ABSTRACT

CORRESPONDING AUTHOR:
Bhupendra Kumar Ratre,
B-4, J K Hospital Campus,
Kolar Road,
Bhopal-462042.
Email: bkratre@gmail.com

ABSTRACT: INTRODUCTION: The coexistence of diabetes and tuberculosis is common and challenge to the community. Diabetes predisposes to tuberculosis and treatment often become complicated. Though the prevalence of tuberculosis is decreasing due to success of combination chemotherapy but coexistence of diabetes with tuberculosis poses a threat to success of anti-tubercular program. India has huge burden of the both diabetes and tuberculosis. We did a prospective study to know the prevalence of diabetes in tuberculosis patients in a tertiary care hospital. MATERIAL AND METHOD: We recruited the patient with tuberculosis in department of general medicine and department of TB and Chest. We screened them for diabetes with fasting blood sugar. RESULTS: Out of total 419 patients who were included in the study 135 patients were found to be diabetic. A prevalence of 32.2% was found in the study. CONCLUSION: The prevalence of diabetes in tuberculosis is very high as compared to that of general population. We recommend that the entire tubercular patients should be screened for diabetes and vice versa at the time of diagnosis, and effective management of both diseases will leads to improve treatment outcome.

KEYWORDS: Diabetes Mellitus, Tuberculosis, Fasting Blood Sugar (FBS), Anti-Tubercular Treatment (ATT), Sputum.

INTRODUCTION: The association of diabetes mellitus and tuberculosis is known since ages. Both the disease present challenge to community due to associated morbidity and mortality. Indian subcontinent contribute big share to the total prevalence of both the diseases globally. The tuberculosis control program has been able to achieve good cure rates in tuberculosis patients without any co morbid conditions.

Diabetes mellitus in tuberculosis present tough challenge to the success of anti-tubercular therapy and overall cure rates. The incidence and prevalence of diabetes is increasing explosively in Southeast Asian countries. So it is expected that population with diabetes and tuberculosis will increase.

Approximately 95% of tubercular patients and 70% of diabetic patients are living in low and middle socio-economic population all over the world^{1, 2}. India is currently hosting huge disease burden of tuberculosis and diabetes mellitus both. Worldwide 33% of population is infected with tubercular bacteria, 8.6 million peoples developed tuberculosis, and 1.3 million people die annually because of this.³

In India 3.1 million persons are diagnosed to have tuberculosis with mortality rate of 0.32 million per year.⁴ Globally India constitute 20 -25 % cases of all tubercular patients.⁴ India is having the second large population of diabetic patients in the world.

Approximately 65.1 million adults are suffering from diabetes mellitus age 20 years and above, giving prevalence of 9.09% and 21.5 million persons were having impaired glucose tolerance.⁵

Diabetes produces an immune-compromised state and diabetic patients are more prone for acquired infections. Previous studies have shown that diabetic patients are three times more prone to develop tuberculosis.^{6, 7} Treatment response of ATT is also varied in diabetic patients in the form of delayed treatment response, treatment failure, relapses, drug resistance and more numbers of death.⁸

 Anti-tubercular drugs also decrease the effectiveness and concentration of anti-diabetic drugs and make blood sugar control difficult.⁹

WHO and the International Union against Tuberculosis and Lung Disease (IUALTD) have jointly published guidelines for joint management of tuberculosis and diabetes mellitus and it recommend simultaneous screening for tuberculosis and diabetes mellitus.¹⁰

The present study we plan to estimate the prevalence of diabetes in Tubercular patients who presented to our institute for management of Tuberculosis.

MATERIAL AND METHODS:

Study Design, Period, Patient: We conducted a prospective observational study in our institute in Department of General Medicine and Department of TB and Chest.

Patient’s age 15 years and more who diagnosed as tubercular case and was registered with our institute DOTS centre from January 2012 to January 2014 were included in the study. All the confirmed cases were started on Anti- Tubercular drugs according to Revised National Tuberculosis Control Program (RNTCP).¹¹

All the patients to whom anti tubercular drug were started; fasting blood glucose test (FBS) (after 8 hour fasting) was done. If FBS was <110mg%, we consider them as non-diabetic patients. If fasting blood glucose was >126mg% we considered them as diabetic patients and included in study. Patients whose FBS was between 110 and 126 mg%, they were considered as having impaired glucose tolerance and was not considered as diabetic.¹²

We followed the guidelines for diagnosis for diabetes given by WHO and International Diabetic Federation (IDF).¹² Patients who were already diagnosed as a case of diabetes mellitus and diagnosed to have new onset tuberculosis were also included in the study.

Tubercular patients with other co morbid conditions like HIV, chronic kidney disease, chronic liver disease, chronic alcoholism, malignancies and patients on long term steroids were excluded from study.

RESULTS: Over 419 patients were diagnosed as tubercular patients during study period, 271 patients were male (64.67%) and 148 were females (35.33%). Most number of patients was from young age groups i.e. from 15-40 years.

Out of 271 male patients, 148 (54.6%) were sputum positive for AFB, 67 (24.7%) were sputum negative and rest 56 (20.6%) were case of extra pulmonary tuberculosis. In female group out of 148 patients 53 (35.8%) were sputum positive for AFB, 49 (33.1%) were sputum negative and rest 46 (31.0%) were extra pulmonary tuberculosis. In both male and female group most common extra-pulmonary tuberculosis was pleural effusion.

Out of 419 patients 300(71.6%) were started on treatment category – I and 119 (28.4%) were started on category – II.

Out of 419 Patients 63 patients (15%) was already diagnosed case of diabetes mellitus as they were taking either OHAs or insulin, so no further screening was done in these patients. Rest 356(85%) patients were screened with FBS, Out of 356 patients 72 (17.18%) patients were having FBS >126 mg%, and diagnosed as case of diabetes mellitus. 80 (19%) patients were having FBS between 110- 126mg%, and considered as having impaired glucose tolerance. Out of 419 tubercular patients diagnosed case of tuberculosis (old + new) were 135(32.2%).

Out of 135 patients of diabetes + tuberculosis 96 (77.11%) patients were male and 39(28.88%) patients were females. Out of 96 diabetic – tubercular males 67(69.49%) were sputum positive while out of 39 females 22(56.41%) were sputum positive.

DISCUSSION: Diabetes mellitus is progressing as an epidemic, in India its overall prevalence is 9.09%³ but incidence of diabetes is different in different regions of country. Incidence of diabetes in central India is not known. Diabetic patients are more prone for acquired secondary infections. Large number of studies in past shown important association between diabetes and tuberculosis and diabetes is an important risk factor for the development of tuberculosis.^{13, 14}

 In present study we planned to see the prevalence of diabetes in tubercular patients. In our study we found 15 percent of cases of tuberculosis were already having diabetes and after screening we diagnosed 17 percent new cases in the study group. So in our study overall prevalence of diabetes was 32.2 percent in tuberculosis patient and it was much higher than the prevalence of diabetes in general population.

The similar high prevalence of diabetes in tuberculosis patient was also reported in studies from southern region of India and abroad. Study from Tamil-Nadu reported diabetes prevalence of 25% in tubercular patients¹⁵. A study from Kerala reported diabetes prevalence of 44% in tubercular patients.¹⁶ The prevalence of diabetes in both the studies was much higher than the prevalence of diabetes in general population. Recently published study from Pondicherry also showed higher diabetic prevalence of 29% in tubercular patients.¹⁷

In Study by Jimenez- corona et al they found a high prevalence of diabetes of 29.63% in tubercular patients, they also reported that dual disease (diabetes+ tuberculosis) was associated with increased morbidity, more pulmonary cavities, delayed sputum conversion, high rate of treatment failure and high recurrence and relapse rate.¹⁸

In our study we found that 19% of tubercular patients were having impaired glucose tolerance. Similar high prevalence of impaired glucose tolerance of 16.98% was also reported by Jain et al. But they have used oral glucose tolerance test for diagnosis¹⁹.

In our study most of the tubercular patients were from younger age group i.e. age < 40 years where as majority patient of dual disease were from 40 plus age, which may be explained by the fact that younger population is more likely to receive medical attention in this region because of poor healthcare infrastructure and malnutrition and low birth weight may be the other important reason.

The majority of patients with dual disease were more than 40 years as the incidence of diabetes increases with age. This finding was partially contradictory to some previous studies done in Korea, Pakistan and India^{20, 21, 22} in which the incidence of both tuberculosis and diabetes increases with age.

In our study group sputum positive patient (non-diabetic + diabetic group) was 54.6% while sputum positive rate was 65.92% in diabetic tubercular group. It shows high number of sputum positivity in diabetic patient. This finding was consistent with study done by Stevenson CR et al, in which the prevalence of sputum positive tuberculosis was 69.2%.²³

Prevalence of diabetes in tubercular patients is very high and diabetes adversely affects the management of tuberculosis so it should be mandatory to screen all the tubercular patients for diabetes. So timely detection and management of diabetes leads to decrease morbidity and improve the treatment outcome in tubercular patients.

CONCLUSION: Overall prevalence of diabetes in tubercular patients is 32.2% in our study and impaired glucose tolerance was seen in 19% tubercular patients. This shows high burden of diabetes in tubercular patients in this region of country. Diabetic patient also have high number of sputum positive cases. So we recommend that the entire tubercular patient should be screened for diabetes at the time of diagnosis and effective management of both diseases will leads to improve treatment outcome.

We also recommend further multi-centric studies with large sample size to know the true prevalence of diabetes in tubercular patients in India. Also as the number of diabetic population is growing it is anticipated that the disease burden with dual disease will grow and hence specific guidelines for management of the dual disease may help in improving the overall success of treatment. More focused research in this domain is required to deal with deadly combination of diseases.

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