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First-line test. Is almost always abnormal in non-immunocompromised individuals. Primary disease commonly presents as middle and lower lung zone infiltrates. Ipsilateral adenopathy, atelectasis from airway compression, and pleural effusion can be seen. Re-activation-type (post-primary) pulmonary TB usually involves apical and/or posterior segment of right upper lobe, apicoposterior segment of left upper lobe, or superior segment of either lower lobe, with or without cavitation. As disease progresses it spreads to other segments/lobes.
Sputum may be spontaneously expectorated or induced, and at least 3 specimens should be collected (minimum 8 hours apart, including an early morning specimen, which is the best to detect M. tuberculosis). The examiner looks for AFB (the stained dye remains even after exposure to acidic media) consistent with M. tuberculosis. Other organisms, especially non-tuberculous mycobacteria (e.g., M. kansasiiand M. avium), may be positive for AFB stain. Thus, a positive AFB smear is not highly specific in populations with low TB prevalence. If sputum is positive for AFB, the results will be graded from 1+ to 4+ depending on number of organisms seen. Smear positivity and its grading may help estimate the degree of infectiousness and burden of TB disease. In the US, sensitivity is 50% to 60%.
The most sensitive and specific test. Should always be performed as it is required for precise identification and for drug susceptibility testing. Growth on solid media may take 4 to 8 weeks; growth in liquid media may be detected in 1 to 3 weeks. Growth on solid media if positive is reported on quantitation scale (1+ to 4+). While on treatment, the patient should have sputum cultures performed at least monthly until 2 consecutive cultures are negative.
Leukocytosis (without left shift) and anaemia each seen in 10%. Other abnormalities include elevated monocyte and eosinophil counts. Pancytopenia may be seen in disseminated disease.
The TST uses purified protein derivative (PPD) to evaluate for delayed hypersensitivity response in order to diagnose prior exposure to TB. Different cut-offs in size of induration are used to define a positive test depending on the patient's risk factors. have low sensitivity in diagnosing active TB and do not distinguish between latent infection and active disease. especially with increased age. which limits their usefulness. similar to TST. Sensitivity of QuantiFERON-TB Gold (QFT-G) for active TB is 75%. interferon-gamma release assays (IGRA) Measure the response of T cells to TB antigens in order to diagnose prior exposure. and advanced disease. There is diminished immune response in patients with active TB. The sensitivity of TST in diagnosing active TB is around 75% to 80% and its inability to distinguish between latent infection and active disease limits its usefulness.   .tuberculin skin testing (TST) A negative TST does not rule out active TB. poor nutrition. IGRAs.
Structure of the Respiratory System The respiratory system is represented by the following structures. shown in Figure 1 : .
The upper vestibular folds (false vocal cords) contain muscle fibers that bring the folds together and allow the breath to be held during periods of muscular pressure on the thoracic cavity (straining while defecating or lifting a heavy object. during swallowing to prevent the entrance of food. called concha. listed in order through which incoming air passes: y The nasopharynx receives the incoming air from the two internal nares. The thyroid cartilage protects the front of the larynx. moisten. y y The oropharyrnx receives air from the nasopharynx and food from the oral cavity. air then funnels into two (left and right) internal nares. The laryngopharynx passes food to the esophagus and air to the larynx. Various sounds. It consists of the following nine pieces of cartilage that are joined by membranes and ligaments. The two auditory (Eustachian) tubes that equalize air pressure in the middle ear also enter here. The nasal septum divides the nasal cavity into right and left sides.y The nose consists of the visible external nose and the internal nasal cavity. naris). shown in Figure 2 . y The pharynx (throat) consists of the following three regions. are formed by facial bones (the inferior nasal concha and the ethmoid bone). are produced in this manner. and eliminate debris from the passing air. Air enters two openings. the external nares (nostrils. The pharyngeal tonsil (adenoid) lies at the back of the nasopharynx. singular. The larynx receives air from the laryngopharynx. for example). and cilia that line the nasal cavity filter. the upper region of the larynx. The lower vocal folds (true vocal cords) contain elastic ligaments that vibrate when skeletal muscles move them into the path of outgoing air. From the meatuses. warm. The paired arytenoids cartilages in the rear are horizontally attached to the thyroid cartilage in the front by folds of mucous membranes. . including speech. Hair. is a flexible flap that covers the glottis. blood capillaries. Figure 2 Anterior and sagittal section of the larynx and the trachea. mucus. the first piece of cartilage of the larynx. The bony walls of the meatuses. and passes into the vestibule and through passages called meatuses. y y y The epiglottis. The palatine and lingual tonsils are located here. A forward projection of this cartilage appears as the Adam's apple.
Alveolar ducts are the final branches of the bronchial tree. The primary bronchi are two tubes that branch from the trachea to the left and right lungs. Gas exchange occurs across this membrane. bubblelike swellings along its length. Each alveolar duct has enlarged. and numerous orders of bronchioles (1 mm or less in diameter). tertiary (segmental) bronchi.5 cm (1 inch) in diameter. including terminal bronchioles (0. The respiratory membrane consists of the alveolar and capillary walls. and the paired corniculate cartilages are the remaining cartilages supporting the larynx. Hyaline cartilage forms 16 to 20 C-shaped rings that wrap around the submucosa. The movement of the cilia sweep debris away from the lungs toward the pharynx. Some adjacent alveoli are connected by alveolar pores. squamous epithelial cells that constitute the primary cell type of the alveolar wall. y y y Alveolar macrophage (dust cells) wander among the other cells of the alveolar wall removing debris and microorganisms. A dense network of capillaries surrounds each alveolus. The trachea (windpipe) is a flexible tube. It consists of areolar connective tissue. y y y The submucosa is a layer of areolar connective tissue that surrounds the mucosa. 10 to 12 cm (4 inches) long and 2. each primary bronchus divides repeatedly into branches of smaller diameters. Inside the lungs. but as the branches of the tree get smaller. The basement membranes of the alveolus and the capillary are often so close that they fuse. A thin epithelial basement membrane forms the outer layer of the alveolar wall. It contains mucusproducing goblet cells and pseudostratified ciliated epithelium. whose wall consists of four layers.5 mm in diameter) and microscopic respiratory bronchioles. as shown in Figure 2 : y The mucosa is the inner layer of the trachea. The rigid rings prevent the trachea from collapsing during inspiration. The wall of the primary bronchi are constructed like the trachea. Type II cells are cuboidal epithelial cells that are interspersed among the type I cells. A reduction in surface tension permits oxygen to diffuse more easily into the moisture. The capillary walls consist of endothelial cells surrounded by a thin basement membrane. The adventitia is the outermost layer of the trachea. the paired cuneiform cartilages. Characteristics of this membrane follow: y y Type I cells are thin. the cartilaginous rings and the mucosa are replaced by smooth muscle.y The cricoid cartilage. Oxygen diffusion occurs across these cells. and a cluster of adjoining alveolar is called an alveolar sac. A lower surface tension also prevents the moisture on opposite walls of an alveolus or alveolar duct from cohering and causing the minute airway to collapse. forming secondary (lobar) bronchi. Each swelling is called an alveolus. Type II cells secrete pulmonary surfactant (a phospholipid bound to a protein) that reduces the surface tension of the moisture that covers the alveolar walls. .