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... Director, National. Institute for Infectious Diseases L Spallanzani IRCCS, Rome, Italy ... Corresponding author: Enrico Girardi, Department of Epidemiology and Preclinical Research, National Institute for. Infectious ... diagnosis or during hospital admission for TB based ... Radiological findings were collected from the chest.
INT J TUBERC LUNG DIS 20(6):771–777 Q 2016 The Union http://dx.doi.org/10.5588/ijtld.15.0295

The diabetes-tuberculosis co-epidemic: the role of international migration E. Caraffa,* M. San˜ e´ Schepisi,* G. Gualano,† M. P. Parracino,* A. Rianda,† A. Corpolongo,† C. Pinnetti,† V. Galati,† M. Carballo,‡ G. Ippolito,§ F. Palmieri,† E. Girardi* *Department of Epidemiology and Preclinical Research, †Clinical Department, National Institute for Infectious Diseases L Spallanzani ‘Istituto di Ricovero e Cura a Carattere Scientifico’ (IRCCS), Rome, Italy; ‡International Centre for Migration, Health and Development, Geneva, Switzerland; §Office of the Scientific Director, National Institute for Infectious Diseases L Spallanzani IRCCS, Rome, Italy SUMMARY SETTING:

A tuberculosis (TB) referral centre in Rome,

Italy. O B J E C T I V E : To identify demographic and epidemiological characteristics associated with diabetes mellitus (DM) among patients with TB and to compare the clinical presentation of TB and TB-DM in the light of the growing worldwide burden of DM. D E S I G N : We performed a retrospective study of TB cases diagnosed from 2007 to 2012. R E S U LT S : Among 971 TB patients, 723 were foreignborn and 63 (6.5%) had DM. DM prevalence was 12.7% (8/63) among those born in countries with DM prevalence 78%, 4.7% (31/660) among patients from countries with DM prevalence ,8% and 9.7% among Italian patients (24/248). In multivariable analysis, DM

OVER THE LAST THREE DECADES, diabetes mellitus (DM), especially type 2 DM (T2DM), has become a global epidemic and is also emerging as one of the most common predisposing factors for the development of active tuberculosis (TB).1–3 Recent reviews and meta-analyses show that T2DM triples the risk of developing active TB,4 and according to the World Health Organization (WHO) about 15% of TB cases globally may be attributed to DM.5,6 DM also modifies the clinical presentation of pulmonary TB, is associated with atypical radiological presentation and increases the risk of treatment failure, death and relapse among patients with TB.7 Current predictions are that DM prevalence, primarily T2DM, is set to rise beyond 592 million by 2035.3 Approximately 80% of these cases will be in low- and middle-income countries (LMICs), where TB prevalence is also high. DM is now the second most important risk factor for TB in the Central European region and in other EC and MSS contributed equally to the study

was independently associated with older age, and with being born in countries other than Italy, compared to Italians; this latter association was stronger in older patients. DM patients were also significantly more likely to be male and less likely to test positive for the human immunodeficiency virus. The presence of cavities was significantly associated with DM. C O N C L U S I O N S : As individuals born in high TB incidence and high DM prevalence countries emerge as a vulnerable population, greater attention to bidirectional low-cost screening in people from these countries is needed. K E Y W O R D S : DM-TB comorbidity; foreign-born; bidirectional screening

established market economies.8 However, the relationship between these two diseases has not yet received much attention.9–15 In Italy, the 2013 age-standardised prevalence of T2DM, as estimated by the International Diabetes Federation (Watermael-Boitsfort, Belgium), was 5.13%3, while the TB incidence rate was 5.7 cases per 100 000 population, with a growing proportion of TB cases occurring in foreign-born patients.16 We conducted a retrospective analysis of demographic and epidemiological characteristics associated with DM, and the timing of DM diagnosis, among TB patients in a major clinical centre in Rome, Italy, with particular emphasis on patient country of origin. We also compared the clinical presentation of TB and TBDM.

METHODS We reviewed the medical records of adult patients aged 718 years with a diagnosis of TB (January

Corresponding author: Enrico Girardi, Department of Epidemiology and Preclinical Research, National Institute for Infectious Diseases L Spallanzani IRCCS, Via Portuense 292, 00149 Rome, Italy. e-mail: [email protected]. Article submitted 1 April 2015. Final version accepted 22 January 2016.

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2007–December 2012) at a referral hospital in Rome, Italy, and screened these records for DM diagnosis. Written informed consent was provided by all patients. Case definitions A TB case was defined as a bacteriologically confirmed (a biological specimen positive on smear microscopy, culture or nucleic-acid amplification test) or clinically diagnosed case (on the basis of Xray or computed tomography abnormalities or suggestive histology). A case of pulmonary TB was defined as any case of TB involving the lung parenchyma or the tracheobronchial tree; a case of extra-pulmonary TB was defined as any case of TB involving organs other than the lungs.17 A DM case was defined as a patient for whom a DM diagnosis was made by a physician before TB diagnosis or during hospital admission for TB based on the following partly modified WHO 1999, 2006 and 2011 criteria:18–20 1) two fasting blood glucose (FBG) levels of 7126 mg/dl (7.0 mmol/l), 2) one oral glucose tolerance test (OGTT) 7200 mg/dl (11.1 mmol/l) (2 h post glucose load of 75 g oral dose), or 3) in a patient with classic symptoms of hyperglycaemia or hyperglycaemic crisis, random plasma glucose (RPG) 7200 mg/dl (11.1 mmol/l). Criteria 1, 2 or 3 should be associated with 4) one glycated haemoglobin (HbA1c) result 76.5% or FBG of 7126 mg/dl (7.0 mmol/l) during anti-tuberculosis treatment. The WHO criteria were partially modified to take into account the risk of TB stress-induced hyperglycaemia (two instead of one FBG test and one HbA1c result 76.5% or FBG of 7126 mg/dl [7.0 mmol/l] during anti-tuberculosis treatment). Patients without a diagnosis of DM before admission were excluded from the analysis if 1) they had no blood glucose tests during admission, or 2) they had only one FBG level result 7126 mg/dl (7.0 mmol/l). Reviewed parameters The following parameters were examined: age, sex, country of origin, human immunodeficiency virus (HIV) status, diagnosis of predisposing clinical conditions, presence of cavitary lesions, pulmonary and extra-pulmonary symptoms, direct microscopy and culture results, time of TB and DM diagnosis, plasma glucose and glycated haemoglobin results. Radiological findings were collected from the chest X-ray reports performed at the time of TB diagnosis. For the purpose of the analysis, high DM prevalence countries were defined as those with a DM prevalence of 78%.3 Statistical analysis We first performed a descriptive analysis of DM prevalence according to country of birth and age; we

also performed an analysis to evaluate the timing of DM diagnosis according to country of birth. We performed univariable and multivariable logistic regression analyses: 1) to identify demographic factors associated with DM among patients with TB, and 2) to compare clinical and radiological findings of TB and TB-DM patients, adjusting for age, sex, HIV status and country of birth among patients with pulmonary disease. The presence of DM was the outcome in all the above-mentioned analyses. To identify demographic and epidemiological factors associated with DM, we fitted a logistic regression model including variables associated with DM in univariable analysis (P , 0.1). Based on observations from the descriptive analysis, we assessed modification of the effect of country of birth on DM prevalence by age. We assessed model fit with and without the interaction term using the likelihood ratio test. Among patients with pulmonary TB, we also fitted a multivariable model comparing the clinical and radiological characteristics of patients with and without DM. In all analyses, an association with P , 0.05 was considered statistically significant. Statistical analysis was performed using Stata Statistical Software: Release 13 (StataCorp, College Station, TX, USA, 2013). To take into account the small number of cases in some categories, multivariable logistic analysis was performed using the Bias Correction method proposed by King and Zeng (http://gking.harvard.edu/ relogit).

RESULTS Study population The study population comprised 978 TB patients, seven of whom were excluded because information on glycaemic control was lacking. Of the remaining 971 patients included in the analysis, 731 (74.7%) were bacteriologically confirmed (615 sputum culture-positive, 54 other sample culture-positive, 62 molecular test-positive). The characteristics of patients included in the study overall and by country of birth (Italy, other countries with DM prevalence ,8% and countries with DM prevalence 78%) are shown in Table 1. Most (n ¼ 723, 74.5%) of the sample was born outside Italy. Of those born outside Italy, 400 (55.3%) were from another European country. The median length of residence in Italy among the foreign-born was 5.5 years (range 1–43). Prevalence of diabetes mellitus Of the 971 TB patients, 63 (6.5%) had DM (type 2, n ¼ 51, 86.2%; type 1, n ¼ 8, 13.8%); 48 (76.2%) were diagnosed with DM before their TB diagnosis and 15 (23.8%) were diagnosed with DM during admission for TB. DM was more frequently diagnosed at the

DM and TB: the role of migration

Table 1

773

Demographic and clinical characteristics of 971 patients with TB enrolled in the study by country of birth Country of birth Total (n ¼ 971) n (%)

Italy (n ¼ 248) n (%)

Countries with DM prevalence ,8% (n ¼ 660) n (%)

Countries with DM prevalence 78% (n ¼ 63) n (%)

Age, years, median (min–max)

40.8 (17.0–96.0)

58.6 (18.9–96.0)

37.8 (17.0–76.7)

39.7 (20.8–86.5)

Sex Female Male

338 (34.8) 633 (65.2)

101 (40.7) 147 (59.3)

226 (34.2) 434 (65.8)

11 (17,5) 52 (82.5)

HIV status Negative Positive Not reported

646 (66.5) 140 (14.4) 185 (19.1)

127 (51.3) 41 (16.5) 80 (32.2)

483 (73.2) 79 (12.0) 98 (14.8)

36 (57.2) 20 (31.7) 7 (11.1)

Other comorbidities No Yes Not reported

710 (73.1) 44 (4.5) 217 (22.4)

168 (67.7) 36 (14.5) 44 (17.7)

487 (73.8) 7 (1.1) 166 (25.2)

55 (87.3) 1 (1.6) 7 (11.1)

Localisation of TB Pulmonary Extra-pulmonary Pulmonary and extra-pulmonary

776 (79.9) 114 (11.7) 81 (8.3)

189 (76.2) 38 (15.3) 21 (8.5)

539 (81.7) 67 (10.2) 54 (8,1)

48 (76.2) 9 (14.3) 6 (9.5)

TB ¼ tuberculosis; DM ¼ diabetes mellitus; HIV ¼ human immunodeficiency virus.

time of TB diagnosis in the foreign-born than in Italian patients (11/39, 28.2% vs. 4/24, 16.7%), although the difference was not significant. Overall, DM prevalence was highest among patients from countries with DM prevalence 78% (8/63, 12.7%), followed by those born in Italy (24/ 248, 9.7%) and by foreign-born patients from countries with DM prevalence ,8%. Table 2 shows the age-stratified DM prevalence among Italian-born and foreign-born TB patients. No cases of DM were diagnosed in Italians aged ,55 years, while DM was also diagnosed in younger foreign-born patients; DM prevalence was extremely high among older foreignborn patients. Factors associated with diabetes mellitus The logistic regression model to identify demographic and epidemiological factors associated with DM included the following variables associated with DM in univariable analysis (P , 0.1): sex, age (continuous variable), HIV status, comorbidities and country of birth. The model with the interaction term between age and country of birth had a better fit than the model without interaction terms (likelihood ratio test 6.24, P , 0.05). Other interactions were not significant. The results of this multivariable analysis (Table 3) indicate that DM was independently associated with older age, and this association was stronger among foreign-born patients. DM was also associated with being born in countries other than Italy with DM prevalence ,8% or in countries with DM prevalence 78% compared to Italians; this association was stronger in older patients. DM patients were also

significantly more likely to be male and less likely to be HIV-positive. Clinical presentation of pulmonary tuberculosis and diabetes mellitus To compare clinical and radiological findings in TB and TB-DM patients, we fitted a regression model including age, sex, HIV status, country of birth and clinical and radiological characteristics found to be associated with DM in univariable analysis (P , 0.1). Pulmonary involvement was recorded in 857 patients: 60/63 (95.2%) DM patients and 797/908 (87.8%) patients without DM. In univariable analysis, patients with DM had a statistically significant higher frequency of weight loss than patients without DM; however, this difference was not significant after adjusting for age, sex, country of birth and HIV status. There were no statistically significant differences in terms of cough, fever, haemoptysis, night sweats, dyspnoea, chest pain and other general symptoms (Table 4). Cavities on chest X-rays were also significantly more frequent in patients with DM

Table 2 Age stratified prevalence of diabetes among tuberculosis patients according to country of birth Country of birth Age group years 18–34 35–54 55–64 765

Italy n/N (%) 0/35 0/81 6/35 (17.1) 18/97 (18.6)

DM ¼ diabetes mellitus.

Countries with DM Countries with DM prevalence ,8% prevalence 78% n/N (%) n/N (%) 3/260 23/357 2/35 3/8

(1.1) (6.4) (5.7) (37.5)

0/20 2/31 (6.5) 3/9 (33.3) 3/3 (100)

55/710 (7.8) 7/44 (15.9) 1/217 (0.5)

Other comorbidities No Yes Not reported 0.06 ,0.005‡

,0.05‡ 0.9

,0.01‡ 0.5

,0.05‡

,0.001



P value

* Model including interaction between age and country of birth/DM prevalence of country of origin. † Each 10-year increase. ‡ Statistically significant. § For individuals aged 55 years (reference age). DM ¼ diabetes mellitus; OR ¼ odds ratio; CI ¼ confidence interval; HIV ¼ human immunodeficiency virus.

1 2.3 (1.0–5.3) 0.1 (0.0–0.4)

1 0.2 (0.0–0.8) 1 (0.5–1.8)

48/646 (7.4) 2/140 (1.4) 13/185 (7.0)

HIV status Negative Positive Not performed

1 1.9 (1.1–3.6) 1 0.5 (0.3–0.8) 1.4 (0.6–3.2)

14/338 (4.1) 49/633 (7.7)

1.8 (1.5–2.0)



OR (95%CI)

Univariable analysis

Country of birth/DM prevalence of country of origin Born in Italy 24/248 (9.7) Foreign born, ,8% 31/660 (4.7) Foreign born, 78% 8/63 (12.7)

Sex Female Male

59.7 (26.8–92.7) (DM) 39.5 (17.0–96.0) (no DM)

DM n/N (%)

No Yes Not reported

Negative Positive Not performed

Born in Italy Foreign born, ,8% Foreign born, 78%

Female Male

Age



1 0.8 (0.3–2.1) 0.1 (0.0–0.6)

1 0.2 (0.0–0.8) 0.4 (0.2–0.9)

1 3.1 (1.2–7.9) 5.9 (1.8–18.1)

1 2.0 (1.0–4.0)

2.4 (1.9–3.0)



OR (95%CI)

Model 1

Prevalence of diabetes according to demographic and clinical characteristics among 971 patients with tuberculosis

Age, years, median (min–max)

Table 3

0.5 ,0.005‡

,0.05‡ ,0.05‡

,0.05‡ ,0.005‡

,0.05‡

,0.001



P value

No Yes Not reported

Negative Positive Not performed

Born in Italy Foreign born, ,8% Foreign born, 78%

Female Male

Born in Italy Foreign-born, ,8% Foreign-born, 78%

Multivariable analysis

1 0.8 (0.3–2.2) 0.1 (0.0–0.5)

1 0.2 (0.0–0.8) 0.5 (0.2–1.0)

1§ 2.1 (1.0–4.5)‡ 4.1 (1.1–4.6)‡

1 2.1 (1.0–4.2)

1.8 (1.4–2.3) 2.7 (1.9–3.9)† 4.1 (1.7– 9.5)†



OR (95%CI)

Model 2*

0.5 ,0.01‡

,0.05‡ ,0.05‡

,0.05‡ ,0.05‡

,0.05‡

,0.001‡ ,0.001‡ 0.001‡

P value

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Table 4 Symptoms and radiological and microbiological findings in 857 tuberculosis cases with pulmonary involvement according to the presence of DM No DM (n ¼ 797) n (%)

DM (n ¼ 60) n (%)

OR (95%CI)

P value

Cough (.2 weeks’ duration) No 174 (21.8) Yes 504 (63.2) Not reported 119 (14.9)

9 (15.0) 45 (75.0) 6 (10.0)

1 1.7 (0.8–3.6) 1.0 (0.3–2.8)

0.1 1

Haemoptysis No Yes Not reported

484 (61.5) 184 (23.4) 119 (15.1)

42 (70.0) 12 (20.0) 6 (10.0)

1 0.8 (0.4–1.5) 0.6 (0.2–1.4)

0.4 0.2

278 (34.9) 400 (50.2) 119 (14.9)

28 (46.7) 26 (43.3) 6 (10.0)

1 0.6 (0.4–1.1) 0.5 (0.2–1.2)

0.1 0.1

590 (74.0) 88 (11.0) 119 (14.9)

47 (78.3) 7 (11.7) 6 (10.0)

1 1 (0.4–2.3) 0.6 (0.3–1.5)

0.1 0.3

438 (55.0) 240 (30.1) 119 (114.9)

26 (43.3) 28 (46.7) 6 (10.0)

1 2 (1.1–3.4) 0.8 (0.3–2.1)

,0.05† 0.7

1 1.3 (0.7–2.3) 0.7 (0.3–1.7)

0.4 0.4

1 1.6 (0.9–2.7) 0.8 (0.3–1.9)

0.1 0.6

31 (51.7) 27 (45.0) 2 (3.3)

1 1.6 (0.9–2.8) 0.3 (0.1–1.2)

0.08 0.08

262 (32.9) 524 (65.7) 11 (1.4)

13 (21.7) 45 (75.0) 2 (3.3)

1 1.7 (0.9–3.3) 3.7 (0.7–18.3)

0.09 0.1

162 (20.3) 562 (70.5) 73 (9.2)

9 (15.0) 47 (78.3) 4 (6.7)

1 1.5 (0.7–3.1) 1.0 (0.3–3.3)

0.3 1

Fever No Yes Not reported Night sweats No Yes Not reported Weight loss No Yes Not reported

Other respiratory symptoms (dyspnoea, chest pain) No 488 (61.2) 36 (60.0) Yes 190 (23.8) 18 (30.0) Not reported 119 (14.9) 6 (10.0) Other general symptoms No 425 (53.3) 28 (46.7) Yes 253 (31.7) 26 (43.3) Not reported 119 (14.9) 6 (10.0) Cavities on chest X-ray No 449 (56.3) Yes 243 (30.5) Not reported 105 (13.2) Sputum smear Negative Positive Not reported Sputum culture Negative Positive Not reported

Univariable analysis

Multivariable analysis* OR (95%CI)

P value

1 1.5 (0.8–2.7) 1.0 (0.3–3.0)

0.2 0.7

1 2.0 (1.1–3.6) 0.3 (0.1–1.6)

,0.05† 0.1

* Adjusted for age, sex, HIV status and country of birth. † Statistically significant. DM ¼ diabetes mellitus; OR ¼ odds ratio; CI ¼ confidence interval; HIV ¼ human immunodeficiency virus.

than in other patients on multivariable analysis (Table 4).

DISCUSSION We observed a DM prevalence of 6.5% in a large population of TB patients attending a specialised clinical centre in Italy; being born outside Italy, and in particular in countries with DM prevalence 78%, was found to be independently associated with DM among patients with TB. Studies conducted in high TB burden countries report a wide range of DM prevalence rates among TB cases, which in general parallel national DM prevalence rates, reaching up to 44% in one state of India.21 The overall prevalence of DM among TB

patients found in this study was similar to that reported in a study conducted in Denmark;12 it was lower than in a recently published study from San Francisco, CA, USA,15 which included high proportions of TB patients born in countries with high DM prevalence, and in a study conducted in Finland14 among a population with a high proportion of cases aged 765 years. Our results concur with previous studies from high-income countries in identifying TB patients migrating from high to low TB burden countries as a group that is vulnerable for TB-DM comorbidity.10,15 In our study, almost 70% of TBDM patients were from countries with DM prevalence 78%, most frequently from Africa (Egypt, Libya, Morocco) and Asia (India), where the risk of developing both diseases is high. It has also been

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hypothesised that migration per se may be a risk factor for the development of DM.22 The design of the present study, however, precludes any inference being made about this issue. The risk of having DM among TB patients increased with age, and this may reflect the current distribution of DM among the general population in Italy.23 However, the age distribution among DM patients born in Italy was different from that recorded among the foreign born: all DM patients aged ,55 years were foreign born. This may reflect the increasing incidence of DM among younger age groups in low-income countries.24 Older foreignborn patients had an extremely high prevalence of DM: in those aged .60 years, DM prevalence was approximately three times higher than that reported for the general population in Italy in that age group. TB patients who were HIV-positive had a reduced risk of DM. The high prevalence of HIV-infected patients in our study population (14% vs. 3% estimate for Italy16) may have underestimated the overall prevalence of DM at our centre. The reason for this negative association is unclear. Interestingly, a case-control study from Tanzania identified DM as a risk factor for TB in the non-HIV-infected, but not in HIV-infected patients,25 and it has been suggested that the high risk of TB associated with HIV infection may override the risk conferred by DM.26 This issue remains, however, a priority for research. It may be speculated that, in some patients with HIV, DM is not diagnosed because of the higher mortality in this group compared to non-HIV-infected TB patients. As in other studies, DM was mainly diagnosed before a TB diagnosis in our patient population. However, approximately one fifth of the patients with DM were identified at the time of TB diagnosis, almost 80% of whom were foreign-born, possibly reflecting difficulties in accessing or obtaining specialised medical care. DM has been found to be an independent risk factor for higher prevalence or greater severity of some symptoms such as cough,27 haemoptysis27 and fever,28 and for greater numbers of acid-fast bacilli on sputum smear examination.28 In our study, no significant differences in the prevalence of symptoms were recorded among TB patients with pulmonary involvement with or without DM. On the other hand, cavitary patterns on chest X-rays were significantly more frequent among DM patients, consistent with previous studies.28 This association could suggest that DM patients with TB are on average more infectious than those without DM.29 Our study was conducted at a single centre in a patient population with a higher proportion of foreign-born patients than the average proportion reported for Italy (74.5% vs. 58.3% in 201230), and this may have led to an overestimate of DM prevalence. Due to its retrospective design, our study also had methodological limitations, such as no

information on smoking, on drug or alcohol use, or on TB outcomes.

CONCLUSION To our knowledge, this is the first study of DM and TB in Italy, where the convergence of these two epidemics is likely to increase given current migration trends from countries with a high prevalence of both TB and DM on the one hand, and the global rising prevalence of DM on the other. A policy of bidirectional low-cost screening (screening DM patients for TB and TB patients for DM) would be an effective way of identifying people requiring treatment for both diseases in a timely manner. As predicted by a modelling study, this could lower TB incidence by 15% in 2035,31 thus contributing to achieving the ambitious post-2015 global TB control targets. This policy has been shown to be effective in China,32 India33 and Mexico,34 and was recently proposed in an expert meeting in Kuwait (unpublished). Patients born in high TB incidence and high DM prevalence countries emerged as a vulnerable population, and this suggests that in our setting they should be a priority target for TB screening among those with DM. The existence of a sizeable proportion of TB patients in whom DM was not diagnosed until TB diagnosis also emphasises the relevance of DM screening, especially in patients migrating from high TB burden countries. Further studies to evaluate whether TB-DM patients contribute to enhanced TB transmission in low TB burden countries, and broader cross-sectional and prospective data that may help in evaluating feasibility and cost-effectiveness of TB-DM bi-directional screening are needed. Acknowledgements The authors thank P Pezzotti and C Angeletti for their contribution to the statistical analysis. The study was supported by the Italian Ministry of Health (Rome, Italy) ‘Ricerca corrente INMI Spallanzani’ and ‘Fondi 5x1000’ Grants. Conflicts of interest: none declared.

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DM and TB: the role of migration

i

RESUME

Un centre de r´ef´erence pour la tuberculose (TB) a` Rome, Italie. O B J E C T I F : Identifier les caract e´ ristiques de´ mographiques et e´ pide´ miologiques associ e´ es au diab`ete (DM) parmi les patients atteints de TB et comparer la pre´ sentation clinique des patients tuberculeux, atteints ou non de DM, vu le fardeau croissant du DM dans le monde. S C H E´ M A : Nous avons r´ealis´e une e´ tude r´etrospective des cas de TB diagnostiqu´es entre 2007 et 2012. R E´ S U LT A T S : Sur 971 patients TB, parmi lesquels 723 e´ taient n´es a` l’´etranger, 63 (6.5%) avaient un DM. La pr´evalence du DM a e´ t´e de 12,7% (8/63) chez les patients n´es dans les pays ou` la pr´evalence du DM e´ tait 78%, de 4,7% (31/660) chez les patients de pays ayant une pr´evalence du DM ,8% et de 9,7% chez les patients CONTEXTE :

italiens (24/248). En analyse multivari´ee, le DM a e´ t´e ind´ependamment associ´e a` un age ˆ plus avanc´e et au fait d’ˆetre n´e dans un pays autre que l’Italie, par comparaison aux Italiens ; cette derni`ere association a e´ t´e plus forte chez les patients plus ag´ ˆ es. Les patients DM ont e´ galement e´ t´e significativement plus susceptibles d’ˆetre masculins et moins susceptibles d’ˆetre positifs pour le virus de l’immunod´eficience humaine. La pr´esence de cavernes a e´ t´e significativement associ´ee au DM. C O N C L U S I O N : Les personnes n´ees dans des pays a` incidence e´ lev´es de TB et a` pr´evalence e´ lev´ee de DM sont apparues comme un groupe vuln´erable qui demande davantage d’attention en vue d’un de´ pistage bidirectionnel peu on´ereux pour les patients venant de ces pays.

RESUMEN

Un centro de referencia de la tuberculosis (TB) en Roma. O B J E T I V O: Determinar las caracter´ısticas demogra´ficas y epidemiologicas ´ que se asocian con la presencia de diabetes sacarina (DM) en los pacientes con diagnostico ´ de TB y comparar el cuadro cl´ınico de estos pacientes con la presentacion ´ cl´ınica de la TB sin DM, dado el aumento de la carga de morbilidad por DM en el mundo. M E´ T O D O: Se llevo ´ a cabo un estudio retrospectivo de los casos de TB diagnosticados del 2007 al 2012. R E S U LT A D O S: Se diagnostico ´ la TB en 971 pacientes, de los cuales 723 nacidos en el extranjero, y 63 presentaron DM (6,5%). La frecuencia de DM fue de 12,7% (8/63) en los pacientes nacidos en pa´ıses con una prevalencia de DM 78%, de 4,7% (31/660) en los pacientes provenientes de pa´ıses donde la prevalencia de DM era ,8% y en los pacientes italianos la frecuencia de M A R C O D E R E F E R E N C I A:

DM fue 9,7% (24/248). El ana´lisis multivariante revelo´ que la DM se asociaba de manera independiente con la ancianidad y con el hecho de haber nacido fuera de Italia, con respecto a los pacientes italianos y la asociacion ´ de la DM con el haber nacido en el extranjero fue mucho mayor en los pacientes ancianos. Fue mucho ma´s probable que los pacientes aquejados de DM fuesen de sexo masculino y fue menos probable que los pacientes diab´eticos obtuviesen un resultado positivo frente al virus de la inmunodeficiencia humana. La presencia de cavernas se asocio´ de manera significativa con la DM. ´ N: Las personas nacidas en pa´ıses con alta CONCLUSIO incidencia de TB y alta prevalencia de DM aparecen como una poblacion ´ vulnerable que justifica una mayor atencion, ´ a fin de realizar una deteccion ´ sistema´tica bidireccional de bajo costo de ambas enfermedades.