. However, it is technically difficult and has been used in few laboratories, since it does not allow achieving the necessary specificity, and with its help it is possible to isolate only a limited number of phage types.

Genotyping makes it possible to use subtle differences in the chromosome of mycobacteria as markers that do not cause phenotype or genetic differences. Since the picture obtained as a result of the study is individual for a particular strain (like fingerprints for a person), this method is called genomic fingerprinting (DNA fingerprint).

For typing, a repeating mobile DNA sequence that is specific for M tuberculosis is most often used, which demonstrates the required level of polymorphism. The copy number of this sequence is high in most M. tuberculosis isolates (7-20), low in most M. bovis isolates from animals (1-4) and in various A/, hovis BCG strains (1-2).

The genotyping method is based on the use of restriction endonucleases. which recognize specific sequences and cut DNA into fragments of different lengths. The content of guanine and cytosine in mycobacterial DNA is high (about 65%), so it is advisable to use enzymes that recognize fragments rich in adenine and thymine and cut D11K into a small number of large fragments.

The standard method involves the following steps: isolation of mycobacterial DNA. its restriction using endonucleases, separation of restriction fragments by electrophoresis and detection of the target sequence by hybridization with labeled DNA. The resulting set of electrophoretic bands (fingerprint) reflects the number of copies of a given DNA sequence (each band corresponds to one copy of the target sequence), as well as heterogeneity in the length of restriction fragments, which usually results from point mutations that create or destroy restriction sites, or deletions or other chromosomal rearrangements, which is reflected in the term “restriction fragment length polymorphism”

Using the standard version of the method is complicated by the need to extract almost 1 μg

DNA from each isolate. Therefore, two versions of the genomic fingerprinting method based on the use of PCR have currently been developed. They allow the use of very small amounts of DNA and obtain a picture comparable in specificity to the standard method. In such cases, the study can be performed on bacteria from several colonies or old non-viable cultures, as well as clinical bacterioscopically positive samples.

MBT isolates isolated during a disease outbreak most likely demonstrate the same genotypic pattern. Therefore, isolates associated with a specific disease outbreak can be easily identified. However, a large-scale study has not yet been conducted to determine the estimated number of possible genogypic variants in a specific geographic region.

The first application of genotyping of MTB isolates was to track tuberculosis outbreaks. Thus, using this method, the cause of an outbreak of tuberculosis caused by injections of contaminated drugs was established. This work demonstrated the utility of genomic fingerprinting for epidemiological studies and showed that outbreak-associated isolates can be identified from a large number of isolates using this method. Genomic fingerprinting has been shown to be useful in tracking the spread of multidrug-resistant strains. Several studies have described the nosocomial spread of such strains among HIV-infected patients. In each of these studies, 1 or 2 outbreak-associated strains were identified. The DNA sequence used for typing does not code for drug sensitivity, so drug resistance does not affect the fingerprint pattern. However, in this case, the fingerprint can serve as a marker of a given strain and indicate drug resistance of new isolates with the same fingerprint.

In epidemiological studies of multidrug-resistant tuberculosis outbreaks, drug resistance indicates the possibility of an epidemiological link between strains, genomic fingerprinting provides definitive evidence. The method is even more useful for conducting research on multidrug-resistant isolates, since it is the only method of proving the relatedness of strains. Large-scale application of this method to all isolates in a given geographic area can identify circulating MTB strains and identify previously unknown sources of tuberculosis infection. However, it has not yet been established whether this application of the method is practical, since laboratory study of MTB isolates is easier than the studies required to trace the spread of strains using genomic fingerprinting. The method can also be used to confirm cross-contamination of cultures and other laboratory errors.

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98. Methods for examining patients with suspected respiratory tuberculosis: mandatory diagnostic minimum, additional examination methods.

negative dubious positive hyperergic

c) puncture biopsy of the pleura

d) computed tomography

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The diagnosis of tuberculosis has recently been made with enviable consistency, and the number of cases of detection of the disease is growing exponentially. To make a correct and accurate diagnosis in modern medicine, there are various methods and studies. Diagnosis of tuberculosis as a widespread infectious disease of the respiratory tract includes 3 main stages: mandatory diagnostic minimum, additional research methods And optional research methods. Each stage has its own specific techniques to answer the question of how to identify tuberculosis.

For diagnostic purposes for tuberculosis, the following measures are carried out:

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72. Methods for examining patients with suspected respiratory tuberculosis: mandatory diagnostic minimum, additional examination methods.

Methods for examining patients with suspected respiratory TB:

a) purposefully collected anamnesis, analysis of the patient’s complaints

b) stetoacoustic and other physical methods of studying the respiratory organs

c) X-ray examinations of the respiratory organs: large-frame fluorography, plain radiography of the chest organs in 2 projections, computed tomography

d) examination of sputum (bronchial lavage water) for MBT using 3-fold immersion or fluorescent (better) bacterioscopy (Ziehl-Neelsen staining, MBT - red, surrounding background and non-acid-fast bacteria - blue) and bacterial culture (Levenshtein's egg medium - Jensen).

e) Mantoux tuberculin test with 2 TE PPD-L - placement technique: 0.2 ml of tuberculin is drawn into a tuberculin syringe, then 0.1 ml of solution is released from the syringe through a needle so that the volume of the injected drug is 0.1 ml - 2 THOSE; on the inner surface of the middle third of the forearm, the skin area is treated with 70% ethyl alcohol and dried with cotton wool; the needle is inserted with the cut upward into the upper layers of the skin parallel to its surface and 0.1 ml of tuberculin is injected; with proper injection, a white papule 7-8 mm in diameter is formed on the skin

By measuring the infiltrate (papule) with a transparent ruler perpendicular to the axis of the forearm after 72 hours, the Mantoux reaction is assessed according to the following criteria: negative– no infiltration and hyperemia, dubious– infiltrate 2-4 mm or only hyperemia of any size, positive– presence of infiltrate with a diameter of 5 mm or more, hyperergic– infiltrate with a diameter of 17 mm or more in children and adolescents and 21 mm or more in adults or the appearance of vesicles, lymphangitis, regional lymphadenitis, regardless of the size of the infiltrate.

With a negative Mantoux test reaction, the state of anergy can be either positive (in persons uninfected with MTB) or negative (in patients with severe progressive TB, with concomitant oncopathology or a severe immunodeficiency state due to various infections). To differentiate these conditions, a Mantoux test is performed with 100 TU PPD-L - if the result is negative, the body is not infected.

f) clinical blood and urine tests

A. Group 1 - non-invasive additional research methods:

a) repeated examination of sputum (bronchial lavage water) for MBT using the flotation method (after shaking the aqueous suspension with hydrocarbon, MBT float to the surface along with the resulting foam, the resulting cream-shaped ring serves as materials for microscopy) with subsequent determination of the virulence of MBT, their sensitivity to antibacterial agents.

Methods for determining the virulence (i.e. degree of pathogenicity) of MBT:

1. According to the type of colonies during bacterial inoculations: R-colonies (rough) are highly virulent, S-colonies (smooth) are low-virulent

2. By the presence of cord factor - determined in highly virulent strains

3. According to catalase activity - the higher it is, the more virulent the strain

4. According to the lifespan of experimental animals during a biological test, the more virulent the MBT is, the faster the guinea pig dies

b) tomography of the lungs and mediastinum

c) in-depth tuberculin diagnostics (determination of the threshold of sensitivity to tuberculin, etc.)

e) BAC: proteinogram, C-reactive protein

A summary assessment of the data from ODM and DMI of the 1st group makes it possible to make a diagnosis or form a deeper understanding of the nature of the identified disease, however, in a number of patients the diagnosis remains unclear and its morphological verification is necessary using DMI of the 2nd group

B. Group 2 – invasive additional research methods:

a) bronchoscopy - survey or in combination with catheterbiopsy, brush biopsy, direct biopsy of the bronchial mucosa and pathological formations in them

b) transthoracic aspiration or open lung biopsy with all kinds of biopsy examination

c) puncture biopsy of the pleura

d) puncture of peripheral lymph nodes.

e) biopsy of pre-calcified tissue

f) mediastinoscopy, pleuroscopy, etc.

Basic imaging methods for examining TB patients:

a) fluorography: film and digital (digital)

b) plain radiography of the lungs

d) computed tomography

e) magnetic resonance imaging

f) general and selective angiopulmonography, bronchial arteriography

g) non-directed and directed bronchography

h) pleurography, fistulography

i) Ultrasound (to determine the level of fluid in the pleural cavity, the condition of the l.u.)

source

Methods for examining patients with suspected respiratory tuberculosis: mandatory diagnostic minimum, additional examination methods

Methods for examining patients with suspected respiratory TB:

a) purposefully collected anamnesis, analysis of the patient’s complaints

b) stetoacoustic and other physical methods of studying the respiratory organs

c) X-ray examinations of the respiratory organs: large-frame fluorography, plain radiography of the chest organs in 2 projections, computed tomography

f) clinical blood and urine tests

A. Group 1 - non-invasive additional research methods:

Methods for determining the virulence (i.e. degree of pathogenicity) of MBT:

1. According to the type of colonies during bacterial inoculations: R-colonies (rough) are highly virulent, S-colonies (smooth) are low-virulent

2. By the presence of cord factor - determined in highly virulent strains

3. According to catalase activity - the higher it is, the more virulent the strain

4. According to the lifespan of experimental animals during a biological test, the more virulent the MBT is, the faster the guinea pig dies

b) tomography of the lungs and mediastinum

c) in-depth tuberculin diagnostics (determination of the threshold of sensitivity to tuberculin, etc.)

e) BAC: proteinogram, C-reactive protein

B. Group 2 – invasive additional research methods:

a) bronchoscopy - survey or in combination with catheterbiopsy, brush biopsy, direct biopsy of the bronchial mucosa and pathological formations in them

b) transthoracic aspiration or open lung biopsy with all kinds of biopsy examination

c) puncture biopsy of the pleura

d) puncture of peripheral lymph nodes.

e) biopsy of pre-calcified tissue

f) mediastinoscopy, pleuroscopy, etc.

Basic imaging methods for examining TB patients:

a) fluorography: film and digital (digital)

b) plain radiography of the lungs

d) computed tomography

e) magnetic resonance imaging

f) general and selective angiopulmonography, bronchial arteriography

g) non-directed and directed bronchography

h) pleurography, fistulography

i) Ultrasound (to determine the level of fluid in the pleural cavity, the condition of the l.u.)

j) radioisotope studies

f) positron emission tomography

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Methods for examining patients with suspected respiratory TB:

1) mandatory diagnostic minimum (ODM):

a) purposefully collected anamnesis, analysis of the patient’s complaints

b) stetoacoustic and other physical methods of studying the respiratory organs

c) X-ray examinations of the respiratory organs: large-frame fluorography, plain radiography of the chest organs in 2 projections, computed tomography

By measuring the infiltrate (papule) with a transparent ruler perpendicular to the axis of the forearm after 72 hours, the Mantoux reaction is assessed according to the following criteria: Negative– no infiltration and hyperemia, Doubtful– infiltrate 2-4 mm or only hyperemia of any size, Positive– presence of infiltrate with a diameter of 5 mm or more, Hyperergic– infiltrate with a diameter of 17 mm or more in children and adolescents and 21 mm or more in adults or the appearance of vesicles, lymphangitis, regional lymphadenitis, regardless of the size of the infiltrate.

f) clinical blood and urine tests

2) additional research methods (ADM):

A. Group 1 – non-invasive additional research methods:

Methods for determining the virulence (i.e., the degree of pathogenicity) of MBT:

1. According to the type of colonies during bacterial inoculations: R-colonies (rough) are highly virulent, S-colonies (smooth) are low-virulent

2. By the presence of cord factor - determined in highly virulent strains

3. According to catalase activity - the higher it is, the more virulent the strain

4. According to the lifespan of experimental animals during a biological test, the more virulent the MBT is, the faster the guinea pig dies

b) tomography of the lungs and mediastinum

c) in-depth tuberculin diagnostics (determination of the threshold of sensitivity to tuberculin, etc.)

e) BAC: proteinogram, C-reactive protein

B. Group 2 – invasive additional research methods:

a) bronchoscopy - survey or in combination with catheterbiopsy, brush biopsy, direct biopsy of the bronchial mucosa and pathological formations in them

b) transthoracic aspiration or open lung biopsy with all kinds of biopsy examination

c) puncture biopsy of the pleura

d) puncture of peripheral l. u.

e) biopsy of pre-calcified tissue

f) mediastinoscopy, pleuroscopy, etc.

Basic imaging methods for examining TB patients:

A) fluorography: film and digital (digital)

B) plain radiography of the lungs

D) computed tomography

D) magnetic resonance imaging

E) general and selective angiopulmonography, bronchial arteriography

G) non-directional and directed bronchography

H) pleurography, fistulography

I) Ultrasound (to determine the level of fluid in the pleural cavity, the condition of the lungs)

For quotation: Mishin V.Yu. DIAGNOSTICS OF TUBERCULOSIS OF THE RESPIRATORY ORGANS // Breast cancer. 1998. No. 17. P. 9

Diagnosis of respiratory tuberculosis is carried out in stages. Mandatory diagnostic minimum methods make it possible to establish a diagnosis at the lowest cost. The two reliable diagnostic criteria remain the detection of Mycobacterium tuberculosis in material obtained from the patient and specific morphological changes in a biopsy sample from the affected organ. In complex and doubtful cases, additional non-invasive and invasive research methods are used to verify the diagnosis.

Diagnosis of tuberculosis of the respiratory system is being established step by step. Two valid criteria of diagnosis are identification of mycobacteria in the material, received from the patient and specific morphological changes in complicated and doubtful cases a supplementary noninvasive and invasive methods of investigation are applied, which permitt to verify the diagnosis.

V.Yu. Mishin - Doctor of Medicine. Sciences, leading researcher at the Central Research Institute

tuberculosis RAMS, Moscow
V.Yu. Mischin, Dr.Sci, leading research worker, Central Institute of Tuberculosis, Academy of Medical Sciences, Russia

P The process of diagnosing respiratory tuberculosis includes several stages. The first is the identification of persons with various lung diseases suspicious for tuberculosis. This stage occurs, as a rule, in clinics and hospitals of the general network.
For many years, the basis for detecting respiratory tuberculosis in adults was X-ray research method. Early detection of tuberculosis was carried out using fluorography , which was performed on all those who applied to clinics and were not examined by X-ray this year, as well as persons included in high-risk groups for tuberculosis (patients with diabetes, patients receiving corticosteroid drugs, radiation therapy, etc.). Fluorography was also carried out annually for “mandatory contingents” subject to examination for tuberculosis (workers of children's and communal institutions, catering establishments, grocery stores, public transport, etc.). Mass fluorographic examinations of adolescents and adults, carried out once every 2 years, covered the majority of the population and made it possible to identify patients with respiratory tuberculosis at relatively early stages of its development. Using the fluorographic research method, patients were identified and selected mainly with limited local processes in the form of focal tuberculosis, limited infiltrates, disseminations and tuberculomas. Clinical manifestations of diseases in such patients were mild or absent. Those examined with such forms of the disease often did not feel sick and remained able to work. In the process of further examination, first of all, X-rays of the respiratory organs were performed to clarify the changes identified during fluorography.
In recent years, preventive fluorographic studies of the population have been significantly reduced, which has led to a very significant decrease in the number of identified tuberculosis patients. Under the current conditions, identifying patients with respiratory tuberculosis among those who sought medical help has acquired particular importance.
The first priority remains identification of bacillary tuberculosis patients of the respiratory system , since such patients, as a rule, have a progressive tuberculosis process, and they pose a great epidemiological danger to others. The cure of identified bacillary patients has both clinical and epidemiological significance, since it allows not only to prevent death from the progression of tuberculosis, but also to stop the spread of mycobacteria, and to avoid the development of a chronic process with constant or periodic release of mycobacteria. Due to the reduction in fluorographic studies, the role of correct assessment of the patient’s clinical symptoms and microscopic examination of sputum for Mycobacterium tuberculosis is increasing. Diagnosis of bacillary tuberculosis should be carried out primarily in patients with manifestations of inflammatory intoxication who produce sputum.
All research methods for diagnosing tuberculosis can be divided into 3 groups: mandatory diagnostic minimum (MDM), additional research methods of non-invasive (DMI-1) and invasive (DMI-2) nature and, finally, optional methods .
ODM includes the study of anamnesis, complaints, clinical symptoms, physical examination, x-ray of the chest organs in frontal and lateral projections, microscopy and sputum culture to detect Mycobacterium tuberculosis, Mantoux test with 2 TU, clinical blood and urine tests.
To DMI-1 include tomography and zonography of the lungs and mediastinum, including computed tomography, ultrasound examination for pleurisy and subpleurally located round formations; repeated examination of sputum and bronchial washings for Mycobacterium tuberculosis using flotation and polymerase chain reaction methods; determination of drug sensitivity of mycobacteria; sputum culture for nonspecific microflora and fungi; in-depth tuberculin diagnostics.
DMI-2 include bronchoscopy with biopsy and bronchoalveolar lavage; puncture of the pleural cavity and pleurobiopsy; transthoracic lung biopsy; thoracoscopy, mediastinoscopy and, finally, open lung biopsy with subsequent cytological, histological and microbiological studies of the obtained material. Optional methods are very numerous and are aimed not so much at diagnosing tuberculosis, but at determining the functional state of various internal organs and metabolic processes. These are studies of blood glucose levels, liver function, cardiovascular system, external respiration function, blood gas composition, pulmonary blood flow, etc.
ODM should be carried out, as the name suggests, in full. DMI and optional methods are used according to indications.
Pulmonary tuberculosis is characterized by a wide variety of clinical symptoms, which vary widely in severity and severity. Usually there is a direct relationship between the severity of clinical symptoms and changes in the lungs, but their inconsistency is also possible: a severe tuberculosis process and mild clinical symptoms or minor changes and a fairly vivid clinical picture.
Based on the severity of local changes, we can distinguish destructive forms of tuberculosis lungs (caseous pneumonia, cavernous and fibrous-cavernous tuberculosis) ; widespread tuberculosis without decay (miliary, disseminated, infiltrative tuberculosis); minor forms of tuberculosis (focal tuberculosis, limited infiltrates, small tuberculomas). The clinical symptoms are most pronounced in patients with destructive and widespread forms of tuberculosis; in minor forms, an asymptomatic course of the disease is usually noted.
In the clinical picture of respiratory tuberculosis, there are mainly inflammatory intoxication syndrome and bronchopulmonary (“chest”) symptoms caused by a specific inflammatory process in the lungs. Inflammatory intoxication syndrome includes clinical manifestations such as increased body temperature, sweating and night sweats, chills, increased fatigue, weakness, decreased or lack of appetite, weight loss, and tachycardia. “Chest” symptoms - cough, sputum production, chest pain, hemoptysis and pulmonary hemorrhage, shortness of breath.
As is known, the onset of respiratory tuberculosis can be acute and gradual, and the course can be wavy, with periods of exacerbation (outbreak) and subsidence of the process.
In most patients, tuberculosis develops gradually, with subtle symptoms. However, recently, acutely onset and progressive destructive forms of the type of “fleeting consumption” (caseous pneumonia), described at the beginning of the century, disseminated, including miliary, tuberculosis, sometimes accompanied by tuberculous meningitis and meningoencephalitis, have become more common.
Attentive questioning The patient’s information about complaints and clinical manifestations of the disease is of great importance for the diagnosis of tuberculosis and determines the course of further research. It is necessary to try to establish the time of onset of the disease to determine its duration, and also to find out whether the patient sought medical help soon after the onset of clinical symptoms or the disease has existed for a long time. When studying the medical history, special attention should be paid to the issue of the patient’s contacts with tuberculosis patients at home or at work, and the presence of relatives with tuberculosis.
Currently, a hereditary predisposition to tuberculosis can be considered proven. Information about the results of a previous medical examination, the time and reasons for its conduct (preventive examinations, seeking medical help for a pulmonary disease, etc.) is of particular importance. Women of childbearing age are asked about pregnancy and childbirth, since sometimes tuberculosis can develop during pregnancy and after childbirth. In young people (under 25 years of age), it is necessary to clarify, if possible, whether they have been vaccinated and revaccinated with BCG against tuberculosis.
Medical inspection a patient with minor forms of respiratory tuberculosis, dissemination and tuberculomas, as a rule, provides little information for diagnosis. More pronounced changes may occur in common and destructive forms of tuberculosis. In such patients, one can detect dullness of percussion sound in the area of tuberculous changes, bronchial or hard breathing, dry or moist rales. In the presence of a cough with sputum production and especially hemoptysis, it is necessary first of all to examine the sputum using microscopy for Mycobacterium tuberculosis. Efficiency increases when examining sputum collected within 24 hours for 3 days in a row. A smear prepared from sputum is stained with Ziehl-Neelsen and viewed under a microscope. Luminoscopic examination of a smear stained with auromin is also possible. The detection of Mycobacterium tuberculosis in 2 of 3 examined smears confirms the diagnosis of pulmonary tuberculosis. Simultaneously with microscopy, sputum culture must be carried out on nutrient media. If the culture grows, the sensitivity of mycobacteria to anti-tuberculosis drugs is determined. To establish the clinical form of tuberculosis, they do chest x-ray in frontal and lateral projections. After determining the clinical form of tuberculosis (in a general hospital or in a clinic with the obligatory participation of a phthisiatrician), the patient is sent to anti-tuberculosis institutions for treatment.
The most difficult situation in diagnosing respiratory tuberculosis occurs in patients with clinical symptoms in the absence of sputum, and also when Mycobacterium tuberculosis is not detected in the sputum. In such patients, during X-ray examination, tuberculosis can manifest itself as focal, infiltrative changes in the lungs, dissemination, cavities, enlarged intrathoracic lymph nodes and pleurisy. Despite the description of the x-ray picture characteristic of tuberculosis, the diagnosis of this disease should not be made solely on the basis of clinical and x-ray examination data. The listed x-ray changes can be observed not only in tuberculosis; they require differential diagnosis. Patients with clinical and radiological manifestations characteristic of tuberculosis, with a satisfactory general condition, can undergo bronchoscopy with examination of bronchial aspirate or bronchoalveolar washings for Mycobacterium tuberculosis. Cytological and histological examination of lung tissue biopsy is also possible. This method is very important and informative not only for verifying the diagnosis of tuberculosis, but also for the differential diagnosis of tuberculosis, cancer and other diseases.
There are non-invasive methods for confirming the diagnosis of tuberculosis, in particular the determination of specific anti-tuberculosis antibodies and antigens of Mycobacterium tuberculosis in blood serum. It is necessary to note a certain diagnostic value tuberculin tests . Currently in Russia they use the Mantoux test (intradermal injection of 2 TE of purified tuberculin PPD). A negative tuberculin reaction usually indicates the absence of tuberculosis infection. A positive reaction is due to sensitization to tuberculin as a result of BCG vaccination or previous primary tuberculosis infection. Lung disease in such patients can be either tuberculosis or another etiology. For the diagnosis of tuberculosis, the variation of the tuberculin test (an increase in the size of the papule by 5 mm or more per year) and the hyperergic Mantoux reaction (the size of the papule is 21 mm or more) are important. This is especially true for cases of the development of primary forms of respiratory tuberculosis in young people.
In cases where these methods do not confirm active tuberculosis, you can use ex juvantibus diagnostic method . Patients with clinical symptoms and radiological changes that indicate active tuberculosis or questionable activity of the process, as well as with a hyperergic tuberculin test, are prescribed chemotherapy with anti-tuberculosis drugs. In such cases, a repeat X-ray examination is necessary after 2 to 3 months. In cases of tuberculous etiology, partial or complete resorption of inflammatory changes is noted. This is the so-called delayed diagnosis. By this time, it is possible to obtain the results of sputum culture on nutrient media, done before the start of chemotherapy. Culture growth in the presence of Mycobacterium tuberculosis in the material is usually noted after 4 - 8 weeks, which confirms the diagnosis.
Currently, respiratory tuberculosis is often combined with various diseases of the internal organs. Clinical manifestations of diseases of non-tuberculous etiology force the patient to seek medical help, and the tuberculosis process is asymptomatic and unnoticed by the patient. In such cases, patients go to clinics and are hospitalized in hospitals of various profiles. If you suspect an asymptomatic course of tuberculosis, you should, if possible, collect sputum and conduct a microscopic examination of the smear, and order an x-ray examination. Detection of mycobacteria and corresponding x-ray changes in the lungs makes it possible to establish a diagnosis without much difficulty. If there are no mycobacteria in the patient’s sputum, the patient must be further examined using the described method.
The diagnosis of tuberculosis must be formulated in accordance with the official clinical classification. First, indicate the clinical form of tuberculosis, localization of the process, phase and results of sputum examination: BC (+) or BC (-), according to microscopic examination, clarified by the results of inoculating the material on nutrient media.
Correct and timely diagnosis of respiratory tuberculosis makes it possible to identify patients in the early stages of disease development, and chemotherapy, started on time, will prevent the development of common, progressive forms with the release of mycobacteria.

Diagnosis of tuberculosis is carried out at different stages of medical care. First step Diagnosis of tuberculosis consists of identifying the main symptoms of the disease: prolonged cough, hemoptysis, prolonged fever, night sweats, etc. Also at this stage, the doctor finds out the characteristics of the evolution of the disease and the fact of the patient’s contact with a patient with tuberculosis. Second step Diagnosis of tuberculosis consists of a clinical examination of the patient. When examining a patient, the doctor pays attention to weight loss, the presence of enlarged lymph nodes, and impaired movement of the chest during breathing. Third step diagnosis of tuberculosis is carried out if suspicion of tuberculosis remains after the first two diagnostic steps. In this case, the patient is sent to a specialized medical institution that diagnoses and treats tuberculosis. To confirm the diagnosis of tuberculosis, a microscopic examination of sputum (smears) is performed for the presence of Acid-Fast Mycobacteria (AFB), which are the causative agents of tuberculosis (at least three smears must be examined). An X-ray examination of the chest is also performed. If both research methods give a positive result (that is, tuberculosis pathogens are determined in the sputum, and an X-ray examination of the lungs shows the presence of foci of inflammation), the patient is sent for a repeat examination, the essence of which is to finally confirm the diagnosis of tuberculosis, determine the specific features of the disease (the form of tuberculosis, sensitivity of tubercle bacilli to antibiotics, etc.), after which the patient is prescribed treatment. If the smear for the presence of AFB is negative, but there are signs of pneumonia of unknown origin in the lungs, the patient is prescribed a course of treatment as for pneumonia and its effectiveness is assessed after 2 weeks. The presence of an effect from treatment (improvement of the patient’s well-being and positive dynamics on repeated x-ray examination) refute the diagnosis of tuberculosis. If treatment remains unsuccessful, the patient is referred for further examination ( fourth step).