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Pulmonary Tuberculosis

Chapter · June 2008

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Sajal De Vk Vijayan
All India Institute of Medical Sciences, Raipur University of Delhi
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 220 Tuberculosis

Pulmonary Tuberculosis
14
VK Vijayan, Sajal De

INTRODUCTION coughed out by ‘open’ [sputum-positive] pulmonary TB

patients who have received no treatment, or have not
Pulmonary tuberculosis [TB] is a chronic infectious
been treated fully. The initial contact with the organism
disease caused by Mycobacterium tuberculosis (1). Other
results in few or no clinical symptoms or signs. The
mycobacteria can also produce pulmonary TB and these
tubercle bacillus sets up a localised infection in the
include Mycobacterium africanum and Mycobacterium bovis.
periphery of the lung. Four to six weeks later, tuberculin
Usually, patients with pulmonary TB who have cavitary
hypersensitivity along with mild fever and malaise
lesions are an important source of infection. These
develops. In the majority of patients, the process is
patients are usually sputum smear-positive. Coughing
contained by local and systemic defenses. Rupture of the
produces tiny infectious droplets. Usually, one bout of
sub-pleural primary pulmonary focus into the pleural
cough produces 3000 droplet nuclei and these can stay
cavity may result in the development of TB pleurisy with
in the air for a long period of time. Ventilation removes
effusion.
these infectious nuclei. Mycobacterium tuberculosis can
Less commonly, tubercle bacilli may be ingested and
survive in the dark for several hours. Direct exposure to
lodge in the tonsil or in the wall of the intestine. This
sunlight quickly kills these bacilli. Of the several factors,
form of TB occurs following the ingestion of contami-
determining an individual’s risk of exposure, two factors
nated milk or milk products. Rarely, TB can occur as a
are important. These include the concentration of droplet
result of direct implantation of the organisms into the
nuclei in contaminated air and the length of time that air
skin through cuts and abrasions. This form of TB is a
is breathed. The risk of transmission of infection from a
health hazard faced by health care workers and labora-
person with sputum smear-negative pulmonary TB and
tory staff who handle materials infected with
miliary TB is low and with extrapulmonary TB is even
Mycobacterium tuberculosis. These lesions were termed
lower. However, infection with Mycobacterium bovis is
“prosector’s warts” (2). Interestingly, Laennec, the
rare in India because milk is often boiled before use. Even
inventor of the stethoscope, acquired TB in this fashion
though nontuberculous mycobacteria [NTM] are
which eventually led to his death (2).
harmless, some can cause human disease especially in
immunocompromised individuals (2). Primary Tuberculosis
From the implantation site, the organisms disseminate
NATURAL HISTORY OF TUBERCULOSIS
via the lymphatics to the regional lymph nodes. The
The cardinal event in the pathogenesis of TB, whether lesion at the primary site of involvement, draining
inapparent or overt is the implantation of Mycobacterium lymphatics and the inflamed regional lymph node
tuberculosis in the tissues. Lung is the most frequent portal constitute the primary complex. When the primary site of
of entry [Figure 14.1]. The organism enters the lung from implantation is in the lung, it is called Ghon’s focus. The
the inhalation of air borne droplets which have been draining lymphatics and the involved lymph nodes

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