Klinički značaj vanplućne tuberkuloze u diferencijalnoj dijagnozi nejasnog febrilnog stanja

Abstract

Tuberkuloza predstavlja infekciju humanim sojem mikobakterije Mycobacterium tuberculosis uz pojavu karakteristiĉnog imunološkog odgovora organizma. Najĉešća forma bolesti je plućna. Po procenama Svetske Zdravstvene Organizacije (SZO) vanplućna tuberkuloza (VPTB) ĉini oko 20-25% formi bolesti. Zbog uglavnom atipiĉne kliniĉke slike (izuzimajući tuberkulozni meningitis), produţenog toka u kome su uz progresivno pogoršanje opšteg stanja, prisutni još samo povišena temperatura i ĉesto pozitivan zapaljenski sindrom, najveći broj ovih bolesnika se razmatra u toku diferencijalne dijagnoze nejasnog febrilnog stanja (NFS). Poseban problem predstavlja teţa dijagnostika VPTB i potreba za ĉešćim korišćenjem invazivne dijagnostike. U periodu do pojave virusa humane imunodeficijencije (HIV) incidenca tuberkuloze u svetu je bila u opadanju, ali se od osamdesetih godina dvadesetog veka tuberkuloza ponovo nameće kao bolest od rastućeg interesa. Procenjuje se da je u svetu oko dve milijarde ljudi inficiranih bacilom M. tuberculosis od kojih je oko 8 miliona godišnje razvije aktivnu tuberkulozu, a oko 2 miliona umre. Incidenca oboljevanja od tuberkuloze i VPTB je u porastu svugde u svetu i u HIV negativnoj populaciji. U takvim okolnostima raste i znaĉaj informisanosti lekara dijagnostiĉara, da se u toku dijagnostiĉkog postupka febrilnog stanja mora razmatrati i tuberkulozna infekcija, kako pluća, tako i vanplućna. Tuberkuloza moţe zahvatiti bilo koji organ u organizmu, s’tim da je plućna lokalizacija najĉešća. Terminom VPTB se oznaĉava izolovana pojava tuberkuloze na bilo kom mestu u organizmu van pluća. Ako je uz vanplućnu lokalizaciju prisutna i zahvaćenost pluća takvi se pacijenti kategorizuju pod dijagnozom plućne tuberkuloze. Varijeteti kliniĉke slike VPTB su mnogobrojni što oteţava dijagnostiku. Uz retke lokalizacije koje daju karakteristiĉne simptome i znake (meningitis) ili bar mogu uputiti u pravcu dijagnoze (tuberkulozni limfadenitis), većina drugih, posebno dubokih lokalizacija se manifestuje samo povišenom temperaturom. Zbog ovakvih teškoća u dijagnostici, proporcionalno je veća zastupljenost VPTB u ukupnom broju otkrivenih bolesnika sa tuberkulozom u tercijarnim ustanovama, nego u primarnoj zdravstvenoj zaštiti...

Tuberculosis is an infection with human mycobacteria strain of Mycobacterium tuberculosis, with the occurrence of the characteristic immune response of the organism. The most common form is lung disease. According to estimates by the World Health Organization (WHO), extrapulmonary tuberculosis (EPTB) accounts for 20-25% of the tuberculosis. Mainly due to atypical clinical features (except for tuberculous meningitis), the prolong course of the illness with progressive deterioration of general condition, present only with fever and often positive inflammatory syndrome, most of theses patients are considered in the differential diagnosis of fever of unknown origin (FUO). A particular problem is a difficult diagnosis of EPTB and the need for more frequent use of invasive diagnostic. Until the appearance of human immunodeficiency virus (HIV) incidence of tuberculosis in the world was in decline, but since the eighties of the twentieth century, tuberculosis re-imposed as a disease of growing interest. It is estimated that the world's two billion people infected with an M. tuberculosis, of which about 8 million develop active TB annually, and about 2 million die. The incidence of tuberculosis and EPTB is increasing everywhere in the world and in the HIV negative population too. In such circumstances, medical doctors must have growing awareness of the importance of tuberculosis infection, both lung and extrapulmonary during the diagnostic procedure in febrile conditions. Tuberculosis can affect any organ in the body; however, the most frequent localization is pulmonary. The term EPTB means an isolated occurrence of tuberculosis anywhere in the body outside the lungs. If present with extrapulmonary localization and involvement of the lungs such patients are categorized under the diagnosis of pulmonary tuberculosis. Varieties of clinical presentations of EPTB are numerous which makes diagnosis difficult. With rare localization which give the characteristic signs and symptoms (meningitis), or at least can make towards the diagnosis (tuberculous lymphadenitis), most of the others, especially the deep localization is only manifested with fever. Because of these difficulties in diagnosis, the greater proportion EPTB was detected in tertiary institutions, instead in primary care. The most common localization of EPTB is tuberculosis of the lymph nodes, genitourinary tuberculosis, abdominal tuberculosis, pleural tuberculosis, tuberculous pericarditis, neurotuberculosis, tuberculosis of bones and joints. Other forms of EPTB occur less frequently...