Endobronchial, endotracheal, andlaryngeal tuberculosis maydevelopwheninfectivematerialisspreadeitherthroughlymphaticchannelsorfromexpectoratedinfectiousmaterial.Themucosalliningmaybestuddedwithminutegranulomatouslesions,sometimesapparentonlyonmicroscopicexamination.
Systemic miliary tuberculosis ensueswhentheorganismsdisseminatehematogenouslythroughoutthebody.Systemicmiliarytuberculosisismostprominentintheliver,bonemarrow,spleen,adrenalglands,meninges,kidneys,fallopiantubes,andepididymis(
Fig.13.37
Isolated-organ tuberculosis mayappearinanyoneoftheorgansortissuesseededhematogenouslyandmaybethepresentingmanifestationoftuberculosis.Organstypicallyinvolvedincludethemeninges(tuberculousmeningitis),kidneys(renaltuberculosis),adrenalglands,bones(osteomyelitis),andfallopiantubes(salpingitis).Whenthevertebraeareaffected,theconditionisreferredtoasPott disease. Paraspinal“cold”abscessescontainingnecrotictissuesmaytrackalongthetissueplanestopresentasanabdominalorpelvicmass.
Lymphadenitis isthemostfrequentformofextrapulmonarytuberculosis,usuallyoccurringinthecervicalregion(“scrofula”).Lymphadenopathytendstobeunifocal,andmostpatientsdonothaveconcurrentextranodaldisease.HIV-positivepatients,ontheotherhand,almostalwayshavemultifocaldisease,systemicsymptoms,andeitherpulmonaryorotherorganinvolvementbyactivetuberculosis.
Inyearspast,intestinal tuberculosis contractedbythedrinkingofcontaminatedmilkwasfairlycommonasaprimaryfocusoftuberculosis.Indevelopedcountriestoday,intestinaltuberculosisismoreoftenacomplicationofprotractedadvancedsecondarytuberculosis,secondarytotheswallowingofcoughed-upinfectivematerial.Typically,theorganismsaretrappedinmucosallymphoidaggregatesofthesmallandlargebowel,whichthenundergoinflammatoryenlargementwithulcerationoftheoverlyingmucosa,particularlyintheileum.
Fig.13.38
Localized secondary tuberculosis may be asymptomatic. When manifestations appear, they are usually insidious in onset, with gradual development of both systemic and localizing symptoms and signs. Systemic manifestations, probably related to the release of cytokines by activated macrophages (e.g., TNF and IL-1), often appear early in the disease course and include malaise, anorexia, weight loss, and fever. Commonly, the fever is low grade and remittent (appearing late each afternoon and then subsiding), and night sweats occur. With progressive pulmonary involvement, increasing amounts of sputum, at first mucoid and later purulent, appear. When cavitation is present, the sputum contains tubercle bacilli. Some degree of hemoptysis
Fig. 13.37 Miliarytuberculosisofthespleen.Thecutsurfaceshowsnumer-ousgray-whitegranulomas.
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