Differential diagnosis method for distinguishing the cases of nonspecific inflammation and tuberculosis of urinary tract

FIELD: medicine.

SUBSTANCE: method involves evaluating blood microcirculation parameters in urethral mucous membrane before tuberculin test and 48 h thereafter. The microcirculation parameters growing worse by 8-12% and higher, tuberculosis is to be diagnosed. The value remaining unchanged or their values not exceeding 8%, nonspecific urinary tract inflammation is to be diagnosed.

EFFECT: high accuracy of diagnosis.

2 tbl

 

The invention relates to medicine, namely to fiziologii.

Tuberculosis of the urinary system has a dominant position in the structure of TB extrapulmonary localizations, and the relevance of this pathology is undeniable. However, diagnosis of the disease is a serious problem. The absence of bright, manifest clinical symptoms later determines the treatment of patients for medical care, and nonspecific manifestations - the difficulties of differential diagnosis of this pathology. Widespread in the differential diagnosis of tuberculosis of the urinary system received provocative tuberculin skin test, the so-called sample Koch. Subcutaneous injection of tuberculin causes the development of hypersensitivity reactions of the delayed type of infected patients. While this may appear like common reactions in the form of malaise, headache, fever, changes in blood and focal, in the case of active TB disease in a particular organ. The task of diagnosis in this case is to fix the focal reaction from the urinary system, which would illustrate the growing phenomenon of inflammation. In the traditional version with tuberculosis of the urinary system is fixed dynamics pyuria and erythrocyturia are crops of urine on the office che is ez 24 and 48 hours after injection of tuberculin [1].

However, in case of violation of outflow of urine, due to robovie processes or edema of the mucosa of the urinary tract can impair outflow purulent urine from the inflammation. In this situation we can not fix gain pyuria, erythrocyturia and the emergence of mycobacterial in response to the provocation, to get a false negative result sample Koch in the presence of active tuberculosis inflammation. The imperfection of the existing diagnostic approaches prompted us to search for additional criteria to differentiate between focal reaction in the urinary system coupled with tuberculin provocation.

We have proposed a method of differential diagnosis of tuberculosis and nonspecific inflammation of the urinary tract by asking provocative TST, characterized in that, in addition to setting the sample and after 48 h estimating parameters of microcirculation of blood in the mucous membrane of the urethra and when changing parameters of microcirculation at 8-12% and more are diagnosed with TB, and if the indicators do not change or deterioration does not exceed 8%, diagnose nonspecific inflammation. The inventive method allows faster diagnosis and to improve its quality by documenting objective data about the change of the local microcirculation.

It is well known that one is th of the fundamental features of inflammation is the reaction of the microcirculation, which is reflected in the consistent development of the activity changes of endothelial cells, congestion and stasis. Starting mechanism for the implementation of these effects is injury to the microvascular endothelial or allocation of inflammatory mediators and cells involved in the development of the immune response. Changing the parameters of microcirculation in the mucosa of the urinary tract can serve as a differential diagnostic criterion for screening patients with suspected tuberculosis of the urinary system in the background tuberculin provocation.

To estimate the parameters of microcirculation in our work we used a Laser Analyzer Capillary blood Flow-01 (LACC-01, SPE "Lazma", Russia) in combination with a computer and a flexible probes for reading from the surface of the skin and mucous membrane.

Laser Doppler Flowmetry (LDF) is a modern method of non-invasive assessment of microcirculation, based on the change in frequency characteristics of the laser beam transmitted into the tissue, when it is reflected from the moving blood components, primarily red blood cells [2, 3]. The laser beam penetrates the tissue to a depth of 1.5 mm, so dopplergram characterizes the blood flow in the superficial microvessels. Computer processing of the received LDF allows you to calculate the integral indicator of the microcirculation (IM, characterizing perfusion of tissues. THEY are directly proportional to the velocity of the erythrocytes, the number of functioning capillaries and the value of hematocrit in microvessels. THEY are expressed in perfusion units (P.E.); also taken into account when analyzing σ - the standard deviation, which reflects the temporal variability of blood flow Tov=GR/σ - coefficient of variation characterizing the ratio of the amount of perfusion of the tissue and its variability.

The velocity of erythrocytes in capillaries exposed to constant rhythmic fluctuations. Slow oscillations (LF), from 1 to 10 per minute, determined by the activity of its own components microvasculature (rhythmic activity of endothelium, vasomotion, functioning paths shunting of blood flow). Fast oscillations (HF), 11-36 per minute, coincide with respiratory rhythms and depend on fluctuations in venous blood flow due to pressure changes in the chest in the phase of inhalation and exhalation. Normally, they are poorly expressed. The increase in the amplitude of these oscillations is happening in terms of the stagnation of blood in the venules. The presence of cardiorenal (CF) is associated with pulse fluctuations of blood flow. Thus, the assessment of the LDF allows not only to determine the amount of tissue perfusion, but also to characterize its variability in time and to evaluate the contribution of active and passive m the mechanisms of microcirculation. However, in practice it is not always convenient to use the absolute value of the amplitudes of the oscillations in the allocated frequency spectrum [4]. In addition to the PM σ andvwe estimated the ratio AmaxHF and AmaxCF to AmaxLF, as well as the performance index of microcirculation, calculated by the formula AmaxLF/AmaxHF+AmaxCF.

The method is as follows.

Before the study of microcirculation produce the calibration of the Laser Analyzer Capillary blood Flow by the standard method. Indoors, performing research, maintain a constant temperature of 20-22°C. Pre-interviewed with the aim to reduce the anxiety and fear of the patient before the procedure. Recording is conducted with the patient in the gynecological chair. In the field of external opening of the urethra at the site are not visually altered mucous membrane, perpendicular to its surface are installing a second probe of the analyzer. Record LDF produce not less than 3 min with subsequent computer processing and storing the results.

Example 1. Patient N., 43 years. Complaints about frequent urination with sharp, repeatedly - episodes macrohematuria. A history of contact with TB patients. On the excretory programme clearly the destruction of the kidneys is not visible. In the analysis of urine - Peoria. The inefficiency of long previous course nonspecific therapy necessitated the exclusion of tuberculosis of the urinary system.

With differential diagnostic target subcutaneous provocative tuberculin skin test Koch. On the background of the sample temperature and kolacny reactions were absent on the hemogram there was a slight increase leukocytosis. Focal reaction to evaluate failed because the original Pirie and pyuria. By the method of fluorescent microscopy mycobacteremia not identified. However, according to the method of LDF recorded deterioration of microcirculation parameters mucous urethra 9.3-14.7 per cent, which helped to establish the diagnosis of tuberculosis and to assign specific treatment. After 3 weeks was obtained microbiological verification of the diagnosis. Thus, the application of the proposed method made it possible to quickly, within one week, to establish the diagnosis of tuberculosis and timely treatment the patient open form. Growth of Mycobacterium tuberculosis was also obtained, but only after 3 weeks.

Example 2. Patient D., 48 years old. Complaints about constant pain in the lumbar region, frequent painful urination, several times was renal colic. A history of contact with TB patients. On the excretory programme clearly the destruction of the kidneys is not seen; by ultrasound mild pyelectasis. In the analysis of urine - pyuria, hematuria. With differential diagnostic target subcutaneous provocative tuberculin PR is BA Koch. On the background of the sample there was a strong okolocha reaction, temperature rise up to subfebrile figures. The hemogram was not changed, focal reaction is not recorded because the original pyuria and hematuria. By the method of fluorescent microscopy mycobacteremia not identified. According to the method of LDF change parameters of microcirculation mucous urethra ranged from 2.4 to 6.7%. Thus, the sample Koch was regarded as negative, the diagnosis of tuberculosis rejected. After 3 months received notice from blaboratory about the lack of growth of Mycobacterium tuberculosis in all urine samples. The patient is given a comprehensive etiopathogenetic therapy backup of broad-spectrum antibiotics, against which received significant clinical and laboratory improvement.

The study analyzed the results of a survey of 55 patients aged 21 to 64 years enrolled in urogenital Department of Novosibirsk TB research Institute in 2001-2003 with suspected tuberculosis of the urinary system. In the study group was dominated by women (48 person - 87.3 per cent). At admission, all patients in addition to standard clinical and laboratory examination was performed on the sample Koch with 50 of THOSE. Source, prior to the introduction of tuberculin, and after 48 hours were recording parameters of microcirculation with mucous from outside is Erste the urethra.

Upon completion of the examination, the patients were divided into 2 groups depending on the diagnosis.

Main - 25 people (45,5%), which during a comprehensive examination, she was diagnosed with tuberculosis: tuberculous papilla 16 people (64%) and cavernous tuberculosis of kidneys from 9 people (36%).

Control 30 patients (54.5 per cent) had nonspecific diseases of the urinary system. They were diagnosed with the following diseases:

- chronic obstructive pyelonephritis - 19 people (63,3%);

- chronic nonspecific cystitis - 6 person (20,0%)

- urolithiasis - 4 (13,3%);

- interstitial cystitis - 1 (3,4%).

The results of the study.

When analyzing dopplergram patients studied groups were evaluated dynamics to THEM, σ andv, the ratio of Amax CARDIORHYTHM, breathing rhythms and Amax in the region of low frequencies AmaxCF/AmaxLF, AmaxHF/AmaxLF)and the performance index of microcirculation (IEM), calculated by the formula AmaxLF/AmaxHF+AmaxCF.

At 48 hours after injection of tuberculin all patients were re-investigation of the microcirculation. The results are presented in tables 1 and 2.

Table 1

Dynamics of microcirculation in patients of the control group (n=30) on the background of tuberculin provocations
IndexEndovesical dimensionChange in %
Prior to the introduction of tuberculinAfter 48 hours
THEY (P.E.)18,2±0,9517,26±1,05,2
σ (P.E.)6,11±0,345,93±0,393,0
Tov(%)36,38±1,934,4±1,1of 5.4
AmaxLF1,66±0,06
AmaxHF+AmaxCF1,62±0,062,4

Significant dynamics of the investigated parameters in patients of the control group (non-specific pathology) on the background of tuberculin provocations we are not found, indicating the absence of false-positive results of the proposed method.

Table 2

Dynamics of microcirculation in patients of the main group (n=25) on the background of tuberculin provocations
IndexEndovesical dimensionChange in %
Prior to the introduction of tuberculinAfter 48 hours
THEY (P.E.)16,73±0,7814,62±0,612,6
σ (P.E.)6,76±0,35,35±0,3220,9
Tov(%)40,74±1,336,32±1,510,8
AmaxLF

AmaxHF+AmaxCF


1,53±0,05
1,4±0,03

8,5

In the group of patients with tuberculosis introduction of tuberculin led to changes in the parameters of microcirculation on the mucous membrane of the urethra. Revealed a decrease in the ratio of AmaxCF/AmaxLF (P<0,05) indicates the presence of angiospasm. The decrease in the performance index of microcirculation (IEM) indicates decompensation of stagnation in the microvasculature of the mucosa of the urinary tract against provocations by the tuberculin tuberculosis patients with urinary system.

Thus, the study of microcirculation parameters in the lining of the urethra on the background of tuberculin provocation confirmed the presence of changes in all patients with tuberculosis of the urinary tract against provocations by tuberculin, while in patients with non-specific pathology such changes were insignificant.

Thus, the claimed method speeds up the diagnosis of tuberculosis of the urinary system and allows you to get an objective documented data on mikroC is kuleli mucous membrane of the urethra and its changes on the background of provocation, which in turn increases the accuracy of differential diagnosis of nonspecific inflammation and tuberculosis of the urinary tract.

LITERATURE

1. Extrapulmonary tuberculosis: a guide for physicians. /Under the editorship of Prof. Avecilla. St. Petersburg, 2000/.

2. Kozlov V.I., MAh AS, Litvin FB and other Method of laser Doppler flowmetry // Manual for doctors. - Moscow. 2001. - 22 S.

3. Johnson J.M. The cutaneous circulation. / In book: Laser-Doppler blood flowmetry. Ed. by A.P.Shepherd. 1990. Kluwer Ac. Pub. P.121-141.

4. Sidorov V.V. Comprehensive analysis of hemodynamic rhythms // proceedings of the III all-Russian Symposium "Application of laser Doppler flowmetry in medical practice". Moscow. 2000. P.16-18.

The method of differential diagnosis of nonspecific inflammation and tuberculosis of the urinary tract by asking provocative TST, characterized in that, in addition to setting the sample and after 48 h estimating parameters of microcirculation of blood in the mucous membrane of the urethra and the deterioration of 8-12% or more are diagnosed with TB, and if the indicators do not change or deterioration does not exceed 8% diagnose nonspecific inflammation of the urinary tract.



 

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