COVID-19 and Chronic Diabetes: The Perfect Storm for Reactivation Tuberculosis?

A Case Series

Genesis P. Aguillón-Durán; Ericka Prieto-Martínez; Doris Ayala; Juan García Jr.; John M. Thomas III; Juan Ignacio García; Brandon Michael Henry; Jordi B. Torrelles; Joanne Turner; Eder Ledezma-Campos; Blanca I. Restrepo

Disclosures

J Med Case Reports. 2021;15(621)

Conclusion

Our findings alert to the heightened risk of M. tuberculosis reactivation among COVID-19 patients with a history of chronic and poorly controlled diabetes. In light of our findings, further research is needed to elucidate the underlying mechanisms and identify those who may be at highest risk, for targeted monitoring and management. In the meantime, we suggest a framework for new guidelines to prevent active TB in individuals affected with the COVID-19 and diabetes.

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Acknowledgements
We thank the health professionals and administrators at the Secretaria de Salud de Tamaulipas, including Q. Cristela Resendez-Cardoso, Drs. Francisco Garcia-Luna Martinez and Ariel Mercado-Cardenas (administration), and Mr. Jorge Perez-Navarro (logistics).

Funding
This work was supported by the National Institute of Aging (NIA) at the National Institutes of Health [P01-AG051428 to JT].

Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations
Ethics approval and consent to participate
This study was approved by the institutional review boards in Mexico (SST/SCAME/DCES/597/2017, Secretaria de Salud de Tamaulipas) and the United States (HSC-SPH-17-0990, University of Texas Health Houston). Written informed consent was obtained from patients and is available for provision to the journal on demand.

Consent for publication
Written informed consent was obtained from the patients for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Table 1. Characteristics of newly diagnosed tuberculosis patients with a multiyear history of diabetes and a recent history of COVID-19
	TR-241	TR-243	TR-247
Demographics^a
Age in years, Sex	43, male	44, male	49, female
COVID-19 history
Timing prior to TB diagnosis	3 months	6 months	4 months
Anti-SARS-CoV-2 IgG at TB diagnosis^b	Positive	Positive	Positive
Symptoms at the time of the COVID-19 episode:
Cough	Yes	Yes	Yes
Fever, chills	Yes	Yes	Yes
Fatigue	Yes	Yes	Yes
Loss of smell and taste	Yes	Yes	Yes
Shortness of breath	Yes	No	No
Body aches	Yes	Yes	No
Duration of TB signs and symptoms prior to reporting to the TB clinic (days)
Cough	90	180	120
Productive cough	60	90	60
Fever, chills	14	15	14
Chest pain	3	N/R	N/R
Weight loss	60	60	60
Fatigue	N/R	N/R	30
TB diagnosis
Acid-fast bacilli smear grade (bacilli/field)	> 10	> 10	> 10
M. tuberculosis culture^c	Positive	Positive	Positive
TB risk factors and other medical conditions
Body mass index	13.4	23.7	29
BCG vaccine	Yes	Yes	Yes
HIV	Negative	Negative	Negative
Smoking	No	No	No
Alcohol excess and illicit drugs^d	No	Yes	No
Type 2 diabetes	Yes	Yes	Yes
Years with type 2 diabetes	13 y	5 y	6 y
HbA1c	8.2%	7.5%	10.6%
Fasting blood glucose (mg/dl)	105	138	126
Diabetes medications^e	Metformin	No	Glibenclamide metformin
Other medical conditions	Peripheral neuropathy	None	High blood pressure
History of past TB or TB exposure
Self-reported past exposure to a TB patient	No	No	Yes, > 2 years ago
Prior testing for latent TB infection	No	No	No
Past history of active TB	No	No	No

N/R symptom not reported, TB tuberculosis, SARS-CoV-2 SARS coronavirus 2, COVID-19 coronavirus disease 2019, HIV Human immunodeficiency virus, HbA1c hemoglobin A1c
^aAll are Hispanic, White
^bAnti-SARS-CoV-2 IgG assay, Abbott Laboratories, Abbott Park, IL
^c M. tuberculosis spp. identified with BioLine MPT64 Rapid, Standard Diagnostics, Korea
^dTR-243: > 10 drinks and cocaine on weekends
^eTR-247: metformin 1700 mg/d; TR-249: Metformin 500 mg/d and glibenclamide 2.5 mg/day