Download MINISTRY OF PUBLIC HEALTH OF UKRAINE Vinnitsa National

MINISTRY OF PUBLIC HEALTH OF UKRAINE
Vinnitsa National Pirogov Memorial Medical University
"Approved"
on the methodical council of the
Department of Tuberculosis,
Clinical Immunology and Allergy
„29___” _avgusta 20 13 yr.
Protocol №
Head of the Department
Professor B. Pukhlic
Manual FOR Students
for preparing to practical classes
(in English)
Learning discipline
Module №1
Thematic module №1
Topic of lesson
Course
Faculty
Phthisiology (Tuberculosis)
Phthisiology (Tuberculosis)
Tuberculous meningitis. Tuberculosis of the
pleura. Curation of patients with pulmonary
tuberculosis.
Tuberculous meningitis. Examination of patients
with tuberculous meningitis. Diagnosis,
treatment. Differential diagnosis with meningitis
of other etiology.
Tuberculous pleurisy (pleural empyema)
Pathogenesis, pathomorphism, clinicoroentgenologic version, clinical picture and
diagnostical aspects, differential diagnosis,
treatment, conseceqences.
Management of tuberculosis patients. Defence of
case history.
4th
General medicine
Edited by Andriy Dudnyk
Vinnitsa
2013
Background: Tuberculosis of the central nervous system remains to the
present time one of the most severe forms of tuberculosis. The compromise of the
central nervous system occurs in two basic forms: meningoencephalitis and
intracranial tuberculoma. Since the introduction of modern chemotherapy and
especially massive BCG vaccination, a lower proportion of the
meningoencephalitis has been observed, but the frequency of this form of TB is
higher among young adults with HIV/AIDS.
Pleural tuberculosis. This is the most common form of extrapulmonary TB, and
can either result from the rupture of a primary subpleural lung focus (evident or not
on conventional chest X-ray) or be secondary to lymphohematogenic
dissemination. The presence of a pleural TB effusion has also been related to
hypersensitivity (Light 1990). Most cases occur several months after the primary
infection, and frequently the patient relates having contact with an active
pulmonary TB case in the two years preceding the current episode.
1. Educational aims
Students need to know:
 Features of pathogenesis and pathomorphology of tuberculous meningitis
and meningoencephalitis.
 Peculiarities of tuberculous meningitis (meningoencephalitis), his clinical
symptoms.
 How to diagnose tuberculous meningitis?
 How to differentiate the diagnosis of tuberculous meningitis and meningitis
of other etiology?
 Modern methods of treatment of tuberculous meningitis.
 Features of etiology and pathogenesis of pleurisy.
 The mechanism of pleural exudation in normal and by various pathological
processes.
 Etiology of pleural effusion.
 Clinical and radiographic manifestations of pleurisy.
 Tactics of treatment of tuberculous pleurisy.
 Possible consequences of tuberculous pleurisy and their description.
Students should be able to:
 To collect case history and examine patients with tuberculous meningitis.
 To distinguish tuberculous meningitis and meningitis that have similar
clinical picture.
 To determine the activity of tuberculosis.
 To recognize the clinical forms of tuberculous meningitis.
 To prescribe treatment and calculate of the daily dose of anti-TB drugs for
individual patients.
 To collect history and examine the patients with tuberculous pleurisy.
 To distinguish tuberculous pleurisy with pleurisy of other etiologies.
 To determine the activity of tuberculous pleurisy.
 To prescribe treatment of tuberculous pleurisy patients.
2. Interdisciplinary integration
Name of discipline
Human Anatomy
Pathological
Physiology
Pathological Anatomy
General and Clinical
Pharmacology
Propedeutics of
Internal Medicine
Operative surgery and
topographic anatomy
Neurology
Necessary skills
Nervous System. Shells of the brain and spinal cord.
Pathways of the brain and spinal cord. The structure of
the cranial nerves. Features of the blood supply of the
brain and spinal cord. Lymphatic vessels of the head
and neck.
Inflammation. Tuberculous inflammation. Exudative
and productive processes. The blood–brain barrier.
Morphological manifestations of tuberculous
inflammation in organs and tissues, residual
tuberculous changes.
TB chemotherapy, classification, dosage, methods of
administration. Pharmacokinetics of antituberculosis
drugs. Adverse reactions to antibacterial drugs,
prevention and elimination.
Methods of physical examination of patients.
Diagnostic value of epidemiological history, physical
methods of examination of patients, puncture of
pleural cavity, microscopic examination of fluid for
M. tuberculosis.
Methods of pleural and spinal puncture puncture of a
lymph node, thoracoscopy with biopsy.
Somatic status. Neurological status: cranial nerves,
motor functions, sensitivity, reflexes, coordination and
gait, higher cortical function, autonomic nervous
system, the function of the pelvic organs. Paraclinical
tests: complete blood count, spinal fluid,
electroencephalography, rheoencephalography,
computer tomography.
3. Tasks
The specific term
1. Meningitis
2.Meningoencephalitis
Definitions
Inflammation of the membranes of the brain and
spinal brain
The transition of the pathological process of the
vessels in the pia mater to the brain tissue
3.Meningeal syndrome
4. Pleuritis
5. Dry pleuritis
6. Exudative pleuritis
It consist of headache, vomiting, neck stiffness,
Kernig’s sign, Brudzinski’s sign Kernig’s sign,
changes in CSF.
Inflammation of pleura
Inflammation of pleura with sedimentation of
fibrin on pleural layers
Inflammation of pleura with pleural effusion
4. Theoretical questions for preparing to class:
1. What are the criteria and characteristics that define tuberculosis of nervous
system?
2. What are the causes and factors may be important in the development of relapse
of tuberculous meningitis?
3. What are the clinical forms of tuberculous meningitis?
4. Describe the physical properties, chemical, biochemical and biological
composition of spinal fluid in tuberculous meningitis?
5. Treatment and rehabilitation of patients with tuberculous meningitis.
6. Pathogenesis and morphological manifestations of tuberculous tuberculous
pleurisy
7. What is the clinical classification of pleurisy?
8. What are the basic principles of treatment of patient with tuberculous pleurisy?
9. What are the possible consequences of tuberculous pleurisy?
5. Write correct answers
Objectives
1. What are the criteria and
characteristics that define tuberculosis of
nervous system?
2. What are the possible variants of
penetration
of
Mycobacterium
tuberculosis in the meninges and central
nervous system?
3. What are the causes and factors may be
important in the development of
tuberculous meningitis?
4. How long is prodromal period of
tuberculous meningitis?
5. What symptoms are persistent on late
prodromal period of illness?
6. What are the clinical forms of
tuberculous meningitis?
7. What are the symptoms of tonic
Etalon of answer
tension of muscles that most often
observed in tuberculous meningitis?
8. What cranial nerves are most
commonly affected with tuberculous
meningitis and which the mechanism of
their injury?
9. Describe the physical properties,
chemical, biochemical and biological
composition of spinal fluid in tuberculous
meningitis?
10. What values reaches content of
cellular elements in the cerebrospinal
fluid of patients with tuberculous
meningitis?
11. What measures should be included in
the complex treatment of patients with
tuberculous meningitis?
12. What are the consequences of the
tuberculous meningitis?
13. Is the tuberculous pleuritis primary
or secondary process?
14. What proportion of tuberculous
pleurisy among other clinical
forms?
15. What are the main ways of
penetration of infection in the
pleura?
16. What is the possible character of
exudate in tuberculous pleurisy?
17. What is the classification of
pleurisy by depend on the location
of fluid?
18. List the clinical syndromes which
are specific to tuberculous pleurisy?
19. What are the characteristic changes
in the pleural fluid in tuberculous
pleurisy?
20. What changes in patient complaints
will be appear if dry pleuritis is
transformed into exudative?
21. List the diseases that have clinical
and radiological picture similar to
tuberculous pleurisy?
22. What are the basic principles of
treatment
of
patient
with
tuberculous pleurisy?
23. What are bacteriostatic drugs that
are used in the treatment of patients
with tuberculous pleuritis?
24. What are the features of admission
of medications in patients with
tuberculous pleurisy?
25. What are the possible consequences
of tuberculous pleurisy?
6. Practical tasks
6.1. Interview and clinical examination of patient with tuberculous
meningitis.
6.2. Analysis of thematic case history.
6.3. Describe of changes in CSF.
6.4. Interview and clinical examination of patient with tuberculous pleuritis.
6.5. Describe of changes in pleural fluid.
7. Tasks for control of quality knowledge and skills during learning activities:
№
1.
2.
3.
4.
5.
6.
question
What
research
gives
accurate
information
about
etiology
of
inflammation of the meninges?
What are the requirements for the
diagnosis of tuberculosis of nervous
system in TB clinics?
What are the clinical and laboratory
findings can indicate about transition
of tuberculous meningitis under
meningoencephalitis?
Principles of treatment of tuberculous
meningitis patients.
What anti-TB drugs used in patients
with tuberculous meningitis and their
daily dose for adults?
Which meningitis of other etiology
carry
differential
diagnosis
of
tuberculous meningitis?
answer
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
In the girl 9 years was appeared
meningeal symptoms. For 2 months
before admission to the hospital
primary tuberculous complex in phase
infiltration was diagnosed. She was
treated at home irregularly. Food was
insufficient. Five days later came the
headache, vomiting, convulsions and
therefore the patient was hospitalized.
Mantoux test - 13 mm papule. Blood:
Leukocytes -11.5 x 10 / l, left shift,
lymphopenia, monocytosis, ESR - 27
mm / h.
а). What should be done to clarify the
diagnosis?
When symptoms of tuberculous
meningitis disappear during an antibacterial treatment?
In some cases the most favorable
prognosis of tuberculous meningitis?
What
research
gives
accurate
information
about
etiology
of
exudative pleurisy?
List the major clinical symptoms of dry
pleurisy.
List the major clinical symptoms of
pleural effusion.
What auscultatory features in dry
pleurisy?
In which side is observed shift of the
mediastinum with pleural effusion?
Name the place often accumulation of
effusion?
What is the nature of exudate in
tuberculous pleural empyema?
8. Supervision of patients with pulmonary tuberculosis.
Interview (collection) complaints, all anamneses (vitae, morbi, epidimiologic
composion of case), inspectation and physical examination of the patient (revealing
of abnormalities in organs and systems).
*mastering to analyze and interpret results of the patient examination, data of chest
X-ray, laboratory & instrument investigation
*mastering to grounding of diagnosis of the patient, prescribe adequate
chemotherapy, detect of prognosis as to life and recovery.
9. Recommended reading list
1. Juan Carlos Palomino et al Tuberculosis 2007 From basic science to patient care
www.TuberculosisTextbook.com
2. American Thoracic Society. Diagnostic standards and classification of tuberculosis
in adults and children. Am J Respir Dis Crit Care Med 2000; 161: 1371-95.
3. Brodie D, Schluger NW. The diagnosis of tuberculosis. Clin Chest Med 2005; 26:
247-71.
4. Busi Rizzi E, Schinina V, Palmieri F, Girardi E, Bibbolino C. Radiological patterns
in HIV-associated pulmonary tuberculosis: comparison between HAART-treated and
non-HAART-treated patients. ClinRadiol 2003; 58: 469-73.
5.Петренко, В.І. Phthisiology — Фтизіатрія: Підручник / В.І. Петренко. — К.:
Медицина, 2008. — 288 с.
6. World Health Organization. Stop TB partnership. Tuberculosis in Countries.
www.stoptb.org./countries/. Date last accessed: May. 8:2007.
7. National Collaborating Centre for Chronic Conditions. Tuberculosis: clinical
diagnosis and management of tuberculosis, and measures for its prevention and
control. NICE clinical guidelines no 33. Royal College of Physicians, 2006.
8. Toman K. How does pulmonary tuberculosis develop and how can it be detected at
an early stage? In Toman K. Toman’s Tuberculosis. Case detection, treatment, and
monitoring—questions and answers. 2nd ed. World Health Organization, 2004:66-71.
9. Lectures.