a clinical example

Patient H.A., 17 years, has arrived in children's tubercular stationary unit in a direction from an antituberculous dispensary with suspicion on infiltrativnyj a tuberculosis of the top share of the left lung with complaints to unproductive tussis, a fervescence to febrile digits, appetite dropping, dream disturbance.

The disease anamnesis: the patient within 3 weeks when after a frigorism there were complaints to tussis, a fervescence to febrile digits, appetite dropping Considers itself. It was treated in an out-patient department on a residence with diagnosis ORVI. Effect from treatment it did not become perceptible. In two weeks from the treatment beginning radiographic inspection is spent. On the survey roentgenogram of organs of a thorax changes are taped: blackout in the top share of the left lung. With suspicion on specific tubercular process in the left lung it is referred to the phthisiatrician on a residence.

Contact to a sick tuberculosis at interrogation to tap it was not possible. The photoroentgenography was in previous year, pathologies is not taped. It is vaccinated BCG in maternity home, a postvaccinal scar of 5 mm; the revaccination was not spent.

At studying of results of a tuberculinodiagnosis on a Mantoux reaction 2 THOSE within 10th years become perceptible positive tuberkulinovye assays with the size of a papule 7 - 8 mm (monotonous character tuberkulinovyh assays).

The life anamnesis: the Girl from the first sorts, was born with weight of 3780 the Period novorozhdennosti proceeded without features. Preventive inoculations on a calendar. The allergological anamnesis - without features. It was observed with neurologic implications at the neurologist since 3th years.

Accompanying diseases: at the age of 15 years the epilepsy, a psychogenic polydipsia is diagnosed.

Heredity and the social anamnesis: the Girl lived in 2 room apartment with conveniences with the grandmother and the grandfather. Mother of the girl was in imprisonment places. Data about the father are not present. Parents of the girl suffered an alcoholism.

In children's tubercular unit has arrived in a moderately severe condition.

The girl astenichnogo a constitution, a subnutrition. Integuments pure, acyanotic; the periorbital cyanosis, a cyanosis nosogubnogo a triangle becomes perceptible. The turgor and elasticity of tissues, a subcutaneously-fatty layer are lowered. The left half of thorax lags behind at breath a little. At a percussion of lungs - on all pulmonary fields a bandbox sound. Breath in lungs rigid, is spent on all pulmonary fields, not numerous wet rhonchuses at the left in subscapular area are auscultated. CHD 20 in a minute. Warm tones rhythmical, are muffled, speeded up; on an apex - systolic hum. The CARDIAC CONTRACTIONS RATE 98 in a minute. A stomach soft, painless. A liver: +1 sm from edge of a costal arch. The lien is not palpated.

At inspection at the moment of entering in children's unit it is taped: In the general analysis of blood: an anaemia (HB - 108 g/l); ESR rising (30 mm/ch); the Mantoux reaction 2ТЕ - 6 mm; Diaskintestj - negative;

At carrying out of radiological inspection: on the survey roentgenogram and the linear tomogram through a root the top share at the left it is intensively non-uniform it is blacked out at the expense of set of focal shades of various size of average and weak intensity of confluent character.

Computer tomography of organs of a thorax: at research in S2, S3, S4, S5 segments of the top share and S6 the bottom share of the left lung
Subsegmentary not homogeneous infiltrates, with lumens of the deformed bronchuses with utolshchennymi walls, with mikrokaltsinatami in structure (fig. 1, 2) are defined.

At sputum inspection on MBT a microscopy method - result positive; at sputum inspection on MBT by a bacteriological method - the positive take in 2 months is received. At carrying out of the test for medicinal sensitivity fastness to Isoniazidum, rifampicin, streptomycin, Ethambutolum is found out.

Consultations of narrow experts: the neurologist: the symptomatic

Epilepsy, neuroendocrinal syndrome, emotionally-strong-willed disturbances; the endocrinologist: a psychogenic polydipsia.

The diagnosis is exposed: Infiltrativnyj the tuberculosis is more true also than the bottom share of the left lung in a phase infiltatsii, MBT (+) MLU.

The accompanying diagnosis: the Psychogenic polydipsia. A symptomatic epilepsy. A neuroendocrinal syndrome. Emotionally-strong-willed disturbances.

On the basis of the spent inspection, the positive analysis on MBT, imenenija indicators of the immune status, despite negative result Diaskintestj, the diagnosis is exposed: Infiltrativnyj a tuberculosis of the top share of the left easy disintegration in a phase and disseminations, MBT (+), the diagnosis is confirmed on TSVKK.

The set example shows probability of negative result Diaskintestjpri active tubercular process. The negative result is bound to features of reaction of immune system.


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Scientific source Ahmerova Tatyana Efimovna. IMMUNODIAGNOSIS OF DIFFERENT MANIFESTATIONS OF TUBERCULOSIS INFECTION IN CHILDREN. Thesis for the degree of candidate of medical sciences. SAMARA - 2014. 2014

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