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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 3  |  Page : 268-270

The effect of glycemic control on clinico-radiological manifestations of pulmonary tuberculosis in patients with diabetes mellitus


1 Department of Respiratory Medicine, Sikkim Manipal Institute of Medical Sciences, Sikkim Manipal University, Gangtok, Sikkim, India
2 Department of Pulmonary Medicine, Ispat General Hospital, Rourkela, Odisha, India

Date of Submission18-Jun-2021
Date of Acceptance27-Jul-2021
Date of Web Publication03-Sep-2021

Correspondence Address:
Kavin Mani Saalai
Department of Respiratory Medicine, Sikkim Manipal Institute of Medical Sciences, Sikkim Manipal University, Gangtok - 737 102, Sikkim
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_133_21

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  Abstract 


Background: The association between diabetes mellitus (DM) and tuberculosis (TB) and their synergistic role in causing human disease has been recognized for centuries. Despite the known synergy between DM and TB, the importance of atypical clinical, radiological presentation and DM as a risk factor for TB is largely unknown. This study was undertaken to know the effect of glycemic control on TB manifestations as it will contribute to the opportunities for detection and treatment of both disease conditions appropriately. Methods: This cross-sectional study included 50 patients attending the pulmonary medicine department in Ispat General Hospital with pulmonary TB and DM during 6 months' period. Clinical data, chest-X ray, HbA1c values were obtained and the effect of glycemic control studied and analyzed. Results: Five patients had good glycemic control (HbA1c ≤7%), 45 patients had poor glycemic control (HbA1c >7%). Cough was present in all patients. Weight loss and night sweats were present in poor glycemic group and sputum smear grade was higher in higher HbA1c patients and both were statistically significant. None of the good glycemic group had lower zone lesion. The commonest type of lesion was nonhomogenous opacity, followed by cavities in both poor and good glycemic groups. Cavities were usually present in lower zones. Size and number of cavities were more as the glycemic control is poor. So, that glycemic control did have an effect on pulmonary TB manifestations, hence achieving and maintaining glycemic control is necessary for DM with pulmonary TB.

Keywords: Glycated hemoglobin A, glycemic control, pulmonary tuberculosis


How to cite this article:
Saalai KM, Mohanty A. The effect of glycemic control on clinico-radiological manifestations of pulmonary tuberculosis in patients with diabetes mellitus. Int J Mycobacteriol 2021;10:268-70

How to cite this URL:
Saalai KM, Mohanty A. The effect of glycemic control on clinico-radiological manifestations of pulmonary tuberculosis in patients with diabetes mellitus. Int J Mycobacteriol [serial online] 2021 [cited 2021 Dec 3];10:268-70. Available from: https://www.ijmyco.org/text.asp?2021/10/3/268/325496




  Introduction Top


The double burden of tuberculosis (TB) and diabetes mellitus (DM) is a significant public health problem, especially in India.[1] Experts suggest that TB control would be further improved by intervening patients with known determinants of TB.[2] This entails both TB prevention through actions to diminish the prevalence of risk factors and targeted diagnostic and treatment intervention in risk groups such as people with DM. Despite the known synergy between DM and TB, the importance of atypical clinical, radiological presentation and Diabetes as a risk factor for TB is largely unknown. This might lead to mismanagement of both the diseases.[3] This study is undertaken to know the effect of glycemic control on TB manifestations as it will contribute to the opportunities for detection and treatment of both disease conditions appropriately. The aim was to study the clinical profile, radiographic pattern of pulmonary TB in good glycemic control and poor glycemic control diabetic patients.


  Methods Top


Study design and study population

This cross-sectional hospital-based study included 50 patients who had Sputum positive Pulmonary TB and DM attending the Pulmonary Medicine department of Ispat General Hospital, Rourkela, Odisha, in the north-eastern part of India. This study was conducted for 2 years from June 2016 to April 2018.

Patient sampling

Adult patients of both sexes with diagnosis of diabetes and pulmonary TB were included in the study. Patients who had other comorbidities such as chronic kidney disease, chronic liver disease, connective tissue disorders, malignancy, HIV seropositivity, and patients on immunosuppressive therapy, chronic steroid use, were excluded.

Data collection

After obtaining informed and written consent from all the patients, basic demographic data such as name, age, sex, occupation, address were recorded. Clinical symptoms with which the patient attended the facility, past history of TB, anti-tubercular treatment was asked and recorded. Chest X-ray, fasting blood glucose, post prandial blood glucose, sputum AFB, and other routine investigations were done.

AFB smears were graded according to RNTCP guidelines. Chest X-rays were studied by Pulmonologists and analyzed based on the location, zone, extent, and type of lesions. HbA1c values were grouped as ≤7%, (good glycemic group) 7%–9%, 9%–12%, >12% (poor glycemic group).

Statistical analysis

Descriptive and inferential statistical analysis has been carried out. Results on continuous measurements are presented on mean ± standard deviation (minimum – maximum) and results on categorical measurements are presented in n (%). Significance is assessed at 5% level of significance.

Student t-test (two-tailed, independent) has been used to find the significance of study parameters on a continuous scale between two groups (Intergroup analysis) on metric parameters. Leven's test for homogeneity of variance has been performed to assess the homogeneity of variance. Analysis of variance has been used to find the significance of study parameters between three or more groups of patients.

Chi-square/Fisher exact test has been used to find the significance of study parameters on categorical scale between two or more groups, nonparametric setting for qualitative data analysis is used. Fisher's exact test used when cell samples are very small. P ≤ 0.05 was considered statistically significant.


  Results Top


Demographics and clinical characteristics

Of the total cases, males and females were 66%, 34% respectively. The mean age was 50.20 ± 11.88 and the most common range was 41–50 years. Cough was present in all the patients, followed by fever in 74%, hemoptysis in 42%, anorexia in 32%, weight loss in 26%, chest pain 10%, night sweats in 8%, and dyspnea in 6% of patients. The glycemic control of the patients was 10% in HbA1C <7, 90% in HbA1C >7. Out of patients with HbA1C >7, HbA1C group 7%–9%, 9%–12%, >12% had 50%, 26%, 14% respectively the most common HbA1C value was 7%–9%.

Clinical symptoms in relation to glycemic control

In HbA1C <7 group, all patients had fever; weight loss was present in 80%. Weight loss in poor glycemic group was 4% in HbA1C 7%–9%, 41.7% in HbA1C 9%–12%, 37.5% in HbA1C >12, and these were statistically significant with P < 0. 001. Night sweats were present in 8% patients totally and all of them belonged to HbA1C 9%–12% group with P = 0.007 which was statistically significant.

Acid fast bacilli smear grading in relation to glycemic control

In this study, all patients in HbA1C >12 group had AFB smear 3+ grade. In HbA1C <7 group, none had 3+ grading and this was statistically significant with P < 0.001

Chest X-ray findings in relation to glycemic control

Location

In this study, the right lung lesion was seen in 44% of patients, of these 32% belonged to HbA1C 7%–9% group, 87.5% patients belonged to HbA1C >12% group, 50% patients belonged to HbA1C 9%–12% group and 20% patient belonged to HbA1C <7% group. Left lung lesions were present in 38% patients, of these 40% patients belonged to HbA1C 7%–9%group, 41.7% patients belonged to HbA1C 9%–12% group, 60% patients belonged to HbA1C <7% group, and only 12.5% patient belonged to HbA1C >12% group. Both lungs were affected in 18% patients, of these 28% patients belonged to HbA1C 7%–9% group, 20% patient in both HbA1C <7%, 9%–12% group. No patient had both lung involvement in HbA1C >12 group.

Zone of involvement

In HbA1C group, >12%, 37.5% patients each with lesions in upper zone and midzones, and 25% patients had in lower zone. In HbA1C 9%–12% group, 41.7% patients had upper zone 33.3% patients had mid zone, 25% patients had lower zone lesions. In HbA1C 7%–9% group, 48% patients had lower zone, 36% patients had upper zone, 16% had in mid-zone lesions. In HbA1C <7 80% had lesions in upper zone, 20% of patients had mid-zone lesion. None had lesions in lower zone.

Extent of the lesion

In this study, HbA1C <7% group had 4 (80%) and 1 (20%) patient with moderate and minimal lesions respectively, none had far advanced lesions. In HbA1C 7%–9% group, 16 (64%) patients had moderate lesions, 4 (16%) patients had far advanced lesions and 5 (20%) patients had minimal lesion. In HbA1C 9%–12% group 10 (83.3%) had moderate lesion, 1 (8.3%) patient had far advanced and 1 patient had minimal lesion. In HbA1C >12% group none had minimal lesion, 6 (75%) patients had moderate lesion and 2 (25%) patients had far advanced lesions.

Type of lesion

The most common lesion was nonhomogenous opacity seen in 48% patients, followed by cavity in 34% and cavity with consolidation in 18%. In HbA1C <7% group, 40% patients had nonhomogenous opacity and cavity lesion each. Twenty percent had cavity with consolidation. In HbA1C 7%–9% group, 64% of patients had nonhomogenous opacity, 24% of patients had cavity, 12% of patients had cavity with consolidation. In HbA1C 9%–12% group, 25% patients had nonhomogenous opacity, 58.3% had cavity, 7% had cavity with consolidation. In HbA1C >12% group, 37.5% had non homogenous opacity, 25% patients had cavity, 37.5% patients had cavity with consolidation.

Cavity characteristics

Totally 26 patients had cavity. In HbA1C >12% group 37.5% patients had cavity in mid zone, 12.5% had cavity in lower zone and in upper zone each. In HbA1C 9%–12% group, 33.3% patient had cavity in lower zone, 16.7% patients had in mid-zone, 3 (25%) patients had in upper zone. In HbA1C 7%–9% group, 2 (8%) patients had lower zone cavity, 3 (12%) patients had midzone cavity, 4 (16%) had upper zone cavity. In HbA1C <7 group, none had lower zone cavity, 1 (20%) had midzone cavity, 2 (40%) patients had upper zone cavity.


  Discussion Top


In this study, the most common HbA1C value was 7%–9%, 50% of patients belonging to this group. This distribution closely matches to that seen in Chaya and Vishwakumar[4] study. Cough was present in all the patients and was the commonest symptom of presentation, followed by hemoptysis, fever, weight loss, anorexia, chest pain and night sweats. These symptoms had no relation with HbA1C value and were not statistically significant. Similarly, the study by Bokam[5] and Gopathi et al.,[6] showed no relation of HbA1C on clinical symptoms.

Several studies have reported an association between diabetes and radiographic manifestations of pulmonary TB. In this study the effect of glycemic control and the radiological presentation were studied. In good glycemic control (HBA1C <7%) patients, the left lung was involved, with more upper zone lesions and moderate involvement with nonhomogenous opacity being the most common type of lesion. In poor glycemic control group, as the HbA1C value increases, the manifestations also change. Right-sided lesions were more common in HbA1C >12% group. Moderate lesions were more common even in poor glycemic group. Lower lung field involvement was not specific to poor glycemic groups. Cavity with consolidation was the most common picture in these groups. Upper zone cavity was more common both in good glycemic and poor glycemic group. Cavity size >2.5 cm was common in poor glycemic groups. But no statistical difference was found between good and poor glycemic groups.


  Conclusions Top


HbA1C is a reliable marker for glycemic control in diabetic patients. Glycemic control has an effect on the clinical and radiological manifestations of pulmonary TB like good glycemic group (HBA1C < 7) had fewer symptoms and less severe symptoms, poor glycemic control group (HbA1C >7) had higher sputum AFB grading and was statistically significant. Lower zone involvement was not seen in good glycemic control group but was seen in poor glycemic group. Number and size of cavities were higher in the poor glycemic group.

Hence, achieving and maintaining glycemic control is necessary for diabetic patients with pulmonary TB and clinicians should be aware of the atypical presentation of pulmonary TB in diabetic patient.

Ethical clearance

Ethical clearance obtained from Institutional ethical committe.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dooley KE, Chaisson RE. Tuberculosis and diabetes mellitus: Convergence of two epidemics. Lancet Infect Dis 2009;9:737-46.  Back to cited text no. 1
    
2.
Lönnroth K, Jaramillo E, Williams BG, Dye C, Raviglione M. Drivers of tuberculosis epidemics: The role of risk factors and social determinants. Soc Sci Med 2009;68:2240-6.  Back to cited text no. 2
    
3.
Harries AD, Kumar AM, Satyanarayana S, Lin Y, Zachariah R, Lönnroth K, et al. Diabetes mellitus and tuberculosis: Programmatic management issues. Int J Tuberc Lung Dis 2015;19:879-86.  Back to cited text no. 3
    
4.
Chaya BE, Vishwakumar SN. A study of pulmonary tuberculosis in diabetes mellitus and its clinicoradiological correlation. Indian J Basic Appl Med Res 2015;4:30-8.  Back to cited text no. 4
    
5.
Bokam DB. Effect of glycemic control on radiographic presntation of pulmonary tuberculosis in Type 2 diabetes mellitus. J Med Sci Clin Res 2017;5:27457-64.  Back to cited text no. 5
    
6.
Gopathi NR, Mandava V, Makala S. Tuberculosis and diabetes: The deadly duo. Int J Adv Med Int J Adv Med 2017;22:241-5.  Back to cited text no. 6
    




 

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