Cirrhotic pulmonary tuberculosis. Symptoms, diagnosis and treatment of pulmonary cirrhosis

Symptoms

If we talk about cirrhotic tuberculosis, it means an active inflammatory process in the lungs. This means that it has a very definite clinical picture. However, the difficulty lies in the diversity and variability of symptoms. Taking into account the prevalence of structural changes, the severity of functional deficiency and its consequences, several clinical variants of the disease have been identified:

Limited process with few symptoms.
Local or widespread cirrhosis with frequent exacerbations.
Tuberculosis with bronchiectasis and hemoptysis.
Cirrhosis with various manifestations of respiratory and heart failure.
“Destroyed” lung with a progressive tuberculosis process.

With a limited process, patients are bothered by a weak, dry cough, sometimes with hemoptysis. Dyspnea is usually absent. The widespread nature of cirrhosis makes these symptoms more pronounced, and obvious deformation of the chest is observed. Exacerbation of the inflammatory process leads to fever and intoxication with general weakness and sweating. And repeated pulmonary hemorrhages leading to asphyxia or aspiration pneumonia become a terrible symptom.

Chronic respiratory failure leads to the formation of cor pulmonale. This leads to increased shortness of breath, increased cyanosis, increased liver size and the appearance of peripheral edema. On the affected side, the chest is reduced, and the bilateral nature of the process is manifested by its symmetrical barrel-shaped expansion. A long course of tuberculosis leads to the deposition of amyloid in various tissues (primarily the kidneys).

Over dense, cirrhotic lung tissue, a dull percussion sound and increased vocal tremor are detected. On auscultation, breathing is weakened and acquires a bronchial hue, and dry wheezing is heard. However, during the exacerbation phase the picture may change slightly. Activation of inflammation leads to the appearance of moist rales of various sizes, which decrease after coughing up sputum.

The clinical picture of cirrhotic tuberculosis mainly consists of manifestations of the inflammatory process and symptoms of pulmonary heart failure.

Additional diagnostics

Additional methods play a key role in diagnosing pathology. Cirrhosis of the lungs is confirmed by laboratory and instrumental studies, which will indicate morphological changes in the organ and determine the activity of the tuberculosis process. These include the following:

Clinical blood test (leukocyte count, ESR).
Sputum analysis (microscopy, bacterial culture, PCR).
Tuberculin tests (Mantoux).
Chest X-ray.
CT scan.
Spirometry.

The identification of the pathogen in the sputum is important for the differential diagnosis of an active process with cirrhosis, as a consequence of tuberculosis. And although bacterial excretion can be extremely small, the use of highly sensitive techniques (for example, PCR) makes it possible to detect it in a patient with great reliability. In addition, it is necessary to distinguish cirrhosis from pneumosclerosis, sarcoidosis, pneumoconiosis, congenital aplasia of the lung, and tumors.

Treatment

Patients diagnosed with cirrhotic tuberculosis are subject to dispensary observation. Since this form is chronic, it requires multidirectional measures: to eliminate exacerbations and prevent them. In the first case, anti-tuberculosis therapy is carried out with the following drugs (according to WHO regimens):

Isoniazid.
Rifampicin.
Pyrazinamide.
Ethambutol.
Streptomycin.

In the initial phase, all 5 medications are taken for two months, and then 4 medications (without streptomycin) are taken for another month. Then therapy is continued with one or two medications (isoniazid with rifampicin). In order to prevent exacerbations, chemotherapy drugs are also prescribed in a seasonal course. If a nonspecific process develops, it is recommended to take antibiotics. Complications of cirrhotic tuberculosis (pulmonary hemorrhage, cor pulmonale, amyloidosis) also require appropriate treatment. If the changes are limited and the general condition of the patients is satisfactory, then resection of the changed areas of the lung (segmentectomy) can be performed.

Tuberculous cirrhosis is a process characterized by intensive development of connective tissue with gross morphological changes in the lung parenchyma. Moreover, the specific inflammation persists, and the pathogen continues to be excreted in the sputum. The long course of tuberculosis and widespread cirrhosis lead to severe respiratory failure and other complications. Therefore, the disease requires full treatment and active follow-up.

Colleagues, I need your help. I hastily wrote a preliminary conclusion, please tell me if anything is wrong. I will be very grateful to you!

Interpretation of the obtained data is difficult due to artifacts from the patient's movement.

The chest is asymmetrical due to a decrease in the volume of the left half of the chest.

There is a sharp decrease in volume of the left lung with replacement of the parenchyma by fibrous tissue with multiple encysted cavities filled with gas.

The mediastinum is significantly shifted to the left, located in the left half of the chest.

The right lung is compensatedly enlarged, occupies ¾ of the thoracic cavity, with multiple subpleural hypodense thin-walled cavities, mainly in the i.d., with perifocal linear fibrous cords, ranging in size from 7.0 mm in diameter to 43.0 * 34.0 mm on axial sections, with a density isodense to the gas.

The roots of the lungs are located atypically in the left half of the chest cavity, fixed in the thickness of the fibrous tissue of the left lung.

The root of the left lung is not structural, with an uneven lumen diameter, making anatomical interpretation difficult.

The dome and sinus of the diaphragm of the right lung is smooth and clean. The left lateral sinus is sealed.

No pathological changes were detected in the organs of the upper floor of the abdominal cavity.

The thoracic spine corresponds to the age group.

CONCLUSION: Taking into account the anamnestic data, the CT picture is most reliably similar to cirrhotic tuberculosis of the left lung. Compensatory emphysema on the right. Fibrocystic transformation of the right lung with multiple subpleural bullae. A fungal infection cannot be ruled out. Foci of destruction in S2, S6 on the right?

The root of the left lung is not

The root of the left lung is not structured

IMHO: this is the terminology of classical radiology and is not applicable to CT. Inject a contrast agent and separate the vessels from the lymph nodes.

It is located in the left half of the chest.

In my opinion, it is more correct to write “in the left half of the chest cavity.”

There was probably an empyema on the left

On the left, there was probably an empyema with a bronchopleural fistula, which they could not cope with, and an obturator was placed in the PHB. Atelectasis developed; taking into account empyema and suppuration in the blocked bronchi, what we see now has developed. In origin, it is fibroatelectasis with residual cavities, including pleural ones. But I would rather call the picture in the posterior segments on the right (without localizing it specifically segment by segment due to dislocation) as pneumocirrhosis. Although more precisely, perhaps, it is fibrous-cavernous tuberculosis. The expansion of the lung towards the reduced collateral, by definition, is called vicarious or compensatory emphysema.

Expansion of the lung to the side

The expansion of the lung towards the reduced collateral, by definition, is called vicarious or compensatory emphysema.

Or mediastinal pulmonary hernia)

In cirrhosis, the process of sclerosis and fibrotic degeneration involves the bronchi, which change their physiological directions, become deformed, narrow in places or become obliterated. This gives cirrhosis some characteristic radiographic features.

Cirrhosis can be unilateral, bilateral or diffuse. The lung, affected by cirrhosis, gradually decreases in volume, the pleura over it thickens. The lung is permeated with coarse fibrous connective tissue, the vessels of the lung are partly obliterated and partly dilated. Bullae and bronchiectasis may form in the affected areas. Less affected and healthy areas of the lungs become emphysematously dilated.

Classification:

Cirrhotic tuberculosis with limited damage to the lung tissue (usually the upper two segments, with deformation, absence of a cavity). Such patients, as a rule, feel well and nothing bothers them. Such patients have no clinical manifestations of relapse for years, decades. Such patients are epidemically dangerous, especially if they are in the family. But mycobacteria are isolated in small quantities. In some cases, this form, against the background of acute respiratory infections or stress, begins to recur frequently.

Cirrhotic tuberculosis with frequent relapses: the patient begins to have a fever (fever, usually low-grade), an intoxication syndrome appears, which most often manifests itself in the fact that the patient loses weight. The patient quickly becomes dehydrated, loses weight and the process, due to frequent relapses, begins to progress and fibrous tissue takes over half the lung, the whole lung. The second lung is often affected due to bronchogenic contamination. Inevitably, bronchiectasis is formed without fail.

Cirrhotic tuberculosis with bronchiectasis. These patients are seriously ill and sometimes produce copious amounts of bacteria (they can produce up to 1 liter of sputum per day). The patient is exhausted and has a high fever. Such patients are extremely difficult. Bronchiectasis is extensive, secondarily infected and very difficult to treat. In this case, surgical treatment methods cannot be used (with pulponectomy of one lung, tuberculosis immediately develops in the other lung). These patients are doomed.

Cirrhotic tuberculosis is a destroyed lung(s). This is formed during a long, constant progression of the process with the development of fibrous tissue. In this case, pulmonary heart failure is observed. However, anasarca with such cardiopulmonary failure is practically not observed, since these patients are constantly feverish, and fever always leads to dehydration. Therefore, in the treatment of such patients it is necessary to carry out infusion therapy.

Pathological anatomy and pathogenesis

The patient's history shows long-term pulmonary tuberculosis, often repeatedly treated with massive doses of antibiotics. By the time of the examination, the main complaints are reduced to dysfunction of external respiration and cardiovascular failure in the form of shortness of breath and palpitations both at rest and during physical activity.

Examination of the patient reveals sharply impaired statics of the upper body. With unilateral cirrhosis on the affected side, attention is drawn to the depression of the chest, drooping of the shoulder, severe scoliosis of the thoracic spine, and narrowing of the intercostal spaces.

With bilateral cirrhosis, there is a bilateral decline in the supraclavicular and subclavian fossae; there is no such asymmetry in the deformation of the chest as with unilateral cirrhosis. X-ray shows a high position of the root of the lungs. With diffuse pneumosclerosis, all symptoms of the formation are less pronounced. When breathing there is a lag of the affected side of the chest, with a symmetrical lesion there is a slight excursion of both lungs.

Percussion reveals pronounced dullness in areas of cirrhosis, often in the upper fields. Auscultation can be noted bronchial breathing and a small number of small, sometimes sonorous wheezing. Diffuse bronchitis is often diagnosed.

With unilateral cirrhosis that develops from lobitis, the mediastinum shifts towards the affected side, the root of the lung is pulled up and outward and stands significantly higher than normal.

G.R. Rubinstein proposed a symptom for determining tracheal displacement, calling it “forked.” Its meaning is that by plunging the index and middle fingers into the suprasternal cavity between both flexors of the neck, with normal topography of the trachea, both fingers penetrate to the same depth. If the trachea is displaced to the side, one finger penetrates quite deeply and feels the edge of the trachea, the other finger does not penetrate deeply, encountering the trachea, but not feeling its edge.

The X-ray picture of cirrhosis is very typical. The X-ray picture is similar to changes in fibrous-cavernous tuberculosis, which often results in cirrhosis of the lung. Cirrhosis usually affects one or more lobes, and is often bilateral. X-rays reveal signs of fibrosis and wrinkling, as in fibrocavernous tuberculosis, but without cavities. You can often see, especially on tomograms, multiple rounded clearings in the wrinkled areas - bronchiectasis and bullae. They are characterized by thin walls and lack of outflow to the root. But sometimes it is difficult to distinguish bronchiectasis and bullous formations from a cavity. Therefore, in case of cirrhosis, it is necessary to look especially carefully for Mycobacterium tuberculosis in the sputum.

The course of cirrhosis is slow, chronic, lasting for years. Chronic bronchitis gradually develops, bronchiectasis forms, and a large amount of mucopurulent sputum accumulates. A characteristic symptom is not profuse, but often repeated hemoptysis. Emphysema is found in the lower lobes with cirrhosis of the upper lobes. In cirrhosis developing from hematogenously disseminated tuberculosis, emphysema is diffuse and is the predominant symptom of the disease.

Significant changes in the heart are observed. There is hypertrophy of the heart muscles and an increase in the second tone in the pulmonary artery. As cirrhosis progresses, cardiovascular failure appears. The boundaries of the heart expand, its tones become dull. Shortness of breath sometimes intensifies to the extreme of lack of air, and cyanosis appears.

With cirrhosis that developed from lobitas, an outbreak may occur during a long chronic process. Most often this occurs in the presence of a cavity. Hemoptysis or aspiration contamination can lead to a fresh infiltrate with disintegration. An outbreak of the process and bronchogenic contamination dramatically change the picture of the disease, especially in the elderly, and lead to the development of an exudative-pneumonic process with a severe prognosis. Most often, with cirrhosis, patients cured of tuberculosis die from its severe complication - cardiopulmonary failure.

Treatment of pulmonary cirrhosis is mainly symptomatic, with the goal of maintaining cardiac activity and reducing oxygen deprivation. A long stay in a dry climate has a beneficial effect on bronchitis and emphysema, so patients are recommended to undergo sanatorium treatment and even move for permanent residence to southern resorts, such as the Southern Beret of Crimea.

As a result of the long course of cirrhosis that arose after pulmonary tuberculosis, as well as due to the very characteristic clinical picture, the diagnosis of cirrhosis does not make it difficult for doctors.

Tuberculosis of the trachea and bronchi is a complication in patients with destructive forms of pulmonary tuberculosis and massive bacterial excretion. In some cases, damage to the bronchi occurs as a result of the transition of the inflammatory process from the intrathoracic lymph nodes to the bronchial wall. Tuberculosis of the upper respiratory tract, trachea, bronchi is, as a rule, a secondary process that complicates various forms of tuberculosis of the lungs and intrathoracic lymph nodes. Of greatest importance is bronchial tuberculosis, which occurs mainly in destructive and bacillary forms of the process in the lungs, as well as in complicated bronchoadenitis. Its clinical signs are: paroxysmal cough, pain behind the sternum, shortness of breath, localized dry wheezing, the formation of atelectasis or emphysematous swelling of the lung, “bloating” or blockage of the cavity, the appearance of a fluid level in it. An asymptomatic course is also possible. The diagnosis is confirmed by bronchoscopy, when infiltrates, ulcers, fistulas, granulations and scars are revealed, which often cause bronchial obstruction.

Tuberculosis of the larynx is rare: dryness, soreness and burning in the throat, fatigue and hoarseness, pain - independent or when swallowing - are noted. When the glottis narrows as a result of infiltration, edema or scarring, difficult stenotic breathing occurs. The diagnosis of laryngeal tuberculosis is made by laryngoscopy. Tracheal tuberculosis is extremely rare; manifests itself as a persistent, annoying loud cough, chest pain and shortness of breath. The diagnosis is made by laryngotracheoscopy.

Pulmonary cirrhosis is a pathological disease in which irreversible changes occur in the cells and tissues of the organ. Let's consider the main causes of the disease, symptoms, signs, methods of diagnosis and treatment.

Cirrhosis - the growth of tissue in organs such as lungs, kidneys, liver and others, is accompanied by partial or absolute changes in their structure, some compactions and various deformations.

The disease is a proliferation of connective tissue in the lungs. Cirrhosis refers to the extreme and most severe stage of pulmonary tuberculosis. With this disease, the vessels, bronchi and alveoli are completely replaced by connective tissue and collagen, gas exchange functions are disrupted and the pleura becomes denser. Cirrhosis entails a process of fibrous degeneration and sclerosis of the bronchi, which become deformed, narrow, that is, change their physiological characteristics. It is this factor that makes it possible to recognize this disease using x-ray examination.

Pulmonary cirrhosis is characterized by a long course. The pathology can be either unilateral or bilateral. But in both the first and second cases, the formation of sclerotic changes in the lung tissue occurs. Not only the bronchi are subject to deformation, but also the blood vessels, the mediastinal organs are displaced, and emphysema appears in the areas adjacent to the lungs.

There is a certain classification of pulmonary cirrhosis, that is, cirrhotic tuberculosis:

Cirrhosis with local damage to the lung tissue - most often the upper segments of the organ are subject to deformation. Patients with this diagnosis feel normal, since the disease may not produce clinical manifestations for decades. Such patients are dangerous because they secrete mycobacteria in small quantities. But stress, acute respiratory diseases and a number of other diseases can trigger a relapse of pulmonary cirrhosis.
Cirrhosis with frequent relapses - the patient suffers from low-grade fever, intoxication and dehydration. Fibrous tissue grows and can invade the entire lung. Bilateral damage due to bronchogenic contamination is very common.
Cirrhosis of the lungs with bronchiectasis - the condition of patients is severe, there is abundant bacterial production of sputum. Bronchiectasis is quite extensive, difficult to treat and becomes secondarily infected. With this form of the disease, surgical treatment is impossible; such patients have a poor prognosis.
Cirrhosis of the lungs, which causes destruction of organ tissue. During long-term progression, fibrous tissue develops against the background of pulmonary heart failure. Patients are constantly feverish, the body is in a state of dehydration. For therapy, infusion treatment is used.

ICD-10 code

J60-J70 Lung diseases caused by external agents

Causes of lung cirrhosis

The causes of lung cirrhosis are varied; the disease can occur against the background of an advanced form of tuberculosis and other pathologies of the body. In recent years, doctors have noted that long-term treatment with antibiotic drugs contributes to the formation of cirrhosis. But most often the disease develops against the background of chronic fibrous-cavernous and hematogenously disseminated tuberculosis. Pleurisy and tuberculous lobitis can also be a source of pathology.

Since the main cause of pulmonary cirrhosis is tuberculosis, it is worth knowing that it is provoked by acid-fast bacteria of the genus Mycobacterium. Cirrhotic tuberculosis develops over a long period of time, and the disease often progresses for years, or even decades. But in some cases the disease develops rapidly. In this case, the age characteristics of the body are of great importance. Since during the aging process, the elastic fibers of the lungs are gradually replaced by connective tissue, which leads to the formation of emphysema.

But people of middle age, young people and even children are susceptible to developing cirrhosis of the lungs. The development of the disease is influenced by various complications, for example, damage to the cardiovascular system and lungs, sclerosis in the lymph nodes and tuberculosis foci. A limited form of cirrhosis can occur against the background of focal tuberculosis due to disruption of pulmonary ventilation and damage to the small bronchi. In the affected area, not only sclerosis is formed, but also grape-shaped swellings.

Cirrhosis can develop after surgery, for example, after lung resection. Pleural empyema and bronchial fistula are also risk factors for the development of pulmonary cirrhosis. Prolonged inhalation of organic and inorganic dust provokes lung damage, which leads to fibrosis. Pathologies of connective tissue, pneumonia, inflammation of the walls of blood vessels and many other diseases can cause cirrhosis of the lungs.

Symptoms of lung cirrhosis

Symptoms of lung cirrhosis come in waves and may not appear for a long period of time. Thus, periods of normal condition are replaced by exacerbations with signs of intoxication. The patient's cough and sputum production intensify, hemoptysis and pulmonary hemorrhage appear. Against the background of these symptoms, due to contamination with microbacteria, new foci of inflammation are formed in different parts of the lungs. As it progresses, disruption of all body systems and damage to various organs develops.

Patients complain of shortness of breath, frequent asthmatic attacks, and sputum production with an unpleasant odor. With the development of pulmonary cirrhosis, the functioning of the cardiovascular system is disrupted, fluid accumulates in the peritoneal cavity, and the liver increases in size. In some cases, cirrhosis is accompanied by amyloidosis, that is, non-tuberculous damage to the kidneys and liver.

The course of cirrhosis is very slow and can last for years, as it takes on a chronic form. The patient may often suffer from chronic bronchitis, against the background of which bronchiectasis forms and mucopurulent sputum accumulates. If the disease develops from hematogenously disseminated tuberculosis, then the predominant symptom of pulmonary cirrhosis is diffuse emphysema.

Diagnosis of lung cirrhosis

Diagnosis of lung cirrhosis presents a number of difficulties, since the clinical symptoms of the disease are difficult to differentiate from a number of other pathologies of the respiratory system. But, despite this, the following methods are used to determine cirrhosis:

Anamnesis collection, that is, analysis of disease complaints (shortness of breath, general weakness, cough, intoxication). The doctor asks the patient about when the first symptoms of the pathology appeared, about previous and existing diseases, working and living conditions.
At the next stage, the doctor listens to the lungs and determines the degree of damage (unilateral or bilateral). In addition, percussion is performed, that is, tapping the lungs. Also, the patient will undergo spirography to determine respiratory function disorders and the volume of the respiratory organs.
After this, the patient is given a chest x-ray, which can be used to recognize changes in the lungs, that is, their deformation. Computer and magnetic resonance imaging are used as additional diagnostic methods. These methods allow you to more accurately determine the degree of pathological changes in the lungs.
A biopsy, that is, an examination of lung tissue obtained using bronchial endoscopy, would not be superfluous. Such a study reveals the proliferation of connective tissues in the lungs at the microscopic level.

In addition to the methods described above, the patient must undergo a number of tests. First of all, this is a general analysis and a detailed blood test, and an analysis of sputum secretion. This will provide information about the course of the inflammatory process and the level of intoxication in the body. Sputum is examined for the presence of mycobacteria and increased sensitivity to antibiotics. The data obtained is used to draw up a treatment plan.

Treatment of lung cirrhosis

Treatment of lung cirrhosis is symptomatic therapy, which is aimed at reducing oxygen deprivation and preserving cardiac activity. In some cases, surgical treatment is performed, for example, with unilateral cirrhosis. The patient is admitted to a hospital and undergoes conservative therapy, after which surgical intervention is possible. In addition, it is necessary to constantly conduct control studies to assess the correctness and effectiveness of the chosen treatment method.

Antibacterial treatment consists of two phases:

In the intensive phase, the patient is given a combination of antibiotics to suppress the intensive proliferation of mycobacteria and to prevent the development of drug resistance.
In the phase of ongoing therapy, the effect is aimed at dormant and intracellular forms of mycobacteria. The patient is prescribed medications to stimulate regeneration processes and prevent the proliferation of bacterial microorganisms.

The patient's nutrition is of particular importance. Doctors recommend a special diet with protein-rich foods. This allows you to correct metabolic disorders. Surgical treatment of pulmonary cirrhosis is carried out in the presence of tuberculomas, single cavities, tricky changes within several or one lobe of one lung. Resection of areas of the lung affected by cirrhosis is prohibited in severe degrees of cardiac and respiratory failure.

Particular attention is paid to collapse therapy. This method is used only when no signs of sclerosis are found, but there are already cavities and pulmonary bleeding. The essence of the treatment is to create an artificial pneumothorax to compress the lungs. Thanks to this, decay cavities collapse, the risk of infection dissemination is significantly reduced, and reparative processes are improved. As a rule, this method is used for cirrhosis localized in the lower lobes of the lungs.

Prevention of lung cirrhosis

Prevention of lung cirrhosis is aimed at preventing the development of diseases that cause pathological damage to the respiratory system. To do this, it is necessary to promptly treat any inflammatory lung diseases. Vaccination (BCG), that is, the introduction of a weakened strain of Mycobacterium tuberculosis to develop immunity, would not be superfluous. This preventive method is included in the routine vaccination calendar for children and remains effective for five years. According to doctors, vaccination can be carried out every five years until the age of 30.

Do not forget about chemoprophylaxis, that is, taking antibiotics. This method can be used for primary infection with mycobacteria or secondary, that is, for patients who have had mild forms of pulmonary tuberculosis. The main indications for such prevention are professional or household contacts with patients with open tuberculosis. A similar method is necessary for patients with tuberculous changes in the respiratory organs who are taking immunomodulators or steroid hormones.

Particular attention should be paid to taking medications that can lead to the development of pulmonary fibrosis. Don’t forget about quitting smoking and annual fluorography. This screening test can detect not only cirrhosis of the lungs, but also other nonspecific lesions of the respiratory system and even tumors of the chest organs.

Prognosis of lung cirrhosis

The prognosis for lung cirrhosis is favorable for life, even if the therapy is supportive and lasts a very long time. But cirrhosis can cause a number of complications, such as chronic cor pulmonale, pulmonary hypertension, respiratory failure, or secondary infection.

Cirrhosis of the lungs is accompanied by a severe cough of blood and sputum production. It is these symptoms that should be a reason to seek medical help, undergo a series of examinations and begin to treat damage to the respiratory organs. The earlier cirrhosis of the lungs is detected, the greater the chance of avoiding serious complications that negatively affect the functioning of the entire body.

Cirrhosis of the lungs is the growth of connective tissue in them as a result of the healing of the pathological process. In recent years, many clinicians have emphasized that massive antibiotic treatment promotes the formation of cirrhosis. Cirrhosis develops most often in chronic fibrous-cavernous forms and in chronic hematogenously disseminated tuberculosis. However, tuberculous lobitis and pleurisy can also be a source of cirrhosis. In the thickness of cirrhotic lesions, slit-like or larger cavities, as well as caseous foci, surrounded by a dense shaft of sclerosis and hidden under layers of cirrhosis, can remain. The presence of such residual effects is confirmed by bacillemia and layer-by-layer tomograms. In cirrhosis, the process of sclerosis and fibrotic degeneration involves the bronchi, which change their physiological directions, become deformed, narrow in places or become obliterated. This gives cirrhosis some characteristic radiographic features. Cirrhosis can be unilateral, bilateral or diffuse. The lung, affected by cirrhosis, gradually decreases in volume, the pleura over it thickens. The lung is permeated with coarse fibrous connective tissue, the vessels of the lung are partly obliterated and partly dilated. Bullae and bronchiectasis may form in the affected areas. Less affected and healthy areas of the lungs become emphysematously dilated. Classification: cirrhotic tuberculosis with limited damage to the lung tissue (usually the upper two segments, with deformation, absence of a cavity). Such patients, as a rule, feel well and nothing bothers them. Such patients have no clinical manifestations of relapse for years, decades. Such patients are epidemically dangerous, especially if they are in the family. But mycobacteria are isolated in small quantities. In some cases, this form, against the background of acute respiratory infections or stress, begins to recur frequently. cirrhotic tuberculosis with frequent relapses: the patient begins to have a fever (fever, usually low-grade), an intoxication syndrome appears, which most often manifests itself in the fact that the patient loses weight. The patient quickly becomes dehydrated, loses weight and the process, due to frequent relapses, begins to progress and fibrous tissue takes over half the lung, the whole lung. The second lung is often affected due to bronchogenic contamination. Inevitably, bronchiectasis is formed without fail. cirrhotic tuberculosis with bronchiectasis. These patients are seriously ill and sometimes produce copious amounts of bacteria (they can produce up to 1 liter of sputum per day). The patient is exhausted and has a high fever. Such patients are extremely difficult. Bronchiectasis is extensive, secondarily infected and very difficult to treat. In this case, surgical treatment methods cannot be used (with pulponectomy of one lung, tuberculosis immediately develops in the other lung). These patients are doomed. cirrhotic tuberculosis - destroyed lung(s). This is formed during a long, constant progression of the process with the development of fibrous tissue. In this case, pulmonary heart failure is observed. However, anasarca with such cardiopulmonary failure is practically not observed, since these patients are constantly feverish, and fever always leads to dehydration. Therefore, in the treatment of such patients it is necessary to carry out infusion therapy.

Pathological anatomy and pathogenesis

Cirrhotic pulmonary tuberculosis occurs as a result of long-term fibrous-cavernous forms, characterized by a massive, diffuse proliferation of connective tissue with deformation of the lung tissue and the development of bronchiectasis. Cavities are absent or have the appearance of narrow slit-like cavities. With a significant amount of sclerotic changes, hypertension of the pulmonary circulation, cor pulmonale and pulmonary heart failure develop. Major complications also include amyloidosis and pulmonary embolism. The patient's history shows long-term pulmonary tuberculosis, often repeatedly treated with massive doses of antibiotics. By the time of the examination, the main complaints are reduced to dysfunction of external respiration and cardiovascular failure in the form of shortness of breath and palpitations both at rest and during physical activity. Examination of the patient reveals sharply impaired statics of the upper body. With unilateral cirrhosis on the affected side, attention is drawn to the depression of the chest, drooping of the shoulder, severe scoliosis of the thoracic spine, and narrowing of the intercostal spaces. With bilateral cirrhosis, there is a bilateral decline in the supraclavicular and subclavian fossae; there is no such asymmetry in the deformation of the chest as with unilateral cirrhosis. X-ray shows a high position of the root of the lungs. With diffuse pneumosclerosis, all symptoms of the formation are less pronounced. When breathing there is a lag of the affected side of the chest, with a symmetrical lesion there is a slight excursion of both lungs. Percussion reveals pronounced dullness in areas of cirrhosis, often in the upper fields. Auscultation can be noted bronchial breathing and a small number of small, sometimes sonorous wheezing. Diffuse bronchitis is often diagnosed. With unilateral cirrhosis that develops from lobitis, the mediastinum shifts towards the affected side, the root of the lung is pulled up and outward and stands significantly higher than normal. G.R. Rubinstein proposed a symptom for determining tracheal displacement, calling it “forked.” Its meaning is that by plunging the index and middle fingers into the suprasternal cavity between both flexors of the neck, with normal topography of the trachea, both fingers penetrate to the same depth. If the trachea is displaced to the side, one finger penetrates quite deeply and feels the edge of the trachea, the other finger does not penetrate deeply, encountering the trachea, but not feeling its edge. X-ray picture cirrhosis is very typical. The X-ray picture is similar to changes in fibrous-cavernous tuberculosis, which often results in cirrhosis of the lung. Cirrhosis usually affects one or more lobes, and is often bilateral. X-rays reveal signs of fibrosis and wrinkling, as in fibrocavernous tuberculosis, but without cavities. You can often see, especially on tomograms, multiple rounded clearings in the wrinkled sections - bronchiectasis and bullae. They are characterized by thin walls and lack of outflow to the root. But sometimes it is difficult to distinguish bronchiectasis and bullous formations from a cavity. Therefore, in case of cirrhosis, it is necessary to look especially carefully for Mycobacterium tuberculosis in the sputum. The course of cirrhosis is slow, chronic, lasting for years. Chronic bronchitis gradually develops, bronchiectasis forms, and a large amount of mucopurulent sputum accumulates. A characteristic symptom is not profuse, but often repeated hemoptysis. Emphysema is found in the lower lobes with cirrhosis of the upper lobes. In cirrhosis developing from hematogenous

disseminated tuberculosis, emphysema is diffuse in nature and is the predominant symptom of the disease. Significant changes in the heart are observed. There is hypertrophy of the heart muscles and an increase in the second tone in the pulmonary artery. As cirrhosis progresses, cardiovascular failure appears. The boundaries of the heart expand, its tones become dull. Shortness of breath sometimes intensifies to the extreme of lack of air, and cyanosis appears. With cirrhosis that developed from lobitas, an outbreak may occur during a long chronic process. Most often this occurs in the presence of a cavity. Hemoptysis or aspiration contamination can lead to a fresh infiltrate with disintegration. An outbreak of the process and bronchogenic contamination dramatically change the picture of the disease, especially in the elderly, and lead to the development of an exudative-pneumonic process with a severe prognosis. Most often, with cirrhosis, patients cured of tuberculosis die from its severe complication - cardiopulmonary failure. Treatment of pulmonary cirrhosis mainly symptomatic, with the goal of maintaining cardiac activity and reducing oxygen starvation. A long stay in a dry climate has a beneficial effect on bronchitis and emphysema, so patients are recommended to undergo sanatorium treatment and even move for permanent residence to southern resorts, such as the Southern Beret of Crimea. In some cases, surgical treatment may be recommended, in particular for patients with unilateral cirrhosis and MBT release. As a result of the long course of cirrhosis that arose after pulmonary tuberculosis, as well as due to the very characteristic clinical picture, the diagnosis of cirrhosis does not make it difficult for doctors. Tuberculosis of the trachea and bronchi is a complication in patients with destructive forms of pulmonary tuberculosis and massive bacterial excretion. In some cases, damage to the bronchi occurs as a result of the transition of the inflammatory process from the intrathoracic lymph nodes to the bronchial wall. Tuberculosis of the upper respiratory tract, trachea, and bronchi is usually a secondary process that complicates various forms of tuberculosis of the lungs and intrathoracic lymph nodes. Of greatest importance is bronchial tuberculosis, which occurs mainly in destructive and bacillary forms of the process in the lungs, as well as in complicated bronchoadenitis. Its clinical signs are: paroxysmal cough, pain behind the sternum, shortness of breath, localized dry wheezing, the formation of atelectasis or emphysematous swelling of the lung, “bloating” or blockage of the cavity, the appearance of a fluid level in it. An asymptomatic course is also possible. The diagnosis is confirmed by bronchoscopy, when infiltrates, ulcers, fistulas, granulations and scars are revealed, which often cause bronchial obstruction. Tuberculosis of the larynx is rare: dryness, soreness and burning in the throat, fatigue and hoarseness of the voice, pain - independent or when swallowing - are noted. When the glottis narrows as a result of infiltration, edema or scarring, difficult stenotic breathing occurs. The diagnosis of laryngeal tuberculosis is made by laryngoscopy. Tracheal tuberculosis is extremely rare; manifests itself as a persistent, annoying loud cough, chest pain and shortness of breath. The diagnosis is made by laryngotracheoscopy.