TB or Not TB?

I was seeing Mr M for the first time. He was brought to me for Diabetes consultation by one of my patients, mainly because of his high glucose levels. I browse through the file. Mr M was 50 years old. Frail and emaciated, he could easily pass off as a 70 year old. I examine him closely and I place the stethoscope on his chest to hear his breath sounds. On examination, he was pale and there was a coarse rattling that followed his rapid breathing, like the gurgle of a mountain stream.

"My glucose levels are high. The fasting glucose level is 434 mg/dL. The HbA1c (a 3-month average glucose level) is 13.2 per cent," he says.

"Yes, I agree. Your HbA1c should be below 7 per cent" I say.

"The pills are doing this to me! I am wasting away and my glucose levels are sky high. That's why I quit my doctor and came to you."

As an afterthought, he adds," I don't want insulin, doctor. And anyway, allopathy is a racket". He coughed.

Despite being an 'allopathic' doctor, I keep my thoughts to myself. The immediate task was to empathise with his suffering. I felt it was not simply a case of uncontrolled Diabetes, which too can cause emaciation. 'Is it tuberculosis complicating Diabetes?' I ask myself silently. I ask him to undergo a chest X-ray. He agrees. All this speaking has tired him out.

Half an hour later, I see him with his X-ray report. The right lung is almost destroyed, covered by a silvery white web of bands, amidst which there is a round space of emptiness. I begin my explanations. He has a bacterial infection called tuberculosis (also called TB), I explain, which has burrowed into his lung causing a cavitation. Yes, it is very common in India. No, it is not incurable. Yes, medicines need to be taken for at least six months.

I also explain to him that high glucose levels can lower immunity and worsen the risk of tuberculosis. Tuberculosis, in turn, can stress the body and worsen Diabetes control. And I emphasise that glucose control is important. Finally, I tell him that it is high glucose and not medication that causes damage to organs, and even predisposes to infections like TB.

Months later, Mr M returns to me. He has gained 6 kilos, the HbA1c was at a satisfying 6.4 per cent, and his skin has a healthy glow. He is all smiles.

In many parts of the world, however, the results are not so good when tuberculosis complicates Diabetes. The disease sometimes affects not just the lungs but other tissues too. Frequently, the disease is resistant to standard medication. Ideally, all people with Type 2 Diabetes and other risk factors for low immunity such as age require an annual chest X-ray to detect tuberculosis so as to treat it early.

Dr Unnikrishnan AG

Editor