TB TW ID etc.: DM-TB, A Syndemic in Vulnerable Populations

DM is consistently identified as a strong, independent risk factor for TB across multiple studies.
In the STREAM trial, 9.4% of MDR-TB patients had DM, and those with DM were generally older, male, and had higher BMI.
LLF-TB was significantly more common in diabetic individuals over 40, with a 6.8-fold increased risk compared to non-diabetics.
In CKD patients, diabetes mellitus was independently associated with increased TB prevalence.
Poor glycemic control (HbA1c > 7%) and long duration of DM (>10 years) were significantly associated with higher rates of LLF-TB.

In Bangladesh, lower lung field TB (LLF-TB) is often misdiagnosed due to overlap with other conditions (e.g., pneumonia, lung cancer).
LLF-TB more common among diabetics, older adults, smokers, and those using insulin without OHAs.
Among CKD patients in Ethiopia:
SAEs in STREAM: 41% of DM patients experienced SAEs, especially related to endocrine/surgical issues, vs. 22% in non-DM.

In Kiambu County, age, income, agricultural land ownership, and TB knowledge significantly influenced TB medication adherence.
Participants with moderate or high TB knowledge showed 14.8–18.2% higher adherence than those with low knowledge.
Non-significant but positive associations were found between employment, education, and adherence.
Health behaviors: low tobacco (4.3%) and alcohol use (15.6%), but flu, pneumonia, and other ailments could interfere with adherence.
Older patients and those with higher income levels adhered better to TB medication regimens.

TB-DM patients showed higher smear positivity (83.3% vs. 20.4%) but lower GeneXpert positivity (8.3% vs. 68.8%).
CKD patients with TB frequently presented with ≥6 symptoms, including decreased appetite, weight loss, and fatigue.
Elevated ESR and high HbA1c were significant markers of LLF-TB in diabetic patients.
Xpert MTB/RIF Ultra assay and culture were important tools in confirming TB among CKD patients, with 10.5% and 7.9% positivity, respectively.

Higher BMI generally protects against TB, possibly due to better nutritional reserves.
However, this protection diminishes at very high BMI levels, especially in younger women.
DM may mediate the relationship between obesity and TB, complicating risk assessments.
Patients who are both obese and diabetic may not have significantly higher TB risk compared to non-diabetics with normal BMI, reflecting complex interactions.
BMI effects are stronger in active TB than in latent infections, underlining differing pathophysiological mechanisms.

References:

Gurumurthy, M., Gopalan, N., Patel, L., Davis, A., Srinivasalu, V.A., Rajaram, S., Goodall, R., Bronson, G. and STREAM Trial Collaboration, 2025. Treatment outcomes in people with diabetes and multidrug-resistant tuberculosis (MDR TB) enrolled in the STREAM clinical trial. PLOS Global Public Health, 5(4), p.e0004259.
Galib, R.K., Paul, S.K., Akter, K., Musa, M.I., Sarker, D.J., Choudhury, S.A.R.A., Paul, S.C. and Chakrabortty, R., 2025. Frequency of Lower Lung Field Tuberculosis in Diabetes Mellitus Patients Attending Tertiary Care Hospital in Bangladesh: A Cross‐Sectional Study. Health Science Reports, 8(1), p.e70413.
Kamui, I. N. (2025). Determinants of tuberculosis medication adherence among TB patients at Kiambu Level Five Hospital, Kiambu County, Kenya. Journal of Medical and Health Sciences, 4(1), 1–15.
Alemu, A., Diriba, G., Seid, G., Wondimu, A., Moga, S., Tadesse, G., Haile, B., Berhe, N., Mariam, S.H. and Gumi, B., 2025. Active tuberculosis among patients with presumptive tuberculosis with chronic kidney disease in a high tuberculosis burden country, Ethiopia: a multi-center study. IJID regions, 14, p.100551.
Herman, D., Machmud, R. and Lipoeto, N.I., 2025. Unraveling the Link between Obesity and Tuberculosis: A Systematic Review of the Underlying Mechanisms. Bioscientia Medicina: Journal of Biomedicine and Translational Research, 9(2), pp.6453-6466.

TBC 063

TB TW ID etc.