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Indian Journal of Community Medicine

Study of Impaired Glucose Tolerance in Pulmonary Tuberculosis

Author(s): M K Jain, P K Baghel, R Agrawal

Vol. 31, No. 3 (2006-07 - 2006-09)

Abstract

Research Question: What is the prevalence of impaired glucose tolerance in pulmonary tuberculosis? Objective: To study the clinical profile of impaired glucose tolerance in pulmonary tuberculosis. Study Design: Cross-sectional. Participants: Patients of pulmonary tuberculosis attending the Outdoor Patient Department and admitted in the General and Tuberculosis wards in a medium-sized teaching hospital, Rewa (M.P.). Study Variable: Age, Sex, Residence, Socioeconomic status, BMl, Radiology. Statistical Analysis: Chi-square test. Result and Conclusion: Out of the 106 patients of pulmonary tuberculosis studied, the prevalence of abnormal glucose tolerance test (GTT) was 16.98%. There was significant increase of prevalence of impaired glucose tolerance test (IGT) with age. IGT was significantly higher in males and among the urban. The lower socioeconomic groups were significantly more affected. Exclusively lower zone was significantly more affected in those with IGT.

Keywords: Impaired Glucose Tolerance, Pulmonary Tuberculosis.

Introduction

Higher prevalence of pulmonary tuberculosis in a diabetic patient is a well-known fact. The inverse relationship, i.e., higher prevalence of impaired glucose tolerance in a tuberculous population is also being increasingly realized. What makes the diagnosis of the combination difficult is the fact that the symptoms of the complicating disease are masked by the co-existing disease.

Material and Method

The study group consisted of 106 patients of pulmonary tuberculosis, who had either positive sputum smear for Acid Fast Bacilli or had clinical and radiological features of pulmonary tuberculosis. All patients were subjected to the standard Oral Glucose Tolerance Test and the results were evaluated according to the criterion laid down by W.H.O. for diabetes.

The study was conducted in patients attending the Outdoor Patient Department and those admitted in the Tuberculosis and General wards of the S.G.M. Hospital, Rewa.

The patient information was collected regarding age, sex, socioeconomic status, occupation etc. Also asked were symptoms relating to pulmonary tuberculosis and diabetes, family and past history of the disease and history of addictions. Samples of blood were drawn in accordance to the W.H.O. guidelines after the patient fasted overnight for at least 12 hrs, then at 1 and 2 hours following 75 grams glucose ingestion.

Results

Out of the 106 patients of pulmonary tuberculosis studied (all aged 30 years and above), 18 (16.98 %) had abnormal Glucose Tolerance Test (GTT) of which 2 (1.88%) had impaired fasting glycemia, 11 (10.34 %) had impaired glucose tolerance and 5 (4.7 %) were frankly diabetic. Results of the Oral Glucose Tolerance Test (OGTT) in relation to age and sex is shown in Table I. Although the number of cases of pulmonary tuberculosis decreased with increasing age, the relative number of those with impaired glucose tolerance increased. The difference in positivity between males (18.67%) and females (12.90 %) was also statistically significant.

Majority of patients belonged to the rural population (69 out of 108) while most were of lower socioeconomic class (76 of 108). The prevalence of Impaired Glucose Tolerance Test (IGT) was interestingly more among the urban 12 (32.44%) and those in the low socioeconomic class 14 (18.42%), both the results were statistically significant (Table II).

Of all the cases studied, fever was the most common symptom. It was also the most common symptom in those with impaired glucose tolerance. Features of diabetes, e.g., increased thirst and micturition was seen in 50% and 22.2% of patients with impaired GTT respectively.

No statistical difference was found in patients with IGT in relation to their addictions or body mass index. On radiological examination, the most common lesion was infiltration in 7 (22.58%) while cavitary lesion with varying fibrosis was seen in 4 (20.0%) cases with IGT. Lower zone was significantly more commonly involved among those with impaired glucose tolerance (4 cases, 47.15%).

Table I: Age & Sex Specific Impaired Glucose Tolerance Among T.B. Patients

Number of subjects
(n=106)
Abnormal GTT
(IFG/IGT/DM)
(n=18)
Age Group (in years)*
30-40 55 4 (7.27%)
40-50 11 2 (18.18%)
50-60 27 7 (25.92%)
>60 13 5 (37.46 %)
Total 106 18 (16.98%)
Sex **
Male 75 14 (18.67%)
Female 31 4 (12.9U %)
Total 106 18 (16.98%)
*χ2 = 9.47 p=<0.05
**χ2 = 44.68 p = <0.001

Table II: Impaired Glucose Tolerance Among T.B. Patients in Relation to Residence and Socio-economic Status

  Number of subjects
(n=106)
Abnormal GTT
(n=18)
Residence *
Rural 69 6 (8.70%)
Urban 37 12 (32.44%)
Socio-economic status**
Lower Class 76 14 (18.42%)
Middle Class 30 4 (7.13%)
*χ2 = 38.96 p = <0.001
**χ2 = 41.2E, p = <0.001

Discussion

Out of 106 patients selected in the study, the prevalence of abnormal GTT result was 18 (16.98%) which included 2 (1.88%) with impaired fasting glycemia, 11(10.34%) with impaired glucose tolerance and 5 (4.7%) were frankly diabetic. This result was statistically significant and compares to those found in the studies of Kishore et al (1973)11 20.9%, Singh et al (1978)21 22.0 %, Mugusi et al(1990)17 19 % and Yamagishi et al (2000)22 14.1%. The result found in the studies of the various workers is given in Table III.

The present study revealed that while with the increasing age the number of tubercular patients declined, the prevalence of IGT increased. The earlier exposure to pulmonary tuberculosis in our country and the development of resistance to the disease in later life accounted for involvement of younger population from tuberculosis. The higher prevalence of impaired glucose tolerance in the elderly was also observed by Kishore et al (1973)11, who found that the prevalence of IGT was higher among patients aged 40 years or more. Yamagishi et al (2000)22 and Roychoudhary and Sen (1980)20 also had similar observations. In some recent studies done by Basuglo et al (1999)1 and Lin et al (1998)13 a higher prevalence of IGT was found among the elderly.

The prevalence of IGT was significantly more in males (14/75-18.67%) than in females (4/31-12.90%). Out of the 18 patients with IGT, majority, i.e., 14(77.78%) were males. Yamagishi et al (2000)22 found the complication twice in males than in females. Fernandez et al (1997)4 found the prevalence in 6.2% in males and 3% in females.

Majority of the patients studied were from the low-socioeconomic class (76/106-71.70%). Interestingly, the prevalence of IGT was also more among them (14/76-18.42%) as compared to the middle class (4/30-7.13%). No patient belonged to the upper class. The common factor of malnutrition and poor access to medical facilities may account for the above observation and also to the development of hither-to uncommon malnutrition-related diabetes. Similar factors were also implicated in the findings of the present study that most had BMI lower than 18.5 (the lean diabetics), although this result was statistically insignificant. Fernandez et al (1997)4 in another lndian study found than BMI was lower in both the IGT and Normal Glucose Tolerance Test (NGTT) groups, while Zack et al (1973)23 and Mugusi et al (1990)17 found no significant differences in BMI in the two groups.

Table III Impaired Glucose Tolerance Tests In Patients of Pulmonary Tuberculosis

Author Year No. of
Tubercular
Patients
Prevalence of
diabetes/IGTT
1. Khanna10 1968 150 6.6%
2. Bloom2 1969 47 34%
3. Kishore et al11 1973 90 20.9%
4. Zack et al23 1973 256 41 %
5. Lahiri and Sen12 1974 851 66%
6. Roychoudhary et al20 1980 961 27.25%
7. Marais14 1980 436 2.1 %
8. Gulbas et a16 1987 30 13.3 %
9. Oluboyo and Erasmus18 1990 54 3.7%
10. Mugusi et al17 1990 506 6.7%
11. Jawad et a19 1995 106 49%
12. Fernandez et al4 1997 300 9.3 %
13. Lin et al13 1998 - 4.86%
14. Basoglu et al1 1999 58 19 %
15. Chukanuva et al3 2000 69102 0.34%
16. Yamagishi et al22 2000 4169 14.1 %
17. Firsova et al5 2000 130 10.8%
18. Guptan and Shah7 2000 9.7%
19. Present Study 2003 106 16.98%

Unlike patients of diabetes developing tuberculosis where the disease tends to be extensive and bilateral, we found that the GTT was abnormal even in early course of the disease long before both the lungs became involved. This may be due to the fact that latent diabetes predates tuberculosis and if patients of tuberculosis are subjected to GTT, early detection of diabetes can be made. Unilateral lung involvement was seen in 11 out of 18 (61.11%) cases with IGTT while bilateral involvement was seen in 7 out of 18 (38.89%) cases. Mugusi et al (1990)17 found bilateral lung involvement in 47.2% of his cases. Infiltration of the lung was seen as the most common lung lesion in 22.58% cases while cavitary lesion with varying amount of fibrosis was seen in 20% cases. Cavitary lesions were seen as the predominant lesion in studies by Mugusi et al (1990)17, Morris et al (1992)16, Fernandez et al (1997)4 and Parez et al (2000)19.

Seven out of 106 patients (6.60%) had exclusive lower zone involvement. This was seen in significantly high number in 20% cases with IGTT. Similar observations were seen in studies by Mugusi et al (1990)17 and Marais et al (1980)14, who found lower zone involvement in 27% and 29% cases respectively.

Several theories have been put forward to explain why tuberculous patients develop glucose intolerance. Bloom (1969)2 suggested that occult glucose intolerance predisposes to diabetes. Zack et at (1973)23 suggested that glucose intolerance was not merely a reaction to acute tuberculous infection but rather a prediabetic state. Hadden (1967) suggested malnutrition in tuberculosis as a possible cause. Acute severe stress, fever, inactivity and malnutrition stimulate the stress hormones epinephrine, glucagon and cortisol which raise the blood sugar level (Guptan et al, 2000)7. Roychoudhary and Sen (1980)6 suggested tuberculosis of pancreas as the possible cause. Similarly, higher incidence of chronic calcific pancreatitis occur in patients of diabetes and pulmonary tuberculosis leading to absolute or relative insulin deficiency state (Mollentz et al, 1990)15. Clinical and subclinical hypoadrenalism has been described in these patients (Guptan and Shah. 2000)7. Plasma levels of IL-1 and TNF-a are also raised in severe illness, which can stimulate anti-insulin responses. Age, co-existing illness and alcoholism also influence the host response (Fernandez et al, 1997)4.

References

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