На фоне ВИЧ-ассоциированной иммуносупрессии диагностика туберкулеза представляет значительные трудности. По данным 2010 г., в Российской Федерации в структуре вторичных заболеваний у больных ВИЧ-инфекцией туберкулез составил 39% (по данным МЗ РФ, ф. 61) и лидировал среди причин смерти людей, живущих с ВИЧ (ЛЖВ), умерших от причин, связанных с ВИЧ-инфекцией (63,4% в 2010 г. по данным МЗ РФ, ф. 61). Следовательно, у лихорадящего пациента с ВИЧ-инфекцией фтизиатрическая настороженность врача любой специальности должна быть приоритетной в диагностическом поиске. Вместе с тем более чем у половины больных на поздних стадиях ВИЧ-инфекции клиническая симптоматика связана с другими вторичными заболеваниями, что значительно осложняет проведение дифференциальной диагностики туберкулеза у этих больных. Анализируя ошибки, допущенные врачами общей лечебной сети при диагностике диссеминированного туберкулеза легких на поздних стадиях ВИЧ-инфекции, И. Ю. Бабаева показала, что большинству пациентов был поставлен диагноз внебольничной пневмонии [3]. В результате анализа летальных исходов среди взрослых больных ВИЧ-инфекцией г. Москвы определено, что частота клинически не распознанных вторичных заболеваний (основным из которых был туберкулез) у пациентов, проходивших лечение в неспециализированных клиниках, составляла до 50% [26].

The paper considers the incidence of tuberculosis in a pediatric population and mentally ill patients and describes the key problems of disease management in these patients. It gives data on patients’ awareness of their disease and factors forming their treatment adherence.

The paper assesses post-Soviet changes in the Russian tuberculosis (TB) service. It shows its role and place in the public health system and in the provision of epidemic safety, particularly under the current conditions of major reforms. It is noted that the TB service that has always perfectly fitted into the Soviet and Russian healthcare system hardly corresponds to it now and at times does not fit at all into the healthcare reforms that are being carried out. As of now, it may be stated that Russian phthisiology is in crisis. At the same time the country with a fairly high TB incidence needs an effective TB service. The fate and place of the TB service under the current conditions are questioned. The paper gives scenarios for the further development of the situation and characteristics of the urgent choice facing phthisiology today.

The specific features of the influence of biomedical, epidemic, and social risk factors for tuberculosis were studied in children in relation to the presence or absence of contact with a tuberculosis patient. In children in contact, the determinants of tuberculosis are its severity depending on the number of infection sources, the presence of bacterial excretion, including in those with drug resistance and a death focus; the absence of antiepidemic measures in an infection focus, including that of cycles of tuberculosis contact preventive therapy. The main conditions for the epidemic risk factor of the disease in persons in contact are the social problems in their family: its low health awareness; non-compliance with the sanitary epidemic regimen in the family of an infection source. In children without established contact, the major risk factors of tuberculosis are social problems that do not appear to a first-line marker for an infection source: the children living in immigrant, large, or asocial families who show low health awareness; as well as poor living conditions. Organizational measures are proposed for the prevention of tuberculosis in children and its early detection.

Examinations were made in 125 children, including 65 with tuberculosis and perinatal HIV infection (a continuous sample) and 60 with tuberculosis (a paired sample). The tuberculous process developing in the presence of perinatal HIV infection was manifested by a more marked progression with the registration of the disseminated and complicated forms of tuberculosis, the high frequency of pathogenic dissemination. Adherence to and timely start of antiretroviral therapy contributed to the predominant formation of tuberculous processes within the lymphatic system in most children and to the adequate time of regression of tuberculous changes. The natural course of HIV infection aggravates the tuberculous process, favors the development of disseminated, including generalized, forms, substantially decreases the efficiency of antituberculosis therapy, and is an important predictor of mortality.

The etiological pattern of pleural effusions was studied, by analyzing the computed database on 11,272 patients examined and treated at the specialized Pleural Pathology Department of the Voronezh Regional Tuberculosis Oncology in 1979-2012. There were the most common etiological groups: tuberculous (31.38%) and parapneumonic (33.68%) pleurisy. Analysis of the data of the clinical manifestations and the results of examination of 110 patients with tuberculous pleurisy and 100 patients with parapneumonic pleurisy identified main criteria for these types of exudative pleurisy and differential diagnosis tactics.

The clinical and radiographic manifestations of maturity-onset tuberculous spondylitis were analyzed in 107 patients. If Mycobacterium tuberculosis (MBT) is drug resistant, the extent and degree of spinal bone destruction, the extent of abscess formation, and the rate of neurological disorders are greater than those in the MBT drug sensitivity group; however, the significant difference concerns only the involvement of vertebral arches in destruction. The pattern and activity of a tuberculous process in the lung and the proportion of bacteria-excreting persons with drug resistance in MBT significantly exceed those with drug sensitivity. All the patients were operated on; the diagnosis was histologically verified in 100% of cases; the postoperative specimens exhibited MBT culture in 72.9%; the polymerase chain reaction was positive n 98.9%. Bacteriological and molecular genetic studies established multiple drug resistance in 73.4%, polyresistance in 17.3%, and monoresistance in 9.3%.

The rate of caseous pneumonia and disseminated pulmonary tuberculosis in the structure of mortality from tuberculosis concurrent with chronic alcoholism or alcoholic disease was found to be 3.4 and 1.3 times greater than that of these forms in tuberculosis without alcohol intoxication. Alcohol-induced multiple organ failure was a cause of death in 21%. Toxic damage of respiratory organs with alcohol and its metabolites is characterized by circulatory disturbance in the microcirculatory system, increased wall vascular permeability, plasmorrhagia, interalveolar septal collagenization with vascular desolation in the microcirculatory bed, which underlies the histogenesis of pulmonary alcoholic disease.

Total lung capacity (TLC), lung capacity (LC), forced LC (FLC), intrathoracic volume (ITV), pulmonary residual volume (PRV), forced expiratory volume in one second (FEV1 ), (FEV1 )/LC%, peak expiratory flow (PEF), maximum expiratory flow rate (MEFR)25, MEFR50, MEFR75, Raw, Rin, Rex, DLCO-SB, DLCO-SB/VА, РаО2 , and РаСО2 were determined in 43 patients with exogenous allergic alveolitis (EAA) before, during, and after treatment with glucocorticosteroids, hemapheresis, ambroxol, and fluimucil. Lung function became better in more than half (53.5%) of the patients and worse in one fourth (25.6%); a combination of positive and negative functional changes was detected in 14.0%. Improved lung function was noted in 75.0, 50.0, and 38.5% of the patients with acute, subacute, and chronic EAA, respectively. Deterioration of lung function was determined in 46.2, 22.2, and 8.3% of the patients with chronic, subacute, and acute alveolitis, respectively. Better lung function manifested itself mainly as positive changes in lung volumes and capacities and pulmonary gas exchange function, less frequently as improved bronchial patency in the patients with acute and subacute EAA whereas the rate of positive functional changes in lung volumes and capacities, bronchial patency, and pulmonary gas exchange function was equal in those with chronic EAA. Poorer lung function appeared as negative changes in lung volumes and capacities in the patients with acute EAA, as worse pulmonary gas exchange function and negative changes in lung volumes and capacities and deteriorated bronchial patency in those with subacute and chronic EAA.

Staining impression smears from organ and tissues with peroxidase conjugated antibodies to Mycobacterium tuberculosis complex antigens, followed by visualization with diaminobenzidine and Kinyoun stains, ensured the painting of acid-resistant Mycobacterium tuberculosis forms to rubin red, acid-susceptible ones to brown, and tissue cells and microorganisms of other species to blue. Typical bacilli were absent in the lymph nodes of patients and animals with latent infection, but acid-resistant (rubin-red) granular forms were encountered in the granulomatous masses. Brown fat cells containing mycobacterial antigens, as well as acid-susceptible granular, reticular, fungoid, and rod-like forms were also found in considerable quantities.

Quantitative changes in immunoglobulins A (IgA), IgE, IgG, IgM, and B lymphocytes in peripheral blood were estimated in non-smoking and smoking patients with chronic obstructive pulmonary disease (COPD). The study included 21 non-smoking patients with COPD, 20 smoking patients with COPD, 20 healthy non-smokers, and 21 healthy smokers. The plasma immunoglobulin concentrations were measured by enzyme immunoassay. A B-lymphocyte population was analyzed by flow cytometry. In the smokers with COPD, IgA and IgE levels were significantly higher than those in the smokers without COPD, as well as in the non-smoking patients with COPD versus the healthy non-smokers. An increase in plasma IgG levels occurred only in the smoking patients with COPD. There were no differences in IgM and B lymphocyte levels in both smoking and non-smoking patients with COPD versus the respective groups of healthy individuals. The smoking patients with COPD showed a moderate positive correlation between total plasma IgE levels and smoking index. The findings suggest that IgA, IgE, and IgG are of pathogenetic value.

The experience with diaskintest (DST) used to screen children for tuberculosis infection gave proof to the rationality of the technique to identify minor tuberculosis forms in children and adolescents. DST and assessment of additional risk factors for tuberculosis could detect children at high risk for the disease, who had undergone chest X-ray computed tomography before examination. The new approach to examining the children, by improving the quality of tuberculosis detection in children and adolescents, led to improved clinical pattern, the higher proportion of minor tuberculosis forms, the lower proportion of complicated tuberculosis forms, and reduced incidence of destructive tuberculosis in adolescents. However, the problem in the assessment of the activity of a tuberculous process remains in children with found minor calcinates in the intrathoracic lymph nodes because positive reactions to DST are also recorded in cases without clinical and X-ray signs of the activity of a tuberculous process.

DST promotes the optimization of diagnosis of latent tuberculosis infection in children, allows identification of a group of children at the highest risk for tuberculosis among the persons with monotonous tuberculin tests, and contributes to the detection of minor tuberculosis forms.

Transition to the screening of schoolchildren (over 8 years of age) and adolescents, by applying DST, makes it possible to improve the quality of diagnosis of tuberculosis infection and may be recommended for introduction in the Republic of Tatarstan as a whole. 

The pathomorphology of tuberculosis was studied in 129 deceased patients with concomitant HIV infection and in 50 patients with acutely progressive forms of the disease (a comparison group). In tuberculosis concurrent with HIV infection, the morphological pattern in the lung and other viscera depends on the primacy of a lesion and reflects the progressive pattern of specific inflammation. In the TB-HIV group, the signs of a pre-existing specific process with foci of fibrosis and hyalinosis, a mild or moderate granulomatous reaction with epithelioid cells always persist in the lung. The tuberculous process progresses due to lymphohematogenic and bronchogenic dissemination. The HIV-TB group is characterized by the preponderance of exudative and alterative changes, the absence of signs of separation and organization of inflammatory pyonecrotic foci having no signs of specificity in the lung and other viscera. Progression of tuberculous inflammation occurs mainly by hematogenic dissemination. In all the observed groups, there is lymphadenopathy that appears as caseuos necrosis in the TB-HIV group and reactive hyperplasia in the HIV-TB group.

В опубликованном в 1999 г. консенсусе по саркоидозу Американского торакального общества (ATS), Европейского респираторного общества (ERS) и Всемирной ассоциации саркоидоза (WASOA) это заболевание относится к числу доброкачественных, системных, хронических интерстициальных процессов, характеризующихся развитием в органах и тканях продуктивного воспаления и эпителиоидно-клеточных гранулем, претерпевающих фиброзирование или рассасывание. Чаще всего поражаются легкие и внутригрудные лимфатические узлы.