Thorax: first published as 10.1136/thx.8.3.223 on 1 September 1953. Downloaded from Tlzo'ax (1953), 8, 223. CONSOLIDATION IN PRIMARY PULMONARY TUBERCULOSIS BY D. ADLER AND W. F. RICHARDS From High Wood Hospital, Brentwood, Essex (RECEIVED FOR PUBLICATION FEBRUARY 3, 1953) The occurrence of large radiological opacities in although atelectasis and consolidation may coexist, the lung parenchyma in cases ofprimary tuberculosis giving rise to a condition of collapse-consolidation. has been recognized since Eliasberg and Neuland NON-TruBERCULOUS PNEUMONIA.-Eliasberg and (1920) described a dense shadow, occurring usually Neuland (1920) doubted that the consolidation they in the right upper lobe, in young children with a described was a true tuberculous process. Engel primary infection. They stated that the onset was (1921) noticed the absence of tubercles in the not acute, the course was benign, and that tubercle consolidated area at necropsy and suggested the bacilli were not recoverable from the sputum. In term " para-tuberculosis," as in his opinion it was a second paper (1921) they differentiated the not a true tuberculous process. Winkler, quoted condition from caseous pneumonia, but made no by Reichle (1933), thought that tuberculosis lowered mention of atelectasis. They suggested that the the resistance of the neighbouring lung tissue to term " epituberculosis " be applied to the condition. other organisms. Pinner (1945) came to the Since the publication of these papers there has conclusion on clinical observation that bronchial been considerable controversy over the condition. occlusion did not produce atelectasis but a benign copyright. The following theories as to its pathology and physiological consolidation of the lung distal to it. pathogenesis have been evolved. Pyogenic infection of a collapse resulting from primary infection is a well-known late complication THEORIES OF PATHOLOGY AND PATHOGENESIS (Brock, 1950), and pus behind a bronchial stenosis ATELECTASLS.-Producing a large homogenous can produce the radiological picture of consolida- opacity of segnental or lobar distribution, which tion. This complication can also occur during the http://thorax.bmj.com/ clears on subsequent re-expansion or re-aeration, active phase of the primary complex, but is a com- atelectasis has been held by many authorities to paratively rare event, occurring in our experience explain sufficiently the radiological and clinical in 3% of cases with bronchial obstruction. course of epituberculosis. Morlock and Pinchin RESOLVABLE TUBERCULOUS CONSOLIDATION. -As (1933) described the case of a boy of 14 in whom the condition is a benign process, necropsy findings atelectasis of the right upper lobe expanded after elucidating the pathology are comparatively rare, removal of part of an enlarged, caseating lymph and are open to the objection that, as the subjects gland at bronchoscopy. This must be the earJiest died, there is no certainty that the condition would on September 30, 2021 by guest. Protected account of bronchoscopic appearances in primary have resolved. The same objection would apply pulmonary tuberculosis. Lightwood and Wilson to resection material. Rubinstein (1928), however, (1936) gave an account of a boy of 5 in whom an published the following case: atelectatic left lung was resected; there was gross A girl aged 6 years had her fourteenth attack of bronchiectasis, but in some areas there was " grippe "; a chest radiograph showed enlargement of a granulomatous condition of tuberculous origin the bronchial nodes, and a massive mediastinal shadow which might have been capable of resolution. at the right root; the lung fields were normal. Two Kent (1942), Jones, Rafferty, and Willis (1942), months later her condition became worse with pyrexia and Graham and Hutchison (1947) from bron- to 1040 F., and radiographs revealed a heavy shadow choscopic and bronchographic studies in their in the right middle lobe from the hilum to the periphery various series came to the in addition to large hilar nodes. Empyema was sus- conclusion that epi- pected, and following an unsuccessful attempt at tuberculosis was, in fact, pulmonary collapse due aspiration rib resection was performed, but no pus was to bronchial occlusion. found. There was a thickened pleura over a firm lung In our view atelectasis alone must be associated and biopsy was done to exclude a tumour. The specimen with reduction in volume of the affected area, revealed histologically pulmonary consolidation, giant Thorax: first published as 10.1136/thx.8.3.223 on 1 September 1953. Downloaded from 224 D. ADLER and W. F. RICHARDS cells, epithelioid cells, lymphocytes, fibroblasts, and pulmonary tuberculosis is now well recognized small areas of caseation; unfortunately staining for (Jones and others, 1942; Richards, 1 944a; tubercle bacilli was not carried out. The child made Macpherson and Lutwyche, 1950). A tuber- a complete recovery, serial radiographs showing a culous bronchopulmonary gland either com- gradual resolution of the opacity. presses or erodes the affected bronchus. When Necropsy findings reported on children who had there is radiological evidence of obstruction the died from accident, intercurrent infection, or tuberculous process has already perforated the tuberculosis of parts of the body remote from the cartilaginous and muscular wall of the bronchus in lungs, usually meningitis, have revealed a closely the majority of cases (Jones and others, similar histology (Armand-Delille and Lestocquoy, 1942; Soulas and Mounier-Kuhn, 1949; Hutchi- 1931; Reichle, 1933; Cameron and De Navasquez, son, 1949; Richards, 1952). Aspiration of caseous 1936; Macgregor and Alexander, 1937; Fish and material containing tuberculo-protein and tubercle Pagel, 1938). Essentially there is consolidation bacilli may follow perforation into the bronchial with the alveolar spaces filled with epitheloid cells, lumen. A frank bronchopneumonic type of tuber- and in the inter-alveolar tissues numerous Langhans- culous infiltration results occasionally from this type giant cells, with a variable number of lympho- incident, but in our experience rarely. Perhaps cytes ana fibroblasts. Tubercle bacilli were not this is due to the paucity of viable tubercle bacilli easily found in the consolidated lung itself; for in caseous material, as has been pointed out by instance, in the case reported by Cameron and Rich (1944), or an immunity of these subjects at De Navasquez (1936) the affected portion ofthe lung this stage of the infection to this type of spread was negative on culture but positive on guinea-pig (Lange and Brunzema, 1930). inoculation. Caseation when present was minimal In the majority of post-mortem reports in these in extent except in associated lesions such as a cases a bronchial perforation has been described. primary focus and in the regional bronchopul- In two of Fish and Pagel's cases (1938) a caseous monary glands. which were invariably enlarged and primary focus perforated into a bronchus instead caseous. of the more usual bronchopulmonary gland. In copyright. It is probable that the underlying histology is not two cases reported by Armand-Delille and identical in all cases which run the typical clinical Lestocquoy (1931) no bronchial perforation was and radiological course of epituberculosis. Kayne, found, but in one there was histologically an area Pag.l, and O'Shaughnessy (1948) suggested three of atelectasis in the affected part of the lung. A histological types: (1) a gelatinous pneumonia, rich resolving pulmonary consolidation can be produced in giant cells, the result of hypersensitive response in sensitized rabbits by the intratracheal injection http://thorax.bmj.com/ to tuberculo-protein; (2) a tuberculous pneumonia, of either live or dead tubercle bacilli; some of similar to that produced by the experimental intra- these experiments will be referred to later. Soulas tracheal injection of tubercle bacilli in animals; and Mounier-Kuhn (1949) did not think that the (3) innumerable small granulomata. perforation of a tuberculous gland played a sig- Spence (1932) described a case in which he nificant part in the development of epituberculosis. obtained caseous material by lung puncture over They stated that the orifice of the bronchus to the the affected area, which was positive to smear and affected part of the lung showed redness and guinea-pig tests; lung puncture repeated four oedema only and that epituberculosis was an early on September 30, 2021 by guest. Protected weeks later at a different site was positive in smears. development in the primary infection and occurred However, this boy, aged 7 months, ran a mild before perforation took place. pyrexia, the radiographic shadow three months ALLERGY.-Some forty years ago a common after admission was slightly diminished, but no procedure in the diagnosis of a tuberculous joint further change was seen six months after admission was the injection of tuberculin subcutaneously; a when the boy was discharged. No account of a focal reaction was produced, the joint becoming follow-up has been given, and he might possibly red, swollen, and tender. It was not uncommon have been suffering from a caseous pneumonia. in these cases to observe consolidated areas in the In this series in some cases which resolved large lungs coincident with the joint reaction. In dis- areas of consolidation were left with calcification cussing the potential dangers of Mantoux testing of varying extent as evidence of previous caseation in the iunstable case Lincoln