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Tuberculosis and diabetes
LEADING
ARTICLE
Tuberculosis and Diabetes Tuberculosis has been recognized as an important complication of diabetes for at least one hundred years. Its frequency during the last few years has been estimated both in the United States and this country. In Philadelphia, 261 (8'4 per cent) of 3, ro6 diabetics examined routinely by mass-radiography had abnormalities in the lung fields suggestive of tuberculosis and 2' 4 per cent were considered to have active disease.' The incidence of suggestive abnormalities in a large group of industrial workers in the same city was 4'3 per cent. Turner- Warwick2 found 34 (1·8 per cent) with active tuberculosis among r ,85 r new patients at a diabetic clinic in London. The incidence among the diabetics was compared with the incidence among patients having routine radiographs on admission to a general hospital." It was higher among diabetics in both men and women and in all the age groups studied; and it was almost four times as high in the whole group. The difference in incidence was greater in the women than in the men at all ages up to 65, the largest difference occurring in those between the ages of 15 and 34 years. In this group the rate was 35 per 1,000 for women and 16 per 1,000 for men, but only 4 per 1,000 and 5 per 1,000 respectively among the general hospital patients. Over 65 years old there was a higher incidence in men, This study suggests, therefore, that in this country young diabetic women and elderly diabetic men are especially prone to develop radiographic evidence of pulmonary tuberculosis. The American survey, on the other hand, found that under the age of 40 diabetic men were affected three times as frequently as women, and among those over 40 the men were still affected twice as frequently. Patients with poorly controlled diabetes appear to develop active tuberculosis more commonly than those with well controlled disease" 4 5. Turner- Wanvick compared a group of tuberculous diabetics with a group of diabetics without tuberculosis: of those under 40 with tuberculosis 60 per cent had been badly controlled compared with only 20 per cent of the non-tuberculous. In those over 40 the difference was even greater, the proportions being 50 per cent and 6 per cent respectively. A history of diabetic ketosis requiring hospital treatment was more common among the diabetics who later developed tuberculosis; and the importance of good management was further emphasized by the high rate of relapse of the tuberculosis among the poorly controlled patients. The severity of the diabetes, as judged by the insulin dosage, did not appear to be related to the development of tuberculosis, although such an association had previously been reported.! Before the introduction of the antibacterial drugs the outlook for the diabetic who developed tuberculosis was extremely grave. Poulsen" in 1945 found that out of 100 patients 70 had died within two years and 86 within six years; and in another reported series 55 per cent died within four years." In 1953 Thosterson and Tibbits reported that 70 per cent of 167 patients treated between 1940 and 1946 had died; the proportion was still high - 43 per cent - among 127 treated between 1947 and I952.A In the group of patients reported by Turner-Warwick, who were treated before antibacterial drugs were used, 25 per cent died within seven years of the diagnosis of tuberculosis. This figure is considerably lower than the majority of
286
TUBERCLE
reports, probably because of the larger number of patients with only a small amount of disease initially. At the time of her report, there had been no deaths among the 57 patients who had received antibacterial drugs during the previous four years; and steady clinical and radiographic improvement had been observed in patients in whom the diabetes was proving almost impossible to stabilize. Luntz" has recently reported good results among 84 diabetics followed for a year: 95 per cent showed clinical improvement, 83 per cent were stated to be quiescent at the end of the year and 8 patients deterioriated. Relatively short periods of treatment were used, the average duration being only twenty-eight weeks. It seems likely that the outlook is now no worse for the well controlled diabetic with tuberculosis than for the non-diabetic, if effective combinations of antibacterial drugs are used for long periods. References Boucot, K. R., Cooper, D. A., Dillon, E. S., Meier, 1'., and Richardson, R. Amer. Rev. Tuberc., ID52. 65, No.1 (Part 2). 2 Turner-Warwick, M., QJlart.]. Med., 1957, a6, 31, 3 Pygott, F., quoted by Turner-Warwick, M. 4 Dunlop, D, M., Brit. med. ]., 1954, ii, 383. H Root, H. F"joslin's Treatment oJ Diabetes A1ellitus, 9th eel., London. o Poulsen, J. E., Acta med. scand., 1945-46, :123,4:03. 7 Ferrara, M., New Engl.]. Med., 1952, :;114:6,55. 9 Thosterson, G. G., and Tibbits, R. S.,}. Midi. med. Soc., 1953, 5:l, 108B. o Luntz, G. R. W., Brit. med, J., 1957, i, 1082. 1
HERE AND THERE PHTIVAZID In the article by Prof Shmelov in the December 1956 number of this journal it was stated that the formula of phtivazid (p. 385) was (I (4-oxy-2-methoxybenzal) 2-isonicotinic acid hydrazone]. Owing to an error of transmission the formula in the manuscript and the printed article was incorrect, a 2 appearing instead of a 3The correct formula is [1 (4-oxY-3-methoxybenzal) 2-isonicotinic acid hydrazone]. We apologize for the error and for any trouble it may have caused. INDIAN JOURNAL OF TUBERCULOSIS The Indian Journal of Tuberculosis, published by the Tuberculosis Association of India, completed three years of publication in September 1956. The journal is edited by Dr P. V. Benjamin, the Tuberculosis Adviser to the Government of India, and is the first of its kind to be produced in that country. Its primary object is to publish original articles on work done in India. It is reported that the early experiences of the journal have shown that there are relatively few institutions and individuals in India able to contribute such articles. However, the mere existence of the journal and its rapid and promising evolution is encouraging more workers in this field to attempt original work. This growth of individual enquiry, together with the expansion of research schemes and co-operative investigations will undoubtedly provide ample material; and it is hoped that the journal, which is now published quarterly, will appear more frequently in the future.
ARTICLE
Tuberculosis and Diabetes Tuberculosis has been recognized as an important complication of diabetes for at least one hundred years. Its frequency during the last few years has been estimated both in the United States and this country. In Philadelphia, 261 (8'4 per cent) of 3, ro6 diabetics examined routinely by mass-radiography had abnormalities in the lung fields suggestive of tuberculosis and 2' 4 per cent were considered to have active disease.' The incidence of suggestive abnormalities in a large group of industrial workers in the same city was 4'3 per cent. Turner- Warwick2 found 34 (1·8 per cent) with active tuberculosis among r ,85 r new patients at a diabetic clinic in London. The incidence among the diabetics was compared with the incidence among patients having routine radiographs on admission to a general hospital." It was higher among diabetics in both men and women and in all the age groups studied; and it was almost four times as high in the whole group. The difference in incidence was greater in the women than in the men at all ages up to 65, the largest difference occurring in those between the ages of 15 and 34 years. In this group the rate was 35 per 1,000 for women and 16 per 1,000 for men, but only 4 per 1,000 and 5 per 1,000 respectively among the general hospital patients. Over 65 years old there was a higher incidence in men, This study suggests, therefore, that in this country young diabetic women and elderly diabetic men are especially prone to develop radiographic evidence of pulmonary tuberculosis. The American survey, on the other hand, found that under the age of 40 diabetic men were affected three times as frequently as women, and among those over 40 the men were still affected twice as frequently. Patients with poorly controlled diabetes appear to develop active tuberculosis more commonly than those with well controlled disease" 4 5. Turner- Wanvick compared a group of tuberculous diabetics with a group of diabetics without tuberculosis: of those under 40 with tuberculosis 60 per cent had been badly controlled compared with only 20 per cent of the non-tuberculous. In those over 40 the difference was even greater, the proportions being 50 per cent and 6 per cent respectively. A history of diabetic ketosis requiring hospital treatment was more common among the diabetics who later developed tuberculosis; and the importance of good management was further emphasized by the high rate of relapse of the tuberculosis among the poorly controlled patients. The severity of the diabetes, as judged by the insulin dosage, did not appear to be related to the development of tuberculosis, although such an association had previously been reported.! Before the introduction of the antibacterial drugs the outlook for the diabetic who developed tuberculosis was extremely grave. Poulsen" in 1945 found that out of 100 patients 70 had died within two years and 86 within six years; and in another reported series 55 per cent died within four years." In 1953 Thosterson and Tibbits reported that 70 per cent of 167 patients treated between 1940 and 1946 had died; the proportion was still high - 43 per cent - among 127 treated between 1947 and I952.A In the group of patients reported by Turner-Warwick, who were treated before antibacterial drugs were used, 25 per cent died within seven years of the diagnosis of tuberculosis. This figure is considerably lower than the majority of
286
TUBERCLE
reports, probably because of the larger number of patients with only a small amount of disease initially. At the time of her report, there had been no deaths among the 57 patients who had received antibacterial drugs during the previous four years; and steady clinical and radiographic improvement had been observed in patients in whom the diabetes was proving almost impossible to stabilize. Luntz" has recently reported good results among 84 diabetics followed for a year: 95 per cent showed clinical improvement, 83 per cent were stated to be quiescent at the end of the year and 8 patients deterioriated. Relatively short periods of treatment were used, the average duration being only twenty-eight weeks. It seems likely that the outlook is now no worse for the well controlled diabetic with tuberculosis than for the non-diabetic, if effective combinations of antibacterial drugs are used for long periods. References Boucot, K. R., Cooper, D. A., Dillon, E. S., Meier, 1'., and Richardson, R. Amer. Rev. Tuberc., ID52. 65, No.1 (Part 2). 2 Turner-Warwick, M., QJlart.]. Med., 1957, a6, 31, 3 Pygott, F., quoted by Turner-Warwick, M. 4 Dunlop, D, M., Brit. med. ]., 1954, ii, 383. H Root, H. F"joslin's Treatment oJ Diabetes A1ellitus, 9th eel., London. o Poulsen, J. E., Acta med. scand., 1945-46, :123,4:03. 7 Ferrara, M., New Engl.]. Med., 1952, :;114:6,55. 9 Thosterson, G. G., and Tibbits, R. S.,}. Midi. med. Soc., 1953, 5:l, 108B. o Luntz, G. R. W., Brit. med, J., 1957, i, 1082. 1
HERE AND THERE PHTIVAZID In the article by Prof Shmelov in the December 1956 number of this journal it was stated that the formula of phtivazid (p. 385) was (I (4-oxy-2-methoxybenzal) 2-isonicotinic acid hydrazone]. Owing to an error of transmission the formula in the manuscript and the printed article was incorrect, a 2 appearing instead of a 3The correct formula is [1 (4-oxY-3-methoxybenzal) 2-isonicotinic acid hydrazone]. We apologize for the error and for any trouble it may have caused. INDIAN JOURNAL OF TUBERCULOSIS The Indian Journal of Tuberculosis, published by the Tuberculosis Association of India, completed three years of publication in September 1956. The journal is edited by Dr P. V. Benjamin, the Tuberculosis Adviser to the Government of India, and is the first of its kind to be produced in that country. Its primary object is to publish original articles on work done in India. It is reported that the early experiences of the journal have shown that there are relatively few institutions and individuals in India able to contribute such articles. However, the mere existence of the journal and its rapid and promising evolution is encouraging more workers in this field to attempt original work. This growth of individual enquiry, together with the expansion of research schemes and co-operative investigations will undoubtedly provide ample material; and it is hoped that the journal, which is now published quarterly, will appear more frequently in the future.