Case Studies
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| Case Study - II | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| Presenting Complaints Weight Loss - Approximately 5 kg over the last two months Fever with Chills - 3 days Case History Evening rise of temperature - 6 months Weakness - 6 months Low grade fever - 3 months Excessive - 3 months His family physician took a detailed history and advised a routine hemogram with ESR, chest X-ray, and Sputum and urine examination. Investigation Reports All investigations were done on 22-8-99 except blood glucose, which was done on 23-8-99 |
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Hb -12.5g% |
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| Managing Diabetes & Tuberculosis Tuberculosis is a common precipitating factor for the diagnosis of diabetes, especially among persons who have a short history of non-specific diabetes related symptoms. Diabetes mellitus is accompanied by compromised host defence mechanisms: with several abnormalities in phagocytic function of palymorphs, macrophages, and monocytes and the antibody producing functions of lymphocytes being described in literature. In this case it was the routine urine examination that elicited the sign of 'glycosuria' and blood glucose examination confirmed that the cause was diabetes mellitus. The median time for diagnosis of diabetes mellitus is about 5 years from onset of hyperglycemia in the diabetes range i.e. venous plasma glucose>140mg/dl fasting and>199mg/dl 2h post-prandially. The glucotoxic effects of sustained hyperglycemia, especially the observations regarding earlier onset, more severe and more widespread atherosclerosis; have prompted leading authorities to reduce the diagnostic fasting venous plasma glucose cutoff value to 126 mg/dl - equivalent to venous whole blood glucose of 106 mg/dl. Today if any patient has a fasting venous whole blood glucose value above100 mg/dl the physician should suspect developing diabetes, inform the patient about the suspicion, and advice diet, exercise and lifestyle modification over the next 3 months and follow-up with a fasting and 2h postprandial blood/plasma glucose estimation! This will immediately reveal whether or not diet and lifestyle modification is helping the patient and allow a decision on the future course of action to be made. In the case of Shreeram which is typical of how some usually well nourished and reasonably affluent, hard working and dedicated persons, the so called 'achievers' present with diabetes, it is clear that he had never needed to see a doctor in the past 25 years! In his own words he was too busy setting up his business either to fall ill, or take rest, or go to the doctor whenever he was ill. He bore things with fortitude and treated himself for illness-he assumed they were all minor because they never made him lose even a day's work. However his stressful life, large appetite, and lack of concern for physical fitness precipitated the development of diabetes. There was no history of diabetes in his family, but his lifestyles and economic status was quite different from his forefathers. The diabetic state manifested itself slowly and insidiously. There may not be any specific symptoms in diabetes and non-specific symptoms are often ignored or treated inappropriately. In Shreeram's case an old tubercular focus in the L upper zone consequently got reactivated. Hematogenous or another type of seeding is probably responsible for and led to a minimal pleural effusion on the R side. The body's battle against reactivated tuberculosis led to an increase in stress hormones, a sudden worsening of the diabetes state, glycosuria and weight loss. Compromised immune defences allowed a viral infection to attack and weaken him future paving the way for a bacterial bronchopneumonia. At this stage he had fever and chills such as he had never had before, was almost prostrate with weakness and therefore consulted his doctor. The doctor initially suspected an acute lobar pneumonia and ordered the chest X-ray, sputum examination, hematology. Instinct made him order a routine urine examination a test, which changed the whole outlook when the result was seen. The blood glucose examination performed the next day confirmed the diagnosis of diabetes and co-existing pulmonary tuberculosis. Treatment Shreeram was put on standard 4 drug regimen of antitubercular therapy consisting of INH, Rifampicin, Ethambutol and Pyrazinamide for the first two months in the correct dose and with the proper advice regarding timing of doses, relationship with food intake, necessity of completing the course of medication, guarantee of successful outcome if his compliance was good, etc. Rifampicin is known to accelerate the metabolism of sulphonylurea agents because it induces hepatic enzymes. It may also cause hyperglycemia and augment intestinal absorption of glucose. INH antagonises sulphonylureas and impairs insulin release and action. Ethambutol and Pyrazinamide do not produce any consistent effect on the diabetic state. The doctor therefore chose Human Mixtard® to initiate antidiabetic treatment and prescribed Human Mixtard® 10 IU every morning before breakfast and 5 IU every evening before supper, given subcutaneously Shreeram wanted the best possible treatment. He therefore purchased the Lifescan blood glucose meter recommended by the doctor and self-monitored his blood glucose. His doctor suggested the specific times of the day to be monitored, and about the need to monitor when suspecting hypoglycemia. The results were as follows: Self Monitoring of Blood Glucose at Home: Results over the first 20 days of SMBG |
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| Rationale for the Treatment Shreeram had tuberculosis and diabetes with plasma glucose values of 196 mg % in fasting, and 236 mg % 2 hours postprandially. Insulin is the preferred hypoglycemic agent of choice while managing diabetes in the patient with acute or chronic infection, especially in tuberculosis Human insulins are preferred for therapy that is expected to be intermittent. Human Mixtard provides the right balance between convenience and control, by catering to the meal induced as well as basal insulin requirements. The starting dose of 10 iu every morning and 5 iu every evening is based on the experience of the doctor in managing hypoglycemia in diabetes, and a dose of 0.2iu/kg body weight per day is recommended for smooth control of glycemia during stressful states like chronic infection. Thus the 75 kg Shreeram required 75 x 0.2 = 15 iu/day. As the reports of self-monitoring of blood glucose show, a smooth reduction of hypoglycemia to near normoglycemic levels occurred. No hypoglycemic episodes were reported. Follow Up After 2 Months Shreeram monitors his blood glucose thrice a week at specified times which he keeps rotating in order to have an adequate representation of his plasma glucose values throughout the day. His One Touch Lifescan meter is plasma calibrated and he gets to know the correct plasma glucose value. He continues with Human Mixtard® 10 iu every morning and 5 iu every evening. He is asymptomatic. His anti-tubercular therapy is continued. He feels strong and healthy once again. But he knows that he needs his medicines till the tuberculosis is completely treated. And Human Mixtard® till his doctor says so. |
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