Diabetes and Tuberculosis: Challenge of Modern Medicine

The world medical community is strongly concentrated on the fight COVD-19, HIV/AIDS, tuberculosis. The combination of two or more concurrent nosologies is a major problem in patient management. Thus considering the abovementioned facts, we would like to focus your attention on such comorbidities as diabetes and tuberculosis. Patient M., 49 y.o., type 2 diabetes during 10 years. In July 2018, she consulted her physician and complained of non-productive mild cough, low-grade fever, fatigue, reduced workability. After the follow-up examination which involved chest X-ray and complete blood cell count, she was diagnosed with an abscess forming pneumonia in the right lower lobe and prescribed treatment with the use of broad-spectrum antibiotics according to the protocol. After the treatment, the patient’s condition has slightly improved, though the labile diabetes with frequent episodes of hypoglycemia and hyperglycemia, and cough still persisted. The level of HbA(1)C was 7.8%. At the patient’s request, she continued to receive: glimepiride 6 mg/day, metformin 1000 mg/day. Considering the patient’s general condition as gradual recovery the doctor has discharged the patient. In January 2019, the patient consulted a tuberculotherapist, because the cough persisted, the body temperature markers sometimes attained feverish indices, the general weakness increased. After the follow-up examination: complete blood cell count, chest X-ray, sputum smear microscopy, genetic-molecular study with GeneXpert-test and culture test on the BACTEC system, the patient was diagnosed with disseminated tuberculosis with bacterial excretion, susceptible. The patient received treatment according to the 2HRZE 4HR scheme. Results: the treatment was completed, whereas the cavern was preserved, the patient refused to undergo surgical treatment. After 7 months, the previous symptoms reappeared, after additional examination the patient was diagnosed with multi-drug resistant tuberculosis and was prescribed treatment with second-line agents for 20 months, and the patient was given insulin degludec/aspart at a daily dose of 64 IU. The therapy resulted in patient’s recovery, the cavern was closed, and compensation of diabetes was achieved: no episodes of hypoglycemia were recorded; the HbA(1)C - 6.5%. Analyzing the previous data it is necessary to note the mistakes that were made. The mismatch of clinical symptoms with the established diagnosis, the absence of a sputum smear for acid-resistant bacteria, apical localization of tuberculosis which is typical for patients with diabetes was not characteristic in this case, all these factors have led to an incorrect diagnosis at the primary level. At the beginning of tuberculosis treatment, the patient should be transferred to the correction of blood glucose levels with insulin and, if the cavern preserves, the patient should be prepared for its surgical removal.