Complications Of Secondary Pulmonary Tuberculosis

Complications Of Secondary Pulmonary Tuberculosis

Fate of Secondary Pulmonary Tuberculosis:

Subapical tuberculous lesions in the lungs can develop following outcomes:

1. The lesions may heal with fibrous scarring and calcification.

2. The lesions may coalesce together to form larger area of tuberculous pneumonia and
produce progressive secondary pulmonary tuberculosis with the following pulmonary
and extrapulmonary involvements:

Read And Learn More: General Pathology Notes

•
o Fibrocaseous tuberculosis
o Tuberculous caseous pneumonia
o Miliary tuberculosis
o Tuberculous empyema
o These lesions are briefly described below.

Fibrocaseous Tuberculosis:

The original area of tuberculous pneumonia undergoes peripheral healing and massive central
caseation necrosis which may:

• Either break into a bronchus from the cavity (cavitary or open fibrocaseous
tuberculosis), or
• Remain, as a soft caseous lesion without drainage into a bronchus or bronchiole to
produce a non-cavitary lesion (chronic fibrocaseous tuberculosis).

The cavity provides favourable environment for the proliferation of tubercle bacilli due to
high oxygen tension. The cavity may communicate with bronchial tree and becomes the
source of spread of infection; this is called open tuberculosis.

Complication Of Tuberculosis

The open case of secondary tuberculosis may implant tuberculous lesion on the mucosal
lining of air passages producing endobronchial and endotracheal tuberculosis.

Ingestion of sputum-containing tubercle bacilli from endogenous pulmonary lesions may

produce laryngeal and intestinal tuberculosis.

• Grossly: Tuberculous cavity is spherical with thick fibrous wall, lined by yellowish,
caseous, necrotic material and the lumen may be traversed by thrombosed blood
vessels. Around the wall of cavity are seen foci of consolidation. The overlying pleura
may also be thickened
Complications Of Secondary Pulmonary Tuberculosis

• Microscopically: The wall and lumen of the cavity shows eosinophilic, granular,
caseous material which may show foci of dystrophic calcification. Widespread
coalesced tuberculous granulomas composed of epithelioid cells, Langhans’ giant
cells and peripheral mantle of lymphocytes and having central caseation necrosis are
seen. The outer wall of cavity shows fibrosis.

Complication Of Tuberculosis

Cavitary secondary tuberculosis may develop the following complications:

• Aneurysms of patent arteries crossing the cavity produce haemoptysis.

• Extension into pleura-producing bronchopleural fistula.
• Tuberculous empyema from deposition of caseous material on the pleural surface.
• Thickened pleura (pleurisy) from adhesions of parietal pleura.

Tuberculous Caseous Pneumonia:

Caseous material from a case of secondary tuberculosis in an individual with high degree of
hypersensitivity may spread to rest of the lung producing caseous pneumonia.

Microscopically, the lesions show exudative reaction with oedema, fibrin, polymorphs and
macrophages. Numerous tubercle bacilli can be demonstrated in the exudates.

Complication Of Tuberculosis - Miliary Tuberculosis:

This is lymphohaematogenous spread of tuberculous infection from primary focus or later

stages of tuberculosis. The spread may occur to systemic organs or isolated organs. The
spread is either by the entry of infection into pulmonary vein producingdisseminated or
isolated organ lesion in different extra-pulmonary sites (for example, Liver, spleen, kidney,
brain, meninges, genitourinary tract and bone marrow), or into the pulmonary artery
restricting the development of miliary lesions within the lung

• History And Evolution Of Pathology Notes

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Complications Of Secondary Pulmonary Tuberculosis
Complications Of Secondary Pulmonary Tuberculosis

• Grossly: Miliary lesions are millet seed-sized (1 mm diameter), yellowish, firm areas
without grossly visible caseation necrosis.
• Microscopically: The lesions show the structure of tubercles with minute areas of
caseous necrosis.

Pleurisy And Tuberculous Empyema:

Caseating pulmonary lesions of tuberculosis may be associated with pleurisy (pleuritis,

pleural effusion) as a reaction and is expressed as a serous or fibrinous exudates.
Complications Of Secondary Pulmonary Tuberculosis

Pleural effusion may heal by fibrosis and obliterate the pleural space (thickened pleura by
chronic pleuritis). Occasionally, pleural cavity may contain caseous material and develop into
tuberculous empyema. Depicts various pulmonary and pleural lesions in tuberculosis

Clinical Features And Diagnosis:

Clinical manifestations in tuberculosis may be variable depending upon the location, extent
and type of lesions. However, in secondary pulmonary tuberculosis which is the common
type,

The usual clinical features are as under:

• Referable to lungs: Such as productive cough (may be with haemoptysis), pleural

effusion, dyspnoea,orthopnoea etc. Chest X-ray may show typical apical changes like
pleural effusion, nodularity, and miliary or diffuse infiltrates in the lung parenchyma.
• Systemic features: — such as fever, night sweats, fatigue, loss of weight and
appetite. Longstanding and untreated cases of tuberculosis may develop systemic
secondary amyloidosis.

Diagnosis of tuberculosis in a suspected case can be made by following tests:

• AFB microscopy of diagnostic specimen such as sputum, and aspirated material.

• Mycobacterial culture (traditional method on LJ medium for 4-8 weeks, newer rapid
method by HPLC of mycolic acid with result in 2-3 weeks).
Complications Of Secondary Pulmonary Tuberculosis
Complications Of Secondary Pulmonary Tuberculosis

• Molecular methods such as PCR.

• Complete haemogram (lymphocytosis and raised ESR).
• Radiographic procedures for example, Chest X-ray showing characteristic hilar
nodules and other
parenchymal changes).
• Tuberculin skin test (TST, Mantoux test).
• Interferon gamma release assay (IGRA) (for example, Quantiferon-TB-gold, elispot)
is a measure of cytokine released in the blood and is advocated as a substitute to the
tuberculin skin test.
• However, serologic tests based on detection of antibodies are not useful although
these are being used some developing countries but are not recommended by the
WHO for the diagnosis of tuberculosis.
• Fine needle aspiration cytology of an enlarged peripheral lymph node is quite useful
and easy way for confirmation of diagnosis and has largely replaced the biopsy
diagnosis of tuberculosis (see Appendix I).
• Causes of death in pulmonary tuberculosis are usually pulmonary insufficiency,
pulmonary haemorrhage, sepsis due to disseminated miliary tuberculosis, cor
pulmonale or secondary amyloidosis.

Tuberculosis:

• In tuberculosis, tissue response to the causative organism, Mycobacterium

tuberculosis, (a strict aerobe) is a classic example of caseating granulomatous
inflammation associated with Langhans’ and foreign body giant cells.
Complications Of Secondary Pulmonary Tuberculosis

• The organism is acid-fast bacillus (AFB) which can be demonstrated by Ziehl-

Neelsen staining.
• Tubercle bacilli contain glycoside cord factor essential for the growth of the organism
and glycolipids in the bacterial cell wall.
• Tuberculosis is worldwide in distribution, more common in developing countries.
Other factors include malnutrition, poverty and chronic debilitating diseases and
immunocompromised states like AIDS.
• The infection is commonly transmitted by inhalation of cough droplets from an
infected individual and self-ingestion of infected sputum. The disease may spread
locally, and by lymphohaematogenous route.
• Primary tuberculosis is infection of an individual who has not been previously
infected, also called childhood tuberculosis or Ghon’s complex.
• It affects lung most commonly and the tissue response is by the formation of a small
area of consolidation in the lung, and granulomatous involvement of lymphatic vessel
and hilar lymph nodes.
• Secondary pulmonary tuberculosis includes fibrocaseous (cavitary) type, tuberculous
caseous pneumonia, military spread to various organs and tuberculous pleurisy.
• Common methods of diagnosis of pulmonary tuberculosis are demonstration of the
organism in the sputum, haematologic tests (raised ESR), positive Mantoux skin test,
and X-ray chest.
• Fine needle aspiration of enlarged lymph nodes is a convenient method of
confirmation of diagnosis.
Complications Of Secondary Pulmonary Tuberculosis
Complications Of Secondary Pulmonary Tuberculosis