Some x-rays of TB patients, some study and some basic in with DM.

1. Welcome you all

2. Dr. Rajat SR Biswas, MD

3. • Tuberculosis with DM

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

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

9. 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!

10. 35 years old male Diabetic had Fever
for 7 days with cough

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

12. 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!

15. Global Burden of DM and TB
Diabetes 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]

16. 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]

17. The global increase in DM
• 2010 285 million with DM
• 2030 440 million with DM
[Diabetes Atlas: International Diabetes federation, 2009]

18. 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

19. Risk of active TB increased in…
• HIV/AIDS
• Other causes of immune suppression (steroids)
• Silicosis
• Malnutrition
• Smoke from domestic stoves and cigarettes
• Diabetes mellitus

20. 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

21. 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

22. Diabetes Mellitus associated with:
• Pulmonary microangiopathy
• Renal failure
• Micronutrient Deficiency
ALSO:-
Increased
risk of TB

23. 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

24. TYPICAL CHEST X-RAY
ATYPICAL CHEST X-RAY

25. 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

26. 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

27. 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%
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 
1
1 1
P RR
PAF
P RR
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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.

28. Thanks