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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 12  |  Issue : 2  |  Page : 143-147

Study of diabetes mellitus in association with tuberculosis


Department of Respiratory Medicine, JN Medical College, Wardha, Maharashtra, India

Date of Web Publication8-Sep-2017

Correspondence Address:
Smaran Cladius
Department of Respiratory Medicine, JN Medical College, Sawangi Meghe, Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_62_17

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  Abstract 

Background: Nanda and Tripathi (1967) stated that influence of diabetes on tuberculosis is as harmful as the impact of tuberculosis on diabetes. The present study was undertaken to determine the incidence of diabetes mellitus in tuberculous patients and to study the clinical profile and therapy of this association. Materials and Methods: The present cross-sectional study was carried out on tuberculosis patients registered at AVBRH, Sawangi, Meghe, Wardha, between July 2014 and June 2016. The patients diagnosed as tuberculosis were subjected for the diabetic status by detailed clinical history and investigations. Results: Of 200 cases the incidence rate of pulmonary tuberculosis with diabetes mellitus was 7% and 5% in extrapulmonary tuberculosis with diabetes mellitus. Far advanced, exudative, and cavitary lesions were higher in frequency in diabetics. All seven cases of extrapulmonary tuberculosis with diabetes had pleural involvement. Conclusion: All patients of tuberculosis should be screened for the presence of diabetes especially those above 40 years of age. Insulin should be given initially till the diabetes is stabilized. Short course antitubercular chemotherapy is highly effective in the management of tuberculosis with diabetes provided that the blood sugar level is adequately maintained throughout the duration of the treatment.

Keywords: Clinical profile, diabetes, incidence, tuberculosis


How to cite this article:
Cladius S, Jadhav U, Ghewade B, Ali S, Dhamgaye T. Study of diabetes mellitus in association with tuberculosis. J Datta Meghe Inst Med Sci Univ 2017;12:143-7

How to cite this URL:
Cladius S, Jadhav U, Ghewade B, Ali S, Dhamgaye T. Study of diabetes mellitus in association with tuberculosis. J Datta Meghe Inst Med Sci Univ [serial online] 2017 [cited 2019 Oct 18];12:143-7. Available from: http://www.journaldmims.com/text.asp?2017/12/2/143/214199


  Introduction Top


The association between diabetes mellitus and tuberculosis was first noted by Deshmukh.[1] Deshmukh,[2] found 14% of the tuberculous patients above the age of 40 years had diabetes. Nanda and Tripathy [3] found the prevalence of diabetes in 12% of tuberculous patients and stated that influence of diabetes on tuberculosis is as harmful as the impact of tuberculosis on diabetes. With this in view, the present study was undertaken to determine the incidence of diabetes mellitus in tuberculous to study the clinical profile and therapy of this association.


  Materials and Methods Top


In this cross-sectional study design, 200 patients of tuberculosis (100 pulmonary tuberculosis and 100 extrapulmonary tuberculosis) who were registered in Acharya Vinoba Bhave Rural Hospital, Sawangi, Meghe, Wardha during the period with effect from July 1, 2014, to June 30, 2016, comprised the material for this study.

Inclusion criteria

  1. All patients of tuberculosis above age of 14 years of both sexes.


Exclusion criteria

  1. Age <14 years
  2. Those patients who are not willing for consent.


After registration in the hospital, detailed history of present complaints with special reference to symptoms suggestive of tuberculosis and diabetes mellitus were taken. The diagnosis of tuberculosis was established by detailed clinical examination, bacteriological examination of the sputum, and the radiological examination. Tuberculin testing, pleural tapping (fluid report and cytological examination), lymph node biopsy (histopathological examination), fine needle aspiration cytology, bronchoscopic aspirate, and lavage for acid-fast bacilli were additive investigations for diagnosis.

Sputum tests were done by sputum smear examination for identification of acid-fast bacilli by the Ziehl-Neelson method of staining for two consecutive days by collecting 24 h sputum. Chest X-rays were taken and extent of tuberculosis was established using criteria laid down by the National Tuberculosis Association of the U. S. A as a minimal lesion, moderately advanced and far advanced.[4]

Routine investigations, hemoglobin estimation, total and differential leukocyte counts, liver functions tests (e.g., Bilirubin, Liver enzymes), blood urea, and urine examinations were also done in each case before starting antituberculosis drug therapy.

The patients so diagnosed as tuberculosis were subjected for the diabetic status by detailed clinical history and investigations such as.

  1. Urine examination for presence of sugar by SD Bio Standard Diagnostics Urine One Step Rapid Glucose and Ketone Test Strips for Urinalysis
  2. Venous blood sugar level-fasting and postprandial
  3. Glucose tolerance test if necessary.


Criteria for diagnosis of diabetes

Diabetes mellitus is classified on the basis of the pathogenic process that leads to hyperglycemia as follows [Table 1] and [Table 2].[5],[6]
Table 1: Criteria for the diagnosis of diabetes mellitus

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Table 2: Classification of diabetes mellitus

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  Observations and Results Top


The range of pulmonary tuberculosis patients was 14–80 years and 14–75 years for extrapulmonary tuberculosis patients. The majority of pulmonary tuberculosis, as well as extrapulmonary tuberculosis patients, were in 21–30 years' age group. The mean age of pulmonary tuberculosis patients was 42 ± 16 years and 38 ± 15 years for extrapulmonary tuberculosis patients.

The range of pulmonary tuberculosis patients, as well as extrapulmonary tuberculosis with diabetes mellitus, was 35–65 years. The majority of pulmonary tuberculosis patients were in 51–60 years' age group and 41–50 years' age group for extrapulmonary tuberculosis patients. The mean age of pulmonary tuberculosis patients with diabetes mellitus was 54 ± 9.4 years and 47 ± 9.9 years for extrapulmonary tuberculosis patients with diabetes mellitus.

In pulmonary tuberculosis with diabetes mellitus, the most common chief complaint was cough with expectoration in 90% (statically significant P < 0.05) followed by fever 70%. Only 10% of patients of pulmonary tuberculosis with diabetes mellitus presented with hemoptysis. In pulmonary tuberculosis, without diabetes mellitus, the most common chief complaint was cough with expectoration in 66.66% followed by fever 62.22%. Only 6.66% of patients of pulmonary tuberculosis with diabetes mellitus presented with hemoptysis.

In pulmonary tuberculosis, with diabetes mellitus, 60% had far advanced lesions in chest radiograph followed by 40% who had moderately advanced lesions (statically significant P < 0.05). No one had minimal lesions in pulmonary tuberculosis with diabetes mellitus. In pulmonary tuberculosis, without diabetes mellitus, 63.33% had moderately advanced lesions followed by far advanced lesions 25.55% and minimal lesions 11.11%.

In pulmonary tuberculosis, with diabetes mellitus, 60% had exudative lesions in chest radiograph followed by 20% who had productive lesions and 20% who had fibrocaseous lesions (statically significant P < 0.05). In pulmonary tuberculosis, without diabetes mellitus, 45.55% had productive lesions followed by fibrocaseous lesions 30% and exudative lesions 24.44%.

In pulmonary tuberculosis, with diabetes mellitus, 70% had cavities in chest radiograph. In pulmonary tuberculosis, without diabetes mellitus, 46.67% had cavities (statically significant P < 0.05).

In pulmonary tuberculosis with diabetes mellitus 70% had cavitary lesions in chest radiograph but only 20% had typical cavitary lesion of diabetic tuberculosis which is the specific radiological appearance characterized by a wedge shaped opacity, in which there is cavitation, spreading from the hilum and occurring in diabetics over the age of 40 years. It was statically significant P < 0.05.

In pulmonary tuberculosis, with diabetes mellitus, 70% were smear positive, and 30% were smear negative. In pulmonary tuberculosis, without diabetes mellitus, 61.11% were smear positive and 38.88% were smear negative.

In pulmonary tuberculosis, with diabetes mellitus, 80% had sputum conversion by the end of 2 months (statically significant P < 0.05) and 90% had sputum conversion by the end of 3 months.

In pulmonary tuberculosis, without diabetes mellitus, 90% had sputum conversion by the end of 2 months and 95.55% had sputum conversion by the end of 3 months.

In extrapulmonary tuberculosis with diabetes mellitus the most common site was hydropneumothorax 42.85% (statically significant P < 0.05) and pleural effusion 42.85% followed by pneumothorax 14.28% (statically significant P < 0.05).

The prevalence rate of diabetes mellitus in pulmonary tuberculosis was 10% and 7% in extrapulmonary tuberculosis. The incidence rate of diabetes mellitus in pulmonary tuberculosis was 7% and 5% in extrapulmonary tuberculosis. Altogether prevalence rate of diabetes mellitus in tuberculosis was 8.5% and incidence rate of diabetes mellitus in tuberculosis was 6%.


  Discussion Top


Reaud (1953)[7] had referred to the highest percentage of diabetes in tuberculosis patients, i.e., 14.2%, predominantly in the Jewish population. Nichols (1957)[8] reported the incidence of 5% diabetes in pulmonary tuberculosis. Deshmukh [2] in his study reported that 14% of Tuberculosis patients had diabetes over the age of 40 years. Nanda and Tripathy [3] in their studies found 12% of the 200 tuberculosis cases they studied for diabetes mellitus. Brij kishor et al. (1973)[9] in their study of 90 patients of pulmonary tuberculosis by standard and prednisolone primed glucose tolerance test found 4.4% manifest diabetes. Bahulkar and Lokhandwala (1975)[10] found 21 cases (4.5%) of diabetes mellitus out of 470 tuberculosis patients. Virendra Singh (1978)[11] reported 22% and Roychowd-hury [12] found 20.7% incidence of diabetes in their studies. In a study done by Sunnetcioglu et al. (2015)[13] incidence of diabetes mellitus in extrapulmonary tuberculosis was 4.32%.

Of 100 patients of pulmonary tuberculosis studied, it was observed that 10 patients had diabetes mellitus giving prevalence rate of diabetes mellitus of 10% in pulmonary tuberculosis. Of these 10 diabetics, 5 were males and 5 were females; 2 were below 40 years, and 8 were above 40 years [Table 3]. There were 10 cases out of 100 were found to have diabetes mellitus in pulmonary tuberculosis, however, three cases (2 males and 1 female) were already known to be diabetics and seven patients were newly detected. Thus, in this study, the incidence rate of diabetes mellitus in pulmonary tuberculosis was 7%. The incidence rate in males was 5% (5 out of 100) and in females was 2% (2 out of 100).
Table 3: Age- and sex-wise distribution of tuberculosis patients

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The frequency of hemoptysis and sputum positivity was higher in diabetics than nondiabetics [Table 4]. Far advanced lesions, exudative lesions, and cavitary lesions were higher in frequency in diabetics than nondiabetics and were statistically significant [Table 5], [Table 6], [Table 7].
Table 4: Age- and sex-wise distribution of tuberculosis patients with diabetes

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Table 5: Symptoms of pulmonary tuberculosis patients

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Table 6: The extent of pulmonary tuberculosis in diabetic and nondiabetic patients

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Table 7: The nature of lesion in diabetic and nondiabetic patients in pulmonary tuberculosis

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“Diabetic tuberculosis” the specific radiological pattern was observed 20% of patients of diabetic pulmonary tuberculosis with diabetes [Table 8]. In a study [14] by the end of 2 months of treatment, sputum conversion rates were slightly lower in diabetic patients compared to nondiabetics. In the study, 80% had sputum conversion by the end of 2 months, 90% by the end of 3 months, and 100% sputum conversion by the end of 4 months [Table 9] and [Table 10]. In pulmonary tuberculosis sputum conversion was 100% by the end of 3 months in diabetics and there was no significant variation in both the groups of diabetic and nondiabetic tuberculosis.
Table 8: Frequency of cavity in diabetic and nondiabetic patients

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Table 9: Diabetic tuberculosis (n=10)

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Table 10: Frequency of sputum positivity in diabetic and nondiabetic patients

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Moreover, out of 100 patients of extrapulmonary tuberculosis studied, it was observed that 7 had diabetes mellitus giving prevalence rate of diabetes mellitus of 7% in extrapulmonary tuberculosis. Out of these 7 diabetics, all 7 were males; 2 were below 40 years and 5 were above 40 years [Table 3]. Seven cases out of 100 were found to have diabetes mellitus in extrapulmonary tuberculosis, however, 2 cases were already known to be diabetics and 5 patients were newly detected. Thus, in this study, the incidence rate of diabetes mellitus in extrapulmonary tuberculosis was 5%.

Interestingly, all 7 cases of extrapulmonary tuberculosis with diabetes had pleural involvement. 42.85% (3 out of 7) had pleural effusion. 14.28% (1 out of 7) had pneumothorax. Moreover, 42.85 (3 out of 7) had hydropneumothorax [Table 11]. This infers that pleural manifestations in extrapulmonary tuberculosis with diabetes mellitus are a common feature.
Table 11: Sputum conversion in diabetic and nondiabetic patients

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Both prevalence rate and incidence rate was more common in pulmonary tuberculosis with diabetes mellitus than in extrapulmonary tuberculosis with diabetes mellitus [Table 12]. Thus, patients with diabetes mellitus are more prone to have pulmonary tuberculosis than extrapulmonary tuberculosis.
Table 12: Diagnosis (site) of tuberculosis lesion of extrapulmonary tuberculosis in diabetic patients

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Altogether, the prevalence rate of diabetes mellitus in tuberculosis was 8.5% and incidence rate was 6% [Table 12] and [Table 13].
Table 13: Incidence rate of diabetes mellitus in tuberculosis

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By the end of 6 months of therapy, majority showed decreased requirement of insulin and were switched over to oral antidiabetic drugs after observing the response. The diagnosis of the diabetes should be considered in patients of tuberculosis who do not respond as expected to anti-tuberculosis therapy. Patients with lower lung field tuberculosis should be investigated to rule out diabetes.

There was a downward trend of insulin requirement by the end of 6 months both in pulmonary and in extrapulmonary tuberculosis and this shows that tuberculosis infection certainly contributes to the rise in blood sugar level and matches with the observation made by the others. Patients treated with antituberculosis drugs with proper control of diabetes show extremely good response.

All patients of diabetes associated with tuberculosis whether pulmonary or extrapulmonary should be hospitalized for stabilization of diabetes. At least, insulin should be given initially till the diabetes is stabilized. Titration of insulin should be assessed by observing blood glucose level rather than urine glucose level.

Rifampicin is a hepatic microsomal enzyme inducer and causes rapid metabolism of antidiabetic drugs. The physician should not fall prey to the patients pleading for oral drugs in a situation where they are ineffective and where insulin is the only alternative.

We infer that short course antitubercular chemotherapy is highly effective in the management of pulmonary as well as extrapulmonary tuberculosis with diabetes provided that the blood sugar level is adequately maintained throughout the duration of the treatment.

Financial support and sponsorship

This research work was supported by thesis grant from Maharashtra State Task Force under Revised National Tuberculosis Control Programme.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Deshmukh MD. Tuberculosis in relation to diabetes. In: Avicenna, editor. Text Book of Tuberculosis. Clinical Tuberculosis - Jaypee Brothers; 1981. p. 252.  Back to cited text no. 1
    
2.
Deshmukh MD, Master TB, David JC, Tripathy S Jr. JJ Group of Hospital and G.M.C. 1966;2:97-102.  Back to cited text no. 2
    
3.
Nanda CN, Tripathy SN. Association of diabetes mellitus with pulmonary tuberculosis. J Assoc Physicians India 1968;16:741-6.  Back to cited text no. 3
    
4.
National Tuberculosis Association editor. Crofton and Douglas's Respiratory Disease. U.S.A: National Tuberculosis Association; 1990.   Back to cited text no. 4
    
5.
Powers AC. Diabetes mellitus: Diagnosis classification and pathophysiology. In: Harrison's Principles of Internal Medicine. In: Harrison TR, editor. New York: McGraw Hill; 2015. p. 2399.  Back to cited text no. 5
    
6.
Powers AC. Diabetes mellitus: Diagnosis classification and pathophysiology. In: Harrison's Principles of Internal Medicine. In: Harrison TR, editor. New York: McGraw Hill; 2015. p. 2401.  Back to cited text no. 6
    
7.
Reaud A. Diabetes and tuberculosis. South Med J 1953;46:148.  Back to cited text no. 7
    
8.
Nichols GP. Diabetes among young tuberculous patients; a review of the association of the two diseases. Am Rev Tuberc 1957;76:1016-30.  Back to cited text no. 8
    
9.
Kishore B, Nagrath SP, Mathur KS, Hazra DK, Agarwal BD. Manifest, chemical and latent chemical diabetes in pulmonary tuberculosis. J Assoc Physicians India 1973;21:875-81.  Back to cited text no. 9
    
10.
Bahulkar, Lokhandwala. Tuberculosis in relation to diabetes. In: Rao KN, Deshmukh MD, editors. Text Book of Tuberculosis. 1981. p. 252.  Back to cited text no. 10
    
11.
Singh V, Goyal RK, Mathur MN. Glucose intolerance in patients with pulmonary tuberculosis. JIMA 1978:31;7081-3.  Back to cited text no. 11
    
12.
Roychowdhury AB, Sen PK. Diabetes in pulmonary. p. 252-7.  Back to cited text no. 12
    
13.
Sunnetcioglu A, Sunnetcioglu M, Binici I, Baran AI, Karahocagil MK, Saydan MR. Comparative analysis of pulmonary and extrapulmonary tuberculosis of 411 cases. Ann Clin Microbiol Antimicrob 2015;14:34.  Back to cited text no. 13
    
14.
Pablos-Méndez A, Blustein J, Knirsch CA. The role of diabetes mellitus in the higher prevalence of tuberculosis among Hispanics. Am J Public Health 1997;87:574-9.  Back to cited text no. 14
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13]



 

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