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was isolated in 10 (26.3+7.1%) patients, in cerebral-spinal liquor it was isolated in 3 (7.9+4.5%) of them. PCR showed MBT in three more patients (7.9+4.5%). PCR of blood in all patients was positive.
CT showed cerebral hypertension and encephalitis in all patients, 6 focal alterations, 2 tuberculoma of brain in the patients with HIV.
In four patients (33.3+13.6%) of twelve who died there was combination of tubercular meningitis with tuberculosis of lungs, in 5 (41+14.2%), in 2 (16.6+10.7) with tuberculosis of skeletal system, 2 (16.6+10.7) with lymphatic nodes, and combination with HIV in 3 (25.0+12.5) patients.
Five patients died during initial three days after coming to clinic, four died within 10 days, and three — within one month. All patients who died had late diagnosed TM, and the main reason of death was cerebral coma with development of paralysis of vascular and respiratory centers.
Thus, the number of patients with TM is increasing, proving unfavorable situation of tuberculosis. The character-
istic features for tubercular meningitis in modern conditions are as follows: prevailing of tubercular meningoencephalitis and decrease of basilar form prevalence, growth of meningitis combination with tuberculosis of lungs and extra pulmonary lesions, absence of general practitioners' vigilance for early revealing of tubercular meningitis. Complex check-up of the patients with tubercular meningitis should include CT of brain and PCR of liquor and blood.
Conclusions.
1. In modern conditions there is notable growth of tubercular meningitis combination with pulmonary and extra pulmonary location of specific lesion.
2. Among the clinical forms the prevailing one is tubercular meningoencephalitis.
3. The complexity of tubercular meningitis diagnostics is conditioned by atypical variants of the meningitis progress, and underestimation of prodromal period of CNS stimulation in tubercular meningitis by general practitioners.
References:
1. Aliyev D. K. Importance of cerebral-spinal liquor analysis in the diagnostics of tubercular meningitis//Materials of the I international scientific-practical conference. Rostov-na-Donu. - 2014. P. 61-71.
2. Bugakova S. L. Tubercular meningitis, its pathogenesis, clinical progress, diagnostics, therapy and outcomes. Astana, 2010. -100 p.
3. Vasilyev A. V. Extra pulmonary tuberculosis. St. Petersburg. 2000 - p. 147-162.
4. Pokrovski V I., Litvinov V I., Lovacheva O. V., Lasareva O. L. Tubercular meningitis - Moscow, 2005. - 243 p.
5. Bidstrup C., Andersen P., Skinhoj P.et al. Tuberculous meningitis in a country with a low incidence of tuberculosis: still a serious disease and a diagnostic challenge//Scand. J. Infect.Dis. - 2002. - v. 34. - P. 811-814.
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Tillyashayhov Mirzogolib Nigmatovich, Director Republican Specialized Scientific Practical Medical Center Phthisiology and Pulmonology Makhmudova Zulfya Primkulovna, Assistant Tashkent Medical Academy E-mail: evovision@bk.ru
Radiographic signs of tuberculous spondylitis combined with pulmonary tuberculosis
Abstract: The use of computed tomographic scanner and NMR-machine before surgery chine in the postoperative period allows obtaining the objective criteria for evaluating the effectiveness of surgical treatment and defining the further treatment tactics.
Keywords: tuberculous spondylitis, tuberculosis of lungs.
Relevance. Problems of tuberculous spondylitis compli- The frequency of combinations of spondylitis with the
cated not only due to the nature of persistent and devastating active specific processes in the lungs, pleura, lymph nodes, disease process, but also to the complexity of its diagnosis and brevity and lack of time intervals between their primary iden-developing complications. However, a major problem in the treat- tification, the trend towards prevalence of process in the spine ment of tuberculosis of the spine is the presence of concomitant suggests about of massive infection, weakening of the body of TB processes in other organs, particularly in the lungs [1; 4; 6]. patients [7; 8; 9].
Radiographic signs of tuberculous spondylitis combined with pulmonary tuberculosis
Therefore, early detection and the target adequate therapy of tuberculosis of the spine and lungs seems in present time the most actual direction in medicine.
The aim of the work was to determine the causes of late diagnosis, clinical manifestations of tuberculosis of the spine combined with pulmonary tuberculosis.
Materials and Methods: The results of the examination and treatment of 86 patients with tuberculosis of the spine, combined with pulmonary tuberculosis. The age of patients ranged from 20 to 60. There were conducted orthopedic and neurological examination, chest roentgenograms and spine, ultrasound of internal organs, computed tomographic scanner and NMR-machine before surgery.
Results and discussion. In the analysis of the age and sex composition of the patients established that the defeat of the spine by tuberculosis among males are more common (58.1%) than among women (41.9%). The defeat of the spine by tuberculosis absolutely dominated in both groups of patients aged 21-50 years and amounted respectively to 83.7%and 77.8%. Period of the defeat of the spine by tuberculosis (the beginning of the process until establish the diagnosis) was as follows: 15 (17.4%) patients in Group 1 up to 6 months, in 8 (9.3%) up to 1 year, 63 (73.3%) patients more than one year. Similar rates were observed among patients in group 2 and amounted to respectively 17 (31.5%), 8 (14.8%), 29 (53.7%).
The limitation period of pulmonary tuberculosis ranged from 2 months to 2 years. In 67 (77.9%) of patients with pulmonary tuberculosis is installed for the first time, 19 (22.1%) patients previously treated with anti-TB drugs and came to the hospital with acute exacerbations in the lungs.
Radiological examination of affected vertebrae showed that patients with defeat of 3-4 and more the vertebrae is more common (48.8%) than patients in group 2 (29.7%). Therefore, the instability of the spinal column established at 65.1% of patients in Group 1 and 42.6% of patients in group 2.
Limiting the mobility of the spine occurred in 72.1% of patients in Group 1 and 53.7% in group 2, which was accompanied by severe pain symptoms, even at low load. The presence of paravertebral abscesses on the background of severe intoxication and violation of the parenchymal organs increases bone destruction that occurred significantly more frequently among patients in Group 1 (88.3%) than in group 2 (66.6%). Fistula forms process observed in 8.1% of patients in Group 1 and 3.7% of patients in group 2.
The progression of destructive changes in affected vertebral bodies on the background of paravertebral abscesses and epiduritis leads to compression of the spinal cord, especially on distant stages of development of tuberculosis. Accordingly 67.4% of patients in group 1 and 53.7% of group 2 patients were defined the presence of spinal disorders with varying degrees of severity. Easy Para paresis by type of pyramidal insufficiency was observed in 19.8% of group 1 and 22.2% in group 2. The severities of spinal disorders were defined by the presence of disorders of the pelvic organs. Disturbance of
function of pelvic organs were observed in 46 (53,5 ± 3,0%) patients in Group 1 and in 17 (31.5%) patients in group 2. The partial urinary retention has been accordingly in 36.0% and 22.2 imperative desires interleaving with delay in 15.1 and 7.4% the paradoxical urination was noted accordingly in 2 and 1 patient.
Based on the analysis of X-ray, CT and MRI of the spine of tuberculous spondylitis by character of destruction was divided into 3 main types: 1) focal destruction of the bodies of the vertebrae; 2) formation of interbody bone cavity with sequesters or cheesy masses peripheral parts of the bodies at the same time preserved and form a kind of "bone box" around the cavity of destruction; 3) the planar contact degradation when Interconnecting parts of bodies are destroyed by uniformly over the entire area. By the depths of destruction of bodies were highlighted 4 different destructions of vertebrae:
— the vertebral bodies are destroyed superficially and up to 1/3 of the height;
— the vertebral bodies are destroyed on 1/2 or 2/3 of the height (the most common);
— subtotal and total destruction of the vertebrae; 4) destruction by type of caries. With involvement of a large number of vertebrae there was a concomitance species and the options of destruction. In rare cases of atypical course of tuberculous spondylitis the character of destruction did not fit into indicated species.
The bone compression of the spinal cord and epidural abscess on survey roentgenogram and computed tomographic scanner without contrasting of the dural sac could be expected at revealing calcified caseous masses and sequesters in the lumen of the spinal canal only in the 31.8% of cases. In other cases, reliably estimate the level, degree and extent of the compression of the dural sac without contrasting were impossible.
On contrasting myelogramms the presence of epidural abscess was determined by the compression, which the abscess had an impact to the contrasted membranes of the spinal cord, forming on their background the defects of filling or causing the block of spinal fluid. The dural sac at the level of compression follows the shape of kyphosis of the spinal canal, deviated and shifted back to the result of outside pressure far as allowed reserve space of the spinal canal. The complete block of tracts of cerebrospinal fluid testified about expressed pathological manifestations of tuberculous spondylitis.
On the KMG in the sagittal projection we have allocated 4 different compression of the dural sac at the evolutive forms of tuberculous spondylitis:
— Local or extended compression of the dural sac by abscess with visualization of the contour and the extent of the abscess (45,8%);
— local bone compression with residue of vertebral body (11,9%);
— unequal contrasting of the dural sac, when the level of compression contour its can not be traced, but in the frontal Myelogram was determined contrast agent above and below the compression (3,4%);
— complete block of cerebrospinal fluid tracts, stop the contrast agent (35,62%);
Two of patients had mixed bone compression of the dural sac with compression of epidural abscess.
Stopping of contrast medium at full block of cerebrospi-nal fluid tracts was a gradual along the concave an arc which skirted and underlined the lower pole of the abscess, or there was a dramatic "breakaway" of contrasted area of the dural sac. Complete block of cerebrospinal fluid pathways with sharp transverse stop of contrast agents, in our opinion, is connected with a high pressure in the epidural abscess, or with involvement in the inflammatory process of the spinal cord membranes. It is corresponded severe neurological disorders such as "A" and "B" (Pk3=0.05) in the localization of lesions in the upper- and middle chest part of spine.
Analysis of our data has shown that the percentage of incorrect interpretation of the results of the radiation survey of tuberculous spondylitis in the early stages is still large, dominated late diagnosis of tuberculous spondylitis. In 96.0% of cases, the process has been revealed at the peak of spondylitic phase in 33.0% on background of developed neurological disorders. The most frequently involved in the process of 2-34-5-6 vertebra.
Infiltrations in the spinal canal were detected in 45 (32.1%) patients. On roentgenograms revealed a well abscess in the thoracic vertebral in which they are seen against the background of the air of the lung tissue. Retroperitoneal abscesses were detected by indirect signs of expansion of contours m.iliopsoas major, when they reached a considerable size. It was impossible to see the abscess of soft tissues of the back and small paravertebral abscesses in the lumbar spine.
The contours of abscesses and their relationships with the surrounding organs on radiographs and tomograms do not always able to determine. Computed tomographic scanner are equally well detected abscesses, their cameras, relations with the vertebrae and surrounding organs and tissues, especially after an internal contrasting. At an early stage of formation of an abscess was observed infiltration of the fat around the body of the vertebra. A comprehensive assessment of changes in bone structure, identified on X-ray and Computed tomo-graphic scanner tomograms and pathological signal changes on MRI, gave an idea of the morphological changes in the spinal column and the phase of tuberculous spondylitis. The use of computed tomographic scanner and MRI has opened up new possibilities in the diagnosis of tuberculous spondylitis; computed tomographic scanner and NMR-machine are highly effective in detecting spinal cord compression in patients with tuberculous spondylitis. MRI is more effective in determining the extent of compression (100%) and is the only method of visualization of changes in the spinal cord. The use of computed tomographic scanner and NMR-machine in the postoperative period allows to obtain objective criteria to evaluate the effectiveness of surgical treatment and to determine further treatment tactics.
Conclusion: According to the MRI compression of the spinal cord and its roots has a in 90.7% of patients with tuberculous spondylitis, whereas neurological disorders in 69.8%. Compression of the spinal cord and its roots revealed by using radiation methods in patients without neurological disorders in 64.1% of cases expands the indications for surgery. The sensitivity of NMR-machine was 88.7%, the specificity — 83.5%.
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