Welcome you all
Aug 09, 2015
A men 50 years with Type 2 DM, with fever, cough and weakness! AFB negative, ESR 67 and MT negative! Amoxyclav given and had
symptomatic improvement!
Pleural calcification in the left is due to the sequele of chest injury with history of hemothorux drainage 6 years back and now in the left there is sputum positive TB lesion! Patient is diabetic also! Left lung is shrinked with evidence of rib crowding with over inflation of right lung is there also!
Global Burden of DM and TBDiabetes Mellitus: 2008
• 250 million people living with DM
• 6 million new cases each year
• 3.5 million people died of DM during the year
[World Diabetes Foundation 2009]
Tuberculosis: 2009
• 14.0 million people living with TB
• 9.4 million new cases each year
• 1.7 million people died of TB during the year
[WHO- Global TB Control 2010]
Global Distribution of DM and TB
Diabetes Mellitus: 2008
• South East Asia 20%
• Western Pacific 23%
• Africa 5%
70% in LIC and MIC
[World Diabetes Foundation 2009]
Tuberculosis: 2009
• South East Asia 35%
• Western Pacific 20%
• Africa 30%
95% in LIC and MIC
[WHO- Global TB Control 2010]
The global increase in DM
• 2010 285 million with DM
• 2030 440 million with DM
[Diabetes Atlas: International Diabetes federation, 2009]
M.tuberculosis bacteria
2.0 billion people carry this bacteria in their bodies
TUBERCULOSIS
Life-time risk of active TB = 5-15%
THE TUBERCLE BACILLUS
Risk of active TB increased in…
• HIV/AIDS• Other causes of immune suppression (steroids)
• Silicosis• Malnutrition• Smoke from domestic stoves and cigarettes• Diabetes mellitus
Diabetes Mellitus increases the risk of TB by a factor of 2 - 3
Dooley and Chaisson, Lancet Infectious Diseases, 2009
Ruslami et al, Tropical Medicine & International Health, 2010
Goldhaber-Fiebert et al, International Journal Epidemiology 2011
Is this biologically plausible?
YES:-• Animal models – diabetic mice have impaired
CMI and have higher M.TB loads than normal mice
• Patients with DM have low levels of IFN-gamma, reduced white cell killing activity
DM impairs innate and immune responses to TB
Diabetes Mellitus associated with:
• Pulmonary microangiopathy
• Renal failure
• Micronutrient Deficiency
ALSO:-
Increased risk of TB
2. Diagnosis of TB and DM
Two main problems:-
• In patients with TB, DM is not suspected or recognised
• In patients with DM, TB may present differently and may not be diagnosed
Why an increased risk of adverse outcomes?
• Drug-drug interactions between oral hypoglycaemic drugs and rifampicin (decreased RF concentrations
and poor glycaemic control)
• DM is a risk factor for hepatic toxicity with TB drugs
• Immune-suppressive effects of DM
Summary: DM-TB is “similar” to HIV-TB
HIV-TB• Increased TB cases• More difficult to
diagnose TB cases• Increased death• Increased recurrent TB
DM-TB• Increased TB cases• More difficult to
diagnose TB cases• Increased death• Increased recurrent TB
Int J Tuberc Lung Dis 2011; 6 September epub ahead of print
Proportion of TB burden attributable to some major risk factors in high TB burden countries
Relative risk for active TB disease
Weighted prevalence
(adults 22 HBCs)
Population Attributable
Fraction (adults)
HIV infection 20.6/26.7* 0.8% 16%
Malnutrition 3.2** 16.7% 27%
Diabetes 3.1 5.4% 10%
Alcohol use (>40g / d)
2.9 8.1% 13%
Active smoking 2.0 26% 21%
Indoor Air Pollution
1.4 71.2% 22%
1
1 1
P RRPAF
P RR
Sources: Lönnroth K, Castro K, Chakaya JM, Chauhan LS, Floyd K, Glaziou P, Raviglione M. Tuberculosis control 2010 – 2050: cure, care and social change. Lancet 2010 DOI:10.1016/s0140-6736(10)60483-7.