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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 16  |  Issue : 2  |  Page : 345-348

To study a specific radiological pattern of “diabetic tuberculosis” (as described by sosman and steidl in 1923) observed in patients with diabetes mellitus associated with pulmonary tuberculosis


Department of Respiratory Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (M), Wardha, Maharashtra, India

Date of Submission16-Apr-2020
Date of Decision22-Sep-2020
Date of Acceptance18-Dec-2020
Date of Web Publication18-Oct-2021

Correspondence Address:
Dr. Ulhas S Jadhav
Department of Respiratory Medicine, Jawaharlal Nehru Medical College, Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_123_20

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  Abstract 


Background: Sosman and Steidl (1923) had described “diabetic tuberculosis” a specific radiological pattern in patients with diabetes mellitus associated with pulmonary tuberculosis. These lesions usually consist of wedge-shaped area of density in which there is often cavitation in the neighborhood of hilum and spreading toward periphery including the bases occurring in diabetics over the age of 40 years. The present study was undertaken to study and highlight this specific radiological pattern of “diabetic tuberculosis” along with the clinical profile of this association. Materials and Methods: The present study was carried out in patients with pulmonary tuberculosis admitted to Poona Chest Hospital Aundh Pune, between July 1, 1991, and June 30, 1992. The patients diagnosed as pulmonary tuberculosis were subjected for diabetic status by detailed history, clinical examination, and investigations. Results: Among 440 cases of pulmonary tuberculosis prevalence rate of diabetes mellitus was 9.55% (42/440) and a specific radiological pattern “diabetic tuberculosis” was observed in 16.66% (7/42) in diabetics associated with tuberculosis. Conclusion: All patients with pulmonary tuberculosis above the age of 40 years should be screened for diabetes and all patients with diabetes should be screened to rule out pulmonary tuberculosis every year. A specific radiological pattern of “diabetic tuberculosis” and lower zone lesions on X-ray observed during clinical examination should be screened to rule out pulmonary tuberculosis as well as diabetes.

Keywords: Chest X-ray, diabetes mellitus, diabetic tuberculosis, pulmonary tuberculosis, Sosman and Steidl


How to cite this article:
Jadhav US. To study a specific radiological pattern of “diabetic tuberculosis” (as described by sosman and steidl in 1923) observed in patients with diabetes mellitus associated with pulmonary tuberculosis. J Datta Meghe Inst Med Sci Univ 2021;16:345-8

How to cite this URL:
Jadhav US. To study a specific radiological pattern of “diabetic tuberculosis” (as described by sosman and steidl in 1923) observed in patients with diabetes mellitus associated with pulmonary tuberculosis. J Datta Meghe Inst Med Sci Univ [serial online] 2021 [cited 2021 Dec 9];16:345-8. Available from: http://www.journaldmims.com/text.asp?2021/16/2/345/328445




  Introduction Top


The association of diabetes mellitus and pulmonary tuberculosis was first noted by the great Arab physician Avicenna[1] (980–1027). Sosman and Steidl[2] (1927) had described “diabetic tuberculosis” a specific radiological pattern in patients with diabetes mellitus associated with pulmonary tuberculosis. These lesions usually consist of wedge-shaped area of density in which there is often cavitation in the neighborhood of hilum and spreading toward periphery including the bases occurring in diabetics over the age of 40 years. These lesions are acute, confluent, and exudative.

Root[3] reported that tuberculosis was two to three times more common in diabetics. Warwick[4] found this radiological pattern of “diabetic tuberculosis” in 30.02% cases in his study. Nanda and Tripathy[5] found an incidence of 12% diabetes in tuberculosis patients and considered this radiological pattern of “diabetic tuberculosis” in their study. They stated that the influence of diabetes on tuberculosis is as harmful as impact of tuberculosis on diabetes. Missing or overlooking diabetes in tuberculosis and vice a versa leads to disastrous culmination. With this in view, the present study was undertaken to study and highlight this specific radiological pattern of “diabetic tuberculosis” and to study the clinical profile of this association.


  Materials and Methods Top


Four hundred and forty consecutive patients with pulmonary tuberculosis admitted to the Poona Chest Hospital, Aundh, Pune, w. e. f. dt July 1, 1991–June 30, 1992 were subjected for diabetic status by detailed history, clinical examination, and investigations.

The diagnosis of tuberculosis was established by detailed history, clinical examination, bacterial examination of the sputum, and radiological examination. Sputum tests were done by sputum smear examination for the identification of acid-fast bacilli by Ziehl–Neelsen Method of staining and culture of sputum sample in Lowenstein–Jensen medium. Bronchoscopic aspirate/lavage for acid-fast bacilli, Mantoux (tuberculin) test, etc., was additive investigations for diagnosis in particular cases.

These 440 patients with pulmonary tuberculosis were investigated to rule out diabetes mellitus by doing fasting and postmeal blood sugars by Folin-Wu method and urine sugar examination by Benedicts test.

The diagnosis of diabetes mellitus was established as per the National Diabetes Data group of the National Institute of Health recommendations:[6]

Fasting (overnight) venous plasma glucose concentration >140 mg per dL on at least 2 separate occasions.

In the absence of fasting hyperglycemia, a diagnosis of diabetes can be made following ingestion of the standard 75 g oral glucose tolerance test. If the 2 h venous plasma, glucose and one another sample (the 306,090 min) exceed 200 mg per dL.

Impaired glucose tolerance exists if the fasting plasma glucose level is <140 mg per dL and if the 30, 60, and 90 min plasma glucose concentration exceeds 200 mg per dL along with a 2 h plasma glucose level between 140 mg and 200 mg per dL.

Investigations included examination of the fundus, urine for albumin and ketone bodies, blood urea, and electrocardiograms. The response to antidiabetic treatment was assessed by symptomatology of the patients and regular monitoring of urine and blood for sugar.


  Results Top


Four hundred and forty patients with pulmonary tuberculosis admitted to the Poona Chest hospital, Aundh, Pune, including males and females varying from 11 years to 75 years with the mean age of 43 years were studied for the spectrum of diabetes mellitus in pulmonary tuberculosis

It was observed that among 440 cases of pulmonary tuberculosis 298 (67.73%) were male and 142 (32.27%) were female. The male and female ratio was approximately 2:1. It was noticed that 210 cases (47.73%) were below the age of 40 years and 230 cases (52.27%) above the age of 40 years.

It was observed that the prevalence rate of diabetes mellitus in pulmonary tuberculosis was 9.55% (42 out of 440) in patients admitted to the Poona Chest Hospital, Aundh. Of these 42 cases of diabetes, 28 cases (66.67%) were male (28 out of 298 male tuberculosis patients) and 14 cases (33.33%) were female (14 out of 142 female tuberculosis patients).

Ten cases of diabetes were below 40 years of age and 32 patients with diabetes were found to have diabetes above 40 years [Table 1], [Table 2], [Table 3].
Table 1: The age and sex distribution of total 440 patients with pulmonary tuberculosis

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Table 2: The age and sex distribution of total 42 diabetic patients with pulmonary tuberculosis

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Table 3: The frequency of radiological pattern of “diabetic tuberculosis” in 42 patients with diabetes associated with tuberculosis

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Diabetic tuberculosis

Sosman and Steidl[2] (1927) had described “diabetic tuberculosis” a specific radiological pattern. These lesions usually consist of a wedge shaped area of density in which there is often cavitation situated in the neighborhood of hilum and spreading toward the periphery including the bases occurring in diabetics over the age of 40 years. The lesions are usually acute, confluent, and exudative.

It was observed that a specific radiological pattern called “diabetic tuberculosis” described by Sosman and Steidl[2] was found in 7 cases (16.66%) above 40 years of age in this combination disease. Of these 7 cases, 5 (11.90%) were in male and 2 (4.76%) were female. All seven patients were confirmed for acid-fast bacilli by smear microscopy/culture. All these patients showed 100% resolution with aggressive treatment of pulmonary tuberculosis (2HRZE + 4HRE) along with antidiabetic therapy (preferably with insulin as per doses required) [Figure 1], [Figure 2], [Figure 3].
Figure 1: Chest X-ray PA view showing specific radiological pattern of “diabetic tuberculosis”

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Figure 2: Chest X-ray lateral view of the same patient

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Figure 3: Chest X-ray PA view of the same patient showing diabetic tuberculosis with adequate resolution after 2 months of short course chemotherapy with proper control of diabetes

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  Discussion Top


In the present study, 440 patients with pulmonary tuberculosis admitted to the Poona Chest hospital, Aundh, Pune, w. e. f. July 1, 1991–June 30, 1992, were screened to find out the prevalence rate of diabetes mellitus and to study and highlight the radiological pattern of “diabetic tuberculosis” as described by Sosman and Steidl[2] (1927). This specific radiological pattern is described as wedge shaped opacity in which there is often cavitation situated in the neighborhood of hilum and spreading toward the periphery including the bases in patients with diabetes mellitus with pulmonary tuberculosis, above the age of 40 years. These lesions are often acute, confluent, and exudative.

Of these 440 patients with pulmonary tuberculosis, 42 (including 28 males and 14 females) had diabetes mellitus giving a prevalence rate of 9.5%. Out of these 42 patients, 32 were above 40 years.

Deshmukh et al.[7] in his masterly study found 14% of tuberculosis patients had diabetes mellitus above 40 years of age. Nanda and Tripathy[5] found prevalence of 12% diabetes mellitus in pulmonary tuberculosis patients and stated that influence of diabetes on tuberculosis is as harmful as impact of tuberculosis on diabetes. They also stated that missing or overlooking presence of diabetes mellitus in pulmonary tuberculosis and vice versa leads to a disastrous culmination. Our study showing the prevalence of 9.55% diabetes mellitus in pulmonary tuberculosis patients correlates very well with these studies.

The specific radiological appearance- “diabetic tuberculosis” which has been reported as common in tuberculous diabetics, characterized by a wedge shaped opacity, in which there is often cavitation situated in the neighborhood of hilum and spreading toward the periphery, including the bases occurring over the age of 40 years.[2]

Warwick[4] in his study of series observed 11 out of 104 patients showed this radiological appearance and only 6 (5.8%) were over the age of 40 years. In the present study, 16.66% (7 out of 42 cases including 5 males and 2 females) were found to have the specific radiological appearance “diabetic tuberculosis” in patients with diabetes mellitus associated pulmonary tuberculosis. This gives a significant observation as it correlates well with the observations made by others.[8],[9],[10],[11],[12],[13],[14]


  Conclusion Top


During extensive studies, it was found that diabetes mellitus and pulmonary tuberculosis frequently occur in association and pose very serious problems for the management. The prevalence of diabetes mellitus in pulmonary tuberculosis and vice-versa is comparatively high than general population because of added stress. Missing or overlooking presence of diabetes in pulmonary tuberculosis and vice-versa leads to disastrous culmination.

All the patients with diabetes mellitus should be screened for pulmonary tuberculosis every year and all the patients with pulmonary tuberculosis above the age of 40 years should be screened to rule out diabetes mellitus.

This specific radiological pattern of “diabetic tuberculosis” described by Sosman and Steidl (1923) above the age of 40 years is mostly diagnostic of this combination disease. This specific radiological pattern of “diabetic tuberculosis” observed during clinical examination should be screened to rule out diabetes mellitus and pulmonary tuberculosis (viz., in patients with pulmonary tuberculosis to be ruled out for diabetes mellitus and patients with pulmonary tuberculosis for diabetes with this pattern of radiological findings).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Deshmukh MD, editor. chapter Tuberculosis in relation to Diabetes. In: Avicenna: Textbook of Tuberculosis 1981. p. 252.  Back to cited text no. 1
    
2.
Sosman M, Steidl J. Diabetic tuberculosis. Am J Roentgenol 1927;17:625.  Back to cited text no. 2
    
3.
Root H. The association of diabetes and tuberculosis. N Engl J Medicine 1952;210:127-47.  Back to cited text no. 3
    
4.
Warwick MT. Pulmonary tuberculosis and diabetes mellitus. Q J Med 1957;26:31-42.  Back to cited text no. 4
    
5.
Nanda CN, Tripathy SN. Association of diabetes mellitus with pulmonary tuberculosis. J Asso Phys Ind 1968:16:741-6.  Back to cited text no. 5
    
6.
Jerrold M. Chapter-diabetes mellitus. In: Cecil Textbook of Medicine. 18th ed. Totowa, NJ: Olefsky; 1988.  Back to cited text no. 6
    
7.
Deshmukh MD, Master TB, David JC, Tripathy S Jr. J. J. Group of Hospitals and G. M. C 1966:2:97-102.  Back to cited text no. 7
    
8.
Rathi N, Taksande B, Kumar S. Nerve Conduction Studies of Peripheral Motor and Sensory Nerves in the Subjects with Prediabetes. J Endocrinol Metab 2019;9:147-50. Available from: https://doi.org/10.14740/jem602. [Last accessed on 2020 Jan 22].  Back to cited text no. 8
    
9.
Walinjkar RS, Khadse S, Kumar S, Bawankule S, Acharya S. Platelet Indices as a Predictor of Microvascular Complications in Type 2 Diabetes. Indian J Endocrinol Metab 2019;23:206-10. Available from: https://doi.org/10.4103/ijem.IJEM-13-19. [Last accessed on 2020 Jan 22].  Back to cited text no. 9
    
10.
Gupta V, Bhake A. Assessment of Clinically Suspected Tubercular Lymphadenopathy by Real-Time PCR Compared to Non-Molecular Methods on Lymph Node Aspirates. Acta Cytol 2018;62:4-11. Available from: https://doi.org/10.1159/000480064. [Last accessed on 2020 Jan 22].  Back to cited text no. 10
    
11.
Gupta V, Bhake A. Reactive Lymphoid Hyperplasia or Tubercular Lymphadenitis: Can Real-Time PCR on Fine-Needle Aspirates Help Physicians in Concluding the Diagnosis?. Acta Cytol 2018;62:204-8. Available from: https://doi.org/10.1159/000488871. [Last accessed on 2020 Jan 22].  Back to cited text no. 11
    
12.
Modi S, Agrawal A, Bhake A, Agrawal V. Role of Adenosine Deaminase in Pleural Fluid in Tubercular Pleural Effusion. J Datta Meghe Inst Med Sci Univ 2018;13:163-7. Available from: https://doi.org/10.4103/jdmimsu.jdmimsu_77_17. [Last accessed on 2020 Jan 22].  Back to cited text no. 12
    
13.
Sharma SK, Dheda K. What Is New in the WHO Consolidated Guidelines on Drug-Resistant Tuberculosis Treatment? Indian J Med Res 2019;149:309-12. Available from: https://doi.org/10.4103/ijmr.IJMR_579_19. [Last accessed on 2020 Jan 22].  Back to cited text no. 13
    
14.
Sharma SK, Mohan A, Singh AD, Mishra H, Jhanjee S, Pandey RM, et al. Impact of Nicotine Replacement Therapy as an Adjunct to Anti-Tuberculosis Treatment and Behaviour Change Counselling in Newly Diagnosed Pulmonary Tuberculosis Patients: An Open-Label, Randomised Controlled Trial. Sci Rep 2018;8:1-9. Available from: https://doi.org/10.1038/s41598-018-26990-5. [Last accessed on 2020 Jan 22].  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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