Primary and secondary forms of tuberculosis.

1. PHEE Kyiv Medical University
LECTURE №4.
Primary and secondary forms of tuberculosis.
Lector: Ivashchenko Oleksandr Andriiovych, assistant of Infectious diseases, pulmonology and phthisiology department.

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3. • Introduction
Mycobacteria have mycolic acids in their outer cell wall which makes them resistant to quick immune destruction.
Mycobacteria typically produce an adaptive immune response with an inflammatory reaction characterized as
granulomatous inflammation, which can continue for weeks to months to years, depending upon the host
response. A robust TH1 adaptive cell-mediated immune response is more effective than a TH2 response. In
persons who are healthy, infection may be subclinical and inapparent, detected only by testing for evidence of an
immune response.
There are two major patterns of disease with MTB:
• Primary tuberculosis: seen as an initial infection, typical for infection in children. The initial focus of infection is
a small subpleural granuloma accompanied by granulomatous hilar lymph node infection. Together, these make
up the Ghon complex. In most cases, these granulomas resolve and there is no further spread of the infection.
• Secondary tuberculosis: seen mostly in adults as a reactivation of previous infection (or reinfection), particularly
when health status declines. The granulomatous inflammation is much more florid and widespread. Typically,
the upper lung lobes are most affected, and cavitation can occur.

4. • Paraspecific reactions (tuberculosis “masks”)
In primary tuberculosis there
are situations where the
disease occurs more on the type
of therapeutic, hematological,
rheumatologic disease. This is
due to the fact that the body is
infected TB patient responsible
development of vasculitis and
allergic reactions.

5. • «Flu-like» tuberculosis mask
The most frequently tuberculosis in
active phase occurs in such frequent,
long, unusual flu-like illness without
clearly expressed inflammation of the
upper respiratory tract and causes the
patient's family outbreaks of influenza
states – its a «flu-like» tuberculosis
mask.

6. The second frequency is ―
«pneumonic» mask. This is
repeated recurrent pneumonia,
especially in the same lungs place
with torpent course, having
atypical clinic and course, difficult
to treated, slowly resolved with
the formation of small focal and
fibrotic changes.
• «Pneumonic» mask tuberculosis mask

7. Tuberculosis can begin on type
«rheumatic» mask, called «Poncet`s
disease». It manifested a long course
articular syndrome with pain,
swelling, breach of mobility in the
joints with deformation, ankylosis.
When X-rays there are typical signs
of rheumatoid arthritis. There no
efficiency after antirheumatic
therapy in «Poncet`s disease» cases,
no complications such as
endocarditis. Only TB positive
tuberculin tests, specific X-ray
changes and the effect of specific
therapy allows to confirm the
diagnosis of tuberculosis.
• «Rheumatic» tuberculosis mask

8. Neurological TB mask
manifests as long,
persistent neuralgia,
which can not be
usually treated,
especially for
intercostal and sciatic
nerves, but without
signs of compression or
inflammatory lesions
nerve.
• «Neurological» tuberculosis mask

9. «Lupus-like» mask
manifests typical
erythema on the face in
the form of "butterfly",
trophic disorders,
arthralgia, leukopenia,
sharply increased ESR
(erythrocyte sedimentation
rate), sometimes specific
blood cells and antibodies
to DNA are finding.
• «Lupus-like» tuberculosis mask

10. «Hematological» mask of tuberculosis occurs with bone
marrow hypoplasia, leukopenia, anemia, thrombocytopenia,
sometimes with leukemoid reactions. Often manifests
lymphadenopathy, splenomegaly, B12-deficiency anemia and
hypoplastic anemia.
• «Hematological» tuberculosis mask

11. • Keratoconjunctivitis phlyctenular
Keratoconjunctivitis phlyctenular.
Most often its tubercular-allergic
process in children with broncho-
adenitis and tuberculosis of the
lymph nodes, and other allergic
reactions. On the bulbar conjunctiva
and cornea near the limbus there
are single or multiple inflammatory
nodules of yellowish-pink color with
a bunch of the blood vessels that are
often completely resolve, but
sometimes disintegrate with the
formation of ulcers followed by
replacement with connective tissue.
Keratoconjunctivitis phlyctenular.
Most often its tubercular-allergic
process in children with broncho-
adenitis and tuberculosis of the
lymph nodes, and other allergic
reactions. On the bulbar conjunctiva
and cornea near the limbus there
are single or multiple inflammatory
nodules of yellowish-pink color with
a bunch of the blood vessels that are
often completely resolve, but
sometimes disintegrate with the
formation of ulcers followed by
replacement with connective tissue.

12. • Forms of primary tuberculosis
• Latent tuberculosis infection
• Tuberculosis of unknown localization
• Primary tuberculosis complex
• Tuberculosis of the intrathoracic lymph nodes

13. • Latent tuberculosis infection
Latent tuberculosis infection (LTBI) is a state of
persistent immune response to MBT antigens, not
associated with BCG vaccination, in the absence of
any clinical manifestations of active TB.
The highest risk of progression from latent to active
form of TB is observed during the first 2 years after
infection (the chance of contracting this infection
during a lifetime is 5–10%, half of the chances occur
during this period). The risk of getting sick is higher
in children, teenagers, pregnant women, patients
with HIV infection, patients with diabetes, chronic
alcoholism, drug addiction, peptic ulcer disease of the
stomach or duodenum, in patients who take steroid
hormones or immunosuppressants.

14. • Tuberculosis of unknown localization
TB of undetermined localization as a separate form of TB is a symptom
complex of functional disorders caused by the primary penetration of
MBT into the body, the "curve" of the tuberculin reaction and
paraspecific reactions. In the presence of signs of tuberculosis
intoxication, it is necessary to conduct a survey radiography and a
median tomography. In case of detection of enlarged lymph nodes, a
diagnosis of small form of TB of intrathoracic lymph nodes is made.
In TB of undetermined localization, histiomacrophagic tubercles
appear in the lymph nodes, later - epithelioid and giant Pirogov-
Langhans cells, lymphocytes and macrophages.
The main symptom of TB of undetermined localization is the
intoxication syndrome, which appears during or immediately after the
tuberculin test turns. The most characteristic are changes in the child's
behavior - irritability or inhibition, rapid fatigue, subfebrile body
temperature, headache, poor appetite and sleep, peripheral lymph
nodes increase (micropolyadenitis). Body temperature does not have a
constant character, it fluctuates throughout the day.

15. • Primary tuberculosis complex
The primary tuberculosis complex is characterized by the presence, for
example, in the lungs of a primary tuberculosis focus (pneumonitis),
lymphangitis and lymphadenitis, as well as "turning" of the tuberculin test and
paraspecific reactions. More often, the focus is localized in the I and III
segments of the right lung.
Timely detection and treatment of the primary tuberculosis complex contributes
to the patient's recovery. Usually complete resorption of the primary
tuberculosis complex occurs. Its complicated course is possible, as well as the
formation of significant residual changes.
Certain radiological changes, which are divided into 4 stages, correspond to
certain phases of the course of the primary tuberculosis complex.
• Stage I - the infiltration stage. Is characterized by the presence of one
homogeneous shadow. The zone of perifocal inflammation merges with the
expanded root of the lung. This stage is sometimes difficult to distinguish
from pneumonia, so it is also called "pneumonic".
• Stage II – stage of bipolarity (corresponds to the absorption phase).
Lymphangitis disappears, perifocal inflammation resolves and 2 poles are
clearly distinguished (Redeker's symptom): primary affect and changed
intrathoracic lymph nodes.
• Stage III (corresponds to the compaction phase) - calcium salts begin to be
deposited.
• Stage IV (corresponds to the calcification phase) is characterized by the
formation
of a Gon focus and petrified intrathoracic lymph nodes.

16. • Primary tuberculosis complex (X-ray)
Stage I - stage of infiltration

17. • Primary tuberculosis complex (X-ray)
Stage II – resorption.
The size of the focus in lung tissue decreases, its intensity raises, the contours become precise.
The flow out to a root and infiltration of lymphatic nodes decreases.

18. • Primary tuberculosis complex (X-ray)
Stage III - condensation.
On a place of focus area remains with the size up to 1 cm, inside of it inclusions of calcinations appear
as fine spots of sharp intensity. Same spots of calcinations are noticeable and in lymphatic nodes of
the lung root. Thin tension bars are determined between the focus and the root.

19. • Primary tuberculosis complex (X-ray)
Stage IV - calcination.
The focus in lung tissue becomes even smaller, more densely, of high intensity, with distinct contour, frequently
rugged and rough. Calcinations are intensified also in root lymphatic nodes. Calcinations in certain cases are
represented by solid, dense formations, in others - they have less intensive shadows of inclusions, which testify
about incomplete calcifications of the focus and preservation of caseous regions in it.

20. • Tuberculosis of the intrathoracic lymph nodes-1
Tuberculosis of the intrathoracic lymph nodes is
a manifestation of primary TB. Very rarely, it
can be a consequence of endogenous
reactivation of tuberculous changes that
previously occurred in the intrathoracic lymph
nodes. This is the main clinical form of TB in
children.
It arises as a result of MBT entering the lymph
nodes by a hematogenous or lymphogenous
route, where they multiply and cause specific
changes, as well as the "turn" of the tuberculin
reaction and paraspecific reactions.
There are infiltrative, tumor-like and small
forms of TB of intrathoracic lymph nodes
(according to X-ray examination data).

21. • Tuberculosis of the intrathoracic lymph nodes-2
In the infiltrative form, there is hyperplasia of lymphoid tissue and
epithelioid tubercles. The lymph node itself is slightly enlarged, perinodular
inflammation prevails, that is, the inflammatory process goes beyond the
lymph node and spreads along the periphery into the lung tissue.
With a tumor-like form, the intrathoracic lymph nodes increase to
significant sizes (up to 5 cm). Lymphoid tissue is replaced by caseosis, but
the inflammatory process does not go beyond the capsule.
The indurative form is characterized by the growth of fibrous tissue with
remnants of caseous foci in the lymph nodes.
The most severe is the tumor-like (caseous) form of TB of the intrathoracic
lymph nodes.
According to Sukennikov's classification with Engel's additions, the
following groups of intrathoracic lymph nodes are distinguished:
• Paratracheal
• Tracheobronchial
• Bronchopulmonary
• Bifurcation
• Para-aortic.

22. • Secondary forms of tuberculosis
• FOCAL PULMONARY TUBERCULOSIS
• INFILTRATIVE PULMONARY TUBERCULOSIS
• DISSEMINATED PULMONARY TUBERCULOSIS
• CASEOUS PNEUMONIA
• FIBROUS-CAVERNOUS PULMONARY TUBERCULOSIS
• CIRRHOTIC PULMONARY TUBERCULOSIS
• TUBERCULOMA

23. • Secondary forms of tuberculosis
FOCAL PULMONARY TUBERCULOSIS
Focal tuberculosis of the lungs is characterized by the presence of small (up
to 10 mm in diameter, mostly productive) foci within 1–2 segments in one
or both lungs of various genesis and history with a mildly symptomatic
course.
Among persons who have contracted TB for the first time, focal forms are
diagnosed in 8–12% of cases.
There are 2 variants of focal TB of the lungs:
• in the infiltration phase (soft focus);
• in the phase of compaction and resorption (fibro-focal).
By size, all foci are divided into small - up to 3 mm in diameter, medium -
from 4 to 6 mm, large - from 7 to 10 mm.
Most patients with focal TB do not have any symptoms of the disease.
However, with focal TB, minor symptoms of intoxication and damage to the
respiratory organs can be observed. Intoxication syndrome is manifested
by prolonged low-grade fever, deterioration of appetite and work capacity,
sweating, malaise. Patients may complain of coughing with slight
expectoration. Symptoms of intoxication are more typical for fresh (soft-
focal) forms of focal TB, i.e. focal TB in the infiltration phase, and damage
to the respiratory organs - for chronic (focal TB in the consolidation phase).
With focal TB in the infiltration phase, there are no percussive changes.
Auscultation can reveal focal rales in the presence of decay.

24. • Secondary forms of tuberculosis
INFILTRATIVE PULMONARY TUBERCULOSIS
Infiltrative TB of the lungs is a specific exudative-pneumonic process with a length of
more than 10 mm, which is prone to a progressive course.
Among people who have fallen ill for the first time, infiltrative TB is diagnosed in 50–
65% of cases.
Infiltrate is a tuberculous focus with perifocal inflammation that develops around fresh
or old foci. Fresh outbreaks arise as a result of: a) exogenous superinfection; b)
endogenous reactivation.
A characteristic feature of infiltrative TB is the predominance of perifocal exudative
inflammation. Each infiltrate has caseous foci.
In the case of fresh foci arising as a result of exogenous exposure to MBT, damage to
the bronchioles first develops. Then the process gradually moves to the alveoli with the
formation of pneumonic foci.
In the case of endogenous reactivation, there is an exacerbation of old foci formed after
treatment with other forms of TB. A perifocal exudative inflammation develops around
them. The contents of the hearth loosen and melt. In the future, the inflammation
affects the lymphatic vessels and the wall of the bronchus, penetrates into its lumen,
from there the process spreads to the alveoli, forming exudative areas of inflammation.

25. • Secondary forms of tuberculosis
INFILTRATIVE PULMONARY TUBERCULOSIS
According to clinical and radiological signs, the following forms of infiltrate are distinguished:
• Lobular - characterized by the presence of a focal shadow with a diameter of 1 to 3 cm in the I-II segment of the lung, limited, irregularly
elongated towards the root. The outer contours of the infiltrate are unclear. It seems to consist of several fresh large foci that have
merged.
• Rounded (Assmann-Redeker) - not sharply contoured foci of irregular round or oval shape, with a diameter of 1.5–2.5 cm or more,
localized in the I, II, VI segments of the lung. An inflammatory "track" goes from them to the root of the lung. On its background, the
projection of the bronchus is often visible. The appearance of such shadow formation in the form of a "tennis racket" indicates the
disintegration of the infiltrate and the lymphobronchogenic spread of the process.
• Cloud-like (Rubinstein) - characterized by the presence of a gentle, low-intensity, homogeneous shadow with indistinct blurred contours.
Rapid decay of lung tissue and the formation of a cavern are often observed.
• A lobe infiltrate is an infiltrate that extends to all or most of a lobe of the lung. Depending on the localization of the process, the X-ray
picture of lobitis is different. In the case of damage to the upper lobe of the right lung, a wedge-shaped shadow with an apex near the root
of the lung and a wide base in the lateral section is visualized on anteroposterior images. The median lobe has the shape of a triangle
with a wide base near the mediastinum and an apex directed outward. In the lateral projection, the shadow of the infiltrate in the middle
lobe has the shape of a triangle or a wedge with the apex near the root of the lung.
Lobular Rounded Cloud-like Periscissuritis

26. Rounded (Assmana-Redekera)
Lobular
Peristsisurit Lobit
• Secondary forms of tuberculosis
INFILTRATIVE PULMONARY TUBERCULOSIS

27. • Secondary forms of tuberculosis
DISSEMINATED PULMONARY TUBERCULOSIS
Disseminated TB of the lungs is characterized by multiple, usually in
both lungs, foci of dissemination of hematogenous, lymphogenous or
mixed genesis of different ages and with a different ratio of exudative and
productive inflammation, acute, subacute or chronic course. Among other
clinical forms of VDTB, disseminated pulmonary TB accounts for 20–
25%. Acute, subacute and chronic disseminated pulmonary TB are
distinguished.
Gradual onset of the disease is more often observed. Complaints become
more frequent over months and even weeks. In some patients, this form
of TB passes under the guise of flu, focal pneumonia or bronchitis with a
protracted course.
Percussion reveals muffled lung sounds in the upper parts of the lungs
and tympanitis in the lower parts, as a result of emphysema.
Auscultatively listen for weakened breathing in the lower areas, in the
upper areas - breathing with a hard component and scattered dry rales.
In the case of progression of the process, when infiltrates appear and
caverns are formed, wet rales are heard.
Chronic disseminated TB of the lung has a wave-like course, during
which the symptoms in the period of remission partially disappear, and in
case of exacerbation of the process - intensify. This form of TB is
accompanied by mild signs of intoxication. Patients often feel satisfactory.

28. • Secondary forms of tuberculosis
CASEOUS PNEUMONIA
Caseous pneumonia is an acute specific pneumonia, characterized by
rapidly growing caseous-necrotic changes and a severe course, often
rapidly progressing, leading to death. Diagnosed in 5–8% of cases
among patients diagnosed for the first time.
The onset of the disease is acute with high body temperature and
rapidly increasing symptoms of intoxication; in the initial period
resembles croup pneumonia. Patients complain of chest pain,
shortness of breath, cough with sputum. Cyanosis of the lips,
acrocyanosis, pronounced tachycardia. On percussion over the area
of the affected lung, a significant dullness or a dull percussion sound
is determined, during auscultation against the background of
significantly weakened breathing, a significant number of wet rales
of various calibers are heard, amphoric breathing is possible over the
area of the large cavern. Significant changes in the hemogram of a
toxic nature. As a result of immunological tolerance, the tuberculin
skin test is weakly expressed or negative.
Caseous pneumonia is characterized by massive bacterial excretion.
In the blood, leukocytosis, a shift of the leukocyte formula to the left,
an increase in ESR to 50–70 mm/h.

29. • Secondary forms of tuberculosis
FIBROUS-CAVERNOUS PULMONARY TUBERCULOSIS
Fibrous-cavernous TB of the lung is characterized by the presence of a
fibrous cavern, the development of fibrous changes in the lung tissue, foci
of bronchogenic effusion of different ages in the same and/or opposite
lung, constant or periodic bacterial secretion, a chronic wave-like, usually
progressive course. Often affected bronchi draining the cavern, and such
morphological changes in the lungs as pneumosclerosis, emphysema,
bronchiectasis. Fibrous-cavernous TB of the lungs develops due to the
progression of infiltrative and disseminated TB of the lungs, caseous
pneumonia, tuberculosis, primary tuberculosis complex. The prevalence
of changes in the lungs can be different, the process can be unilateral or
bilateral with one or many caverns. Diagnosed in 2–4% of cases among
newly diagnosed TB.
The clinical picture of the majority of patients with fibro-cavernous TB
may not have complaints at first, because after the removal of caseous
masses, tuberculous intoxication decreases and a clinically satisfactory
condition occurs. In the future, in the event of a decrease in the body's
reactivity, the progression of the tubercular process occurs, which is
accompanied by an increase in tubercular intoxication, a cough with
sputum, a violation of the function of the heart and respiratory systems.

30. • Secondary forms of tuberculosis
CIRRHOTIC PULMONARY TUBERCULOSIS
Cirrhotic TB of the lungs is characterized by a significant growth of
scar tissue, in which active tuberculosis foci remain, causing periodic
exacerbations and possible scanty bacterial excretion. With cirrhotic
TB of the lungs, the development of connective tissue in the lungs
and pleura occurs as a result of the involution of fibrocavernous,
chronic disseminated, massive infiltrative TB of the lungs, lesions of
the pleura, TB of the intrathoracic lymph nodes, which was
complicated by bronchopulmonary lesions.
Cirrhosis is the growth of connective tissue in a parenchymal organ,
which causes restructuring of its structure, compaction and
deformation. The formation of cirrhosis is due to a violation of the
regulation of the growth of connective tissue, stimulation of the
formation of collagen.
Cirrhotic TB of the lungs can be long-lasting with mild symptoms.
Most often, patients suffer from rapid fatigue, cough with
expectoration, shortness of breath, extrasystole, which indicates the
development of pulmonary and heart failure. Bacterial secretion is
not characteristic. The presence of bronchiectasis (as a result of
violation of the structure of the bronchi) causes the addition of a
secondary infection. Therefore, periods of exacerbation of the process
can be caused by the activation of both specific and non-specific
infection.

31. • Secondary forms of tuberculosis
TUBERCULOMA
Pulmonary tuberculosis is a clinical form of pulmonary TB
that combines substrates of various origins, which are
characterized by a rounded caseous formation in the lungs
with a diameter of more than 1 cm, surrounded by granulation
and fibrous tissues, as well as a predominantly productive
nature of the inflammatory reaction.
There are small tuberculomas (up to 2 cm in diameter),
medium (2–4 cm), large (over 4 cm in diameter), giant (over 6
cm). Clinical and X-ray pictures of pulmonary tuberculosis are
mildly symptomatic and depend on the course of the disease.
With tuberculosis, you can observe cough, expectoration,
fatigue, weight loss, low-grade fever. Pain in the chest can
occur in the case of a peripheral location of the tuberculoma
and is associated with the involvement of the pleura in the
process, often of an acute nature, intensifies during deep
breathing, but passes relatively quickly. During the X-ray
examination, a round focus with clear contours is observed.

32. • Generalized form of tuberculosis
Miliary TB is a hematogenous, almost always generalized, form of TB, characterized by a
uniform, dense rash of small, millet-like, tuberculous nodules in the lungs. It is mostly
generalized with the formation of foci in the lungs, liver, spleen, intestines, and meninges.
Clinically, miliary TB is divided into 5 types:
• Acute tuberculous (miliary) sepsis (Landuzi's disease) is the most acute reactive
tuberculous sepsis.
• Typhoid form of acute miliary TB. Millet-shaped tubercles are located in almost all organs -
lungs, heart, kidneys, serous membranes, liver. The onset of the disease is sudden, after
moderate prodromal phenomena (weakness, headache), accompanied by high body
temperature, sweating, tachycardia, moderate cyanosis, discomfort in the intestines and
stomach.
• Meningeal form of acute miliary TB. It is more often observed in children with primary TB,
although it also occurs in adults. Pronounced symptoms of general infection and
intoxication. From the first days, a sharp headache appears, which worsens at the slightest
disturbance of rest.
• Pulmonary form of acute miliary TB. Sharply increasing shortness of breath, cyanosis, dry
cough, tachycardia appear against the background of severe intoxication. Emphysema
occurs in the lungs, a box tone of the lung sound is revealed by percussion, and by
auscultation – weakened, hard breathing, sometimes dry and small-bubble moist rales. In
the early stages of the disease (the first 7–14 days), shadows in the lungs may not be
determined, but a general decrease in pneumatization of the lungs is observed - a symptom
of "cobwebs".
• Chronic miliary TB. Meager clinical manifestations are characteristic, often not noticeable
to the patient. Sometimes periodic low fever, shortness of breath during physical exertion.
On the X-ray of the lungs, multiple miliary foci of different intensity are determined.
MILIARY TUBERCULOSIS

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