Remission of Tuberculosis Following Control of Glycemic Excursions in a Patient with Type 2 Diabetes Mellitus

Abstract

Rationale: Tuberculosis (TB) and diabetes mellitus (DM) are converging epidemics, each worsening the morbidity of the other. Chronic hyperglycemia is associated with dysfunctional immunity to Mycobacterium in patients with DM and, therefore, is likely to decrease the efficiency of anti-mycobacterial treatment. Early aggressive management of TB and timely initiation of insulin therapy helps in controlling the glycemic excursions that are otherwise not controlled by multiple oral antidiabetic agents. Patient Concerns: A 42-year-old female with type 2 diabetes for six years presented with complaints of persistent cough, pain in the chest, weight loss, and loss of appetite for two months in November 2018. Diagnosis: The patient was diagnosed with multidrug-resistant TB (MDR-TB), which further progressed to extensively drug-resistant TB (XDR-TB) in February 2019. Her hemoglobin A1c (HbA1c), which was 8.3% prior to TB diagnosis, increased to 13.8%. Interventions: The patient was initiated on anti-TB medications as per the Revised National TB Control Programme (RNTCP) guidelines. The antidiabetic regimen consisted of glimepiride 2 mg b.i.d, metformin 500 mg b.i.d, and voglibose 0.2 mg b.i.d. On confirmation of XDR-TB and persistently high HbA1c, insulin glargine was initiated in July 2019. Due to continued uncontrolled blood glucose levels, insulin IDegAsp (30% Aspart and 70% Degludec) was initiated in February 2020. Results: After the initiation of IdegAsp, HbA1c levels reduced significantly and there was improvement in the measures of daily blood glucose level indices such as time in target range (TIR), time below target range (TBR), and time above target range (TAR). Optimal blood glucose was achieved in a significant amount of time in a day. Sputum was negative for XDR-TB in February 2021, and the patient recovered from TB. Her HbA1c was reported to be 7.5% in February 2021. Conclusion: In patients with type 2 diabetes and TB, maintaining optimal blood glucose level for a longer duration of time can have a positive impact on host immunity and also enhance the effect of ATT and better outcomes of TB infection. This case study highlights the importance of good glycemic control in patients with type 2 diabetes who acquire TB infection.