Scholarly article on topic 'Clinical Manifestations and Outcome of Tuberculosis in Diabetic Patients Admitted to King Abdulaziz University Hospital in Jeddah, Saudi Arabia'

Clinical Manifestations and Outcome of Tuberculosis in Diabetic Patients Admitted to King Abdulaziz University Hospital in Jeddah, Saudi Arabia Academic research paper on "Clinical medicine"

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Abstract of research paper on Clinical medicine, author of scientific article — Aisha Mukarram Siddiqui

Abstract Objectives Compare epidemiology, clinical manifestations and outcome of tuberculosis between diabetic and non-diabetic patients admitted to King Abdulaziz University Hospital in Jeddah, Saudi Arabia. Methods Review the medical data of adult inpatients with tuberculosis from January 2002 to December 2007.Demographic data, location of tuberculosis, sputum positivity for acid fast bacilli, duration of hospitalization and outcome (relapses, drug resistance and inhospital mortality) were compared between the two groups. Results From total of 216 tuberculosis cases, 35 (16%) had diabetes. These were older in age. 68% diabetics were over 50 years compared to 16% non-diabetics. (p=0.0001). Ratio of Saudis to non-Saudis with tuberculosis was greater in diabetics than in non-diabetics (p=0.003). Pulmonary tuberculosis was the most common site affected and was associated with poor glycemic control (p=0.013). Smear positivity for acid fast bacilli was not different in diabetics and non-diabetics (p=0.66).Outcome was favorable and not significantly different in diabetic patients (p=0.0%) Conclusion Saudi diabetic patients have increased risk of tuberculosis. Pulmonary tuberculosis is most common in diabetics and is associated with poor glucose control. Diabetes does not alter the outcome of tuberculosis significantly.

Academic research paper on topic "Clinical Manifestations and Outcome of Tuberculosis in Diabetic Patients Admitted to King Abdulaziz University Hospital in Jeddah, Saudi Arabia"

CLINICAL STUDY

Clinical Manifestations and Outcome of Tuberculosis in Diabetic Patients Admitted to King Abdulaziz University Hospital in Jeddah, Saudi Arabia

Aisha Mukarram Siddiqui FRCP (Edin)

Department of Medicine, King Abdulaziz University Hospital Jeddah, Kingdom of Saudi Arabia

Abstract

Objectives

Compare epidemiology, clinical manifestations and outcome of tuberculosis between diabetic and non-diabetic patients admitted to King Abdulaziz University Hospital in Jeddah, Saudi Arabia. Methods

Review the medical data of adult inpatients with tuberculosis from January 2002 to December 2007. Demographic data, location of tuberculosis, sputum positivity for acid fast bacilli, duration of hospitalization and outcome (relapses, drug resistance and inhospital mortality) were compared between the two groups. Results

From total of 216 tuberculosis cases, 35 (16%) had diabetes. These were older in age. 68% diabetics were over 50 years compared to 16% non-diabetics. (p=0.0001). Ratio of Saudis to non-Saudis with tuberculosis was greater in diabetics than in non-diabetics (p=0.003). Pulmonary tuberculosis was the most common site affected and was associated with poor glycemic control (p = 0.013). Smear positivity for acid fast bacilli was not different in diabetics and non-diabetics (p = 0.66). Outcome was favorable and not significantly different in diabetic patients (p = 0.0%) Conclusion

Saudi diabetic patients have increased risk of tuberculosis. Pulmonary tuberculosis is most common in diabetics and is associated with poor glucose control. Diabetes does not alter the outcome of tuberculosis significantly.

Keywords: Tuberculosis, diabetes mellitus, clinical outcome

Journal of Taibah University Medical Sciences 2009; 4(2):148 -155

Correspondence to: Dr. Aisha M. Siddiqui

Associate professor, Department of Internal Medicine King Abdulaziz University Hospital e 80215, Jeddah 21589 Kingdom of Saudi Arabia S +9662 6408272 Ä+966 2 640 8315

medconf@yahoo.com

Introduction

Tuberculosis remains a major global public health problem with a high morbidity and mortality. Annually 8-10 million new cases and 3 million deaths are reported a. A strong association between diabetes mellitus (DM) and tuberculosis (TB) is well documented 2. Both these diseases are major health problems in the Kingdom of Saudi Arabia, where TB is considered an endemic disease 3 and the prevalence of DM is growing rapidly.4 There is very little data on TB in DM patients in Saudi Arabia. We conducted this study to compare the epidemiology and clinical aspects of TB between diabetic and non- diabetic patients admitted to King Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia.

Materials and Methods

This retrospective study was conducted in KAUH, Jeddah, which is a tertiary hospital in the Western region of Saudi Arabia. Approval of the ethical committee in KAUH was taken.

The medical records were reviewed for data collection. Information about demographic data, location of TB, sputum positivity for acid fast bacilli (AFB) staining in case of pulmonary TB (PTB), presence or absence of DM, blood glucose level on admission and 2 months before, duration of hospital stay, number of relapses, resistance to antituberculosis treatment and inhospital mortality, were recorded. Inclusion criteria included adult patients aged 13 years and above who were admitted during the period of January 2002 to December 2007 with a discharge diagnosis ofTB.

Exclusion criteria included patients with positive HIV result, patients on steroids or immunosuppressive therapy. Diagnosis of PTB was based on positive AFB staining, positive culture for TB bacilli, or typical radiological findings with high clinical probability of TB5. For extra pulmonary TB, the diagnosis was based on histopathology of tissue specimens5.

Patients were considered to be diabetic if they had a previous history of DM and were receiving antidiabetic therapy at the time of hospital admission or were later found to have two fasting blood glucose levels >126mg/dL or random blood glucose level >200mg/ dL in the presence of classical symptoms of DM. Diabetic patients were considered controlled if their fasting blood glucose was <130mg/ dL or peak post prandial blood glucose <180mg/ dL according to the guidelines of the American Diabetes Association in 2009. Blood tests were done on admission and 2 months before admission.

Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 13.0. Chi-square test was performed to analyze the categorical variables, studenf s t-test was used to analyze numerical variables for group differences, p-value of 0.05 or less was considered of statistical significance.

Results

As shown in Table 1, there were total of 216 TB patients admitted in KAUH during the study period. 35/216 (16%) were diabetic. TB patients with DM were older than non-diabetics. 68% TB diabetics were over 50 years of age compared to 16% non-diabetic patients which was statistically significant with p=0.0001.

TB patients with DM had a higher men:women ratio than non diabetics. They had higher Saudi to non-Saudi ratio than non-diabetics.

Saudi diabetics were 27% (18/66) and were more than non-Saudi diabetics who were 11% (17/150).

Also Saudi diabetics were more than Saudi non-diabetics (51% vs 26%). These figures were significant (p=0.003). For disease location, the lungs were the most common site (54% in diabetics and 39% in non-diabetics). In extra pulmonary TB, bones were the most common site in diabetics (20% vs. 13%) while lymph nodes were the predominant site in non-diabetic patients (17% vs. 3%). This was statistically significant with p=0.041. As shown in Table

Outcome of tuberculosis in diabetic patients

2, smear positivity for AFB in PTB was 40% (36/90) and was higher in diabetics than non-diabetics 42% (8/19) vs. 37% (26/71), but did not reach statistical significance (p=0.6)

As shown in Table 3 there was no significant difference between both groups regarding the duration of hospital stay (27±18 days, range 7-75) in TB patients, (30 + 18 days, range 10-80) in TB DM patients, with p= 0.138.

Readmission for TB occurred in 11/216 (5%) patients. Nine had one recurrence (6 of whom had PTB and 2 were diabetics), two had 2 recurrences (both had PTB and one was diabetic).

Multi drug resistance to TB treatment (MDR-TB) developed in 4/216 (2%) patients. All had PTB and only one was diabetic. All improved on second line antituberculosis therapy.

In-hospital mortality was 3.7% (8/216). All had PTB and although 9% (3/35) were diabetic and 3% (5/181) were non-diabetic, the p-value was not significant (0.096). Most of the diabetics had high blood glucose on admission to the hospital, 26/35 (75%). It was found that these patients had more PTB than patients with controlled blood sugar and it was of significant statistical value (p=0.013) as shown in Table 4. As shown in Table 5 there was no statistical significant difference between controlled and uncontrolled diabetics regarding AFB positivity (p=0.178). Table 6 shows the duration of hospital stay which was not different between the 2 groups, (p=0.55). It also shows that all the 3 diabetics who had relapses were uncontrolled still the result was not significant statistically (p=0.61). MDR - TB occurred in only 1 diabetic who had uncontrolled blood glucose and the result was not significant (p=0.58) Inhospital mortality occurred in 3 diabetics, 2 had controlled blood glucose but it was in significant (p=0.65)

Discussion

From the total number of TB patients who were studied, 16% had coexisting DM. This

figure is similar to other reported cases from Turkey, Malaysia, Indonesia and India. M In Saudi Arabia, it was found that the prevalence of DM in Saudi population is 23.7%, as reported by A1 Nozha et al in 20044. In our study DM was found in 27% of our Saudi patients.

This figure is higher than the one reported by the above-mentioned study, meaning that the prevalence of DM was found to be more in TB patients in our study. The current study showed few differences in some aspects between DM and non DM patients who had TB (including PTB). It showed that as the age increased, more TB was found in DM patients, a similar finding reported by others. 7,io,ii-ia Moreover it demonstrated that the percentage of TB in Saudi diabetics was significantly higher than that in Saudis without DM (51% vs 26%). This finding is similar to another study from Saudi Arabia, n

It also showed that the percentage of male diabetic patients was slightly higher in comparison to non-diabetic males, which is supported also by previous studies. 7<n'12 The above findings showed statistical significance and it is alarming to know that Saudi diabetics are having higher prevalence of TB than non-Saudis and non-diabetic Saudis which shows the positive association between DM and TB in Saudi Arabia.

In the present study, PTB was considered the most common form found in DM patients, whereas in non-diabetics extrapulmonary TB was more common. The increased association of DM with PTB rather than extrapulmonary TB was also reported previously 7, indicating that the presence of DM continues to play an important role in the development of PTB. In extrapulmonary TB, bone disease was the most common form found in DM patients, whereas lymph node involvement was the predominant site in non-diabetic patients, as was the case in another report.7 The high rate of involvement of lymph nodes in extrapulmonary TB in our total TB patients in comparison to other sites was also seen in other studies.14'15

Table 1: Characteristics of 216 patients with tuberculosis

Variables TB group (181) No. (%) TB DM group (35) No. (%) p value

Range of Age 13-70 years 25-75 years

Mean ± SD 29 ± 16 years 48 ± 14.6 years

Age group:

10-19 45 (25%) 0 (0%)

20-29 37(21%) 3 (9%)

30-39 42 (23%) 6 (18%)

40-49 27 (15%) 2 (5%)

50-59 16 (9%n 9 (26%

60-69 8(4%) Ll6% 13 (37%) I 68% 0.0001

70< 6 (3%) J 2(5%)J

Gender:

Men (M) 73 (40%) 18 (51%)

Women (W) 108 (60%) 17(49%)

M:W ratio 1:1.5 (2/3:1) 1:1

Nationality 0.003

Saudi (S) 48 (26%) 18 (51%)

NonSaudi (NS) 133 (74%) 17(49%)

S: NS ratio 1:3 (1/3:1) 1:1

Disease location: 0.041

Lungs 71 (39%) 19 (54%)

Lymph nodes 31 (17%) 1 (3%)

Bones 22 (13%) 7(20%)

Pleura 18 (10%) 1 (3%)

Nervous system 17(9%) 2 (6%)

Gastrointestinal system 14 (8%) 1 (3%)

Reproductive system 4 (2%) 0 (0%)

Others 4 (2%) 4 (11%)

SD = Standard deviation

TB DM group = Tuberculosis patients with diabetes mellitus TB group = Tuberculosis patients without diabetes mellitus Others = breasts, skin, kidneys, heart

Table 2: Smear positivity for AFB in ptb diabetics and non-diabetics

Smear Positivity for AFB PTB Group (71) No. (%) PTB DM Group (19) No. (%)

Positive 8 (42%)

Negative 11 (58%)

p = 0.661

151 J T U Med Sc 2009; 4(2)

Outcome of tuberculosis in diabetic patients Table 3: Comparison between diabetics and non-diabetics according to different variables

Table 4: Relation of blood glucose to location of tuberculosis in diabetic patients

Location Uncontrolled Blood Glucose (High) NO. (%) Controlled Blood Glucose NO. (%) Total

Lungs * 19

Bones 6

Nervous system 2

Pleura 1

Lymph nodes 2

Gastrointestinal system 1

Others 4

TOTAL 26 (75%) 9 (25%) 35 (100%)

* = p value of 0.013

Others = breasts, skin, kidneys, heart

Table 5: Relation of blood glucose control to smear positivity for afb in ptb diabetics

Smear positivity for AFB Uncontrolled (high) blood glucose (17) Controlled blood glucose (2)

Positive 0

Negative 9 2

p = 0.178

Table 6: Relation of blood glucose control to different variables in diabetic patients

Several studies reported strong association between DM and smear positive PTB 9>13'16 but that was not seen in our study as the difference was not great to be of statistical significance although V2 of DM patients were positive for AFB compared to about 1/3 of non-diabetic patients. This finding was similar to findings in other studies.617 Although there is evidence that DM patients with TB have worse TB outcome than those without DM,16'18 this was not shown in the number of relapses in our study, which had no relation to the presence of DM, and it was consistent with other reports.7 MDR-TB was 4% in our study, that was lower than that reported previously in Jeddah (5.1% and 20.7%) 19<2° and there was no relation between the presence of DM and MDR-TB. A finding that was consistent with previous reports 6<7 and one from Saudi Arabia.11

Inhospital mortality showed a difference between diabetics and non diabetics (9% vs 3%) in our study but the statistical value was not significant, probably because the number of mortalities was small and hindered reaching to significant conclusions. Most of the DM patients had uncontrolled blood glucose levels and had significantly more PTB than those with controlled blood glucose. The reason probably is the adverse

effect of PTB on glycemic control that improves with antituberculosis treatment.21 Another explanation is that poorly controlled glucose level is usually considered to be the main factor causing increased susceptibility to infections.22 It is well known that DM is associated with an increased risk of TB with an overall increased risk around 1.5 to 8 times higher than the normal population.16 This is why both these diseases are considered to be bad companions. In our study, high blood glucose had no relation to smear positivity for AFB, to duration of hospital stay nor to the outcome of these patients. Probably a bigger number of patients may have yielded a positive result than shown here. We conclude that Saudi diabetic patients are more affected with TB, but there is no difference in the outcome between diabetic and non-diabetic patients with TB. Since both diseases are highly prevalent in our community and influence each other, we recommend that more strict measure to be carried out to combat the spread of TB and tightly control DM. Active case finding is recommended by performing chest x-rays routinely for all diabetic patients at diagnosis and whenever they develop unexplained deterioration of health. Latent PTB cases should be offered

Outcome of tuberculosis in diabetic patients

chemoprophylaxis. We also recommend to consider having combined clinics for both diseases for better follow up of patients. It would be interesting to do a prospective study in diabetic patients with TB in different regions of Saudi Arabia to see the trend of clinical presentations and outcome and would be better to include larger number of patients than our current study to reach to more significant results.

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