Pulmonary Tuberculosis in Diabetics· Joseph L Morris, Maj, MC, USA; Barbara] Seaworth, M.D.; and C. Kenneth McAllister; Col, MC, USA
Pulmonary tuberculosis is found predominantly in the lung apices. In diabetics it has been suggested that tuberculosis tended to occur predominantly in the lower lobes. A retrospective chart review was performed of all patients with a diagnosis of diabetes and pulmonary tuberculosis admitted to a health care facility to determine the presenting chest roentgenographic location of tuberculosis. Multiple lobe involvement was the predominant chest roentgenographic finding in both diabetics and IlOndiabetics with
pulmonary tuberculosis is found predominantly in the upper lobes. Lower lung field tuberculosis occurs but is often misdiagnosed as pneumonia, carcinoma, or lung abscesses. The incidence of lower lung field tuberculosis has been reported to comprise approximately 7 percent of patients with active pulmonary tuberculosis. 1,2 Disease ofthe lower lung fields is most likely the result of transbronchial perforation of a hilar node with spread to the adjacent lobe. In 1927, Sosman and Steidl3 first suggested that tuberculosis in diabetics tended to occur predominantly in the lower lobes. 4 Many physicians are unaware of this association and in fact, controversy surrounds this association. A retrospective chart review of all patients with a diagnosis of diabetes and pulmonary tuberculosis admitted to the San Antonio (Tex) State Chest Hospital (SASCH) between January 1989 and October 1990 was undertaken to determine whether this relationship existed. MATERIALS AND METHODS
The medical records of 20 patients who had active pulmonary tuberculosis and diabetes mellitus at the SAseH between January 1989 and October 1990 were reviewed. The SASCH is a l15-bed health care facility operated by the State of Texas Health Department. Indigent individuals with tuberculosis are referred from throughout the state of Texas to this facility for treatment. The records of a reference group of 20 nondiabetic patients who were admitted to SAseH during the same time period and were matched according to age and sex were reviewed. Demographic information, including age, sex, site of tuberculous pulmonary involvement seen on chest roentgenogram, and number of antituberculosis medications was extracted from each record. Noncompliance, recurrent pulmonary tuberculosis, and other risk factors for tuberculosis were extracted when available. *From the Infectious Disease Service, Brooke Army Medical Center, Fort Sam Houston, Tex (Drs. Morris and McAllister), and San Antonio State Chest Hospital, Infectious Disease Consultant, San Antonio, Tex (Dr. Seaworth). The views of the authors do not necessarily reflect the position of the Department of the Army or the Department of Defense. Manuscript received December 30; revision accepted March 6.
pulmonary tuberculosis. Since tuberculosis and diabetes frequently coexist in the population at risk for tuberculosis, clinicians should suspect tuberculosis in the diabetic with an abnormality on chest roentgenogram. Aggressive diagnostic measures and specific chemotherapy should be given and monitored to treat pulmonary tuberculosis. (Chest 1992; 102:539-41) 1r---SA-S-C-H-=-s-a-n-An-to-n-j-o-S-ta-te-C-he-s-t-H-o-sP-j-ta-'--I
Lower lung field tuberculosis was defined as tuberculosis involving the middle lobe, lingula, and one or both lower lobes. Patients were considered to have a diagnosis of diabetes mellitus if they were receivin~ insulin or an oral hypo~lycemic agent at the time of hospital admission or were found to have two or more fasting blood glucose levels greater than 140 mgldl. Active tuberculosis was defined as a positive sputum smear and! or culture on hospital admission or within six weeks of admission. The extent of lung field involvement with pulmonary tuberculosis was assessed through the evaluation ofdetailed chest roent~eno~ram reports notin~ unilateral or bilateral lung involvement, cavitary or no cavitary disease, and the number of lobes involved with pulmonary tuberculosis. RESULTS
Over this 22-month period, 20 patients with both pulmonary tuberculosis and diabetes mellitus were admitted to the SASeH. Male patients outnumbered female patients in both the study and control groups. The mean age was 49.4 years in the diabetic group and 48.95 years in the nondiabetic group (Table 1). In both the diabetic and nondiabetic groups, multilobe involvement was the predominant chest roentgenographic finding (Tables 2 and 3). Although many patients with diabetes had multilobe involvement with tuberculosis, only two (10 percent) of the 20 had cavitary disease confined to the lower lung fields. No patients with lower lung tuberculosis were found in the nondiabetic group. An average of 2.25 lobes were involved with tuberculosis in the diabetic group with left upper lobe disease predominating (Table 2). The nondiabetic group had an average of 2.55 lobes inTable I-Characteristics a/Diabetic and Nondiabetic Patients with Pulmonary Tuberculosis Mean Age, yr Diabetic Nondiabetic
(Range)
Sex, M:F
No. Noncompliant (%)
Drug Resistant
49.4 (35-60) 48.95 (35-60)
16:4 16:4
5120 (25) 9/20 (45)
3120 0/20
CHEST I 102 I 2 I AUGUS"T, 1992
539
Table 2-Roentgenographic Involvement in Patients with Pulmonary Tuberculosis and Diabetes· Patient No.
LUL
1
+
3 4t 5 6t 7 8 9 10 11 12 13 14 15 16 17 18 19
+
2
20 Total
Lingula
+ +
+
+
+
2 4 1
+
+
5
RLL
+
+
+
+
+
+
+
+
+
+
Cavitary Disease
RML
+
+
Total Lobes
RUL
LLL
+
1
2
4 1
1
+
0
+
+
+
+
+ + + + + + +
+
16
+ +
+
+
+
+
+
+
+
+
9
9
6
5
+
+ + + +
2 3 1 3
+
1
+ + + + + 16
2
+ +
+
+
5
2 4 1
+ +
*LUL= left upper lobe; LLL= left lower lobe; RUL= right upper lobe; RML= right middle lobe; RLL= right lower lobe. t Lower lung field involvement only.
volved with disease most frequently involving the right or left upper lobes (Table 3). Cavitary disease was the predominant chest roentgenographic finding seen in 16 of 20 patients in the diabetic group and 17 of 20 patients in the nondiabetic group. The remaining patients in both groups had chest roentgenographic patterns described as fibronodular disease, apical pleural thickening, a mass lesion, and/or linear densities.
The primary reason for hospitalization in both groups was for treatment of pulmonary tuberculosis. Three patients in the diabetic group had multidrugresistant tuberculosis and required four or more antituberculosis drugs for treatment. Multidrug-resistant tuberculosis was not found in the nondiabetic group. Both groups had multiple patients who were noncompliant. One patient in the nondiabetic group was seropositive for the human immunodeficiency virus.
Table 3-Hoentgenographic Involvement in Patients with Pulmonary Tuberculosis· Patient No.
1
2
3 4 5 6
7 8 9
10
11
12
13 14 15 16 17 18 19
20 Total
LUL
Lingula
LLL
+
+ + +
+ + +
+ +
+
+ + + + + + + +
18
Cavitary Disease
+ + + +
2 2 2 2
+ + + +
+ + +
2
+ + + + +
2
+
RML
RLL
1
+
+
+
lhtal Lobes
RUL
+ +
+ + + + + + +
+ 0
4
+
+
17
+ + +
+
+
+ +
4 3
+ +
1
+
+
+ +
+
7
3 3 2 5 1
+
5
2
+
1
+
3
+ 17
4
5
+
*LUL = left upper lobe; LLL = left lower lobe; RUL = right upper lobe; RML = right middle lobe; RLL = right lower lobe. 540
Pulmonary Tuberculosis in Diabetics (Morris, Seaworth, McAllister)
DISCUSSION
Multiple lobe involvement was the predominant presenting location of tuberculosis in all ofthe patients examined. Lower lung field involvement is an infrequent location of pulmonary tuberculosis, occurring in 7 percent or less of patients with active pulmonary tuberculosis. 1,2 Lower lung field tuberculosis was seen in 10 percent of our diabetic patients. No lower lung field disease was noted in the nondiabetic patients. Multilobe involvement was the most common presenting chest roentgenographic abnormality with an average of more than two lobes involved in both groups of patients. The left upper lobe was the lobe most frequently involved with cavitary disease in the diabetic group, whereas both the right and left upper lobes were involved with cavitary disease in the nondiabetic group. In a previous report of 20 patients with coexisting pulmonary tuberculosis and diabetes, four (20 percent) of 20 patients were noted to have only lower lobe involvement. 4 Although the sample size was the same, our study showed a smaller incidence of only lower lobe involvement with tuberculosis in patients with both tuberculosis and diabetes. We do not believe that this 10 percent incidence is statistically significant due to the small sample size. The smaller incidence can also be attributed to patients presenting to the SASCH late in the course of their disease process at which
time spread to other lobes may have already occurred. Our study does not support the original observation of Sosman and Steidl3 that tuberculosis tends to occur predominantly at the lower lung fields in patients with diabetes. 4 Multiple lobe involvement is the predominant presentation of pulmonary tuberculosis in diabetics. The small number of patients involved in our study may account for this finding and a study involving a larger number of patients may find the observations of Sosman and Steidl to be true. 3,4 Tuberculosis and diabetes frequently coexist in patients at risk for pulmonary tuberculosis. Clinicians should include tuberculosis in the differential diagnosis of a chest roentgenographic abnormality in the diabetic population. Aggressive diagnosis with tuberculin skin testing, appropriate processing of sputum cultures for Mycobacteria tuberculosis, and treatment with appropriate antituberculosis medications is strongly recommended. REFERENCES
1 Parmer M. Lower lung field tuberculosis. Am Rev Respir Dis 1967; 96:310-13 2 Berger H. Lower lung field tuberculosis. Chest 1974; 65:522-26 3 Sosman MC, Steidl JH. Diabetic tuberculosis. Am J Roentgenol 1927; 17:625 4 Weaver R. Unusual radiographic presentation of pulmonary tuberculosis in diabetic patients. Am Rev Respir Dis 1974; 109:162-63
CHEST I 102 I 2 I AUGUS'T, 1992
541
Pulmonary tuberculosis is found predominantly in the lung apices. In diabetics it has been suggested that tuberculosis tended to occur predominantly in the lower lobes. A retrospective chart review was performed of all patients with a diagnosis of diabetes and pulmonary tuberculosis admitted to a health care facility to determine the presenting chest roentgenographic location of tuberculosis. Multiple lobe involvement was the predominant chest roentgenographic finding in both diabetics and IlOndiabetics with
pulmonary tuberculosis is found predominantly in the upper lobes. Lower lung field tuberculosis occurs but is often misdiagnosed as pneumonia, carcinoma, or lung abscesses. The incidence of lower lung field tuberculosis has been reported to comprise approximately 7 percent of patients with active pulmonary tuberculosis. 1,2 Disease ofthe lower lung fields is most likely the result of transbronchial perforation of a hilar node with spread to the adjacent lobe. In 1927, Sosman and Steidl3 first suggested that tuberculosis in diabetics tended to occur predominantly in the lower lobes. 4 Many physicians are unaware of this association and in fact, controversy surrounds this association. A retrospective chart review of all patients with a diagnosis of diabetes and pulmonary tuberculosis admitted to the San Antonio (Tex) State Chest Hospital (SASCH) between January 1989 and October 1990 was undertaken to determine whether this relationship existed. MATERIALS AND METHODS
The medical records of 20 patients who had active pulmonary tuberculosis and diabetes mellitus at the SAseH between January 1989 and October 1990 were reviewed. The SASCH is a l15-bed health care facility operated by the State of Texas Health Department. Indigent individuals with tuberculosis are referred from throughout the state of Texas to this facility for treatment. The records of a reference group of 20 nondiabetic patients who were admitted to SAseH during the same time period and were matched according to age and sex were reviewed. Demographic information, including age, sex, site of tuberculous pulmonary involvement seen on chest roentgenogram, and number of antituberculosis medications was extracted from each record. Noncompliance, recurrent pulmonary tuberculosis, and other risk factors for tuberculosis were extracted when available. *From the Infectious Disease Service, Brooke Army Medical Center, Fort Sam Houston, Tex (Drs. Morris and McAllister), and San Antonio State Chest Hospital, Infectious Disease Consultant, San Antonio, Tex (Dr. Seaworth). The views of the authors do not necessarily reflect the position of the Department of the Army or the Department of Defense. Manuscript received December 30; revision accepted March 6.
pulmonary tuberculosis. Since tuberculosis and diabetes frequently coexist in the population at risk for tuberculosis, clinicians should suspect tuberculosis in the diabetic with an abnormality on chest roentgenogram. Aggressive diagnostic measures and specific chemotherapy should be given and monitored to treat pulmonary tuberculosis. (Chest 1992; 102:539-41) 1r---SA-S-C-H-=-s-a-n-An-to-n-j-o-S-ta-te-C-he-s-t-H-o-sP-j-ta-'--I
Lower lung field tuberculosis was defined as tuberculosis involving the middle lobe, lingula, and one or both lower lobes. Patients were considered to have a diagnosis of diabetes mellitus if they were receivin~ insulin or an oral hypo~lycemic agent at the time of hospital admission or were found to have two or more fasting blood glucose levels greater than 140 mgldl. Active tuberculosis was defined as a positive sputum smear and! or culture on hospital admission or within six weeks of admission. The extent of lung field involvement with pulmonary tuberculosis was assessed through the evaluation ofdetailed chest roent~eno~ram reports notin~ unilateral or bilateral lung involvement, cavitary or no cavitary disease, and the number of lobes involved with pulmonary tuberculosis. RESULTS
Over this 22-month period, 20 patients with both pulmonary tuberculosis and diabetes mellitus were admitted to the SASeH. Male patients outnumbered female patients in both the study and control groups. The mean age was 49.4 years in the diabetic group and 48.95 years in the nondiabetic group (Table 1). In both the diabetic and nondiabetic groups, multilobe involvement was the predominant chest roentgenographic finding (Tables 2 and 3). Although many patients with diabetes had multilobe involvement with tuberculosis, only two (10 percent) of the 20 had cavitary disease confined to the lower lung fields. No patients with lower lung tuberculosis were found in the nondiabetic group. An average of 2.25 lobes were involved with tuberculosis in the diabetic group with left upper lobe disease predominating (Table 2). The nondiabetic group had an average of 2.55 lobes inTable I-Characteristics a/Diabetic and Nondiabetic Patients with Pulmonary Tuberculosis Mean Age, yr Diabetic Nondiabetic
(Range)
Sex, M:F
No. Noncompliant (%)
Drug Resistant
49.4 (35-60) 48.95 (35-60)
16:4 16:4
5120 (25) 9/20 (45)
3120 0/20
CHEST I 102 I 2 I AUGUS"T, 1992
539
Table 2-Roentgenographic Involvement in Patients with Pulmonary Tuberculosis and Diabetes· Patient No.
LUL
1
+
3 4t 5 6t 7 8 9 10 11 12 13 14 15 16 17 18 19
+
2
20 Total
Lingula
+ +
+
+
+
2 4 1
+
+
5
RLL
+
+
+
+
+
+
+
+
+
+
Cavitary Disease
RML
+
+
Total Lobes
RUL
LLL
+
1
2
4 1
1
+
0
+
+
+
+
+ + + + + + +
+
16
+ +
+
+
+
+
+
+
+
+
9
9
6
5
+
+ + + +
2 3 1 3
+
1
+ + + + + 16
2
+ +
+
+
5
2 4 1
+ +
*LUL= left upper lobe; LLL= left lower lobe; RUL= right upper lobe; RML= right middle lobe; RLL= right lower lobe. t Lower lung field involvement only.
volved with disease most frequently involving the right or left upper lobes (Table 3). Cavitary disease was the predominant chest roentgenographic finding seen in 16 of 20 patients in the diabetic group and 17 of 20 patients in the nondiabetic group. The remaining patients in both groups had chest roentgenographic patterns described as fibronodular disease, apical pleural thickening, a mass lesion, and/or linear densities.
The primary reason for hospitalization in both groups was for treatment of pulmonary tuberculosis. Three patients in the diabetic group had multidrugresistant tuberculosis and required four or more antituberculosis drugs for treatment. Multidrug-resistant tuberculosis was not found in the nondiabetic group. Both groups had multiple patients who were noncompliant. One patient in the nondiabetic group was seropositive for the human immunodeficiency virus.
Table 3-Hoentgenographic Involvement in Patients with Pulmonary Tuberculosis· Patient No.
1
2
3 4 5 6
7 8 9
10
11
12
13 14 15 16 17 18 19
20 Total
LUL
Lingula
LLL
+
+ + +
+ + +
+ +
+
+ + + + + + + +
18
Cavitary Disease
+ + + +
2 2 2 2
+ + + +
+ + +
2
+ + + + +
2
+
RML
RLL
1
+
+
+
lhtal Lobes
RUL
+ +
+ + + + + + +
+ 0
4
+
+
17
+ + +
+
+
+ +
4 3
+ +
1
+
+
+ +
+
7
3 3 2 5 1
+
5
2
+
1
+
3
+ 17
4
5
+
*LUL = left upper lobe; LLL = left lower lobe; RUL = right upper lobe; RML = right middle lobe; RLL = right lower lobe. 540
Pulmonary Tuberculosis in Diabetics (Morris, Seaworth, McAllister)
DISCUSSION
Multiple lobe involvement was the predominant presenting location of tuberculosis in all ofthe patients examined. Lower lung field involvement is an infrequent location of pulmonary tuberculosis, occurring in 7 percent or less of patients with active pulmonary tuberculosis. 1,2 Lower lung field tuberculosis was seen in 10 percent of our diabetic patients. No lower lung field disease was noted in the nondiabetic patients. Multilobe involvement was the most common presenting chest roentgenographic abnormality with an average of more than two lobes involved in both groups of patients. The left upper lobe was the lobe most frequently involved with cavitary disease in the diabetic group, whereas both the right and left upper lobes were involved with cavitary disease in the nondiabetic group. In a previous report of 20 patients with coexisting pulmonary tuberculosis and diabetes, four (20 percent) of 20 patients were noted to have only lower lobe involvement. 4 Although the sample size was the same, our study showed a smaller incidence of only lower lobe involvement with tuberculosis in patients with both tuberculosis and diabetes. We do not believe that this 10 percent incidence is statistically significant due to the small sample size. The smaller incidence can also be attributed to patients presenting to the SASCH late in the course of their disease process at which
time spread to other lobes may have already occurred. Our study does not support the original observation of Sosman and Steidl3 that tuberculosis tends to occur predominantly at the lower lung fields in patients with diabetes. 4 Multiple lobe involvement is the predominant presentation of pulmonary tuberculosis in diabetics. The small number of patients involved in our study may account for this finding and a study involving a larger number of patients may find the observations of Sosman and Steidl to be true. 3,4 Tuberculosis and diabetes frequently coexist in patients at risk for pulmonary tuberculosis. Clinicians should include tuberculosis in the differential diagnosis of a chest roentgenographic abnormality in the diabetic population. Aggressive diagnosis with tuberculin skin testing, appropriate processing of sputum cultures for Mycobacteria tuberculosis, and treatment with appropriate antituberculosis medications is strongly recommended. REFERENCES
1 Parmer M. Lower lung field tuberculosis. Am Rev Respir Dis 1967; 96:310-13 2 Berger H. Lower lung field tuberculosis. Chest 1974; 65:522-26 3 Sosman MC, Steidl JH. Diabetic tuberculosis. Am J Roentgenol 1927; 17:625 4 Weaver R. Unusual radiographic presentation of pulmonary tuberculosis in diabetic patients. Am Rev Respir Dis 1974; 109:162-63
CHEST I 102 I 2 I AUGUS'T, 1992
541
