Diabetes Mellitus as Hub for Tuberculosis Infection: A Snapshot

Prevalence of Latent Tuberculosis Infection and its Associated Factors Among Diabetic Patients Availing Primary Health Care in Terengganu State, Malaysia

Objectives

Diabetes mellitus (DM) patients are considered to be at high risk for contracting latent tuberculosis infection (LTBI). This study aimed to determine the prevalence of LTBI and its associated factors among diabetic patients attending primary care clinics in Terengganu state, Malaysia.

Methods

This cross-sectional study was conducted among diabetic patients attending 11 health clinics in the Terengganu region from June 2017 to November 2018. The selected participants were administered a tuberculin skin test (TST). Simple and multivariate logistic regressions were applied to evaluate the significant associated factors of LTBI.

Results

The total number of participants were 703 DM patients. The factors found associated with LTBI were poor diabetic control status (odds ratio (OR) = 8.53; p=0.008), being a healthcare worker (OR = 7.91; p=0.001), history of contact with TB patients (OR = 5.69; p < 0.001), bronchial asthma (OR = 5.28; p=0.019), coronary heart disease (OR = 3.45; p=0.026), and nephropathy (OR = 0.34; p=0.040). The presence of LTBI was found in 34 (4.8%) participants.

Conclusions

At 4.8%, the prevalence of LTBI among DM patients in Terengganu is relatively low. Diabetics with poorly controlled blood glucose levels, nephropathy, bronchial asthma, coronary heart disease, history of TB patient contact, or working in the healthcare profession should be periodically tested for LTBI.

Correlates of quality of life among persons living with tuberculosis: A cross-sectional study

Introduction

The correlates of quality of life originating from the demographic characteristics, comorbidities and sources of social support among persons living with tuberculosis remain underreported. The aim of this study was to examine the correlates of quality of life among persons living with tuberculosis within Greater Accra, Ghana.

Methods

A cross-sectional survey design was used to assess the correlates of quality of life among 250 randomly sampled persons living with tuberculosis. Quality of life was assessed with the Quality of Life Brief Version (WHOQOL-BREF) questionnaire and correlates were derived using Spearman rho correlations. Chi-square analyses assessed associations among respondent characteristics.

Results

All four quality of life domains (physical, psychological, social relationship and environmental) of persons living with tuberculosis were positively correlated. Furthermore, receiving social support from family or friends correlated positively with respondents’ quality of life. Human Immunodeficiency Virus (HIV) infection and receiving social support mainly from work colleagues or religious institutions correlated negatively with respondents’ quality of life domains. Other correlates of quality of life included age, pleuritis with pleural effusion, number of dependants and distance to tuberculosis treatment centres. Social support from family and friends corresponded with better quality of life among persons living with tuberculosis.

Conclusion

The quality of life domains of persons living with tuberculosis are interrelated and can be enhanced by social support. Healthcare providers should involve the significant others of persons living with tuberculosis, human immunodeficiency virus and pleuritis with pleural effusion in their care to promote patients’ quality of life.

Exploring key molecular signatures of immune responses and pathways associated with tuberculosis in comorbid diabetes mellitus: a systems biology approach

Background

Comorbid type 2 diabetes mellitus (T2DM) increases the risk for tuberculosis (TB) and its associated complications, although the pathological connections between T2DM and TB are unknown. The current research aims to identify shared molecular gene signatures and pathways that affirm the epidemiological association of T2DM and TB and afford clues on mechanistic basis of their association through integrative systems biology and bioinformatics approaches. Earlier research has found specific molecular markers linked to T2DM and TB, but, despite their importance, only offered a limited understanding of the genesis of this comorbidity. Our investigation used a network medicine method to find possible T2DM-TB molecular mediators.

Results

Functional annotation clustering, interaction networks, network cluster analysis, and network topology were part of our systematic investigation of T2DM-TB linked with 1603 differentially expressed genes (DEGs). The functional enrichment and gene interaction network analysis emphasized the importance of cytokine/chemokine signalling, T cell receptor signalling route, NF-kappa B signalling pathway and Jak-STAT signalling system. Furthermore, network analysis revealed significant DEGs such as ITGAM and STAT1, which may be necessary for T2DM-TB immune responses. Furthermore, these two genes are modulators in clusters C4 and C5, abundant in cytokine/chemokine signalling and Jak-STAT signalling pathways.

Conclusions

Our analyses highlight the role of ITGAM and STAT1 in T2DM-TB-associated pathways and advances our knowledge of the genetic processes driving this comorbidity.

Liposomal Glutathione Helps to Mitigate Mycobacterium tuberculosis Infection in the Lungs

Mycobacterium tuberculosis (M. tb), the causative agent of tuberculosis (TB), is responsible for causing significant morbidity and mortality, especially among individuals with compromised immune systems. We have previously shown that the supplementation of liposomal glutathione (L-GSH) reduces M. tb viability and enhances a Th-1 cytokine response, promoting granuloma formation in human peripheral blood mononuclear cells in vitro. However, the effects of L-GSH supplementation in modulating the immune responses in the lungs during an active M. tb infection have yet to be explored. In this article, we report the effects of L-GSH supplementation during an active M. tb infection in a mouse model of pulmonary infection. We determine the total GSH levels, malondialdehyde (MDA) levels, cytokine profiles, granuloma formation, and M. tb burden in untreated and L-GSH-treated mice over time. In 40 mM L-GSH-supplemented mice, an increase in the total GSH levels was observed in the lungs. When compared to untreated mice, the treatment of M. tb-infected mice with 40 mM and 80 mM L-GSH resulted in a reduction in MDA levels in the lungs. L-GSH treatment also resulted in a significant increase in the levels of IL-12, IFN-γ, IL-2, IL-17, and TNF-α in the lungs, while down-regulating the production of IL-6, IL-10, and TGF-β in the lungs. A reduction in M. tb survival along with a decrease in granuloma size in the lungs of M. tb-infected mice was observed after L-GSH treatment. Our results show that the supplementation of mice with L-GSH led to increased levels of total GSH, which is associated with reduced oxidative stress, increased levels of granuloma-promoting cytokines, and decreased M. tb burden in the lung. These results illustrate how GSH can help mitigate M. tb infection and provide an insight into future therapeutic interventions.

SNPs in Genes Related to DNA Damage Repair in Mycobacterium Tuberculosis: Their Association with Type 2 Diabetes Mellitus and Drug Resistance

Genes related to DNA damage repair in Mycobacterium tuberculosis are critical for survival and genomic diversification. The aim of this study is to compare the presence of SNPs in genes related to DNA damage repair in sensitive and drug-resistant M. tuberculosis genomes isolated from patients with and without type 2 diabetes mellitus (T2DM). We collected 399 M. tuberculosis L4 genomes from several public repositories; 224 genomes belonging to hosts without T2DM, of which 123 (54.9%) had drug sensitive tuberculosis (TB) and 101 (45.1%) had drug resistance (DR)-TB; and 175 genomes from individuals with T2DM, of which 100 (57.1%) had drug sensitive TB and 75 (42.9%) had DR-TB. The presence of SNPs in the coding regions of 65 genes related to DNA damage repair was analyzed and compared with the resistance profile and the presence/absence of T2DM in the host. The results show the phylogenetic relationships of some SNPS and L4 sub-lineages, as well as differences in the distribution of SNPs present in DNA damage repair-related genes related to the resistance profile of the infecting strain and the presence of T2DM in the host. Given these differences, it was possible to generate two discriminant functions to distinguish between drug sensitive and drug resistant genomes, as well as patients with or without T2DM.

Tuberculosis and Diabetes in India: Stakeholder Perspectives on Health System Challenges and Opportunities for Integrated Care

Background

India has a dual burden of tuberculosis (TB) and diabetes mellitus (DM). Integrated care for TB/DM is still in the early phase in the country and can be considerably enhanced by understanding and addressing the challenges identified from stakeholders’ perspectives. This study explored the challenges and opportunities at individual, health system and policy level for integrated care of TB/DM comorbidities in India.

Methods

We used an outlier case study approach and conducted stakeholder interviews and focus group discussions with relevant program personnel including field staff and program managers of TB and DM control programs as well as officials of partners in Indian states, Kerala and Bihar.

Results

The integrated management requires strengthening the laboratory diagnosis and drug management components of the two individual programs for TB and DM. Focused training and sensitization of healthcare workers in public and private sector across all levels is essential. A district level management unit that coordinates the two vertical programs with a horizontal integration at the primary care level is the way forward. Substantial improvement in data infrastructure is essential to improve decision-making process.

Conclusion

Bi-directional screening and management of TB/DM comorbidities in India requires substantial investment in human resources, infrastructure, drug availability, and data infrastructure.

Prevalence of latent tuberculosis and associated factors in patients with chronic kidney disease on hemodialysis

Objective:

to identify the prevalence of latent tuberculosis in patients with chronic kidney disease on hemodialysis and associated factors.

Method:

a cross-sectional study conducted with 176 patients with chronic kidney disease on hemodialysis. The tuberculin test was performed with the standardized antigen, distributed by the Brazilian Ministry of Health, and the reading occurred after 72 to 96 hours of the application. An association test (Chi-square, Fisher’s exact), prevalence ratio, and multivariate regression tests were performed.

Results:

the prevalence of latent tuberculosis diagnosed through Tuberculosis Skin Test was 8.5% (15/176). The “has/has had diabetes” (aOR: 0.117; 95%CI: 0.015-0.92) and “having regular garbage collection (aOR: 0.076; 95%CI: 0.008-0.702) factors were associated with a lower probability of having a Positive skin test.

Conclusion:

the low prevalence of latent tuberculosis identified and the factors associated with it reinforce the need for screening for latent tuberculosis infection for diabetics combined with an analysis of previous risk factors and comorbidities.

Latent tuberculosis infection among patients with and without type-2 diabetes mellitus: results from a hospital case-control study in Atlanta

OBJECTIVE

The purpose of this study is to compare the prevalence of latent TB infection (LTBI) among patients with type-2 diabetes mellitus (T2DM) to healthy controls without T2DM. To achieve this objective, we conducted a case-control study in a large hospital in Atlanta from 2016 to 2019.

RESULTS

We enrolled 98 cases; 119 potential controls were screened, 84 of which had HbA1c  ≥  5.7% and one did not have QFT result, leaving 34 (28.6%) individuals enrolled as controls. LTBI prevalence was 9.2% among cases and 14.7% among controls (crude odds ratio 0.59, 95% CI 0.19-2.04). After adjusting for age and sex, the adjusted odds of LTBI among patients with T2DM was 0.45 (95% CI 0.13, 1.71) times the controls. We did not observe a statistically significant association between LTBI and T2DM. However, we reported a positive correlation between HbA1c level and nil count among individuals with LTBI (R²  =  0.55, p  <  0.01). In addition, we reported a high prevalence of LTBI among adults with T2DM and family members without T2DM.

Application of responsibility-based nursing in patients with both DM and PTB

OBJECTIVE

To evaluate the application value of responsibility-based nursing intervention in the nursing of patients with both diabetes mellitus (DM) and pulmonary tuberculosis (PTB).

METHODS

A total of 180 patients with both DM and PTB admitted to our hospital from April 2019 to April 2020 were enrolled as research objects, of which 86 patients were under routine nursing intervention as a regular group (Reg group) and other 94 patients were under responsibility-based nursing intervention as a responsibility group (Res group). The unhealthy emotion, treatment compliance, self-efficacy, self-care ability, and life quality of both groups were evaluated after nursing intervention, and they were compared in blood glucose level and PTB treatment outcome.

RESULTS

After intervention, the Res group got lower self-rating anxiety scale (SAS) and self-rating depression scale (SDS) scores than the Reg group (both P<0.05). The Res group also got higher scores of self-efficacy, self-care ability, and life quality, and showed significantly higher treatment compliance rate and nursing satisfaction than the Reg group after intervention (all P<0.05). Additionally, after intervention, the Res group got higher scores of life quality than the Reg group (all P<0.05). The levels of fasting blood glucose (FBG), 2 hour postprandial blood glucose (2h PG), and glycosylated hemoglobin (HbA1c) in the Res group were lower than those in the Reg group, and the cavity closure rate, sputum negative conversion rate, and focus absorption rate of the Res group were all significantly higher than those of the Reg group (all P<0.05).

CONCLUSION

Responsibility-based nursing intervention can improve the treatment compliance, self-management ability, self-efficacy, and life quality of patients with both DM and PTB.

United States immigration detention amplifies disease interaction risk: A model for a transnational ICE-TB-DM2 syndemic

Detention and removal of unauthorised immigrants by United States (U.S.) Immigration and Customs Enforcement (ICE) has steadily increased despite declining rates of unauthorised migration. ICE detainees are held in overcrowded detention centres, often without due process and deprived of adequate food, sanitation, and medical care. Conditions of ICE detention contribute to malnutrition and increase the likelihood of infectious disease exposure, including tuberculosis (TB). TB infection interacts with Type 2 Diabetes (DM2), disproportionately affecting individuals who are routinely targeted by federal immigration practices. When two diseases interact and exacerbate one another within a larger structural context, thereby amplifying multiple disease interactions, this is called a syndemic. In this paper, we examine malnutrition in ICE detention as a pathway of bidirectional risks for and interactions between TB and DM2 among ICE detainees. Drawing from literature on detention conditions, TB, and DM2 rates along the U.S.-Mexico border, we propose an ICE-TB-DM2 syndemic model. We present a map displaying our proposed syndemic model to demonstrate the spatial application of syndemic theory in the context of ICE detention, strengthening the growing scholarship on syndemics of incarceration and removal.

Engagement of private healthcare providers for case finding of tuberculosis and diabetes mellitus in Pakistan

BACKGROUND

The rising co-epidemic of tuberculosis (TB) and diabetes mellitus (DM) is a challenge for constrained health systems in low and middle-income countries. Diabetes is a known risk factor for tuberculosis and associated with poor tuberculosis treatment outcomes, while tuberculosis is associated with worsening glycemic control. We investigated the performance of bi-directional TB and DM case finding approaches through a private-sector engagement model in Karachi, Pakistan.

METHODS

Between July 2016 and July 2018, private health care providers were engaged to generate referrals for bi-directional TB and DM screening at private diagnostic and treatment centers in Karachi, Pakistan. Individuals diagnosed with TB underwent glycated hemoglobin (HbA1c) testing at the time of anti-tuberculous treatment initiation and at three -month follow up stage. All individuals with a history of diabetes or random blood sugar of greater than 200 mg/dl were screened for TB using a chest X-ray and Xpert MTB/RIF.

RESULTS

A total of 6312 persons with tuberculosis were tested on HbA1c at treatment initiation, of whom 1516 (24%) were newly diagnosed with DM. About one third of those with HbA1c in the diabetic range (≥ 6.5%) at baseline were found to have a normal HbA1c (< 5.7%) result at 3-month follow-up. A total of 3824 individuals with DM, of whom 2396 (63%) were known cases and 1428 (37%) were newly identified with random blood sugar > 200 mg/dl, underwent chest x-ray and Xpert MTB/RIF testing, with 321 (13.4%) known and 54 (3.8%) new diabetics respectively identified with tuberculosis.

CONCLUSION

This study demonstrates a high yield of TB and DM through bidirectional screening and the feasibility of engagement of private sector in finding missing cases of tuberculosis and diabetes. Given the high prevalence of undiagnosed DM in individuals with TB tuberculosis patients, there is a need to scale-up DM screening within TB programmes. Increased awareness of the high risk of TB among individuals with DM is needed among private health providers and screening for TB among diabetics should be strongly considered.

Pulmonary Tuberculosis Characteristics in a Patient with Type 2 Diabetes Mellitus

Tuberculosis (TB) and diabetes mellitus (DM) are two chronic diseases with major impact on worldwide morbidity and mortality. DM significantly increases the risk of death, therapeutic failure and relapse of TB, requiring a much more careful monitoring of these patients. In this article we present the case of a patient with type 2 DM in the stage of major chronic complications, with numerous risk factors for TB and atypical symptomatology, pulmonary X-ray showing active TB lesions. The patient did not follow the diabetologist's recommendations, discontinuing the antidiabetic treatment on his own initiative. The glycemic imbalance and chronic alcoholism caused the failure of the anti TB therapy.

Host-directed therapies to combat tuberculosis and associated non-communicable diseases

Mycobacterium tuberculosis (Mtb) has coevolved with a human host to evade and exploit the immune system in multiple ways. Mtb is an enormously successful human pathogen that can remain undetected in hosts for decades without causing clinical disease. While tuberculosis (TB) represents a perfect prototype of host-pathogen interaction, it remains a major challenge to develop new therapies to combat mycobacterial infections. Additionally, recent studies emphasize on comorbidity of TB with different non-communicable diseases (NCDs), highlighting the impact of demographic and lifestyle changes on the global burden of TB. In the recent past, host-directed therapies have emerged as a novel and promising approach to treating TB. Drugs modulating host responses are likely to avoid the development of bacterial resistance which is a major public health concern for TB treatment. Interestingly, many of these drugs also form treatment strategies for non-communicable diseases. In general, technological advances along with novel host-directed therapies may open an exciting and promising research area, which can eventually deliver effective TB treatment as well as curtail the emergent synergy with NCDs.

Glibenclamide Reduces Primary Human Monocyte Functions Against Tuberculosis Infection by Enhancing M2 Polarization

Tuberculosis (TB) is a global public health problem, which is caused by Mycobacterium tuberculosis (Mtb). Type 2 diabetes mellitus (T2DM) is one of the leading predisposing factors for development of TB after HIV/AIDS. Glibenclamide is a widely used anti-diabetic drug in low and middle-income countries where the incidence of TB is very high. In a human macrophage cell line, glibenclamide, a K⁺ATP-channel blocker, promoted alternative activation of macrophages by enhancing expression of the M2 marker CD206 during M2 polarization. M2 macrophages are considered poorly microbicidal and associated with TB susceptibility. Here, we investigated the effect of glibenclamide on M1 and M2 phenotypes of primary human monocytes and further determined whether specific drug treatment for T2DM individuals influences the antibacterial function of monocytes in response to mycobacterial infection. We found that glibenclamide significantly reduced M1 (HLA-DR⁺ and CD86⁺) surface markers and TNF-α production on primary human monocytes against mycobacterial infection. In contrast, M2 (CD163⁺ and CD206⁺) surface markers and IL-10 production were enhanced by pretreatment with glibenclamide. Additionally, reduction of bactericidal activity also occurred when primary human monocytes from T2DM individuals who were being treated with glibenclamide were infected with Mtb in vitro, consistent with the cytokine responses. We conclude that glibenclamide reduces M1 and promotes M2 polarization leading to impaired bactericidal ability of primary human monocytes of T2DM individuals in response to Mtb and may lead to increased susceptibility of T2DM individuals to TB and other bacterial infectious diseases.

[Tuberculosis and comorbidities in urban areas in Argentina. A gender and age perspective]

INTRODUCTION

Tuberculosis continues to be a major health problem in the world with an incidence of more than 10 million cases in 2015. There are factors that change the risk of developing the disease after infection, as well as the presentation of the disease.

OBJECTIVE

To determine the main comorbidities and demographic, clinical and microbiological characteristics of tuberculosis adult patients in Argentina from a gender and age perspective.

MATERIALS AND METHODS

We conducted a cross-sectional study in urban referral hospitals for patients with tuberculosis. We included tuberculosis patients of 15 years or more of age who were hospitalized or treated in outpatient clinics with bacteriologically confirmed pulmonary or extrapulmonary forms of the disease, as well as those who, although not bacteriologically confirmed, had clinical and radiological characteristics consistent with tuberculosis. The study period was from August 1st, 2015 to August 31st, 2016.

RESULTS

We included 378 patients. The median age was 37 years. Male gender was associated with extrapulmonary tuberculosis, hospitalization, smoking, drug addiction and alcoholism. Tuberculosis and aids (22.6%) was related to drug use, admission into hospital, extrapulmonary tuberculosis, nonaddiction to tobacco, non-pathological radiology, absence of cavitation, and negative sputum smear microscopy. Patients less than 40 years of age had a higher rate of drug addiction and low weight, while those aged 40 or over had a higher proportion of diabetes, alcoholism and chronic obstructive pulmonary disease (COPD).

CONCLUSIONS

This study will help recognize tuberculosis patients' characteristics and comorbidities influencing the development and evolution of the disease from an age and gender perspective to enable the development of social and community-based strategies.

The Diabetes-Tuberculosis Co-Epidemic: The Interaction between Individual and Socio-Economic Risk Factors

Worldwide, tuberculosis (TB) is a major cause of morbi-mortality, about 30% of the population having a Mycobacterium tuberculosis infection. Patients with diabetes mellitus (DM) have a threefold increased risk of developing the disease. The prevalence of DM is rapidly increasing, especially in countries with low and middle income, where TB incidence is also increased, thus baffling the efforts for TB control. The DM-TB co-epidemic is more frequent in married, older men, with reduced level of education, low income, without a steady job, with lifestyle habits such as alcohol consumption, smoking, sedentarism, living in an urban environment, in crowded areas, in insanitary conditions. These patients have a higher body mass index (BMI) compared with those without DM and frequently present family history of TB, family history of DM, longer duration of DM and reduced glycemic control. TB associated with DM is usually asymptomatic, more contagious, multidrug resistant and is significantly associated with an increased risk of therapy failure, relapse and even death. Thus, the DM-TB comorbidity represents a threat to public health and requires the implementation of urgent measures in order to both prevent and manage the two diseases.