'The tubercular diabetic': the impact of diabetes mellitus on tuberculosis and its threat to global tuberculosis control

Immuno-Hematological and Biochemical Changes in Patients with Tuberculosis in Dessie Comprehensive Specialized Hospital, Dessie, Ethiopia

Background

Tuberculosis (TB) is a serious worldwide health issue, particularly in developing nations like Ethiopia. Patients with tuberculosis experience a range of hematological, immunological, and biochemical alterations. The purpose of this study was to evaluate immunological, hematological, and biochemical alterations of newly diagnosed TB patients at Dessie comprehensive specialized hospital, Dessie, Ethiopia.

Methods

A comparative, cross-sectional study was carried out to evaluate the immuno-hematological and biochemical changes in patients with tuberculosis at Dessie comprehensive specialized hospital from January to July 2018. One hundred sixty-four (164) newly diagnosed TB patients, and 80 apparently healthy controls were included consecutively. The variables were expressed in frequency, percentage, and mean ± SD. To compare mean ± SD of the groups or within the groups, we used an independent sample t-test. Statistical significance was defined as a P value less than 0.05.

Results

Male TB patients had significantly high mean absolute WBC count, neutrophil count, lymphocyte, platelet count, and systemic immune-inflammation compared with male healthy controls (P=0.001, P=0.011 P=0.021, P=0.001, and P=0.018, respectively). The mean platelet count of female TB patients was significantly higher than that of the female control group (P=0.015). However, mean RBC counts, Hgb, HCT, and MPV of TB patients were significantly lower than those of male (p<0.001) and female healthy controls (P=0.022, 0.015, and 0.001, respectively). The TB patients had developed anemia (23.8%), WBC abnormalities (29.3%), thrombocytosis (11.6%), and thrombocytopenia (9.8%). The cases had significantly higher mean alanine amino transferase, total bilirubin, and glucose level, but the mean total protein, alkaline phosphatase, and total cholesterol of cases were significantly lower than healthy control groups.

Conclusion

TB patients in this study showed significant alterations in a number of hematological and biochemical profiles. This indicates that hematological and biochemical profiles should be monitored and properly interpreted for the differential diagnosis of tuberculosis and evaluation of response to treatment.

The association between type 2 diabetes and pulmonary cavitation revealed among IGRA-positive tuberculosis patients

The co-occurrence of tuberculosis (TB) and diabetes mellitus (DM) presents a significant obstacle to TB eradication. Pulmonary cavitation can occur in severe cases of TB, particularly in patients with DM. From 1 May 2014 through 30 June 2019, we conducted a cross-sectional study of 1,658 smear- or culture-confirmed pulmonary TB (PTB) patients at the Second Department of Pulmonary Medicine and Tuberculosis, Shenzhen, China. A total of 861 participants who satisfied the criteria (chest CT scan for cavitation, interferon-gamma release assay (IGRA), diagnosis of diabetes mellitus), with the median age of 36.7 years, 63.6% of male, 79.7% IGRA positive, 13.8% with diabetes, and 40.8% with pulmonary cavitation, were included in the study. The association between diabetes and pulmonary cavitation was confirmed in these TB patients (adjusted OR, 2.54; 95% CI, 1.66-3.94; p < 0.001). No associations were observed between diabetes and IGRA, as well as between lung cavitary and IGRA. Based on the criteria of IGRA+/-, pulmonary cavitation+/-, and DM+/-, the further analysis with univariate and multivariate logistic regression were conducted in six subgroups. The significant association between diabetes and pulmonary cavitation was further confirmed in the IGRA+ subgroup (adjusted OR, 3.07; 95% CI, 1.86-5.16; p < 0.001) but not observed in IGRA- individuals. This observation suggests that different immunological mechanisms of pulmonary cavitary/DM may be employed in IGRA+ TB patients from IGRA- TB patients.

How can tuberculosis services better support patients with a diabetes co-morbidity? A mixed methods study in the Philippines

BACKGROUND

People with diabetes mellitus (DM) have an estimated two- to three-times greater risk of adverse tuberculosis (TB) treatment outcomes compared to those without DM. Blood glucose control is a primary aim of managing DM during TB treatment, yet TB programmes are not generally adapted to provide DM services. The purpose of this study was to understand perceptions and the lived experiences of diabetic patients in TB treatment in the Philippines, with a view to informing the development of disease co-management strategies.

METHODS

This mixed methods study was conducted within a prospective cohort of adults newly-starting treatment for drug-sensitive and drug-resistant TB at 13 public TB clinics in three regions of the Philippines. Within the subset of 189 diabetic persons who self-reported a prior DM diagnosis, or were diagnosed by screenings conducted through the TB clinic, longitudinal blood glucose data were used to ascertain individuals' glycaemic control (controlled or uncontrolled). Univariable logistic regression analyses exploring associations between uncontrolled glycaemia and demographic and clinical factors informed purposive sampling of 31 people to participate in semi-structured interviews. All audio-recorded data were transcribed and thematic analysis performed.

RESULTS

Participants - both with controlled and uncontrolled blood glucose - were knowledgeable about diabetes and its management. However, a minority of participants were aware of the impact of DM on TB treatment and outcomes. Many participants newly-diagnosed with DM at enrolment in TB treatment had not perceived any diabetic symptoms prior and would have likely not sought clinical consult otherwise. Access to free glucose-lowering medications through TB clinics was a key enabling resource. However, participants expressed fear of side effects and interrupted access to glucose-lowering medications, and a preference for phytotherapy. Many participants felt that physical and financial impacts of TB and its treatment were challenges to DM management.

CONCLUSIONS AND RECOMMENDATIONS

Results of this study indicate that public TB clinics can provide diabetic patients with additional health care resources and education to address co-morbidity. TB programmes might consider identifying patients with complicated DM, and offering diabetic monitoring and management, as DM and diabetic complications may compound the burden of TB and its treatment.

Infectious diseases associated with pediatric type 1 diabetes mellitus: A narrative review

Diabetes mellitus (DM) has been frequently associated with an impaired immune response against infectious agents, making affected patients at risk for more severe disease and sometimes causing worse outcomes. The recent COVID-19 pandemic has seriously affected patients with both diabetes, in particular those carrying comorbidities or with poor glycemic control. As regards pediatric diabetes mellitus, the availability of more accurate and technological tools for glycemic management and the improved markers of metabolic control might mitigate the negative impact of infections. Notably, good metabolic control of diabetes since its diagnosis reduces not only the risk of microangiopathic complications but also of impaired immune response to infectious diseases. Therefore, vaccinations are strongly recommended. Our paper aims to provide the most updated evidence regarding infectious diseases in type 1 pediatric DM.

United States immigration detention amplifies disease interaction risk: A model for a transnational ICE-TB-DM2 syndemic

Detention and removal of unauthorised immigrants by United States (U.S.) Immigration and Customs Enforcement (ICE) has steadily increased despite declining rates of unauthorised migration. ICE detainees are held in overcrowded detention centres, often without due process and deprived of adequate food, sanitation, and medical care. Conditions of ICE detention contribute to malnutrition and increase the likelihood of infectious disease exposure, including tuberculosis (TB). TB infection interacts with Type 2 Diabetes (DM2), disproportionately affecting individuals who are routinely targeted by federal immigration practices. When two diseases interact and exacerbate one another within a larger structural context, thereby amplifying multiple disease interactions, this is called a syndemic. In this paper, we examine malnutrition in ICE detention as a pathway of bidirectional risks for and interactions between TB and DM2 among ICE detainees. Drawing from literature on detention conditions, TB, and DM2 rates along the U.S.-Mexico border, we propose an ICE-TB-DM2 syndemic model. We present a map displaying our proposed syndemic model to demonstrate the spatial application of syndemic theory in the context of ICE detention, strengthening the growing scholarship on syndemics of incarceration and removal.

Molecular clustering of patients with Mycobacterium tuberculosis strains cultured from the diabetic and non-diabetic newly diagnosed TB positive cases

BACKGROUND

Social determinants of health, biological, and individual variants have been associated with Pulmonary TB (PTB) case clustering. None of the studies have focused on diabetes mellitus (DM) despite it being one of the co-morbidity affecting TB patients. Minimal data is available and it is not clear whether patients with DM and TB are more likely than TB patients without DM to be grouped into similar molecular clusters thus indicating a bias in transmission among TB/DM co-morbidity patients.

OBJECTIVE

To determine proportion of TB strains within TB and TB/DM cases that were clustered with their corresponding clinical outcomes and hence could be attributable to active TB transmission in the two urban counties of Nairobi, Kenya.

METHODS

We carried out a prospective cohort study of non-pregnant patients aged 15 years and above that tested positive for TB in two peri‑urban counties in Kenya between February 2014 and August 2015. Clinical and socio-demographic data were obtained from a questionnaire and medical records of the National TB program patient data base at two, three, five and six months. Spoligotyping data was then obtained and compared from previously identified strains in a data bank from the spolDB4.

RESULTS

We identified 7 different TB strains out of which East Asia Beijing, Euro America and Indo oceanic being the most dominant strain within the two counties accounting for 92.4% of the infections. DM was not a significant factor in increasing the likelihood of PTB patients to cluster according to the genotype of the infecting Mycobacterium tuberculosis bacillus. TB lineages, DM and County of the patient were found to be independent of the clinical outcomes that were observed in the study.

CONCLUSION

Diabetes mellitus is not a significant factor in increasing the molecular clustering among PTB patients.

Use of classification and regression tree (CART), to identify hemoglobin A1C (HbA1C) cut-off thresholds predictive of poor tuberculosis treatment outcomes and associated risk factors

Background

Rifampin-based therapy potentially exacerbates glycemic control among TB patients who are already at high risk of hyperglycemia. This impacts negatively to the optimal care of TB- diabetes mellitus co-affected patients. Classification and regression tree (CART), a machine-learning algorithm impervious to statistical assumptions is one of the ideal tools for clinical decision-making that can be used to identify hemoglobin A1C (HbA_1C) cut-off thresholds predictive of poor TB treatment outcomes in such populations.

Methods

340TB smear positive patients attending two peri-urban clinics were recruited and prospectively followed up for six months. Baseline HbA_1C and random blood glucose (RBG) levels were determined. CART was then used to identify cut-off thresholds and rank outcome predictors at end of therapy by determining Risk ratios (RR) and 95% confidence interval (CI) of each predictor threshold. Fractal geometry law explained effect of weight, while U-shaped curve explained effect of HbA_1C on these clinical outcomes.

Results

Of the 340 patients enrolled: 84%were cured, 7% completed therapy and 9% had unfavorable outcomes out of which 4% (n = 32) had microbiologic failure. Using CART HbA_1C identified thresholds were >2.95%, 2.95–4.55% and >4.55%, containing 8/11 (73%), 111/114 (97%) and 189/215 (88%) of patients who experienced favorable outcomes. RR for favorable outcome in patients with weight <53.25 Kg compared to >53.25 Kg was 0.61 (95% CI, 0.45–0.88) among patients with HbA1C >4.55%. Simulation of the CART model with 13 patients data failed therapy revealed that 8/11 (73%) of patients with HbA1C <2.95%, 111/114 (97%) with HbA_1C between 2.95% and 4.55% and 189/215 (88%) of patients with HbA1c >4.55% experienced microbiologic failure.

Conclusion

Using fractal geometry relationships to drug pharmacokinetics, low weight has profound influence on failure of anti-tuberculosis treatment among patients at risk for diabetes mellitus.

Screening for Diabetes Mellitus among Tuberculosis Patients: Findings from a Study at a Tertiary Hospital in Lusaka, Zambia

BACKGROUND

Diabetes mellitus (DM) is known to be associated with active tuberculosis (TB). Zambia is a low-income sub-Saharan African country with a high TB burden and increasing numbers of newly diagnosed DM patients.

MATERIALS AND METHODS

This was an observational study conducted at the University Teaching Hospital in Lusaka, Zambia, from October 2014 to February 2016. Adult patients with active TB were screened for DM.

RESULTS

A total of 127 individuals were enrolled in the study. Six patients (5%) were found to have diabetes. Of these, three had a prior diagnosis of diabetes and were on medication while three were newly diagnosed. Low education level was significantly associated with DM (p=0.001; 95% CI 0.001-0.148).

CONCLUSION

The prevalence of DM among individuals with smear positive TB in our study population was similar to that of the general population in Zambia.

Hematological and Biochemistry Profile and Risk Factors Associated with Pulmonary Tuberculosis Patients in Guyana

Objective. To evaluate the hematological and biochemistry profile of patients with or without HIV-TB at the Georgetown Chest Clinic, Guyana. Methods. An observational, laboratory based study was designed to assess the relationship of PTB and HIV with patients routine biochemical and hematological values. The study was conducted during the period January 2013 to December 2014; a total sample size of 316 patients was enrolled following exclusion and inclusion criteria. Results. Mean age of study population was 40.1 ± 13.8 (95% CI 38.6–41.7) and most were between 40 and 49 age group (27.8%, 95% CI 23.2–33.0). More males were in the study 74.4% (95% CI 69.3–78.8) than females 81% (95% CI 21.1–30.7). 30% (95% CI 25.3–35.3) had a sputum smear grade of 3+ and 62.5% (95% CI 47.0–75.7) showed a CD₄ count <200. The study demonstrated significantly low hemoglobin (Hb) 91.7% (95% CI 78.2–97.1), low WBC 27.8% (95% CI 15.8–44.0), high indirect bilirubin 7.4% (95% CI 2.1–23.3), ALT 41.8% (95% CI 28.4–56.7), and AST 72.2% (95% CI 57.3–83.3) among TB-HIV patients. Homelessness RR (relative risk) 2.2 (95% CI 0.48–12.3), smoking RR 1.09 (95% CI 1.01–1.19), and gender (male) RR 1.2 (95% CI 0.61–2.26) were main associated risk factors. Conclusions. There is slight variation among PTB and PTB-HIV coinfected patients in some hematological and biochemistry parameters.

Management of diabetes in resource-poor settings

Diabetes mellitus is an emerging problem in the developing world. In sub-Saharan Africa, for example, the incidence and prevalence of the disease is unknown, diagnosis is often made on the basis of poor information and a loosely defined set of criteria, and access to oral hypoglycaemic agents and insulin is patchy and expensive. The best system of management is currently unclear and this article explores lessons learnt, good practice and the applicability of the structured 'directly observed treatment, short course' (DOTS) approach (the current best care system for tuberculosis disease management in resource-poor settings) to the management of chronic diseases such as diabetes.

The effect of combination IFN-alpha-2a with usual antituberculosis chemotherapy in non-responding tuberculosis and diabetes mellitus: a case report and review of the literature

A limited number of publications indicate that certain interferons (IFNs) may have a role in difficult-to-treat tuberculosis. We present a 48-year-old male diabetic patient who was referred to our department with the presumptive diagnosis of multidrug resistant tuberculosis. During the previous 8 months, he had been treated initially with a four-drug regimen (rifampicin, isoniazid, pyrazinamide, and ethambutol), which was later modified by the addition of streptomycin and ciprofloxacin, but his clinical condition had not improved and his sputum smear microscopy had remained positive to acid-fast bacilli. Cultured Mycobacterium tuberculosis from his sputum was sensitive to rifampicin and isoniazid. We administered IFN-alpha-2a at a low dose of 3 million IU intramuscularly weekly, in combination with isoniazid, rifampicin, ethambutol, and pyrazinamide. Two months after initiation of this therapy, sputum smears became negative, and a dramatic improvement in the patient's clinical and radiological findings occurred. During a 4-year follow-up, all consecutive sputum cultures remain negative. This case provides additional confirmation that certain IFNs could, potentially, be useful as therapeutic adjuncts for selected cases of non-responding tuberculosis and, therefore, merit further consideration.

Host susceptibility to tuberculosis: insights from a longitudinal study of gene expression in diabetes

Tuberculosis (TB) remains a major global disease, and diabetes, which is documented to increase susceptibility to TB threefold, is also becoming pandemic. This susceptibility has been attracting extensive research interest. The increased risk of TB in diabetes may serve as a unique model to understand host susceptibility to specific pathogens in humans. To examine this rationale, we investigated the expression of reported TB candidate genes in a longitudinal diabetes study. Two genes, HK2 and CD28, emerged as potential culprits in diabetes-increased TB susceptibility.

Editorial: "Old lamps for new"

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