Difficulties of the stage-by-stage surgical treatment of a teenager with bilateral advanced fibrotic-cavernous tuberculosis. Сlinical case

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Abstract

BACKGROUND: To achieve success in the management of adolescents with tuberculosis, a comprehensive approach including surgical intervention is needed so as to eliminate disease clinical manifestations, to achieve persistent healing of tuberculous changes with restoration of bodily functions and complete social rehabilitation

CLINICAL CASE DESCRIPTION: In patient U., 17 y.o., sudden and acute onset of the disease broke out after her contacts with her aunt who had tuberculosis. The initial form was infiltrative pulmonary tuberculosis in the decay phase. A course of anti-tuberculosis therapy was prescribed considering the bacteria sensitivity to antibiotics. After the course, fibrous lesions and cavities were detected in both lungs at computed tomography examination of the chest organs. A personalized therapy was developed for the patient with consideration of her body weight and sensitivity to bacteria. In 7 months, an endobronchial valve was inserted at the bronchus mouth in the right superior lobe because of the large cavity in the right upper lung lobe and lack of changes in the cavity size. In six more months, the blocker was removed due to the lack of dynamics, and a video-assisted thoracoscopic combined resection of the right lung (upper lobectomy with resection of part SV, anatomical resection SVI with part SVIII) was performed. On analyzing surgical material, it was found out that the patient was resistant to Isoniazid, Rifampicin and fluoroquinolones, so therapy was corrected. In six months, a video–assisted thoracoscopy combined resection of the left lung (SI–III anatomical resection and marginal resection of SVI part) was made.

CONCLUSION: After the performed treatment, patient's oxygenation improved, persistent abacillation was achieved, due to which the patient could return to normal lifestyle.

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About the authors

Ruslan V. Tarasov

Central Research Institute of Tuberculosis; Medical University "Reaviz"; Russian Medical Academy of Continuous Professional Education

Author for correspondence.
Email: etavnai@yandex.ru
ORCID iD: 0000-0001-9498-1142
SPIN-code: 4245-1560
Scopus Author ID: 211623482
ResearcherId: AGK-3113-2022

MD, Cand. Sci. (Medicine), Associate Professor

Россия, Moscow; Moscow; Moscow

Larisa N. Lepekha

Central Research Institute of Tuberculosis

Email: lep3@yandex.ru
ORCID iD: 0000-0002-6894-2411
SPIN-code: 6228-8382

Dr. Sci. (Biology), Professor

Россия, Moscow

Svetlana S. Sadovnikova

Central Research Institute of Tuberculosis

Email: sadovnikova.sv@mail.ru
ORCID iD: 0000-0002-6589-2834

MD, Dr. Sci. (Medicine)

Россия, Moscow

Elena V. Krasnikova

Central Research Institute of Tuberculosis

Email: el.krasn@gmail.com
ORCID iD: 0000-0002-5879-7062
SPIN-code: 4252-8340

MD, Dr. Sci. (Medicine)

Россия, Moscow

Genrik A. Asoyan

Central Research Institute of Tuberculosis

Email: henoasoyan@gmail.com
ORCID iD: 0000-0003-2927-7495
SPIN-code: 6213-7691

MD

Россия, Moscow

Alexandra M. Zakharova

Medical University "Reaviz"

Email: alexandra-turunen@yandex.com
ORCID iD: 0000-0001-5450-2610

MD

Россия, Moscow

Mammad A. Bagirov

Central Research Institute of Tuberculosis; Russian Medical Academy of Continuous Professional Education

Email: bagirov60@gmail.com
ORCID iD: 0000-0001-9788-1024
SPIN-code: 8820-5448

MD, Dr. Sci. (Medicine), Professor

Россия, Moscow; Moscow

References

  1. Ovsyankina ES, Panova LV, Khiteva AY, Viechelli EA. Reasons for late diagnostics of tuberculosis in adolescents. Russ Bull Perinatol Pediatr. 2019;64(1):76–80. EDN: YZDVTF doi: 10.21508/1027-4065-2019-64-1-76-80
  2. Ovsyankina ES, Panova LV, Poluektova FG, et al. Adolescent tuberculosis: A medico-social portrait taking into account the epidemic risk factor of disease development. Clinical practice in pediatrics. 2018;13(2):32–38. EDN: XQKJTN doi: 10.20953/1817-7646-2018-2-32-38
  3. Ergeshov AE, Ovsyankina ES, Gubkina MF. Tuberculosis of the respiratory organs in children and adolescents. Guide for doctors. Moscow: Mireya i Ko; 2019. 520 p. (In Russ).
  4. Panova LV, Ovsyankina ES, Giller DB, et al. Role of surgical methods in the treatment of destructive lungs tuberculosis in children and adolescents. Tuberculosis Lung Dis. 2010;(8):18–22. EDN: OFXZED
  5. Giller DB, Ogay IV, Martel II, et al. Long-term results of surgical treatment of respiratory tuberculosis in children and adolescents. Tuberculosis Lung Dis. 2012;(1):345–346. EDN: CDIDHG
  6. Ovsyankina ES, Panova LV, Firsova VA, et al. The structure of clinical forms and features of the course of tuberculosis with lung tissue destruction in older children and adolescents. Tuberculosis Lung Dis. 2012;89(1):10–13. EDN: PIGIGB

Supplementary files

Supplementary Files
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1. JATS XML
2. Fig. 1. Computed tomography of the chest organs upon admission: fibrous-cavernous pulmonary tuberculosis, giant cavities in both lungs — SI–III, VI, VIII on the right and SI, II, VI on the left (description in the text).

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3. Fig. 2. Computed tomography of the chest organs 6 months after valvular bronchoblocation: positive dynamics when one of the cavities in SVI of the left lung was closed (description in the text).

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4. Fig. 3. Macro-preparation of the removed lung area.

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5. Fig. 4. Histological picture of surgical material of the right lung: a — compacted caseosis with microcalcinates (МК) surrounded by sclerosed lung tissue (staining with hematoxylin and eosin, magnification ×320); b — conglomerate of withering and sclerosing epithelioid cell granulomas (ЭГ) (hematoxylin and eosin staining, magnification ×220); c — a focus of caseous necrosis (КН) surrounded by granulation tissue with manifestations of granulomatous reaction, multinucleated macrophages (ММ) (staining with hematoxylin and eosin, magnification ×120); d — a focus of granulomatous (Гр) inflammation in the pleura (staining with hematoxylin and eosin, magnification ×360).

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6. Fig. 5. Computed tomography of the chest organs 3 months after combined resection of the right lung: fibrotic cavernous tuberculosis SI, II, VI of the left lung with a giant cavern (description in text).

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7. Fig. 6. Histological picture of the surgical material of the left lung: a — a focus of caseous necrosis (КН) surrounded by granulation (ГТ) and fibrous tissue (ФТ), the presence of epithelioid cell granulomas (ЭГ) in the perifocal lung tissue (hematoxylin and eosin staining, magnification ×120); b — foci of caseous necrosis (КН) surrounded by a connective tissue capsule (K) in the bronchial wall (staining with hematoxylin and eosin, ×180).

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8. Fig. 7. Computed tomography of the chest organs 3 months after combined resection of the left lung (description in the text).

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