Presentation of pulmonary tuberculosis in diabetics and response to anti-tuberculosis therapy

Background: Diabetes and Tuberculosis are known to be mutually affective. In high tuberculosis and Diabetes burden country like ours, it is essential that we understand all the aspects concerning both these diseases individually and in mutual coexistence, in order to improve the management of this unhealthy partnership.Methods: This is a prospective hospital based observational study, in which 100 patients with coexisting Diabetes and new sputum confirmed pulmonary tuberculosis with no other comorbidities were included. Detailed history, examination and appropriate investigations were done evaluating the clinical and radiological presentation and treatment response in terms of sputum conversion at follow up visits.Results: Predominant symptoms were anorexia, fever and cough with sputum, majority with duration of more than 4 weeks. About half of them had diabetes duration of less than 1 year, most being newly diagnosed. All cases had upper lobe involvement; two thirds of them had lower lung field and multiple lobe involvement. Confluent consolidation, cavitary lesions and fluffy infiltrates were common. 27 of the 100 cases had a delayed sputum conversion. Longer duration of diabetes, maintenance on oral hypoglycaemic drugs alone and uncontrolled diabetes had delayed sputum conversion.Conclusions: Presenting symptoms of tuberculosis in diabetics is more or less similar to that in non-diabetics. Atypical radiological presentation with lower lung field involvement and confluent consolidation mimicking pneumonia is common. Delay in sputum conversion is common in dual disease and is increased with increasing DM duration and poor glycemic control. Better results may be obtained with insulin therapy.

Bronchial wash Gene Xpert MTB/RIF in lower lung field tuberculosis: Sensitive, superior, and rapid in comparison with conventional diagnostic techniques

BackgroundLower lung field tuberculosis (LLF TB) is an atypical presentation of tuberculosis (TB). LLF TB is common, and a proportionate number of non-resolving pneumonia cases are diagnosed to have pulmonary TB.Materials and MethodsThe prospective observational study was conducted during June 2013 to December 2015 in the Department of Pulmonary Medicine, MIMSR Medical College, Latur, India; the objective of the study is clinical, microbiological, and radiological presentation of LLF TB and the comparison of yield of conventional diagnostic techniques and bronchoscopy-guided modalities in LLF TB. Additional important objective of the study is to find LLF TB in patients with nonresolving pneumonia (NRP). A total of 2,600 patients with pulmonary TB were included in the study after inclusion and exclusion criteria. Ethical clearance was taken from the ethical committee of the institutional review board. Consent was taken from the patients before inclusion in the study. Statistical analysis was done using chi-square test.ResultsIn the present study, 300 (11.53%) cases of LLF TB of total 2600 pulmonary tuberculosis were included, females constitutes 66.66% (200/300) with mean age of 58.4 ± 11.8 years and males constitutes 33.34% (100/300) with mean age of 56.8 ± 10.6 years. Constitutional symptoms were observed as cough in 93% cases, fever in 83% cases, shortness of breath in 72% cases, anorexia in 91% cases, and weight loss in 84% cases. Radiological assessment of study cases documented the involvement of right lower zone in 84% cases and left lower zone in only 16% cases. In the studied LLF TB cases, 57 cases (20.66%) were diagnosed by routine sputum microscopic examination for acid fast bacilli (AFB) and 80 cases (28%) were diagnosed by induced sputum microscopic examination for AFB. In the study of 170 LLF TB cases, head-to-head comparison between conventional diagnostic techniques (sputum microscopy and Induced sputum microscopy for AFB) made diagnosis in 60 cases, while bronchoscopy-guided sampling techniques (BAL for AFB and BAL for Gene Xpert MTB/RIF) made diagnosis in 155 cases (91.17%) (P< 0.00001). Comorbid conditions such as human immunodeficiency virus (HIV) coinfection in 36 cases (12.00%), Diabetes mellitus in 64 cases (21.33%), and chronic kidney disease (CKD) in 22 cases (7.33%) were observed. Comorbidities were observed in 41.67% of the studied cases and found very significant assessment to have successful treatment outcome (P< 0.00001). In the study of 300 LLF TB cases, 60 cases were having NRP pattern. In LLF TB cases with NRP pattern, bronchoscopy-guided bronchial wash microscopy for AFB made diagnosis in 18 cases (42%), while bronchoscopy-guided BAL for Gene Xpert MTB/RIF made diagnosis in 58 cases (96.66%) (P< 0.00001).ConclusionLLF TB is usually underdiagnosed because of diverse clinical and radiological presentation, less diagnostic yield of conventional diagnostic modalities, and these modalities used routinely and universally. Bronchoscopy-guided diagnostic techniques are superior, sensitive, and reliable to confirm LLF TB. Gene Xpert MTB/RIF in bronchial wash samples is found to be best diagnostic modality in evaluating LLF TB and should be used routinely to have successful treatment outcome. A proportionate number of NRP cases are having LLF TB and a high index of suspicion is a must while evaluating these cases.

Nutritional effect, care and support for patients with tuberculosis among diabetes: a study from Warangal district

Objective: Tuberculosis is one of the important infections among the diabetes as per our study and survey reports. Diabetes mellitus has been reported to modify the presenting features of pulmonary tuberculosis, but there are varying data, particularly regarding the association with lower lung field involvement. In our study we would like to determine whether diabetes mellitus alters the clinical and radiographic manifestations of tuberculosis in hosts and to define the determinants of lower lung field involvement due to effect of nutrition supply.Methods: A total of 500 diabetes were identified from both rural and urban population and were confirmed the diabetic status based on questioner and consent of patients. Off 500 patients 200 suspects with bronchial infections was tested for other bacterial and Tuberculosis infections by Grams staining, and culture on Nutrient and blood Agar for bacterial infections based on the staining and culture they were identified to be grams positive or Grams negative bacterial infections.Results: We had conducted a survey and study in Warangal and adjoing districts of Telangana state during 2014- 2017 period, in the study we had counseled approximately 1000 -2000 populations off which 500 were suspects for early diabetes based on the symptoms and clinical investigations off 500 were able to found 200 diabetic type 2 causes. Off 200 55 were positive for tuberculosis all the suspects were counseled for their nutritional status and other prevailing side effects with treatment. Conclusions: Based on this study we had tried to evaluate the effect, care and support of nutritional among diabetic TB patients.

Abstract 9978: Effect of Balloon Pulmonary Angioplasty on Respiratory Function in Patients With Chronic Thromboembolic Pulmonary Hypertension: Different Effects According to the Lung Field Involved

Background: Treatment of chronic thromboembolic pulmonary hypertension (CTEPH) with balloon pulmonary angioplasty (BPA) reportedly improves hemodynamics, exercise capacity, and right ventricular function. However, the effect of BPA on respiratory functions is unclear. Methods: We enrolled consecutive patients with inoperable CTEPH who underwent BPA. BPA was performed primarily on the lower lobe arteries during the first series and on the upper and middle lobe arteries during the second series. We examined right heart catheterization, the respiratory function test, and the cardiopulmonary exercise test, and compared the change in these parameters according to the BPA performed field (divided into the upper-middle and lower lobe before BPA, after BPA, and the follow-up period). Results: In total, 62 BPA sessions were performed in 13 CTEPH patients. Hemodynamics significantly improved after BPA (mPAP: 44±8 to 24±5 mmHg, PVR: 818±383 to 293±68 dyne/s/cm-5), and WHO-FC improved from 3.1±0.3 to 2.2±0.6 after BPA. Hemodynamic improvement tended to be larger in BPA in the lower lung field. The %DLco significantly decreased (p=0.001) in BPA in the lower lung field, and did not appear to recover during the follow-up period. In contrast, %DLco significantly increased in BPA in the upper-middle lung field (p=0.030), and tended to increase until the follow-up period (p=0.077) (Fig). In addition, VE/VCO2 slope significantly improved after BPA in the lower lung field (p=0.014), and showed further improvement at the follow-up period (p=0.007); however, VE/VCO2 slope remained unchanged after BPA in the upper-middle lung field (Fig). Furthermore, during follow-up, change in %DLco and VE/VCO2 slope were significantly different between lower and upper-middle lung field BPA performed (p<0.001 and p=0.020, respectively, Fig). Conclusions: We observed that the effect of BPA in CTEPH patients may have a different effect on respiratory function according to the lung field.

Clinicoradiological Profile of Lower Lung Field Tuberculosis Cases among Young Adult and Elderly People in a Teaching Hospital of Madhya Pradesh, India

Aim. To study the clinical and radiological features of lower lung field tuberculosis (LLFTB) in relation to the patients of nonlower lung field tuberculosis (non-LLFTB).Material and Methods. All the patients of lower lung field tuberculosis defined by the lesions below an arbitrary line across the hila in their chest X-rays were included in the study. Their sputum for acid fast bacilli, HIV, blood sugar, and other relevant investigations were performed.Results. The total of 2136 cases of pulmonary tuberculosis was studied. Among them 215 (10%) cases of patients were diagnosed as the case of lower lung field tuberculosis. Females (62%) were more commonly affected. Most common clinical feature in non-LLFTB was cough (69%) followed by fever (65%), chest pain (54.7%), and weight loss (54.4%). Chest X-ray showed predominance of right side (60.9%) in cases of LLFTB. The relative risk of having the LLFTB in diabetes patients, HIV seropositive patients, end stage renal disease patients, and patients on corticosteroid therapy was high.Conclusion. Lower lung field tuberculosis is not an uncommon entity. It is more common in diabetes, HIV positive, end stage renal disease, and corticosteroid treated patients. Clinical and radiological features are different from upper lobe tuberculosis patients.