ФГБОУ ВО

СМОЛЕНСКИЙ ГОСУДАРСТВЕННЫЙ МЕДИЦИНСКИЙ

УНИВЕРСИТЕТ
Кафедра фтизиопульмонологии

SMOLENSK STATE MEDICAL UNIVERSITY

Phthisiopulmonology department

Е.Е.Рашкевич, Т.В.Мякишева

ДИФФЕРЕНЦИАЛЬНАЯ ДИАГНОСТИКА
ИНФИЛЬТРАТИВНЫХ ПРОЦЕССОВ В ЛЕГКИХ
Учебное пособие

E.E.Rashkevich, T.V.Myakisheva

DIFFERENTIAL DIAGNOSTIC OF INFILTRATIVE

PROCECESS IN THE LUNGS

Study guide for foreign students

Смоленск, 2020
Smolensk, 2020
 2
Дифференциальная диагностика инфильтративных процессов в
легких. Практикум для иностранных учащихся.
Составители: доц. Е.Е. Рашкевич, доц. Т.В. Мякишева.
Смоленск, 2020 – 18 с.

Практикум составлен в соответствии с программой обучения в

мед. вузах Российской Федерации.
Предназначен студентам факультета иностранных учащихся
СГМУ для внеаудиторной подготовки к занятиям и аудиторной
работы.

The practical guide meets the requirements of the training program-

mer for medical schools of the Russian Federation. The practical
guide is for homework and practical classes.

© Smolensk state medical university

© Составители: доц. Е.Е. Рашкевич, доц. Т.В. Мякишева.
 3
Differential diagnostic of infiltration process in the lung is very
difficult problem for a doctor. The amount of diagnostic techniques is
increases but the amount of mistaken diagnoses non-decreases and
may be from 30 to 50%.
Knowledge’s doctor about up-to-date clinical features of lung dis-
eases and opportune equipped of hospital are used for right diagnos-
tic of the lung diseases.
Defects of diagnostic techniques are conditioned by:
1) insufficient of information about examination of the patient;
2) irregular interpretation of clinical, roentgenological and la-
boratory techniques;
3) difficult and insufficient of the clinical features or rarity of
disease.
Differential diagnostic of TB and non-TB disease consist of:
1. anamnesis and clinical features of disease;
2. character of chest X-ray;
3. tuberculin sensitivity;
4. data of bacteriological techniques;
5. data of bronchial techniques;
6. results of puncture of pathology process with cytological, hys-
tological, bacteriological techniques;
7. data of lung’s biopsy;
8. results of information of techniques such as immunological,
biochemical, CT.
Differential diagnostic is used between infiltrative TB, non-
specific pneumonia and lung cancer very often.
1 stage of diagnostic involves obligate techniques.
Three situations are differenced very often such as:
1) tuberculosis and lung cancer;
2) TB and non-specific pneumonia;
3) combination of tuberculosis with one of this diseases.
Additional techniques are used for detect of diagnose.
 4
Doctor should remembers Heglin’s rule: “every pathological
process in the lung is considered as tuberculosis until the other
disease isn’t diagnosed. Necessary, early diagnostic the mycobac-
terium of TB in the sputum, a bronchial washing smear in during
any lung process”.

Differential diagnostic of infiltrative lung process and specific,

non-specific process.
Infiltrative lung TB is clinical form of tuberculosis, is character-
ized by discharging inflammatory, fast decay, bacterium-discharge
and same clinical features with pneumonia. This clinical form of TB
lung occurred in 65-70% (per cent) of cases. Infiltrative TB is special
type of TB pneumonia. Perifocal changes more express than focus of
caseous and it inclined to fast changes.
Clinical features of pneumonia begins more acute than TB infil-
trate. Symptoms of intoxication more express, especially headaches.
Patient is suffered by round and cloudy infiltrate has not symptom
of intoxication or it lesser express. Patient with non-specific pneu-
monia has more hard condition than the who is suffered by tuberculo-
sis infiltrate. Non-specific pneumonia has more express auscultation
picture.
Infiltrative tuberculosis is symptomlessness very often. Usually
this clinical form of the lung TB has normal physical signs and is di-
agnosed by preventive fluorography. Auscultation is very important
for early recognition of the infiltrative lung TB.

Characteristic of chest X-ray for pneumonia.

Chest X-ray confirms:
1. shadow with non-even form, not well defined out-line;
2. pathological process spreads on the lung tissue;
3. non-tuberculosis process is localized in basal segments of low-
er lobes and around lung roots area, often;
 5
4. shadows are characterized by lesser intensity and more homo-
geneous;
5. non-specific pneumonia is appeared by enlargement intrathorac-
ic lymph nodes, inflammation of the lung pattern;
6. “path” to the root from pathological process is expressed rare
and weaker than for TB.

Characteristic of chest X-ray for infiltrative TB.

Chest X-ray shows:
1) right round or oval forms shadow, very often;
2) TB infiltrate spreads in II or VI lung segments;
3) old tuberculosis lesions such as petrification, deformation of the
diaphragm, fibrous of the pleura.
Tuberculosis infiltrate is characterized by:
1. focal in structure non-gomogeneous shadow;
2. detect fresh focals (bronchial dissemination),
3. enlargement intrathoracic lymph nodes absent or lesser express,
4. “path” to the root from pathological process is appeared.
Famous tetrada:
-increased temperature, leucocytosis, deviation of the differential
count to the left; raised ESR are more expressed when pneumonia
than tuberculosis. This changes in non-specific pneumonia survives
to all regression pathological process in the lungs, but in tuberculosis
infiltrate it fast returns to normal.
Treatment of non-specific antibiotics leads to positive pictures
clinical pictures and chest X-ray, so this non-specific process. Myco-
bacterium is diagnosed in the sputum, in the bronchoalveolar lavage,
so this tuberculosis process.
Caseous pneumonia is spreading process, often two-side, may be
is localized in segment, lobe or total. This disease begins acute, has
symptoms of intoxication, fever (from 39C to 40C), soaking sweats,
loss weight, pulse is quick, blood pressure is low, breathlessness, col-
lapse. The main reason of the death in first 2 weeks is acute cardio-
 6
vascular insufficiency. Sometimes may be diarrhea. 1|4 of the pa-
tients have neurological symptoms but liquor is normal.
Chest X-Ray confirms the massive pneumonia infiltration, often
spreading more than one lobe. 1/5 patients have subtotal variety dis-
semination from small focal such as “snow-fall”. During first days of
disease small focal is diagnosed in 2 or 6 lung segments by chest X-
Ray. Condition of the patients is very hard even with small lesions in
the lung tissue, condition of the patient is fast deteriorated by treat-
ment of non-specific antibiotics. Lung lesion is increased by during
caseous pneumonia. Pathology changes in the lung include spreading
infiltration in other part of the lung, may be in total lung, in pleura,
may be destruction, bronchogenic and lymphohematogenic dissemi-
nation.
Chest X-ray shows small focus of pneumonia often in II or VI
segments of the lung. Pathology process in the lung develops very
fast.
Changes of fool blood count in first days may be small: non-
higher leucocytosis (8x10-6), stab neutrophils - 5-10%, ESR 20-30
mmhour. Changes in fool blood count are increased by in during of
the caseous pneumonia, especially ESR.
In during first weeks of the disease mycobacteria isn’t diagnosed
by microbiological evidence even with destruction, only after 2-3
weeks it is detected by this technique
Caseous pneumonia is differenced by with acute infection destruc-
tion in the lung.

Differential diagnostic of caseous pneumonia and acute infec-

tion destruction of the lung.
Acute infection destruction includes diseases such as: abscess,
pulmonary gangrene, pneumonitis, abscess-forming pneumonia.
It is pathological inflammatory process, is characterized by de-
struction of the lung tissue in result of influence of microorganisms.
Infection destruction is separated by clinical-morphological features
 7
and consists of: purulent abscess, pulmonary gangrene, gangrenous
abscess.
Lung’s abscess is more or lesser limited cavity, is formed in result
of destruction of the lung tissue.
Pulmonary gangrene is more hard pathological condition, is
characterized by spreading necrosis and destruction of the lung tissue.
Pathological process is not inclined to limit and fast destruction.
Gangrenous abscess is transitional form between abscess and
pulmonary gangrene.
In etiology infection destruction is separated on infection microor-
ganism. In pathogenesis lung destruction is separated by bronchogen-
ic, hematogenic and traumatic process.
This disease develops among males middle age and 23 patients
using alcohol.

Clinical features of pulmonary gangrene.

Disease begins acute with high fever and chest pain. Patient com-
plains on the cough with plentiful (about 500 ml and more), not well
smell sputum, may be hemoptysis. Sputum is defended by laboratory
technique and doctor sees three layers.
Discharging of the sputum doesn’t relieve condition of the patient
in different from patient is suffered by acute abscess. Massive dull-
ness is detected by percussion, relax of respiration is diagnosed by
auscultation.
Fast increased anemia, leucocytosis, sometimes leucopenia with
deviation of the differential count to the left, hypoproteinemia are
detected by fool blood count. Changes in urine same with toxic ne-
phritis. Chest X-ray confirms non-even form, usually plural enlight-
enment with rate of liquid on background of massive shadow.
Disease has complications such as:
1) process spreads on opposites lung,
2) lung bleeding,
3) sepsis.
 8
Complications causes to death.
Clinical picture of gangrenous abscess has features of hard puru-
lent abscess and pulmonary gangrene.
Chest X-ray shows large cavity with non-even inner out-line and
shadow in cavity. Material for bacteriological examination doctor
takes from destruction cavity or empyema.
Mistakes in diagnose of TB instead of pneumonia are depended
by:
1) imperceptible or gradual beginning of the disease;
2) absence or symptomlessness of intoxication;
3) contact with patient with tuberculosis;
4) single detecting of MBT in the sputum;
5) hemoptysis;
6) abscesses;
7) location in upper lobe;
8) slow current of pneumonia.
Mistakes in diagnose of acute pneumonia instead of lung TB
are depended by:
1) acute or sub-acute beginning of TB process as pneumo-
nia;
2) pneumonia in the past;
3) insufficient detection of MBT in sputum;
4) location of the process in low lobe;
5) roentgenological features remind infiltrates in acute
pneumonia.

Differential diagnostic of infiltrative lung process and atypical

pneumonia.
Both diseases are characterized by symptomlessness, normal da-
ta of percussion and auscultation.
Characteristic of atypical pneumonia.
1) basic pathological lesion of surrounding bronchial and sur-
rounding vascular tissues is diagnosed by chest X-ray;
 9
2) inflammation of the lung root;
3) leucopenia;
4) pleura is attacked by pathological process very often.
After recovery, consolidation of the surrounding bronchial and
vascular lung tissues survives.

Differential diagnostic of infiltrative lung process and simple,

prolonged pulmonary eosinophilia.
Simple pulmonary eosinophilia is a relatively mild illness with a
slight fever and cough is usually lasted about 2 weeks. It is probably
due to a transient allergic reaction in the alveolus. Many allergens
have been implicated, including Ascaris lumblicoides, Trichinella,
Strongiloides and other. Drugs such as aspitrin, penicillin, nitrofu-
rantoin, sulphonamides etc. have been implicated. Often, no aller-
genis identified. No treatment is required and the disease is self-
limiting. Occasionally, the disease becomes more prolonged, with
cough, weakness, breathlessness, chest pain, soaking sweets, hemop-
tysis a high fever, is lasted more than 1 month. There is usually an
eosinophilia in the blood and this condition is then called prolonged
pulmonary eosinophilia. In both conditions the chest X-ray shows
either localized or diffuse opacities. Corticosteroid therapy is indicat-
ed with resolution of the disease over the ensued weeks.
Chest X-ray confirms infiltrate shadow with intensity center and
perifocal zones of inflammation. Size of infiltrate in X-ray may be
from small to 10x20 sm. Focal and “path” to the root absent in differ-
ent from TB infiltrates. Fast disappearance infiltrative shadow and
eosinophilia are main distinctions from tuberculosis. After regression
of pulmonary eosinophilia lung pattern becomes normal.
RESULTS.
Relapses arise in 70% of patients. So pulmonary eosinophilia be-
gins in new part of the lungs or bronchial asthma, chronic obstructive
bronchitis, vasorinitis, attack of the skin are developed in result of
relapses.
 10
Patients have prolonged allergic anamnesis. Sputum is absent or
poor discharged. It is clear-yellow, serous by the patients. Mycobac-
terium are absent. Tuberculin skin-prick tests are negative, often.

Small limited pleurisy.

The chest x-ray appearances homogeneous limited shadow, occu-
pying part of the lung field. Pleurisy is diagnosed by more deep chest
x-ray when the doctor detects the shadow near to chest wall and by
pleural aspiration.

Differential diagnostic of infiltrative lung process and pulmo-

nary infarction.
Pulmonary infarction is local inflammatory process wich develops
in result of embolism of lung vessels. Often this disease is complicat-
ed by pneumonia.
Infiltrative tuberculosis and infiltrative pneumonia have general
features such as:
1) acute beginning;
2) fever;
3) hemoptysis;
4) changes on chest X-ray.
So, it is necessary differential diagnostic between pulmonary in-
farction and tuberculosis infiltrate. Occlusion by embol occurs in re-
sult of:
1) heart defects,
2) right-auricular insufficiency,
3) thrombophlebitis,
4) thrombus arises in the right heart.
Doctor must take into a count in anamnesis: rheumatism, endocar-
ditis, hypertension, myocardial infarction, thrombosis of peripheral
and deep veins.
Pulmonary infarction begins acute, with chest pain, breathlessness,
cyanosis. It is complicated by pleural effusion.
 11
Chest X-ray confirms focus changes with various length and
forms: three cornered, globe-shaped, rounded, high position of the
dome of the diaphragm, enlargement and “amputation” of the lung
root, poor of lung pattern, disciform atelectasis. Pathological process
of TB localizes in upper lobe of the lung; but lession of infiltrate
pneumonia spreads on the middle lobe and basal segments of the
lung’s low lobe.
Diagnose of the infiltrative pneumonia is confirmed by electrocar-
diogram (ECG). ECG detects features of the acute pulmonary heart.
Mycobacterium of TB absents in the sputum.

Differential diagnostic of infiltrative lung process and periph-

eral lung cancer.
Many features of the peripheral lung cancer and TB may be same,
such as:
1. age of the patient;
2. duration of the disease;
3. undulating course;
4. absence of mycobacterium in the sputum at the beginning of
the disease.
The patients are suffered by a peripheral lung cancer have had of-
ten in anamnesis chronic bronchitis, pulmonary abscess, increased
temperature is right type. Patients are suffered by lung tuberculosis,
so they have a contact with other patients with TB.
Chest pain is detected often in peripheral lung cancer in different
from TB. Pain has increasing character.
Sputum cytology is extremely useful in the diagnosis of lung can-
cer. Many bronchial and lung tumors have more than one cell type
and prognosis is depended from the dominant cell type seen. There
are several histological types which important for prognosis and re-
sponse to treatment (squamous cell, carcinoma, adenocarcinoma,
small cell carcinoma, alveolar cell carcinoma).
 12
A peripheral lung cancer with size from 1 to 2,5 sm. has rounded
and polycyclic form with well defined out-line. This is detected by
chest X-ray. When the size of the tumor more than 2-2,5 sm. out-line
of the tumor more than 2-2,5 cm out-line of the peripheral lung is not
well defined because pathological process grows in surrounding lung
tissue. Chest X-ray confirms:
1) uneven out-line of the a tumor;
2) nodular tumor;
3) absence destruction in large nodulars of tumor with size from 5
to 6 cm in diameter;
4) if cancer has destruction chest X-ray shows many-focal resolu-
tion and forming cavity with thick-layer wall. Cavity may be a hori-
zontal rate of the liquid;
5) absence in adjacent lung tissue of the fresh foci;
6) changes of the lung root and mediastinum (dilation of the
lung’s head, enlargement lymph nodes with polycyclic out-line of the
mediastinum).
7) location of the tumor in III, IV, V and VIII segment of the lung.
When the doctor suspects the peripheral lung cancer, he must car-
ry repeated sputum examination from 5 to 10 time on atypical cells
and MBT and bronchoscopy.
Cytological sputum examination has importance. Sputum, bron-
choalveolar lavage’s material, smears are exposed to cytological
analysis.
Instrumental and biopsy techniques with cytological and microbio-
logical diagnostic of material have importance and high result in dif-
ferential diagnostic of tuberculosis and a peripheral lung cancer.
Transbronchial biopsy of the lung occurred invasive technique but
has high information when the tumor detects near the lung root.
If rounded focus in the lung is diagnosed in subpleural part by a
doctor, he must make transthoracic punctional-aspirational biopsy of
the lung.
 13
Differential diagnostic of infiltrative lung process a central
lung cancer.
It is necessary differentiate infiltrative TB and the central lung
cancer when the tumor attacks segmental or lobar bronchus. Patho-
logical process leads to hypoventilation or atelectasis of the lung with
developing pneumonia.
Lung cancer and tuberculosis have general features such as: loss
of body weight, pain in the chest, cough, hemoptysis.
The central lung cancer is characterized in different from TB by:
1) the higher risk of central lung cancer develop can be among:
long time smoking males, males above 40 years of age;
2) leucocytosis, deviation of the differential count to the left, lym-
phopenia, sharp increased ESR, increased L-fraction of the blood se-
rum protein and fibrinogen.

X-ray characteristic of the central lung cancer.

1) pathological process is localized in walls of the bronchus and so
the increased and thickened lung pattern are detected in medial and
middle parts of the lung fields;
2) changes of the lung pattern have local character and maximum
spread on two intercostal;
3) changes of the lung pattern more expressed and grows, consoli-
dation of the bronchus, shadows appear when the tumor has
peribronchial growth;
4) when the lung cancer has endobronchial growth hypoventilation
arises which forms atelectasis. Bulls may be remained the destruction
changes in infiltrative TB in faze of valve-emphysema;
5) characteristically the out-line of the tumor has a fluffy or spiked
appearance, though sometimes it may be entirely smooth with cavita-
tion;
6) lung cancer causing partial obstruction of a bronchus interrupts
the mucociliary escalator, and bacteria are retained within the affect-
ed lobe. This gives rise to the so-called secondary pneumonia;
 14
7) the central lung cancer is complicated by pneumonitis, is char-
acterized by other clinical features such as: obturation and stenosis
lumen of the large bronchus (71%), combination of the stenosis and
peribronchial node (22%), more homogeneous shadow of the patho-
logical process (71%); retrostenosis destruction (8-9%), developing
of retrostenosis pneumonia often appears first acute clinical manifes-
tation and takes same clinical features with tuberculosis segmentitis
and lobitis;
8) phenomena of “amputation” is detected by absence shadows of
the bronchi on background pulmonary atelectasis;
9) tumor shadow in lumen of the large bronchus, narrowing one or
several segmental bronchi may be are diagnosed by tomography;
10) chest X-ray is the most valuable test for lung cancer. However,
it is a relatively insensitive test since the tumor mass to be 1-2 cm in
size to be recognized reliably. CT scanning can identify small tumor
masses but is too time-consuming and expensive to replace the chest
X-ray as a screening test.
Computed tomography.
CT is particularly useful for identifying pathological changes in
the mediastinum, such as enlarged lymph node. Lymph nodes larger
than 1 cm are considered pathological, although whether they are due
a metastatic tumor, reactive hyperplasia or previous lung disease (e.g.
tuberculosis) can only be determined by biopsy.
11) fibreoptic bronchoscopy with biopsy determines to final diag-
nosis of the central lung cancer.
Diagnostic videothoracotomia with biopsy of the lung is carried
by the doctor when the bronchological examination and needle-
transthoracal biopsy are non-effective.
X-ray characteristic of the infiltrative process.
Tuberculosis is characterized by:
1) location of the process in apex of the lung - 179%.
2) non-homogeneous shadow (88%); pathological process has de-
struction and focal changes in other zones of the lung (33%);
 15
3) stenosis of the bronchus in result of caseous mass in lymph
nodes or tuberculosis of the lung’s segment (lobe);
4) clear well-defined stripes of bronchi are diagnosed by tomogra-
phy.

Differential diagnostic of infiltrative lung process and mycosis

of the lung.
Infiltrative tuberculosis may be remind actinomycosis of the
lung which has primary and secondary character. In primary charac-
ter process arises in result of penetration radiant fungi in air ways. In
secondary situation infection spreads on cellular tissue and connec-
tive tissue layers from abdominal cavity (patient with neck-jaw-face
actynomycosis) and hematogenic way from other organs.
Clinical features.
Actinomycosis is during as chronic bronchitis of infiltrarive-
pneumonia form, chronic interstitial abscess-forming pneumonia. Ac-
tinomycosis attacks basic part of the lung and one lobe, often.
In beginning of the disease patient complains on the fever, puru-
lent sputum, may be hemoptysis, weakness, moderate leucocytosis,
deviation of the differential count to the left, raised ESR.
Dullness is detected by percussion on the attacked zone. Moist
rales is diagnosed by auscultation.
Radiant fungi appear but MBT absents in the sputum.
Tuberculin tests is negative.
Attack of costal, mediastinal (diaphragmatic, especially) pleura.
Chest X-ray confirms foci of infiltrative type more in lower part of
the lung and near the lung roots on background of interstitial chang-
es. In beginning foci have not well defined out-line than it has well
defined out-line. Foci of dissemination absent around foci. Chest X-
ray shows fibrous and bronchiectasis, may be cysts with slim walls.
In progressive process chest X-ray shows increased size of infiltrative
focus with destruction, intensity of non-even sclerosis of interstitial
lung tissue increased.
 16
All this changes are accompanied “burning” chest pain when the
pleura is attacked by the pathological process.
Lung tuberculosis is complicated by other super-infection myco-
sis which has out-lung and lung location. Candidosis of the mouth’s
mucous more spreading between out-lung mycosis. Lung mycosis
has three clinical-pathological versions: colonization in the lung tis-
sue; allergic disease. Specter of the fungi consists of: Candida sp.,
Aspergillus sp., Cryptococcus sp., Penicillinum sp..
Fundamental factor which influences on the fungal super-
infection in lung TB, such as:
1) duration of TB infection,
2) duration of preceding specific treatment,
3) combination with other disease.

Dynamic in treatment of non-specific antibiotics.

Results of the treatment:
1) positive clinical effect;
2) positive effect on the chest X-ray;
3) decrease number of antibodies to fungi such as Candida and
Aspergillus to normal.
It is necessary mycological examination of the patient with
tuberculosis, especially in non-effective treatment.

Conclusion.
It is necessary remember that differential diagnostic of infiltrative
process in the lung is detected by:
1) anamnesis;
2) clinical features of disease;
3) changes of chest X-ray;
4) bacterioscopy, bacteriological, cytological examination of ma-
terial on mycobacterium, non-specific microorganisms, atypical cells;
5) result of fibreoptic bronchoscopy and other additional tech-
niques
 17

QUESTIONS FOR REWIEW.

1).Why do defects present in differential diagnostic of syndrome
of infiltration in the lung?
2) Stages of differential diagnostic of tuberculosis and non-
tuberculosis diseases.
3) Frequent situations for differential diagnostic of infiltrative pro-
cess.
4) Differential diagnostic between tuberculosis and non-specific
pneumonia.
5) Differential diagnostic of caseous pneumonia and non-specific
pneumonia.
6) Differential diagnostic of caseous pneumonia and destruction of
the lung.
7) Differential diagnostic of tuberculosis and atypical pneumonia.
8) Differential diagnostic of tuberculosis and simple and pro-
longed pulmonary eosinophilia.
9) Differential diagnostic of small limited pleurisy with TB pro-
cess.
10) Differential diagnostic of infiltrative pneumonia and tubercu-
losis.
11) Differential diagnostic of a peripheral lung cancer and lung
tuberculosis.
12) Differential diagnostic of the central lung cancer with lung tu-
berculosis.
13) Differential diagnostic of mycosis of the lung and lung TB.

Литература. Literature.
1.Фтизиатрия. М.И. Перельман, В.А. Корякин, И.В. Бога-
дельникова. М., Медицина, 2014 г.
2. Фтизиатрия: национальное руководство под ред. М.И.
Перельмана.- М.: ГЭОТАР - Медиа, 2017-512с.
 18
3. Infectious disease and their etiological agents. Daniel Fitz-
gerald. David W. Haas, 2000.
4. “Tuberculosis”, V.A. Koshechkin, Z.A. Ivanova. Moscow,
2015.