Key diagnostic points and differential diagnosis of hematogenous disseminated tuberculosis.
Diagnostic points.
The diagnostic points of hematogenous disseminated tuberculosis include acute, subacute and chronic hematogenous disseminated tuberculosis.
1. It is common in adolescents, but can also develop in middle-aged and elderly people.
2. Patients have a history of close contact with tuberculosis, or a history of primary tuberculosis with other parts of the body.
3, Predisposing factors.
Acute and chronic infectious diseases, malnutrition, diabetes, excessive fatigue, mental depression, heavy application of glucocorticoids or immunosuppressants, female patients often have pregnancy or childbirth, etc.
4.Acute onset.
Such as sudden onset of high fever, extreme weakness, night sweats, lack of food and drink, cough, chest tightness, headache, nausea, vomiting, drowsiness, etc.
5.Signs.
In the early stage, there are no obvious signs in the lungs, but if the disease worsens, coarse breath sounds or small vesicular sounds can be heard. In case of concurrent tuberculous meningitis, meningeal irritation signs may appear. Nodular chorioretinitis may appear in the fundus choroid. Sometimes the liver and spleen are enlarged.
6.X-ray chest film or CT.
Acute patients with two lungs full of corn shadows, characterized by “three uniform”, that is, uniform size, density, distribution. In subacute patients, the two lungs or the middle of one side of the lung show nodular shadows of different sizes, and in the case of perihilar inflammation, the nodular shadows have a fusion phenomenon, and the nodules can be interspersed with fibrous cord shadows, which are characterized by “three uneven”, i.e., uneven size, density, and distribution.
7.Laboratory examination.
Positive PPD test; three positive nodules. White blood cells are normal or increased, monocytes are increased, lymphocytes are decreased; blood sedimentation is increased.
8. Most of the anti-tuberculosis drug treatment can recover.
For patients with tuberculous meningitis combined with high cranial pressure, they should be treated actively to lower cranial pressure, which is a serious tuberculosis disease with high mortality if not treated timely.
Differential diagnosis.
1. Alveolar carcinoma.
It is mostly seen in middle-aged and elderly people with a history of smoking and slow onset. Main symptoms: cough as choking, blood in sputum, wasting, shortness of breath after activity, often accompanied by chest pain and pleural effusion, no fever. On auscultation, small dry sounds were heard in both lungs. The imaging manifestations are nodular shadows of variable size and uneven density in both lungs, and enlarged lymph nodes in mediastinum and hilum. Cancer cells can be detected in the sputum, and if it is difficult to check the sputum, bronchoscopy biopsy will be sent for pathology.
2. Pulmonary cryptococcosis.
Slow onset, with a history of long-term use of immunosuppressive drugs or antibiotics. The main symptoms are cough, coughing white mucous sputum with lacrimation, low or high fever. There is wet rales on auscultation in the presence of concomitant infection. Imaging manifests as indistinctly bounded patches, small nodular shadows, and fusion of lesions may form cavities. Sputum smear may reveal novel cryptococci, and PPD test is negative.
3. Diffuse chronic interstitial lung fibrosis.
The etiology is unknown, the onset is slow, and it occurs mostly in middle-aged and elderly people. The main symptoms are progressive shortness of breath, dry cough, and pus sputum when secondary infection occurs. On auscultation, there is a widespread superficial fine high-pitched dry sound. There are no enlarged lymph nodes. Imaging is characterized by mid and lower cornu, nodular, and reticular shadows in both lungs, and the lesions may fuse to form patchy shadows. Early pathology is nonspecific alveolitis, with advanced alveolar wall thickening and interstitial fibrous tissue hyperplasia.
4. Silicosis.
The onset is slow with coal mine operations, blasting, grinding, glass making, enamelling and rust removal work experience. The main symptoms are progressive shortness of breath, dry cough, and no fever. Imaging showed nodule-like shadows with high density in the lower and middle lungs and eggshell-like lymph node calcification in the hilum. Lung function was significantly decreased. Bronchoscopic lavage fluid appeared as sulfur dioxide poisoning particles.
5. Acute bronchitis.
Mostly caused by upper respiratory tract infections, often occurring in infants and young children. Common symptoms are fever, dyspnea, and cyanosis. Wet rales can be heard on auscultation. PPD test is negative and anti-inflammatory treatment is effective.
6. pulmonary nodular disease.
The etiology is unknown and occurs mostly in young adults. The main symptoms are fever, progressive shortness of breath, cyanosis, wasting, often accompanied by hemoptysis, superficial lymph node enlargement, may involve the liver, spleen, brain, skin, bones and eyes. Major complications are erythema nodosum, subcutaneous nodules, polyarthritis, iridocyclitis, and mumps. On auscultation, there is scattered wet rales in both lungs. Imaging showed nodular shadows of variable size and density in the mid and lower distribution of both lungs. The pathology is granulomatous nodules.
7, rheumatoid lung.
There is a history of rheumatoid disease. The main symptoms are wasting, fever, shortness of breath, cyanosis, and no hemoptysis. The main concomitant symptom is small joint spindle enlargement or hyperplasia. The imaging presentation is a reticular nodular shadow in the middle and lower part of both lungs. It is often combined with hilar lymph node enlargement. The pathology is rheumatoid nodules.