Журнал «Актуальная инфектология» Том 8, №2, 2020

Introduction. The problem of diabetes mellitus (DM) does not lose relevance due to the increasing number of patients with multiple pathologies against the background of increasing incidence of diabetes both in Ukraine and in many other countries. The epidemiological and immunological relationship between tuberculosis and diabetes has been proven. Diabetes mellitus is the background that contributes to the emergence and adverse course of tuberculosis, but the tuberculosis process itself creates the preconditions for the development of a disorder of carbohydrate metabolism, in the pathogenesis of which are involved numerous factors, such as dysfunction in the system of hormonal regulation of carbohydrate hydrocarbons some anti-tuberculosis drugs, damage to the processes of free radical oxidation of cell membranes, which leads to increased insulin resistance of fabrics. The incidence of diabetes among adolescents with tuberculosis is 1.3–3.2 %. Percentage of patients that were admitted with active tuberculosis combined with diabetes is 5–7 % of cases. The large amount of the incidence of tuberculosis among adolescents in the conditions of epidemic disease and the increasing incidence of diabetes among them determine the relevance of the study of this problem. 

The purpose of the study to establish the characteristics of the course of tuberculosis and the efficacy of his treatment in adolescents with tuberculosis. 

Materials and methods. The study involved 80 adolescents who were treated in the Kharkov hospital TB dispensary No. 1 for 20 years. The main (experimental) group consisted of 40 adolescents (23 girls and 17 boys) aged 14 to 17 years with newly diagnosed pulmonary tuberculosis and diabetes mellitus. The comparison group consisted of 40 adolescents (29 girls and 11 boys). Thus, gender and age structures of the groups, there were without significant differences between groups. Tuberculosis among the study was firstly diagnosed. All patients underwent complete medical examination. The following investigations were performed: chest x-ray and tomographic imaging, clinical analysis of blood, urine, sputum for Mycobacterium tuberculosis (MTB), sensitivity to tuberculin (Mantoux test). The glycemic and glucosamine profiles were studied. The level of glucose in blood was studied glucose-oxidase method. Clinical findings — the presence and prevalence of intoxication and bronchopulmonary syndrome. Evaluation criteria of efficiency of treatment were clinical indicators in dynamics, x-ray changes (presence of infiltration, the presence or absence of cavitation), the presence of bacilli excretion. 

Results and discussion. Most patients are diagnosed with infiltrative tuberculosis. The peak incidence of infiltrative tuberculosis at the age of 14–17 years can be explained by the peculiarities of adolescence, which is marked by the restructuring of the main regulatory systems of the body, which leads to a decrease in immune resistance. Among the methods for identifying TB inpatients with DM were their active seeking medical help. Thus, in 29 (64.04 %) patients of the experimental group, pulmonary tuberculosis was detected when visiting a doctor of the general medical network with complaints about health disorders. According to tuberculin diagnostics, no patients were identified. In the comparison group, the majority of patients were detected in prophylactic examinations (36 cases — 90.00 %). One of the most important factors in the development of tuberculosis in adolescents with DM is the epidemiological factor. It was found to be high among adolescents surveyed. Thus, in 20 (50 %) people were contacted with adults with tuberculosis, in 8 (40 %) — the source of tuberculosis infection was accompanied by drug resistance of mycobacterium tuberculosis. In 2 adolescents contact was with 2 cases of tuberculosis. The course of pulmonary tuberculosis in both groups was followed by late complications: in 8 adolescents in the txperimental group and in 8 adolescents from the control group (pleurisy, lesionsoflargebronchi, hemoptysis). Different types of infiltrates were found in both groups. But only in the observation group were wide spread processes such as lobitis and caseous pneumonia. In 14 (33,33 %) patients of the experimental group and in 20 (50.00 %) patients of the control group the disease course was without clinical manifestations, which was due to its timely detection. 26 (66.67 %) patients from the experimental group at the admission at the hospitalobserved the presence of intoxication syndrome. Intoxication syndrome was less pronounced in 20 (50 %) controls. Cough, sputum discharge, catarrhal phenomena were observed in 24 (51.00 %) of the study group and 18 (45.00 %) of the control group. The difference between the groups is probable. Cavitation was present in 28 patients in the experimental group (70 %) and 9 patients (22.50 %) from the control group with a significant difference between the groups. Bacilli excretion was observed in 32 patients (76.19 %) of the experimental group and in 13 patients (32.50 %) of the comparison group. The difference between the groups is probable. Tuberculin sensitivity estimated by Mantoux test with 2 TO of PPD-L showed that adolescents with tuberculosis and DM had doubtful reactions in 9 patients (22.50 %); slightly positive (5–9 mm) — in 26 patients (65.00 %); moderate intensity (10–14 s) — in 5 patients (12.50 %); expressed intensity (15–16 mm) — in 2 patients (5.00 %). None of the adolescents in this group had hyperergic reactions. These indices are different from those of the comparison group, in which the intensity of tuberculin reactions was more pronounced and the hyperergic results of tuberculin reactions were found in 19 patients (47.50 %). In the comparison group there were no doubtful and weakly positive reactions to tuberculin. In 21 patients, tuberculin responses (51.90 %) were expressed. The weakening of the cellular immunity of patients with DM leads to the attenuation of tuberculin reactions. The course of DM in patients with tuberculosis was severe. These patients suffered from type I of DM — insulin dependent. The duration of diabetes differed: in 5 patients of the experimental group diabetes was diagnosed simultaneously with tuberculosis, in 11 patients — in 1–3 years, in 9 patients — in 5–7 years, in 17 patients — in 8–13 years before tuberculosis disease. All adolescents were admitted to the ward with decompensated DM with high glycaemia (24.90 ± 1.20 mlMol/l) with ketoacidosis and labile course. In adolescence, diabetes is characterized by the lability of metabolic processes. In 30 patients the course of DM was with complications: angiopathy — in 16, retinopathy — in 4, nephropathy — in 3, hepatitis — in 5. The correction of insulin therapy was made in all patients by endocrinologist. Daily dosage of insulin was increased in average with 16–32 IU. The compensation of hydrohydrate metabolism was performed by bolus-basic method. The insulins of human type, less immunogenic, preferable in adolescences with tuberculosis. During treatment, the average glycemic level was reached: 11.15 ± 1.24 mlMol/l. Most patients were treated by standardizedchemotherapy regimens. Patients were prescribed 4 antituberculosis drugs: isoniazid, rifampicin, pyrazinamide, ethambutol. The duration of the intensive phase of therapy was from 2 to 6 months. Treatment efficacy was evaluated by clinical, bacteriological, and radiological criteria. During the course of treatment, the degree of intoxication gradually decreased and after 2–3 months it was absent in all patients, except for 2 patients with caseous pneumonia from the observation group, who observed chroniccourse of tuberculosis process and its transition to fibro-cavernous tuberculosis. Catarrhal changes stopped in all patients. During the course of treatment, the degree of intoxication gradually decreased and after 2–3 months it was absent in all patients, except for 2 patients with caseous pneumonia from the observation group, who observed chronic running of tuberculosis process and its transition to fibro-cavernous tuberculosis. Catarrhal changes stopped in all patients. The blood formula was normalized in most patients at the end of the intensive care phase. Bacilli excretion was stopped observed in 32 patients of the experimental group (80.00 %) and in 40 (100 %) cases of control group. During the treatment caverns were healed in 23 of the 28 patients (82.14 %) in experimental group and in all (100 %) of patients of control group with a significant difference between the groups. Thus, stopping of bacilli excretion and healing of caverns in the group without disturbance of carbohydrate metabolism was probably better. The termination of stopping of bacilli excretion and healing of caverns were also significantly shorter than in the diabetic group. The dynamics of resorption of infiltration in the lungs in patients with DM was slower. The peculiarity of the subsequence of treatment in experimental group was pneumosclerosis and fibrosis scarring. During 3 years after completing of the chemotherapy relapse of tuberculosis developed 10 % of patients with DM and no patients of control groups developed relapse. 

Conclusions. 1. In adolescents with diabetes mellitus tuberculosis takes severe running with large area of caseous necrosis, frequent cavitations and bacilli excretion. 2. The terminations of stopping of bacilli excretion and healing of the cavitation in adolescents with diabetes mellitus more slow compared with tuberculosis in adolescents without carbohydrate disturbances. 3. Tuberculosis subsequence and relapses of the disease develops more frequently in adolescents with diabetes mellitus compared with tuberculosis in adolescents without compared with tuberculosis in adolescents without carbohydrate disturbances. 4. The compensation of carbohydrate metabolism is paramount convention of successive antituberculosis chemotherapy. 5. Adolescents with diabetes mellitus is a group of higher risk to develop of tuberculosis and must be screening for tuberculosis by Mantoux testing and annual x-ray checking starting from 15 years.