The impact of glycemic status on radiological manifestations of pulmonary tuberculosis in diabetic patients

Prior tuberculosis, radiographic lung abnormalities and prevalent diabetes in rural South Africa

BACKGROUND

Growing evidence suggests that chronic inflammation caused by tuberculosis (TB) may increase the incidence of diabetes. However, the relationship between post-TB pulmonary abnormalities and diabetes has not been well characterized.

METHODS

We analyzed data from a cross-sectional study in KwaZulu-Natal, South Africa, of people 15 years and older who underwent chest X-ray and diabetes screening with hemoglobin A1c testing. The analytic sample was restricted to persons with prior TB, defined by either (1) a self-reported history of TB treatment, (2) radiologist-confirmed prior TB on chest radiography, and (3) a negative sputum culture and GeneXpert. Chest X-rays of all participants were evaluated by the study radiologist to determine the presence of TB lung abnormalities. To assess the relationships between our outcome of interest, prevalent diabetes (HBA1c ≥6.5%), and our exposure of interest, chest X-ray abnormalities, we fitted logistic regression models adjusted for potential clinical and demographic confounders. In secondary analyses, we used the computer-aided detection system CAD4TB, which scores X-rays from 10 to 100 for detection of TB disease, as our exposure interest, and repeated analyses with a comparator group that had no history of TB disease.

RESULTS

In the analytic cohort of people with prior TB (n = 3,276), approximately two-thirds (64.9%) were women, and the average age was 50.8 years (SD 17.4). The prevalence of diabetes was 10.9%, and 53.0% of people were living with HIV. In univariate analyses, there was no association between diabetes prevalence and radiologist chest X-ray abnormalities (OR 1.23, 95%CI 0.95-1.58). In multivariate analyses, the presence of pulmonary abnormalities was associated with an 29% reduction in the odds of prevalent diabetes (aOR 0.71, 95%CI 0.53-0.97, p = 0.030). A similar inverse relationship was observed for diabetes with each 10-unit increase in the CAD4TB chest X-ray scores among people with prior TB (aOR 0.92, 95%CI 0.87-0.97; p = 0.002), but this relationship was less pronounced in the no TB comparator group (aOR 0.96, 95%CI 0.94-0.99).

CONCLUSIONS

Among people with prior TB, pulmonary abnormalities on digital chest X-ray are inversely associated with prevalent diabetes. The severity of radiographic post-TB lung disease does not appear to be a determinant of diabetes in this South African population.

Characteristics of atypical Pulmonary Tuberculosis without typical clinical features diagnosed by pathology

PURPOSE

Some patients with pulmonary tuberculosis (PTB) do not display typical clinical features, leading to delays in diagnosis and treatment.

METHODS

We retrospectively analyzed PTB patients admitted to the Second Affiliated Hospital of Chongqing Medical University between 2017 and 2020. They are divided into pathological group (diagnosed through pathological biopsy) and control group (diagnosed via sputum or lavage fluid). Clinical data of both groups were compared. Based on radiographic features, the pathological group was further divided into the inflammation group, peripheral nodule group, and central occupancy group. We then statistically analyzed the computed tomography (CT) signs, bronchoscopic manifestations and results of pathological biopsy for each subgroup.

RESULTS

The pathological group consisted of 75 patients, while the control group had 338 patients. Multivariate logistic regression analysis showed that the pathological group had more diabetes (OR = 3.266, 95% CI = 1.609-6.630, P = 0.001), lower ESR (OR = 0.984, 95% CI = 0.971-0.998, P = 0.022), and lower CRP (OR = 0.990, 95% CI = 0.980-0.999, P = 0.036). In the three subgroups, the exudative lesions in the inflammation group were mostly located in atypical areas of PTB. The lobulation sign and spiculation sign were frequently observed in the peripheral nodule group. All presented with significant hilar mediastinal lymphadenopathy in the central occupancy group. In the pathological group, bronchoscopic manifestations typically included mucosal edema and bronchial stenosis.

CONCLUSION

Diabetes is an independent risk factor for atypical PTB. Expression of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in atypical PTB is low. Radiologically, it is most easily misdiagnosed when presented as peripheral solid nodules or masses, so a biopsy is recommended.

Tuberculosis and diabetes mellitus: The complexity of the comorbid interactions

The double burden of tuberculosis (TB) and diabetes mellitus (DM) represents a major public health challenge that demands urgent and integrated approaches. The interplay between these two chronic conditions presents unique clinical and public health management challenges, as well as social and economic implications. We explored the bidirectional relationship between TB and DM, emphasizing how DM increases susceptibility to TB and complicates its management, while TB may exacerbate glycemic control in diabetic patients. This review underscores the challenges associated with the management of both diseases, obstacles in screening TB patients for DM and TB preventive therapy for DM since inadequate glycemic control can impact treatment outcomes. Several studies have investigated the disease interplay; however, the results have been equivocal, and this may be exerting negative impacts on the disease prevention and treatment. TB-diabetes comorbidity has been linked to poor treatment outcomes whereas TB prevention in people with DM at present is a dilemma. In addition to highlighting how urgent it is to address this comorbidity, this review offers a road map for better prevention, treatment, and control of several factors underlying the TB-diabetes syndemic interaction.

The Effect of Diabetes Control Status on CT Findings in Pulmonary Tuberculosis: Emphasis on Bronchial Erosive Changes

PURPOSE

Studies on the effect of diabetes mellitus (DM) on the radiologic findings of pulmonary tuberculosis (PTB) have reported inconsistent results. These findings may have been influenced by the glycemic control status of the patients studied. To our knowledge, no recent data have described the effect of the DM control status on CT findings in PTB in terms of medium-sized airway involvement that is visualized as bronchial erosion on CT. The aim of this present study was to determine whether the DM control status influenced radiological manifestations in patients with PTB, with an emphasis on bronchial erosive changes.

METHODS

We conducted a retrospective single-center study on patients who were newly diagnosed with PTB. A total of 426 consecutive patients with PTB who underwent CT scans at the time of diagnosis from 1 January 2017 to 31 March 2020 were included in this study. The included patients were categorized as having no DM (non-DM), controlled DM, or uncontrolled DM. The patient medical charts, microbiology study results, and pulmonary changes on the CT scans were analyzed.

RESULTS

Among 426 patients with PTB who underwent CT scans at the time of diagnosis, 91 were excluded either due to undetermined hemoglobin A1C (HbA1C) levels (n = 25) or concomitant pulmonary diseases (n = 66) that would make the analysis of the pulmonary changes on CT scans difficult. Finally, 335 patients were included in this study (224 men and 111 women; mean age, 59 years; range, 16-95 years). Among the 335 patients, 82 (24.5%) had DM and 52 of those (63.4%) had an uncontrolled status. The frequency of cavitation (43% vs. 23% vs. 79%, p < 0.001) and bronchial erosion (44% vs. 30% vs. 73%, p < 0.001) was significantly different between the three groups. The uncontrolled DM group showed a high frequency of cavitation and bronchial erosion compared to the non-DM (cavitation, p < 0.001 and bronchial erosion, p < 0.001) and controlled DM groups (p < 0.001 and p < 0.001). However, the frequency of cavitation and bronchial erosion in the controlled DM group was not different compared to the non-DM group.

CONCLUSION

The glycemic status (HbA1C ≥ 7.0), not the presence of DM, influenced the radiologic manifestations of PTB, especially in terms of medium-sized bronchial involvement, appearing as bronchial erosive changes and the feeding bronchus sign on chest CT scans. This difference in the uncontrolled DM group was likely to contribute to the higher frequency of cavitation.

Computed tomography findings in patients with pulmonary tuberculosis and diabetes at an infectious disease hospital in China: a retrospective cross-sectional study

BACKGROUND

This study aimed to investigate the relationship between active pulmonary tuberculosis (TB) and type 2 diabetes mellitus (T2DM) by analysing the clinical features and computed tomography (CT) findings of patients with active pulmonary TB and comorbid T2DM (TB-DM) in the LiangShan Yi regions.

METHODS

We collected data from 154 hospitalised patients with TB-DM initially confirmed at an infectious disease hospital in the Liangshan Yi Autonomous Prefecture between 1 and 2019, and 31 December 2021. These were matched by sex and age ± 3 years to 145 hospitalised patients with initially confirmed pulmonary TB without comorbid T2DM (TB-NDM) over the same period. The clinical characteristics of the two groups were analysed separately. Three group-blinded radiologists independently analysed the CT findings and classified them into mild-to-moderate and severe groups. Severe chest CT lesion refers to a lesion that is less diffused or moderately dense and either exceeds the total volume of one lung, a high-density fused lesion greater than one-third of the volume of one lung, or a cavitary lesion with a maximum diameter ≥ 4 cm.

RESULTS

No significant differences were observed in the presentation of clinical features. Regarding the severity of chest CT manifestation, patients with TB-DM had significantly more severe TB than those with TB-NDM (89.61% vs. 68.97%, P < 0.0001). Regarding CT findings, patients with TB-DM had higher proportions of consolidation (79.22% vs. 52.41%, P < 0.0001), cavitary lesions (85.06% vs. 59.31%, P < 0.0001), bronchiectasis (71.43% vs. 31.03%, P < 0.0001), exudative lesions (88.96% vs. 68.28%, P < 0.0001), and fibrous lesions (93.51% vs. 68.97%, P < 0.0001) than patients with TB-NDM. In conclusion, patients with TB-DM have more severe pulmonary TB CT findings than those without. There were no significant differences in the distribution of lesions in the lung lobes between TB-DM and TB-NDM patients.

CONCLUSIONS

Among patients hospitalised with pulmonary TB, those with T2DM had more severe findings on chest CT than those without T2DM. However, the clinical presentation was not significantly different.

The cause-effect relation of tuberculosis on incidence of diabetes mellitus

Tuberculosis (TB) is one of the oldest human diseases and is one of the major causes of mortality and morbidity across the Globe. Mycobacterium tuberculosis (Mtb), the causal agent of TB is one of the most successful pathogens known to mankind. Malnutrition, smoking, co-infection with other pathogens like human immunodeficiency virus (HIV), or conditions like diabetes further aggravate the tuberculosis pathogenesis. The association between type 2 diabetes mellitus (DM) and tuberculosis is well known and the immune-metabolic changes during diabetes are known to cause increased susceptibility to tuberculosis. Many epidemiological studies suggest the occurrence of hyperglycemia during active TB leading to impaired glucose tolerance and insulin resistance. However, the mechanisms underlying these effects is not well understood. In this review, we have described possible causal factors like inflammation, host metabolic changes triggered by tuberculosis that could contribute to the development of insulin resistance and type 2 diabetes. We have also discussed therapeutic management of type 2 diabetes during TB, which may help in designing future strategies to cope with TB-DM cases.

Immunologic, metabolic and genetic impact of diabetes on tuberculosis susceptibility

Due to the increasing prevalence of diabetes mellitus (DM) globally, the interaction between DM and major global diseases like tuberculosis (TB) is of great public health significance, with evidence of DM having about a three-fold risk for TB disease. TB defense may be impacted by diabetes-related effects on immunity, metabolism, and gene transcription. An update on the epidemiological aspects of DM and TB, and the recent trends in understanding the DM-associated immunologic, metabolic, and genetic mechanisms of susceptibility to TB will be discussed in this review. This review highlights gaps in the incomplete understanding of the mechanisms that may relate to TB susceptibility in type 2 DM (T2DM). Understanding these three main domains regarding mechanisms of TB susceptibility in T2DM patients can help us build practical treatment plans to lessen the combined burden of the diseases in rampant areas.

Glycemic control and the risk of tuberculosis in patients with diabetes: A cohort study in a Mediterranean city

Background

Diabetes mellitus (DM) is one of the leading chronic diseases globally and one of the most common causes of death, morbidity, and poor quality of life. According to the WHO, DM is also one of the main risk factors for developing active tuberculosis (TB). Subjects with DM are at a higher risk of infections, in addition to frequent micro and macrovascular complications, and therefore sought to determine whether poor glycemic control is linked to a higher risk of developing TB.

Methods

We used a retrospective cohort of diabetic subjects to predict the incidence of TB. All DM patients were recruited from Ciutat Vella (the inner-city of Barcelona) from January 2007 until December 2016, with a follow-up period until December 2018 (≥2 years). Data were extracted from Barcelona's Primary Care medical record database - SIDIAP, and linked to the Barcelona TB Control Program. The incidence of TB and the impact of glycemic control were estimated using time-to-event curves analyzed by Cox proportional hazard regression. Hazard ratios (HRs) and 95% confidence intervals (CIs), unadjusted and adjusted by potential confounding variables, were also assessed, which included age, sex, diabetes duration, macrovascular and microvascular signs, BMI, smoking habit, alcohol consumption and geographical origin.

Results

Of 8,004 DM patients considered for the study (equating to 68,605 person-years of follow-up), 84 developed TB [incidence rate = 70 (95% CI: 52-93) per 100,000 person-years]. DM subjects with TB were younger (mean: 52.2 vs. 57.7 years old), had higher values of glycosylated hemoglobin (HbA1c) (7.66 vs. 7.41%) and total triglycerides (122 vs. 105 mg/dl), and had twice the frequency of diabetic nephropathy (2.08 vs. 1.18%). The calculated incidence rate increased with increasing HbA1c: 120.5 (95% CI 77.2-179.3) for HbA1c ≥ 7.5%, 143 (95% CI 88.3-218.1) for HbA1c ≥ 8% and 183.8 (95% CI 105-298) for HbA1c ≥ 9%. An increase in the risk of TB was also observed according to a poorer optimization of glycemic control: adjusted HR 1.80 (95% CI 0.60-5.42), 2.06 (95% CI 0.67-6.32), and 2.82 (95% CI 0.88-9.06), respectively.

Conclusion

Diabetic subjects with worse glycemic control show a trend toward a higher risk of developing TB.

Extensive Radiological Manifestation in Patients with Diabetes and Pulmonary Tuberculosis: A Cross-Sectional Study

Background

Diabetes mellitus (DM) is believed to affect tuberculosis (TB) at multiple levels in disease control and treatment efficacy, but clinical and radiological presentation resulting from interaction of the two diseases is not known.

Methods

A cross-sectional study was conducted on data obtained from medical records of 438 patients confirmed with TB-DM comorbidity at the Third people's hospital of Shenzhen from May 01, 2014, to April 30, 2019. Their CT images were reviewed, and patients were divided into subgroups according to lung cavitation: with and without cavities, and number of segments showing pulmonary infiltration: <4 segment, 4-8 segment, >8 segment infiltrates. We then compared clinical parameters between these groups.

Results

The median age of the patients was 50.0 years (IQR 43.3-56.0) and 86% (n=375) of them were male. Pulmonary cavities were found in 80.8% patients. About 42.7% and 27.2% patients were seen to have infiltration involving 4-8 and >8 lung segments, respectively. Patients presented with cavitation and infiltration involving a greater number of lung segments had significantly higher values of WBC, MONO%, GRA%, CRP, lower LYN% level and higher bacterial burden in sputum (P<0.001). Higher HbA1c and FBG were only observed in patients with lung cavities (P<0.001). There was no difference in positive ELISPOT.TB and PCT level between the groups regardless of presence or absence of lung cavity (P>0.9 and P=0.1 respectively). Lower HGB, ALB and higher PCT were observed in patients with infiltration involving more lung segments.

Conclusion

Hyper-inflammation in peripheral blood was significantly associated with cavity and the number of lung lesions. Hyperglycemia was significantly associated with the development of lung cavity. Glycemic control and inflammation influenced radiographic manifestations in patients with TB-DM.

CT Image Features of the FBP Reconstruction Algorithm in the Evaluation of Fasting Blood Sugar Level of Diabetic Pulmonary Tuberculosis Patients and Early Diet Nursing

The study was aimed at exploring the application value of the CT image based on a filtered back projection (FBP) algorithm in the diagnosis of patients with diabetes complicated with tuberculosis and at analyzing the influence of dietary nursing on patients with diabetes complicated with tuberculosis. In this study, the FBP algorithm was used to optimize CT images to effectively obtain reconstructed ROI images. Then, the deviation from measurement values of reconstructed images at different pixel levels was analyzed. 138 patients with diabetes complicated with tuberculosis were selected as research subjects to compare the number of lung segments involved and the CT imaging manifestations at different fasting glucose levels. All patients were divided into the control group (routine drug treatment) and observation group (diet intervention on the basis of drug treatment) by random number table method, and the effect of different nursing methods on the improvement of patients' clinical symptoms was discussed. The results showed that the distance measurement value decreased with the increase in pixel level, there was no significant difference in the number of lung segments involved in patients with different fasting glucose levels (P > 0.05), and there were statistically significant differences in the incidence of segmental lobar shadow, bronchial air sign, wall-less cavity, thick-walled cavity, pulmonary multiple cavity, and bronchial tuberculosis in patients with different fasting glucose levels (P < 0.05). Compared with the control group, 2 h postprandial blood glucose level in the observation group was significantly improved (P < 0.05), there was a statistical significance in the number with reduced pleural effusion and the number with reduced tuberculosis foci in the two groups (P < 0.05), and the level of hemoglobin in the observation group was 7.1 ± 1.26, significantly lower than that in the control group (8.91 ± 2.03, P < 0.05). It suggested that the changes of CT images based on the FBP reconstruction algorithm were correlated with fasting blood glucose level. Personalized diet nursing intervention can improve the clinical symptoms of patients, which provides a reference for the clinical diagnosis and treatment of patients with diabetes complicated with tuberculosis.

Diabetes-Associated Susceptibility to Tuberculosis: Contribution of Hyperglycemia vs. Dyslipidemia

Diabetes is a major risk factor for tuberculosis (TB). Diabetes increases the risk of the progression from latent tuberculosis infection (LTBI) to active pulmonary TB and TB patients with diabetes are at greater risk of more severe disease and adverse TB treatment outcomes compared to TB patients without co-morbidities. Diabetes is a complex disease, characterised not only by hyperglycemia but also by various forms of dyslipidemia. However, the relative contribution of these underlying metabolic factors to increased susceptibility to TB are poorly understood. This review summarises our current knowledge on the epidemiology and clinical manifestation of TB and diabetes comorbidity. We subsequently dissect the relative contributions of body mass index, hyperglycemia, elevated cholesterol and triglycerides on TB disease severity and treatment outcomes. Lastly, we discuss the impact of selected glucose and cholesterol-lowering treatments frequently used in the management of diabetes on TB treatment outcomes.

Impact of Type 2 Diabetes on the capacity of human macrophages infected with Mycobacterium tuberculosis to modulate monocyte differentiation through a bystander effect

Type 2 diabetes mellitus (T2DM) is a risk factor for the development of tuberculosis (TB) through mechanisms poorly understood. Monocytes and macrophages are key effector cells to control TB, but they are also subverted by Mycobacterium tuberculosis (Mtb). Specifically, Mtb can induce a bystander effect that skews monocyte differentiation towards macrophages with a permissive phenotype to infection. Here, we evaluated whether T2DM impacts this TB aspect. Our approach was to differentiate monocytes from healthy control (HC) subjects and T2DM patients into macrophages (MDM), and then assess their response to Mtb infection, including their secretome content and bystander effect capacity. Through flow cytometry analyses, we found a lower level of activation markers in MDM from T2DM patients in comparison to those from HC in response to mock (HLA-DR, CD86, and CD163) or Mtb challenge (CD14 and CD80). In spite of high TGF-β1 levels in mock-infected MDM from T2DM patients, cytometric bead arrays indicated there were no major differences in the secretome cytokine content in these cells relative to HC-MDM, even in response to Mtb. Mimicking a bystander effect, the secretome of Mtb-infected HC-MDM drove HC monocytes towards MDM with a permissive phenotype for Mtb intracellular growth. However, the secretome from Mtb-infected T2DM-MDM did not exacerbate the Mtb load compared to cmMTB-HC, possibly due to the high IL-1β production relative to Mtb-infected HC-MDM. Collectively, despite T2DM affecting the basal MDM activation, our approach revealed it has no major consequence on their response to Mtb or capacity to generate a bystander effect influencing monocyte differentiation.

Clinical and Radiological Presentations of Various Pulmonary Infections in Hospitalized Diabetes Mellitus Patients: A Prospective, Hospital-Based, Comparative, Case Series Study

Background

Diabetes mellitus is associated with increased rate of respiratory tract infections. The objective was to compare demographic, clinical, serum biochemical, and typical and atypical radiological profiles among hospitalized diabetics and nondiabetics with lower respiratory tract infection. Material and Methods. A prospective, hospital-based, consecutive, comparative observational study of 12-month study duration was conducted. Patients aged 13–90 years diagnosed with lower respiratory tract infection with or without diagnosed diabetes mellitus participated in the study. Demographic, clinical, serum biochemistry, and radiological profiles of diabetics (n = 44) and nondiabetics (n = 53) were compared.

Results

Diabetics were older than nondiabetics at presentation (p < 0.0001). Difference in mean random blood sugar (RBS) (p < 0.001), fasting blood sugar (FBS) (p < 0.001), and postprandial blood sugar (PPBS) (p < 0.0001) was significant between diabetics and nondiabetics. Nondiabetics more frequently presented with fever (p = 0.0032), chest pain (p = 0.0002), and hemoptysis (p = 0.01) as compared to diabetics. Diabetics more frequently presented with extreme temperatures (hypothermia or hyperpyrexia) (p = 0.022), lower serum sodium levels (p = 0.047), and lower partial arterial pressure (p < 0.001) than nondiabetics. The mean pneumonia patient outcomes research team (PORT) risk score was higher in diabetics (124.84 ± 41.31) compared to nondiabetics (77.85 ± 39.77) (p < 0.001). Diabetics more commonly displayed bilateral lesions with multilobe or lower lobe involvement, the most common type of lesion being exudative.

Conclusion

Diabetic patients usually had severe pulmonary infection and poor prognosis as suggested by higher mean PORT risk score. They also more frequently presented with bilateral lesions with multilobe or lower lobe involvement as evidenced by radiography as compared to nondiabetic patients.

Slow radiological improvement and persistent low-grade inflammation after chemotherapy in tuberculosis patients with type 2 diabetes

Background

Diabetes mellitus type 2 (DM) may impede immune responses in tuberculosis (TB) and thus contribute to enhanced disease severity. In this study, we aimed to evaluate DM-mediated alterations in clinical, radiological and immunological outcomes in TB disease.

Methods

Newly diagnosed pulmonary TB patients with or without DM (TB n = 40; TB-DM n = 40) were recruited in Dhaka, Bangladesh. Clinical symptoms, sputum smear and culture conversion as well as chest radiography were assessed. Peripheral blood and sputum samples were collected at the time of diagnosis (baseline) and after 1, 2 and 6 months of standard anti-TB treatment. Blood samples were also obtained from healthy controls (n = 20). mRNA expression of inflammatory markers in blood and sputum samples were quantified using real-time PCR.

Results

The majority of TB-DM patients had poor glycemic control (HbA1c > 8%) and displayed elevated pulmonary pathology (P = 0.039) particularly in the middle (P < 0.004) and lower lung zones (P < 0.02) throughout the treatment period. However, reduction of clinical symptoms and time to sputum smear and culture conversion did not differ between the groups. Transcripts levels of the pro-inflammatory cytokines IL-1β (P = 0.003 at month-1 and P = 0.045 at month-2) and TNF-α (P = 0.005 at month-1) and the anti-inflammatory cytokine IL-10 (P = 0.005 at month-2) were higher in peripheral blood after anti-TB treatment in TB-DM compared to TB patients. Conversely in sputum, TB-DM patients had reduced CD4 (P < 0.009 at month-1) and IL-10 (P = 0.005 at month-1 and P = 0.006 at month-2) transcripts, whereas CD8 was elevated (P = 0.016 at month-2). At 1- and 2-month post-treatment, sputum IL-10 transcripts were inversely correlated with fasting blood glucose and HbA1c levels in all patients.

Conclusion

Insufficient up-regulation of IL-10 in the lung may fuel persistent local inflammation thereby promoting lung pathology in TB-DM patients with poorly controlled DM.

Severe pulmonary radiological manifestations are associated with a distinct biochemical profile in blood of tuberculosis patients with dysglycemia

Background

Diabetes mellitus (DM) is thought to affect tuberculosis (TB) clinical presentation and treatment response. Whether DM impacts radiological manifestations of pulmonary TB is still not clear. This study investigated the impact of glycemic status on radiological manifestations of pulmonary TB cases and its relationship with concentration of biochemical parameters in peripheral blood.

Methods

A retrospective cross-sectional study used data from 132 microbiologically confirmed pulmonary TB patients from Lima, Peru, evaluated in a previous investigation performed between February and December 2017. Chest radiographs were analyzed by a radiologist and a pulmonologist. Radiographic lesions were identified as cavities, alveolar infiltrates and fibrous tracts. Hyperglycemia in TB patients was identified by use of fasting plasma glucose, HbA1c and oral glucose tolerance test. Clinical, biochemical and hematological parameters were also analyzed.

Results

TB patients with hyperglycemia presented more frequently with cavities, alveolar infiltrates and fibrous tracts than those with normoglycemia. Hierarchical clustering analysis indicated that patients with more diverse and higher number of lung lesions exhibited a distinct laboratorial profile characterized by heightened white blood cell counts and circulating levels of total cholesterol, triglycerides and transaminases and simultaneously low levels of albumin and hemoglobin. Multivariable regression analyses adjusted for age, sex, prior TB, hemoglobin levels and acid-fast bacilli ≥2+ in sputum smears, demonstrated that presence of prediabetes or diabetes in TB patients was associated with increased odds of having 3 pulmonary lesion types (p = 0.003 and p < 0.01 respectively) or ≥ 4 lesions (p = 0.001 and p = 0.01 respectively).

Conclusion

Hyperglycemia (both DM and prediabetes) significantly affected the presentation of radiographic manifestations and the number of lesions in pulmonary TB patients as well as the biochemical profile in peripheral blood.

A valuable computed tomography-based new diagnostic tool for severe chest lesions in active pulmonary tuberculosis: combined application of influencing factors

The objective of the present investigation was to explore the influencing factors and value of computed tomography (CT) for diagnosing severe chest lesions in active pulmonary tuberculosis (APTB). This retrospective investigation included 463 patients diagnosed with APTB. Relevant clinical features were collected. Patients were assigned to mild/moderate group or advanced group depending on the lesion severity on chest CT, severe chest CT lesion refers to the moderately dense or less diffuse lesion that exceeds the total volume of one lung, or the dense fusion lesion greater than one third of the volume of one lung, or the lesion with cavity diameter ≥4 cm. Independent risk factors for severe lesions were determined by univariate and multivariate logistic regression analyses, and the diagnostic efficiency of the risk factors was assessed by receiver operating characteristic curve (ROC). Chest CT demonstrated that there were 285 (61.56%) cases with severe lesions; multivariate Logistic regression analysis showed dust exposure [odds ratio (OR) = 4.108, 95% confidence interval (CI) 2.416–6.986], patient classification (OR = 1.792, 95% CI 1.067–3.012), age (OR = 1.018, 95% CI 1.005–1.030), and albumin-globulin ratio (OR = 0.179, 95% CI 0.084–0.383) to be independently correlated with severe lesions on chest CT. ROC curve analysis showed the cutoff values of age, albumin-globulin ratio and combined score to be 39 years, 0.918 and −0.085, respectively. The predictive value of combined score area under the curve 0.753 (95% CI 0.708–0.798) was higher than that of any single factor. The combined score of these four factors further improved the predictive efficacy.

A public-private model to scale up diabetes mellitus screening among people accessing tuberculosis diagnostics in Dhaka, Bangladesh

Background:

Data are scarce regarding the prevalence of diabetes mellitus (DM) among tuberculosis (TB) patients in Bangladesh. This study was undertaken to estimate the number needed to screen (NNS) to identify a case of DM among those with TB symptoms and those with confirmed TB disease, and to identify factors predicting treatment outcomes of TB patients with and without DM.

Methods:

Persons attending public–private model screening centres in urban Dhaka for the evaluation of TB were offered free blood glucose testing in addition to computer-aided chest X-ray and sputum Xpert MTB/RIF.

Results:

Among 7647 people evaluated for both TB and DM, the NNS was 35 (95% confidence interval (CI) 31–40) to diagnose one new case of DM; among those diagnosed with TB, the NNS was 21 (95% CI 17–29). Among those with diagnosed TB, patients with DM were more likely to have cavitation on chest X-ray compared to those without DM (31% vs 22%). Treatment failure (odds ratio (OR) 18.9, 95% CI 5.43–65.9) and death (OR 2.08, 95% CI 1.11–3.90) were more common among TB patients with DM than among TB patients without DM. DM was the most important predictor of a poor treatment outcome in the classification analysis for TB patients aged 39 years and above.

Conclusions:

A considerable burden of DM was found among patients accessing TB diagnostics through a public–private model in urban Bangladesh, and DM was associated with advanced TB disease and a high rate of poor treatment outcome.

Changes in Host Response to Mycobacterium tuberculosis Infection Associated With Type 2 Diabetes: Beyond Hyperglycemia

Tuberculosis (TB) remains as the first cause of death among infectious diseases worldwide. Global incidence of tuberculosis is in part coincident with incidence of type 2 diabetes (T2D). Incidence of T2D is recognized as a high-risk factor that may contribute to tuberculosis dissemination. However, mechanisms which favor infection under T2D are just starting to emerge. Here, we first discuss the evidences that are available to support a metabolic connection between TB and T2D. Then, we analyze the evidences of metabolic changes which occur during T2D gathered thus far for its influence on susceptibility to M. tuberculosis infection and TB progression, such as hyperglycemia, increase of 1AC levels, increase of triglycerides levels, reduction of HDL-cholesterol levels, increased concentration of lipoproteins, and modification of the activity of some hormones related to the control of metabolic homeostasis. Finally, we recognize possible advantages of metabolic management of immunity to develop new strategies for treatment, diagnosis, and prevention of tuberculosis.

Pulmonary tuberculous cavities in diabetic patients: Glycemic control is still the dominant factor despite the emerging role of metformin

BACKGROUND

Previous studies have reported an increased risk of cavities in diabetic patients with pulmonary tuberculosis (PTB), which may be associated with poor glycemic control. Cavities have a negative impact on PTB treatment outcomes; however, the possible interaction of other potentially confounding diabetes-related variables regarding pulmonary cavities have not been fully evaluated.

METHODS

We conducted a retrospective cohort study of diabetic patients with culture-proven PTB. The patients' chest X-rays (CXRs) and computed tomography (CT) scans were reviewed to assess the effects of clinical factors, glycosylated hemoglobin (HbA1c) levels, and antidiabetic agents on cavitary lesions.

RESULTS

Among 128 diabetic PTB patients, those with pulmonary cavities on CXRs and CT scans presented younger ages, lack of metformin treatment, and significantly higher HbA1c levels than those without cavities. Multivariate logistic regression analysis revealed significantly higher HbA1c levels in patients with cavities than in those without cavities on CXRs (odds ratio [OR], 1.34; 95% confidence interval [CI], 1.12-1.61) and CT scans (OR, 1.36; 95% CI, 1.13-1.64). Patients with multiple cavities had significantly higher HbA1c levels than those with a single cavity on CT scans (p = 0.002). No significant differences in other variables, including metformin treatment, were noted between the groups.

CONCLUSION

This study suggests that despite multiple potential confounding variables, including metformin use, poor glycemic control is still the dominant risk factor for cavitary lesions in diabetic patients with PTB. Efforts to improve glycemic control in diabetic PTB patients may be of considerable value in facilitating antimycobacterial treatment.

Impact of Diabetes Mellitus on the Presentation and Response to Treatment of Adults With Pulmonary Tuberculosis in Qatar

BACKGROUND

Persons with diabetes mellitus (DM) have a 3-fold increased risk of tuberculosis (TB). Atypical radiographic findings and differences in bacteriologic response during anti-TB treatment have been reported in earlier studies; however, the findings have varied. We evaluated the effect of DM on manifestations and response to treatment in adults with pulmonary TB in Qatar.

METHODS

The impact of DM on the clinical and radiographic presentations of pulmonary TB and bacteriologic response during anti-TB treatment was evaluated between January 2007 and December 2011, comparing patients with and without DM. This is a retrospective unmatched case-control study conducted at a large national hospital. Cases and controls were randomly selected from patients diagnosed with pulmonary TB over a 5-year period. Sputum culture conversion was assessed after 2 months of anti-TB treatment.

RESULTS

Clinical symptoms were similar between patients with and without DM. Patients with DM had a higher initial sputum acid-fast bacillus (AFB) smear grade and were less likely to have cavitary lesions on initial chest radiographs than patients without DM. Of 134 adults with DM and TB, 71 (53%) remained sputum culture positive after 2 months of anti-TB treatment, compared with 36 (27%) patients without DM.

CONCLUSIONS

DM was associated with atypical radiographic findings and delayed sputum culture conversion at 2 months in adults with pulmonary TB in Qatar. Increased health education of patients with DM about symptoms of TB, low thresholds for evaluation for active TB, and close monitoring of bacteriologic response to treatment among patients with TB and DM are warranted.

The correlation between CT features and glycosylated hemoglobin level in patients with T2DM complicated with primary pulmonary tuberculosis

To investigate the correlation between computed tomography (CT) features and glycosylated hemoglobin (HbAlc) levels in patients with type 2 diabetes mellitus (T2DM) complicated with primary pulmonary tuberculosis (PTB). One hundred and eighty untreated PTB patients complicated with T2DM were selected. Based on the HbAlc level, the patients were divided into three groups: HbAlc level <7% (Group I: 32 patients), 7%–9% (Group II: 48 patients), and >9% (Group III: 100 patients). The changes of CT manifestations and HbAlc were analyzed after TB and T2DM treatment. In the three groups, the detection rate of large segmented leafy shadow was 50%, 56.2%, and 87%; the air bronchogram sign detection rate was 40.6%, 47.9%, and 77%; the discovery rate of mouth-eaten cavity was 31.2%, 45.8%, and 65%; thick wall cavity detection rate was 25%, 31.2%, and 52%; the rate of multiple cavities was 34.3%, 50%, and 73%; and bronchial TB was found in 33.3%, 21.8%, and 46%, respectively. The detection rates of lesions in Group III were significantly higher than in Group II and Group I (p<0.05), and this increase was significant (p<0.05). After treatment, the HbAlc level reached control target (<7%) among all three groups and CT absorption improvement rates were 100%, 72.9%, and 56% respectively. The therapeutic efficacy of group I was better than group II (p<0.01), and the treatment efficacy of group II was better than group III (p<0.05). CT manifestations of T2DM complicated with PTB were closely related to HbAlc level. The effect is better when HbAlc level <7%. HbAlc level effectively reflects the severity and therapeutic effect to a certain extent. CT scan can provide some important information for clinical imaging. The above two examinations can guide clinicians to formulate the appropriate diagnosis and treatment in a timely manner.