TB with DM a double edged sword

Welcome you all

Dr. Rajat SR Biswas, MD

• Tuberculosis with DM

AFB +ve PTB with irregular intake of Anti TB with DM, Male, age 55 years! Diagnosed in Omam

History of PTB 4 years back with new onset fever and cough, male, 65 years with DM, AFB

negative

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!

35 years old male Diabetic had Fever for 7 days with cough

Male 72 years on Insulin had history of fever and cough for last one month

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

TYPICAL CHEST X-RAY

ATYPICAL CHEST X-RAY

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.

Thanks