TB in patients with HIV and diabetes [0076]

·  Tuberculosis (TB) is present in all countries and affects all age groups.

·  The five main risk factors for progression to TB disease are:

  • Undernourishment
  • HIV infection
  • Alcohol use disorders
  • Smoking (especially among men)
  • Diabetes mellitus (DM)

·  It is unknown how many people suffer from a combination of TB, HIV, and DM.

·  The risk of TB is much higher in people living with HIV (PLWH) than in those with DM, and is strongly associated with the level of immunodeficiency.

·  Soon after HIV infection, the risk of TB disease increases 2–5-fold compared to non-HIV-infected individuals.

·  With progression to HIV-induced severe immunodeficiency, the risk of TB increases at least 20-fold compared to the general population.

·  Antiretroviral therapy (ART) for HIV-1 does not fully restore the baseline level of TB risk.

·  Glycaemic control is likely to be an important factor in reducing the risk of TB.

·  The clinical presentation of TB in PLWH varies by CD4 T-cell count:

  • Low CD4 T-cell count: Lung lesions are similar to those in non-HIV-infected individuals, with upper lobe infiltrates and cavity development.
  • Very low CD4 T-cell count: Extrapulmonary TB is more common, occurring in 40-80% of cases, with manifestations such as lymphadenitis, pleuritis, pericarditis, meningitis, CNS tuberculomas, or disseminated disease.

·  Radiological images in PLWH may show atypical features, including:

  • Lower lobe or middle lobe diseases
  • Miliary infiltrates without cavitation

·  Unlike HIV, DM is not associated with extrapulmonary or disseminated TB. However, some studies indicate that DM is associated with:

  • More pulmonary cavities
  • A higher bacterial load

·  Diabetic TB patients tend to be older and heavier than TB patients without DM.

·  For initial pulmonary TB diagnosis in PLWH, a molecular test such as GeneXpert (Cepheid, Sunnyvale, CA, USA) should be used.

·  Microbial diagnosis of HIV-associated TB may be difficult in advanced HIV disease due to:

  • Low bacilli counts detected using standard procedures
  • The higher prevalence of extrapulmonary TB

·  Mycobacterial blood cultures and urine lipoarabinomannan have shown considerable sensitivity in patients with advanced HIV.

·  DM is associated with an almost two-fold higher prevalence of multidrug-resistant TB (MDR-TB), for both primary and acquired resistance. See also: https://tbreadingnotes.blogspot.com/2024/07/enhanced-dm-management-reduce-risk-and.html

·  TB treatment is similar for both TB-HIV and TB-DM cases. However:

  • Some guidelines suggest prolonged TB therapy, though evidence does not support this.
  • TB treatment success rates remain lower among PLWH (77% globally in 2021) compared to non-HIV-infected individuals (86% globally in 2021).

·  ART should be started within 2 weeks of initiating TB therapy, regardless of CD4 T-cell count. However, for PLWH with TB meningitis, ART should be delayed for at least 4 weeks to avoid severe neurological TB-IRIS, which may require adjunctive glucocorticoids.

·  In TB-DM cases, treatment is similar, but therapy failure, disease recurrence, toxicity, and dangerous drug interactions are more common. See also: https://tbreadingnotes.blogspot.com/2024/07/association-of-obesity-diabetes-and.html

·  Drug toxicity is a major challenge due to the shared toxicity of ART and anti-TB drugs. Drug-induced liver injury is the most serious adverse event linked to antiretrovirals and some anti-TB drugs.

·  Prevention of HIV-associated TB relies on TB disease screening and preventive therapy.

·  Proposed measures to control TB-HIV and TB-DM include:


Goletti, D., Pisapia, R., Fusco, F.M., Aiello, A. and Van Crevel, R., 2023. Epidemiology, pathogenesis, clinical presentation and management of TB in patients with HIV and diabetes. The International Journal of Tuberculosis and Lung Disease, 27(4), pp.284-290.

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