presenation fibrous cavernous tuberculois teachers version

8/17/2019 Presenation Fibrous Cavernous Tuberculois Teachers Version

1/49

Lecture on pathomorphology forLecture on pathomorphology for

the 3-rd year studentsthe 3-rd year students

By T.G. FilonenkoBy T.G. Filonenko 1


2/49

TuberculosisTuberculosis

TuberculosisTuberculosis is a chronicis a chronic

communicable disease withcommunicable disease with

specifc granulomatousspecifc granulomatous

inammationinammation caused by acaused by a

variety o tubercle bacilli,variety o tubercle bacilli,especiallyespecially MicobacteriumMicobacterium

tuberculosis hoministuberculosis hominis andand M.M.

t. bovis.t. bovis. 2


3/49

Mode of transmissionMode of transmission

• By inhalation into the respiratory tract.By inhalation into the respiratory tract.• Ingestion. Through ingestion into GIIngestion. Through ingestion into GI

tract leads to development to tonsillartract leads to development to tonsillar

or intestinal tuberculosis.or intestinal tuberculosis.• Inoculation. Through mucousInoculation. Through mucous

membranes o mouth and throat, sin.membranes o mouth and throat, sin.

• Transplacental route Transplacental route results inresults indevelopment o congenital tuberculosisdevelopment o congenital tuberculosis

in etus rom inected mother.in etus rom inected mother.

3


4/49

Classication ofClassication of

tuberculosistuberculosis 1.1. Primary tuberculosisPrimary tuberculosis

2.2. Post primary tuberculosis:Post primary tuberculosis:a)a) Hematogenous tuberculosisHematogenous tuberculosis

b) b) Secondary tuberculosisSecondary tuberculosis

4


5/49

5


6/49

PostprimaryPostprimary

6


7/49

Pathogenesis ofPathogenesis of

TuberculosisTuberculosis• !s the most common portal o entry is the!s the most common portal o entry is the

respiratory tract by inhalation.respiratory tract by inhalation.

• The inhaled organism enters into alveoli and is The inhaled organism enters into alveoli and isingested by the alveolar macrophage.ingested by the alveolar macrophage.

• The "T can either be illed by the macrophage# The "T can either be illed by the macrophage#its growth inhibited or multiplies inside theits growth inhibited or multiplies inside themacrophage.macrophage.

• "T lives in symbiosis with the cell."T lives in symbiosis with the cell.

•$uring the course o the ne%t & to ' wees both$uring the course o the ne%t & to ' wees bothcell(mediated immunity and the delayed type ocell(mediated immunity and the delayed type ohvpersensitivity develop in the host and thesehvpersensitivity develop in the host and theseater the host response to the inection andater the host response to the inection andresult in the ormation o the classic tubercle.result in the ormation o the classic tubercle.

7


8/49

y v yimmunity inimmunity in

tuberculosistuberculosis Hypersensiti!ity or allergy" and immunity orHypersensiti!ity or allergy" and immunity orresistance" plays a ma#or role in t$e de!elopmentresistance" plays a ma#or role in t$e de!elopment

o% lesions in tuberculosis.o% lesions in tuberculosis.

&issue c$anges seen in tuberculosis are not t$e&issue c$anges seen in tuberculosis are not t$e

result o% any e'oto'in or endoto'in but areresult o% any e'oto'in or endoto'in but are

instead t$e result o% $ost response to t$einstead t$e result o% $ost response to t$e

organism" ($ic$ is in t$e %orm o% de!elopmentorganism" ($ic$ is in t$e %orm o% de!elopment

o% cellmediated $ypersensiti!ity *or type +,o% cellmediated $ypersensiti!ity *or type +,

$ypersensiti!ity) and immunity.$ypersensiti!ity) and immunity.-


9/49

Features of PrimaryFeatures of Primary

TuberculosisTuberculosis• $evelopment o disease at the frst getting o the$evelopment o disease at the frst getting o the

activator into the organism.activator into the organism.

• )ensibili*ation and allergy o +IT +ypersensitivity o)ensibili*ation and allergy o +IT +ypersensitivity o

Immediate Type-Immediate Type- ..

• revalencerevalence o the e%udative ( necrotic changes.o the e%udative ( necrotic changes.• Tendency to hematogenous and lymphogenous Tendency to hematogenous and lymphogenous

generali*ation and also to chronic duration.generali*ation and also to chronic duration.

• araspecifc reactions such as/ vasculitis, nodousaraspecifc reactions such as/ vasculitis, nodous

erythema, arthritis.erythema, arthritis.• rimary Tuberculosis used to be ound most oten inrimary Tuberculosis used to be ound most oten in

young children, but in industriali*ed countries it hasyoung children, but in industriali*ed countries it has

become more common in the elderly and debilitated,become more common in the elderly and debilitated,

in alcoholics, and in high(ris racial groups.in alcoholics, and in high(ris racial groups.


10/49

"Ghon complex""Ghon complex" is theis the

characteristic gross appearancecharacteristic gross appearancewith primary tuberculosiswith primary tuberculosis

The primary complex isThe primary complex islocated inlocated in

the lo!er part of the right the lo!er part of the right

upper lobes orupper lobes or the upper part of the lo!er the upper part of the lo!er

lobes in # $# %# &'lobes in # $# %# &'

segments usually(segments usually( 1/


11/49

P)*M+), C-MP./0 -F T12/)C1.-3*3P)*M+), C-MP./0 -F T12/)C1.-3*3

"Ghon complex4"Ghon complex4

consists of consists of *(*( PulmonaryPulmonary

component socomponent so

calledcalled PrimaryPrimary

a5ect ora5ect or primaryprimary

focus or Ghon6sfocus or Ghon6s

focus(focus(

**( .ymphatic vessel**( .ymphatic vessel

component occurscomponent occurs byby TuberculousTuberculous

lymphangitis(lymphangitis(

***( .ymph node***( .ymph nodecomponent occurscomponent occurs

+++

+

++

11


12/49

There is There is smallsmalltan(yellowtan(yellow

subpleuralsubpleural

granuloma ingranuloma in

the mid(lungthe mid(lungfeld on the rightfeld on the right 0-0-. In the hilum. In the hilum

is a small yellowis a small yellow

tan granulomatan granuloma

in a hilar lymphin a hilar lymph

node ne%t to anode ne%t to a

bronchusbronchus 1-1-..

P)*M+), C-MP./0 -F T12/)C1.-3*P)*M+), C-MP./0 -F T12/)C1.-3*

12

12


13/49

It isIt is 0(1 cm0(1 cm

solitary area osolitary area ocaseouscaseous

pneumoniapneumonia

surrounding bysurrounding by

periocal serousperiocal serous

inammation.inammation. !! central area ocentral area o

necrosis appearsnecrosis appearsirregular,irregular,

amorphous, andamorphous, and

pin. Grossly,pin. Grossly,

areas oareas o

Microscopical picture ofMicroscopical picture of

Primary a5ectPrimary a5ect

13


14/49

)een here in a)een here in ahilar lymphhilar lymph

nodenode is ais a

2caseating22caseating2

granuloma.granuloma.Granulomas haveGranulomas have

prominentprominent

caseous necrosis.caseous necrosis.

Grossly, areas oGrossly, areas ocaseation appearcaseation appear

cheese(lie.cheese(lie.

TuberculousTuberculous lymphadenitislymphadenitis

14


15/49

CASEATING LYMPHCASEATING LYMPH

NODE TUBERCULOSISNODE TUBERCULOSIS

PRODUCTIVEPRODUCTIVE

TUBERCULOSISTUBERCULOSIS

OF THE LYMPH NODESOF THE LYMPH NODES 15


16/49

In the case oIn the case oprimaryprimary

tuberculosis otuberculosis o

alimentary tractalimentary tract

due to ingestiondue to ingestion

o tubercleo tubercle

bacilli, a smallbacilli, a small

primary ocus isprimary ocus isseen in theseen in the

intestine. It isintestine. It is

tuberculoustuberculous

Primary tuberculosis of alimentary trPrimary tuberculosis of alimentary tr

16


17/49

The lymph nodes in this The lymph nodes in this

mesenterymesentery are enlargedare enlargedand have cut suracesand have cut suraces

that appear yellow(tan.that appear yellow(tan.

These nodes are flled These nodes are flled

with sheets owith sheets o"ycobacterium avium("ycobacterium avium(

comple% "!3-comple% "!3-

organisms, and theorganisms, and the

immune response is soimmune response is sopoor in this !I$) patientpoor in this !I$) patient..

The enlarged and The enlarged and

caseous mesentericcaseous mesenteric

4ymph nodes may4ymph nodes may

rupture into peritonealrupture into peritoneal

Tuberculous mesenterial lymphadeni Tuberculous mesenterial lymphadeni

17


18/49

7uration of Primary7uration of Primary

tuberculosistuberculosisIn course o time, the primary lesion canIn course o time, the primary lesion canheal, expand locally or lead to disseminatedheal, expand locally or lead to disseminated

disease.disease.

This can occur at both the This can occur at both the

sites/ the lung and the lymph nodes.sites/ the lung and the lymph nodes.

5 variants o the duration o rimary5 variants o the duration o rimarytuberculosis are probable/tuberculosis are probable/

• healing o primary comple%#healing o primary comple%#• generali*ation o process lymphogenousgenerali*ation o process lymphogenous

and hematogenous-#and hematogenous-#

• chronic duration.chronic duration.1-


19/49

Healing of the Primary comHealing of the Primary com

+ealing o primary+ealing o primary

comple% begins atcomple% begins atinitial a6ect/initial a6ect/

0. eriocal0. eriocal

inammation resoluteinammation resolute

and e%udativeand e%udativeinammationinammation

replaces by fbrousreplaces by fbrous

capsule 0-#capsule 0-#

1. 3aseous masses1. 3aseous masses

are being dehydratedare being dehydratedand petrifcated, andand petrifcated, and

then ossifcated 1-.then ossifcated 1-.

)uch healed initial)uch healed initial

ocus is calledocus is called

1

2

1


20/49

3alcifed pulmonary lymph3alcifed pulmonary lymph

nodes in tuberculosisnodes in tuberculosis

+ealing in+ealing in

lymphatic nodes islymphatic nodes is

similar tosimilar to

pulmonary center.pulmonary center.

0alci%ication

2/


21/49

Hematogenous generali8ationHematogenous generali8ation

of primary tuberculosisof primary tuberculosis• The most serious immediate complication is The most serious immediate complication is miliarymiliary

tuberculosis#tuberculosis# in which there is invasion o thein which there is invasion o thebloodstream bybloodstream by MTMT and dissemination throughout theand dissemination throughout thebody.body.

• This occurs when the parenchymal part o the Ghon This occurs when the parenchymal part o the Ghoncomple% involves a pulmonary artery or vein andcomple% involves a pulmonary artery or vein and

discharges its inected contents into the blood.discharges its inected contents into the blood.• "ultiple miliary granulomas develop in many organs o"ultiple miliary granulomas develop in many organs othe body.the body.

• 4arger nodules may have central necrosis nown as4arger nodules may have central necrosis nown ascaseation((a process o necrosis that includes elements ocaseation((a process o necrosis that includes elements o

both li7ueactive and coagulative necrosis.both li7ueactive and coagulative necrosis.• 8ew organs are spared# those most oten involved are the8ew organs are spared# those most oten involved are the

lung mainly by recirculation o the organisms-, spleen,lung mainly by recirculation o the organisms-, spleen,liver, idney, meninges, and bone marrow.liver, idney, meninges, and bone marrow.

• The most serious complication and cause o death can be The most serious complication and cause o death can be

tuberculous leptomeningitis.tuberculous leptomeningitis. 21


22/49

The lesions are The lesions areclassically 9.: mmclassically 9.: mm

to 1 mm into 1 mm in

diameter,diameter, frm andfrm and

tantan

, and evenly, and evenly

distributed throughdistributed through

the a6ected organ.the a6ected organ.

The name 2miliary2 The name 2miliary2

derives rom theirderives rom their

supposedsupposedresemblance toresemblance to

millet seeds. !millet seeds. !

punctate area opunctate area o

necrosis may benecrosis may beseenseen in the center.in the center.

Hematogenous generali8ation ofHematogenous generali8ation of

Primary TPrimary Tuberculosisuberculosis

22


23/49

+ere are two+ere are twopulmonarypulmonary

granulomas.granulomas.

GranulomatousGranulomatous

inammationinammation

typically consiststypically consists

o epithelioido epithelioid cells,cells,macrophagemacrophage

s, giant cells,s, giant cells,

lymphocytes,lymphocytes,plasma cells, andplasma cells, and

fbroblasts. Therefbroblasts. There

may be somemay be some

neutrophils.neutrophils.

Microscopical featuresMicroscopical features

of Miliary Tuberculosisof Miliary Tuberculosis

23


24/49

iant cells are aiant cells are a

committee o%committee o%epit$elioidepit$elioid

mmacrop$ages. Seenacrop$ages. Seen

$ere are t(o$ere are t(o

ang$ans type giantang$ans type giant

cells in ($ic$ t$ecells in ($ic$ t$e

nuclei are lined upnuclei are lined up

around t$e perip$eryaround t$e perip$ery

o% t$e cell. dditionalo% t$e cell. dditional

pin epit$elioid pin epit$elioidmacrop$agesmacrop$ages

compose most o% t$ecompose most o% t$e

rest o% t$e granuloma.rest o% t$e granuloma.

24


25/49

These are epithelioid cells around These are epithelioid cells around

thethe center o a granuloma. They getcenter o a granuloma. They gettheir name rom the act that theytheir name rom the act that they

have lots o pin cytoplasm similarhave lots o pin cytoplasm similar

to s7uamous epithelial cells. Theirto s7uamous epithelial cells. Their

nuclei tend to be long and stringy.nuclei tend to be long and stringy.25

.ymphogenous.ymphogenous


26/49

.ymphogenous.ymphogenous

generali8ationgenerali8ation +t is c$aracteried by in!ol!ement t$e ne( groups o%+t is c$aracteried by in!ol!ement t$e ne( groups o%

lymp$ nodes" suc$ as: paratrac$eal" supracla!icular "lymp$ nodes" suc$ as: paratrac$eal" supracla!icular "subcla!ian" cer!ical and de!elopment o% tuberculoussubcla!ian" cer!ical and de!elopment o% tuberculousmeadenitis.meadenitis.

&$e enlargement o% t$e bronc$ial lymp$ nodes may cause&$e enlargement o% t$e bronc$ial lymp$ nodes may causee'trinsic compression on t$e bronc$us or erode into t$ee'trinsic compression on t$e bronc$us or erode into t$ead#acent structures.ad#acent structures.

&$e e%%ect o% e'ternal compression o% t$e ymp$ nodes&$e e%%ect o% e'ternal compression o% t$e ymp$ nodes

on t$e bronc$us is similar to ($at $appens in t$eon t$e bronc$us is similar to ($at $appens in t$eretrograde in!ol!ement %rom t$e parenc$yma o% t$e lung"retrograde in!ol!ement %rom t$e parenc$yma o% t$e lung"complete or partial obstruction. &$e enlargement o% t$ecomplete or partial obstruction. &$e enlargement o% t$elymp$ nodes may produce a ($eee by compressing t$elymp$ nodes may produce a ($eee by compressing t$e

bronc$us. bronc$us.

26

Growth of primary parenhymalGrowth of primary parenhymal


27/49

Growth of primary parenhymalGrowth of primary parenhymal

injury injury • Progressive primary tuberculosis most commonly occurs inpatients !ith suppressed or defective immunity(

• The primary Ghon focus in the lung enlarges rapidly# erodes

the bronchial tree# and spreads# a se9uence that results inad:acent 4satellite; lesions(

• The lesion may enlarge in si8e and li9uefy !ith a cavityformation as in an adult or produce an area of consolidation(

• The caseous material can enter into a bronchus and thenspread to other parts of the lung or the opposite lung#

resulting in a tuberculous bronchopneumonia(•


28/49

;hen there is;hen there is

e%tensivee%tensive

caseation and thecaseation and the

granulomasgranulomas

involve a largerinvolve a larger

bronchus, it isbronchus, it is

possible or muchpossible or much

o the sot,o the sot,necrotic center tonecrotic center to

drain out anddrain out and

leave behind aleave behind a

cavity. 3avitationcavity. 3avitationis typical or largeis typical or large

tuberculotuberculouuss

granulomas.granulomas.

3avitation is more3avitation is more

common in thecommon in the 2-


29/49

HematogenousHematogenous

TuberculosisTuberculosis

Conditions of the development :Conditions of the development :t$e presence o% sensibiliation to tuberculinstrongly pronounced immunity

t$e presence o% %oci are $ealed a%ter$ematogenous generaliation o% primary

tuberculosis *si%ting)absence o% tuberculous lymp$adenitis.

Hematogenous tuberculosis is c$aracteried

by proli%erati!e reaction or %ormation o% t$e

granulomas and $ematogenous spreading. 2


30/49

;ith a poor immuneresponse to theagents producing

granulomatousinammation, thereis e%tensive spreado inection with the

production o a2miliary2 pattern ogranulomas as seenhere in the lung o apatient with miliary

tuberculosis. The 0to 1 mmgranulomas arescattered around

lie millet seeds. 3/


31/49

The ocal The ocal

nature onature ogranulomatogranulomato

usus

inammationinammation

isisdemonstratedemonstrate

d in thisd in this

microscopicmicroscopic

section osection o

lung in whichlung in which

there arethere are

scatteredscatteredranulomas

"iliary pulmonary tuberculosis"iliary pulmonary tuberculosis

31


32/49

ClassificationsClassifications

of h!ato"no#s t#$%c#losisof h!ato"no#s t#$%c#losis• Generalized hematogenous tuberculosis:Generalized hematogenous tuberculosis:


33/49

8eatures8eatures oo hematogenous(hematogenous(

disseminative tuberculosis/disseminative tuberculosis/• may by in adults only#may by in adults only#• prevalenceprevalence ape%( plural locali*ationape%( plural locali*ation##

• prolierative tissue reactionprolierative tissue reaction##

• development o the pneumosclerosisdevelopment o the pneumosclerosisand emphysema o lungsand emphysema o lungs##

• ??cor pulmonale@cor pulmonale@ hypertrophy o righthypertrophy o right

ventricle o heartventricle o heart-#-#• simmetrical small cavernes#simmetrical small cavernes#

• presence o unpulmonary tubercularpresence o unpulmonary tubercularoci.oci.

33


34/49

An closer inspection,An closer inspection,

thethe granulomas havegranulomas have

areas o caseousareas o caseousnecrosisnecrosis withwith

ormation o theormation o the

small cavernes.small cavernes. This This

is very e%tensiveis very e%tensive

granulomatousgranulomatousdisease.disease. This pattern This pattern

o multiple caseatingo multiple caseating

granulomas primarilygranulomas primarily

in the upper lobes isin the upper lobes ismost characteristic omost characteristic o

postprimarypostprimary

hematogenoushematogenous reactivation-reactivation-

tuberculosis.tuberculosis. 34


35/49

&89;08


36/49

T#$%c#lo#s n&o!t%itisT#$%c#lo#s n&o!t%itis

pit$elioid cells

ang$ans cell

36


37/49

&uberculosis&uberculosis

o% t$e testis *1)o% t$e testis *1)

andand

epididymus *2)epididymus *2)

37


38/49

T#$%c#lo#s !nin"itisT#$%c#lo#s !nin"itis

3-


39/49

RENAL TUBERCULOSISRENAL TUBERCULOSIS

arge %oci o%

caseous necrosis

3


40/49

=++;> &89;08 &89;08


41/49

Milia%' t#$%c#losis of th s(lnMilia%' t#$%c#losis of th s(ln

41

CharacteristicsCharacteristics


42/49

CharacteristicsCharacteristics

of the Secondaryof the Secondary

TuberculosisTuberculosis• "ay be in adults only with

postprimary disease or reinection-#

• Anly ulmonary locali*ation oten 0(st and 1(nd segments so called?)imons oci@-#

• 3ontact and intracanalicular

spreading#• )hits o the clinical(morphological

orms.

42

Forms or stagesForms or stages


43/49

Forms or stagesForms or stages

of the secondaryof the secondary

tuberculosistuberculosis::)*)*Ac#t local t#$%c#losis*Ac#t local t#$%c#losis*

+*+*Fi$%o#s,local t#$%c#losis*Fi$%o#s,local t#$%c#losis*

-*-*Infilt%ati. t#$%c#losis*Infilt%ati. t#$%c#losis*

/*/*T#$%c#lo!a*T#$%c#lo!a*

0*0*Caso#s (n#!onia*Caso#s (n#!onia*

1*1*Ac#t ca.%no#s t#$%c#losis*Ac#t ca.%no#s t#$%c#losis* 2*2*Fi$%o#s 3 ca.%no#s t#$%c#losis*Fi$%o#s 3 ca.%no#s t#$%c#losis*

4*Ci%%hotic4*Ci%%hotic t#$%c#losis*t#$%c#losis*

43


44/49

+pical pulmonary tuberculosis+pical pulmonary tuberculosis

There are There are

several 0 cmseveral 0 cmdiametdiameteer,r,

partiallypartially

calcifed ocicalcifed oci

dry,dry,

crumbly,crumbly,

and white-and white-

that arethat aresurroundedsurrounded

by slaty,by slaty,

induratedindurated

scar tissue.scar tissue. 44


45/49

ung, tuberculosis, secondary

(reactivation) - Gross, cut surface, and

radiograph

44a


46/49

Caseous# partly gelatinous pneumoniaCaseous# partly gelatinous pneumonia

45


47/49

Fresh tuberculous cavityFresh tuberculous cavity

reyis$($ite

(all o% t$eca!ity 2 to 3

mm t$ic

46


48/49

@ibrotic scar in t$e (all o%

tuberculous ca!ity consists o%

%ibroblast" collagen" and

scattered anger$ans giant cells

&$e (all o% tuberculous ca!ity

contains %oci o% calci%ication

replacing t$e caseating

granulomas 47

C li i d fC li ti d f


49/49

Complications and causes ofComplications and causes of

deathdeath Scarring and calci%ication.Scarring and calci%ication.

Pneumot$ora'.Pneumot$ora'.

mpyema.mpyema.

Pleural %ibrosis and ad$esions" (it$ associatedPleural %ibrosis and ad$esions" (it$ associated

pleurisy" s$arp pleuritic pain" and s$ortness o% breat$. pleurisy" s$arp pleuritic pain" and s$ortness o% breat$.

0$ronic respiratorycardiac insu%%iciency due to0$ronic respiratorycardiac insu%%iciency due to

de!elopment Acor pulmonaleB.de!elopment Acor pulmonaleB.

cute $emorr$age due to erosion o% !essels.cute $emorr$age due to erosion o% !essels. 0$ronic renal insu%%iciency due to de!elopment o%0$ronic renal insu%%iciency due to de!elopment o%

amiloidosis o% idneys.amiloidosis o% idneys.

presenation fibrous cavernous tuberculois teachers version

Documents