PNEUMOLOGIE

MEDICINA DENTARA
CURS 1- partea 2
Tuberculoza –diagnostic
CONF. Dr.Habil.Antigona Trofor
 Clasificare
• TB primara (copil)
• TB secundara (adult)
• TB diseminata (miliara)
• TB extrapulmonara
• Forme particulare ( tuberculom,
fibrotorax, etc.)
 TB primara (primoinfectia)
-caracteristici generale-
• Apare la persoane indemne de infectia
bK.
• Adenopatia traheobronsica.
• Evolutie imprevizibila –f de varsta,
durata,intensitatea, repetarea
contaminarii.
 i.d.r. la tuberculina- rol important in dg.
 TB primara
-forme clinice-
• TB PRIMARA LATENTA (90%)
-asimptomatica
-i.d.r.tuberculina… >9mm….ex.radiologic.
-viraj tuberculinic: i.d.r.negativ…..pozitiv.
-salt tuberculinic:peste 8 mm intre 2
teste succesive.
 TB primara manifesta
 Simptome: febra,scadere ponderala,oboseala,
tuse,tiraj,stridor (compresiune ganglionara).
 Sindroame de debut:
1.ERITEM NODOS
2.TIFOBACILOZA LANDOUZI:2-3 sapt,febra lent
instalata-platou 38-39C.
3.Sd.PSEUDOREUMATISMAL-dureri,sd.infectios acut.
4.KERATOCONJUNCTIVITA FLICTENULARA
(lacrimare, fotofobie, flictene conjunctivale)
Caz Tb primara copil 11
ani
 Caz Tb primara tanar 17
ani
• TB caz nou,
tratament
incorect, pulmonar
si extrapulmonar,
interventie
chirurgicala
 TB primara-diagnostic
• Simptome clinice
• Radiologic: adenopatia traheo - bronsica
• i.d.r.la tuberculina
• Hematologic: sd.inflamator
• Bacteriologic: sputa(?)/spalatura gastrica
• Bronhoscopic-fistula ganglio-bronsica
 TB secundara (adult)
• Polimorfism clinic,Rx,evolutiv,tendinta la
cronicizare.
• Mecanism: reactivare focar endogen/reinfectie.
• Debut: a) latent:febra,scadere G, astenie
b)inaparent:asimptomatic,dg.Rx/bacteriologic.
c)acut:pseudogripal/pneumonic-herpes,facies
vultuos,febra,frison.
d)accident evocator:hemoptizie,laringita,
pneumotorax.
 TB adult-diagnostic
• Anamneza-APP epidemiologice.
• Examen fizic-sarac.
• i.d.r.-rol ajutator.
• Examen radiologic
• Examen bacteriologic al sputei.
• Alte teste:ex.lichidului pleural,biopsia
pleurala, bronhoscopia.
 Anamneza
• Istoric de tuse productiva, prelungita
(>3sapt.),smptome generale,+/-hemoptizie
 Istoric de simptome extrarespiratorii
(dureri coloana vertebrala,precordiale, cefalee,hematurie,
raguseala,etc.)
 Notiunea de “contact”/ ”focar” TB:
(rude/anturaj cu TB,idr+,factori favorizanti,fost bolnav
TB,evidenta fisier ambulator TB.)
 TB adult
I.D.R.Tuberculina

• Indicatii:suspecti/contacti TB,screening
populational,completarea dg.TB.
• Tehnica:inj. i.d. 2 U.I.tuberculoproteine purificate-PPD-
ID65(0,1ml.)f.ant.antebrat stg
pielea-deformeaza in coaja de portocala 5-6mm
• Pastrare: intuneric,+4C.
• Interpretare: 72 ore-DOAR INDURATIA DERMICA
PALPABILA-D maxim transversal-mm.
-scala Palmer:I)-lemnoasa,II) renitenta,III)depresibila.
IV) absenta induratiei-doar eritem.
 NEGATIV:D 0-9mm/ POZITIV: D> 10 mm.
 I.D.R.
• Greseli de interpretare:
-executie incorecta(s.c.),pastrarea PPD,
subnutritie, copii< 6 luni-sistem imun imatur.
-i.d.r.fals negative: in cele 2-10 sapt.de la
infectare-raspunsul imun nu este dezvoltat.
-efect Booster -la batrani: repetarea reactiei la
2-3 sapt./repetarea cu 10 U.I.PPD.
 TB adult-dg.radiologic
• Specific: mare varietate,dinamism,
predominant in lobii superiori,segmentele
apicodorsale,opacitati neomogene.
-INFILTRATIVA(forma,dimens,topografie,intensit)
-CAVITARA(dimensiuni,contur,bronhie drenaj,nivel)
-MILIARA(opacitati multiple difuze bilaterale)
-FIBROASA: (benzi reticulare,calcificari,retractii)
 TB adult-dg.bacteriologic
• Ex.bacteriologic sputa: evid.bK MO/culturi.
3 probe- purulenta/mucopurulenta.
 Pacienti care nu expectoreaza-spalaturi
bronsice, gastrice(copii), aspirat bronsic.
 Cultura- evid.specia de mycobacterii,
masurarea sensibilitatii la antibiotice-drog
rezistenta.
 Recoltare de produse patologice extraresp.
(urina,l.c.r., lichid intraarticular,secretii
cutanate,etc.)
 TB pleurala
• La tineri, scurt timp dupa primoinfectie.
• Hipersensibilizare a compon.pleurale la Ag Myc
• Prin diseminare limfatic/hematogen-contiguitate
• Dg:APP,idr,lez.pulmonare
• Ex.lichid pleural: exsudat(P>3g/l,gluc.<0,6%,
Gl.pl/Gl.sg<0,5, LDH>200,nr.celule>1000/mmc.
Limfocitoza>85%,granuloame TB-ex.anat.patol.
biopsie pleurala(60-70%),toracosopie(80-90%).
 Particularitati TB-varsta
Copii 0-5 ani-f.grave-bronhopneumonii,meningite,
TB diseminate sau Pleurezii,TB bronsica,
Batrani: sex M,simpt.frusta,atipica,torpida,forma
pleuro pericardica/peritoneala -efect booster.
Pubertate-fete-13-15 ani-TB I/II-pot coexista
adenopatii traheo-bronsice,calcificari cu
infiltrate sau caverne pulmonare.
 TB si infectia HIV
1997- 16mil.persoane dubla infectie.
Infectia HIV deprima imunitatea celulara.
Inf.HIV precoce:TB parenchim pulmon,bk sputa+,Rx-
infiltrat/caverna.
Inf.HIV final-adenopatii mediastinale,TB
extrarespiratorie(meningita, pleurezie,
pericardita),Rx.pulm. normala,bk sputa-.
Complicatii:limfoame, infectii F,P,CMV,Pc
Idr> 5 mm pozitiv/LyTCD4<200/mmc!!/contacti TB
Chimipoprofilaxie-HIN 5 mg/kgc 12 luni,Myc atipice/MDR.
 TB extrarespiratorie
• Def.:orice localizare,alta decat parenchimul pulmonar.
• Dg:semne clinice generale/de organ, idr,
anamneza,teste de laborator,imagistice,consult specialist
pneumolog.
Osteoarticular(dureri,impotenta fct.,poz.antalgice,inflamatie)
Urologic(hematurie,polakiurie, urini tulburi-leucociturie,bK+).
Genital(amenoree,sterilitate/epididimita)
Ganglioni limfatici periferici,Oftalmologic(cornee,sclera,uveite),
Endocrinologic(Tiroida-h/Hfunctie;Suprarenala-b.Addison-
hiperpigmentare,scadere ponderala,astenie,varsaturi,hTA.
 Forme rareTB
Tuberculom-stratificat fibroza/caseum-
indicatie chirurgicala+Ab.-incapsulat.
TB pulm.hipercronica-esec
terapeutic/trat.incorect,evolutie
lenta,bk persistenti.
Plaman distrus TBC
TB retractile-incert stabilizate,trat
inadecvat,reactivitate particulara org.
 Forme grave TB primara
• Pneumonia/Bronhopneumonia TB
-tablou clinic zgomotos,evolutie nefavorabila-
 TB primara cavitara
-extensie rapida a bolii,raspuns terapeutic slab,adenopatii
mediastinale-fistule ganglionar-bronsice,
dg. bronhoscopic-caseum,bK +,inalta contagiozitate.)
 Evolutia TB
• Vindecare fara sechele 85-90%.
• Nefavorabila:hemoptizii mari,insuficienta
respiratorie,deces
amiloidoza.
 Sechele-sd.postTB:disfunctie
respiratorie(BPCO),bronsiectazii,noduli
fibrosi apicali,fibroze /scleroze
cicaticeale,emfizem bulos).