Online Journal of Health and Allied Sciences

Peer Reviewed, Open Access, Free Online Journal

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Published Quarterly : Mangalore, South India : ISSN 0972-5997 This work is licensed under a
Volume 15, Issue 3; Jul-Sep 2016 Creative Commons Attribution-
No Derivative Works 2.5 India License

Original Article:
Effect of Type 2 Diabetes Mellitus on Clinical and Radiological Presentation and Drug
Resistance in Pulmonary Tuberculosis

Authors
Sukriti Arora, MBBS Student,
Bharti Chogtu, Department of Pharmacology,
Rahul Magazine, Department of Pulmonary Medicine,
Kasturba Medical College, Manipal, Manipal University, Karnataka 576104, India.

Address for Correspondence

Dr. Rahul Magazine,
Department of Pulmonary Medicine,
Kasturba Medical College, Manipal,
Manipal University,
Karnataka - 576104, India.
E-mail: rahulmagazine@gmail.com

Citation
Arora S, Chogtu B, Magazine R. Effect Of Type 2 Diabetes Mellitus on Clinical and Radiological Presentation and Drug Resistance in
Pulmonary Tuberculosis. Online J Health Allied Scs. 2016;15(3):5. Available at URL: http://www.ojhas.org/issue59/2016-3-5.html

Open Access Archives

http://cogprints.org/view/subjects/OJHAS.html
http://openmed.nic.in/view/subjects/ojhas.html

Submitted: Aug 4, 2016; Accepted: Oct 7, 2016; Published: Oct 25, 2016

Abstract: Studies suggest that tuberculosis (TB) patients with
diabetes mellitus (DM) present atypically. This study was
done to assess symptoms, radiological findings and multidrug
resistance in TB patients with or without diabetes. A
prospective study on 100 TB patients was carried out in a
tertiary care hospital. The clinical presentation of patients in
two groups did not vary. Bilateral and lower lobe involvement
was seen more in diabetics. Lung cavitation and multidrug
resistance was predominant in non-diabetics. Though clinical
presentations remain the same, radiological findings vary in
diabetics. This information can help in better understanding
and thereby better treatment outcomes in patients with TB and
DM.
Key Words: Tuberculosis, diabetes mellitus, radiological
findings
Introduction:
Diabetes Mellitus (DM) and tuberculosis (TB) represent a
critical intersection between communicable and non-
communicable diseases in developing countries. Studies
examining the incidence of TB show that patients with DM
have 1.5 times higher risk of developing TB than the non-
diabetic ones.[1] A systematic review of 13 studies suggested
that diabetic patients had about a 3-fold risk of developing TB
when compared to those without diabetes.[2] The association
between these two diseases may become even more important,
as the prevalence of diabetes is on rise.[3]
Two factors responsible for treatment failure in TB with DM
are chronic hyperglycemia disabling the immunity to
mycobacterial TB [4] and suboptimal plasma levels of
antitubercular drugs in diabetics as compared to non-
diabetics.[5] Evidence concerning radiological appearances in
TB patient groups with and without concurrent DM is
conflicting. Some studies suggest that TB patients with DM
are more likely to present with atypical images [6] whereas
others suggest there are no differences in the radiological
findings.[7] Diabetes cause changes in the clinical
manifestations of TB, often exacerbating them. Effects of DM
on the treatment and outcomes of TB infection show varied
results.[8] An association between DM and multi-drug
resistant TB (MDR-TB) has been shown in some studies [9],
while others suggest that there exists no association.[10] Since
the nature of relationship between DM and TB has been
evaluated but not fully understood, the study assessed the
clinical presentation, chest X-Ray findings and multi-drug
resistance in TB patients with and without DM.
Materials and Methods
A prospective study was performed in diagnosed cases of
pulmonary TB with or without concurrent diabetes mellitus in
a tertiary care hospital in South India after approval from the
Institutional ethics committee. The patients were enrolled as
per the inclusion criteria and a written informed consent was
taken. Patients of tuberculosis of both sexes aged over 12 years
with or without diabetes were included in the study. The
investigator visited the pulmonary medicine wards and
recorded the baseline investigations-like hemoglobin, ESR
and sputum status of patients diagnosed with pulmonary TB.
The presenting symptoms, radiological findings, and presence
or absence of MDR tuberculosis in TB patients without DM
was compared with those with concurrent DM.
Results:
A total of 100 patients with pulmonary tuberculosis were
included in the study. The following results were obtained:
1. Socio-demographic Parameters: The patients were in the
age group of 16-89 years. Of these, patients in the age group
of 41-60 years constituted 47% of the study population. The

1
number of male patients (67%) was almost double that of
females (33%). Most of the patients were agriculturists(39), 7
were drivers and of the 33 females, 27 were homemakers.
2. Baseline Investigations: 56% of the patients had
hemoglobin less than 12g%. 89% of the patients had high ESR
values. Deranged renal function tests were noted in 19% of the
patients.A high proportion (~50%) of the patients was found
to have abnormal liver function tests. The random blood
glucose of diabetics and non-diabetics is shown in Fig 1. WBC
count was increased in 60% of patients.

Fig 4: Presenting Symptoms: Diabetics (N = 44)

LOA/LOW=loss of appetite/loss of weight

Fig 1: Random Blood Sugar levels of patients

3. Treatment category: Out of the 44 patients with concurrent
diabetes, 32 were on Category I DOTS, 8 on Catgory II and 4
were prescribed MDR TB treatment (Fig. 2). Out of the 56
non-diabetic patients , 31 were on Category I, 15 on Category
II and 10 on treatment for MDR-TB (Fig.3)
Fig 5: Presenting Symptoms: Non-Diabetics (N = 56)
LOA/LOW=loss of appetite/loss of weight
5. Radiological Findings:
Bilateral lung involvement was seen more in diabetics as
compared to non-diabetics (Figure 6)

Fig 6: Involvement of Lungs

Fig 2: Treatment Plan: Diabetics (N = 44)

Fig 7: Lobar Involvement

Lobar Involvement: Lower lobe involvement was more in
diabetics as shown in Figure 7
Lung Cavitation: Lung cavitation was more in nondiabetics
as compared to diabetics as shown in Figure 8

Fig 3: Treatment Plan: Non-Diabetics (N = 56)

4. Clinical Features: Presenting symptoms of diabetics and
non diabetics with pulmonary tuberculosis is shown in the
following Figures 4,5.

Fig 8: Lung Cavitation

2
Discussion:
Co-morbidity with TB and DM is associated with deterioration
in both the conditions. It is therefore important that poor
glycemic control in patients suffering from chronic infectious
diseases like TB be taken care of. Also TB, a chronic infection,
can be associated with reactionary hyperglycemia secondary
to increased production of counter-regulatory stress hormones
like epinephrine, glucagon, cortisol, and growth hormone that
act synergistically.[11] DM alters the clinical presentation of
TB and its outcomes like delayed sputum conversion,
treatment failure and increased mortality.[12] DM increases
the risk of TB, and on the other hand affects anti-tubercular
treatment adversely.[13] Increased blood glucose levels also
decrease the mobility, adhesion, and bactericidal phagocytosis
of white blood cells.[14] DM by suppressing immunity
decreases ability to produce immunoglobulin and lymphocyte
transformation for immune protection thereby impairing the
function of T cells, B cells, and antibodies.[15] TB patients
with DM have a higher risk of death when compared to TB
without DM.[13]
This prospective study was performed to assess the clinical
and radiological manifestations and drug resistance in a total
of 100 diagnosed cases of Pulmonary TB with and without co-
existent Type 2 Diabetes Mellitus, number of patients in each
group being 44 and 56 respectively. The sputum status of 96
of these patients was positive for acid-fast bacilli whereas the
bacilli were demonstrated in the bronchial lavage fluid of 4
patients.
Patients were in the age group of 16-89 years. Those in the age
group of 41-60 years comprised 47% of the study population.
Also, 26 patients belonged to the age group of 20-40 years,
indicating that a large proportion of the working population is
affected by the disease. This results in loss of productive days
directly due to the disease. Of the patients, 67% were males,
most of them agriculturists and daily wage workers. This is in
consistence with the fact that overcrowded houses and poor
ventilation increase both the likelihood of exposure to
tubercular bacilli and progression to disease.
The baseline investigations showed that 56% of the patients
had hemoglobin levels less than 12 gm%. Anemia was
observed in 32-94% of patients with tuberculosis.[16]
Malnutrition is severe in patients of tuberculosis with anemia
as compared to those without anemia.[17] Most of them (89%)
had raised ESR. These findings reassert that active TB is
mostly associated with very high ESR values (>100 mm/hr) as
stated in a study conducted in South Africa.[18]
The treatment group of Category I includes the newly
diagnosed sputum smear positive or sputum smear negative
pulmonary TB patients. Cases of sputum positive relapse,
sputum positive failure or re-treatment after default are
included in category II. Patients in whom the tubercular
isolates are multiply resistant to isoniazid and rifampicin, the
most powerful first line anti-TB drugs are labeled as MDR-TB
patients. It was observed in our scenario that most of the
diabetic patients (73%) were receiving Cat I DOTS, 18% on
Cat II and there were 4 cases of MDR TB. Of the non-
diabetics, 55% were receiving Cat I DOTS, Cat II was being
given to 27% and 10 were multi-drug resistant. A study
conducted in Saudi Arabia proposed that pulmonary TB-DM
patients had a lower prevalence of resistance to any anti-
tubercular drug (6.4% vs. 16.0%).[8] A study done in Texas
and Mexico on the contrary found that type 2 diabetes mellitus
patients with TB were more prone to drug resistance.[19]
Sputum smear-positive PTB is more common in TB patients
with DM [20], while no difference in type of TB at diagnosis
has also been reported.[21] In sputum smear conversion at 2
months, no significant differences among sputum smear-
positive TB patients with and without DM was noted and there
was no difference in the rates of treatment success between the
two groups.[22] So authors are of the opinion that presence of
DM does not adversely affect the outcomes in TB.
The presentation of TB in diabetic subjects may not always be
different as they manifest themselves with the common
symptoms in diabetic subjects as in any other individual
without DM. In agreement with this statement, patients from
both groups presented with similar symptoms; fever with
cough being the commonest symptom. 26 out of the 44
diabetic patients manifested dry cough whereas 13 had cough
with expectoration. This was comparable with the non-
diabetic group in which the number of patients presenting with
dry cough and cough with expectoration was 33 and 12
respectively. Loss of weight and loss of appetite was seen
more frequently in the non-diabetic patients (33.9% vs 22.7%
). A possible explanation of this finding may be that obesity
and weight gain are important determinants of insulin
resistance.
A study done in Thailand including 227 patients with TB
proclaimed that significantly higher proportion of TB patients
with DM presented with anorexia and haemoptysis whereas
cough was predominant in patients without DM.[23] In
another study, no significant difference between symptoms
was seen between patients of TB with or without diabetes.[24]
In the present study, 46.4% of the non-diabetic patients had
isolated left lung lesions in contrast to only 29.5% of those
with concurrent diabetes. Bilateral lung involvement was seen
in 22 diabetic and 17 non-diabetic patients. Lower lobe
involvement was more in diabetics as compared to non-
diabetics which has been reported in other studies.[25] Isolated
lower lung field TB was seen in 6.2% of patients and the
proportion of patients with isolated lower lung field TB was
higher among diabetes (11%) in comparison to non-diabetic
patients(5.3%).[26] Diabetes-related opacities in lower lung
field was seen predominantly in younger patients.[27] Tight
glycemic control might reduce diabetes-related radiographic
change in lower lung field.[27]
Cavitary lesions were found in 8 non-diabetic and only 2
diabetic subjects. As lung cavities are associated with higher
bacterial burden in sputum, TB patients with DM contribute in
spread of TB. Reports regarding higher bacillary burden in
patients with diabetes is conflicting.[28] In a retrospective case
controlled study, comparing the radiological appearances of
tuberculosis in 100 diabetics with controls, it was revealed that
cavitation occurred less frequently in diabetics as compared to
controls.[29] In patients with bilateral lung involvement,
lesions were worse on the left in the diabetics (27% versus
15% in controls.[29]
Of total 318 newly diagnosed patients with TB it was found
that patients with TB-DM had more cavitation, higher smear
grade and more multidrug-resistant TB. However, the
treatment outcome was similar in the two groups.[30] In a
study of 192 patients, diabetics with TB had more severe
infections, higher mycobacterial loads, higher treatment
failure rates and longer delayed clearance of mycobacteria
than TB patients without diabetes. After one year, three
patients from diabetes group and one TB patient had MDR-
TB. Mycobacterial strains were not significantly different in
the two groups.[31]
Evidence for an association between DM and TB affecting
both disease rates and outcomes is growing. People with DM
may be important targets for interventions such as active case
finding and treatment of latent TB. In people with TB it may
be appropriate to actively screen for hyperglycemia. An
optimal glycemic control results in a better patient outcome;
therefore vigorous efforts should be made to achieve such
control. Authors have suggested that all confirmed TB patients
be systematically screened for diabetes, and that all diabetic
patients be screened for TB when symptomatic.[32] It is
conceivable that without active intervention the burgeoning
diabetes epidemic will adversely impact TB control in India.
3
A better understanding of the differences in clinical and
radiological manifestations would help in managing TB with
concomitant diabetes in a rational way and lead to better
treatment outcomes.
Acknowledgements:
Authors acknowledge Indian Council of Medical research for
its support
Conflict of Interest:
The authors declare that there exists no conflict of interest in
the making of this paper.
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