Saturday, July 30, 2011

Primary Tubercular Complex-Plain CXR


A young child with cough and fever

Chest Xray shows subsgemetnal atelectasis with transverse fissure thickening with hilar lymphadenopathy and mottled infrahilar reticulation possibly lymphangitis – together called primary complex disease(Ranke’s complex)


Teaching points by Dr MGK Murthy

-       Tubercle bacilli as little as 1-3 can reach the respiratory tree  of the child invariably from cavitating adult contact usually at home or school/daycare environment as the bacilli are  really killed by ultraviolet light outside
·       The bacilli can be expelled by the cilia to be swallowed and destroyed by the stomach acid or can reach alveoli to be inhibited/killed by the macrophages.
·       If they are virulent , multiply and burst macropahges to spread forming tubercle (aggregation of macrophages, epitheloid cells and lymphocytes)
·       Immune response at this stage(3-8 wks) is delayed hypersensitivity and tuberculin test is positive
·       Bacilli escape from edge, multiply and reach lymphnodes .
·       All the 3 components alveolar site (ghon’s focus), lymphangitis and infected mediastinal lymphnode form Primary complex mediated by cell mediated immunity (Ranke’scomplex)
·       Chest Xray/CT is + by 4-8 wks after the exposure
·       Can involve any part  of the lung but middle lobe is least involved
·       95%do not suffer from disease and X ray  shows only fibrosis, calcification or completely normal
·       Radiological hallmark is lymphadenopathy
·       Because of peculiarity of lymphatics, left parenchymal lesion produces bilateral and right parenchymal shows only right hilar  lymphnodes possibly along with transverse fissure fluid
·       When the lesion erodes the lymphnode and spreads along the bronchus it will become progressive primary TB
·       If TB infection occurs 1 year or later after the original infection, referred to as post primary from usually because of reactivation
·        Post primary prefers colonization in upper lobes specially apical and posterior segments
·       Child to child transmission is rare because of lack of tussive outburst
·       Miliary and Meningeal forms develop in 1st 3months after primary complex
·       Pleural and peritoneal forms take 3-7 months to manifest
·       One variety called congenital TB is extremely rare possibly because  of hypoxic intrauterine environment does not promote TB bacilli growth.
·       But when occurs ,usually via transplacental spread-----primary complex is in liver –periportal LNs –other organs and lungs can remain latent for 2-4 wks after birth and when Xray is +, it shows miliary form
·       Even more rarely can occur by foetus swallowing bacilli in genital TB

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