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Factors associated with diabetes mellitus

among adults with tuberculosis in a large
European city, 20002013

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INT J TUBERC LUNG DIS 19(12):15071512
Q 2015 The Union
http://dx.doi.org/10.5588/ijtld.15.0102

Factors associated with diabetes mellitus among adults with

tuberculosis in a large European city, 20002013

A. Moreno-Martnez,* M. Casals,* A. Orcau,* P. Gorrindo,* E. Masdeu,* J. A. Cayla;* and the TB

Diabetes Working Group of the Barcelona TB Investigation Unit
*Epidemiology Service, Agencia de Salut Publica de Barcelona, Barcelona, Biomedical Research Consortium of the
Epidemiology and Public Health Network (CIBERESP), Barcelona, Spain

SUMMARY

B A C K G R O U N D : Diabetes mellitus (DM) can contribute
to the development of tuberculosis (TB).
O B J E C T I V E : To analyse the prevalence of DM and its
associated factors among adults with TB in a large city
in an industrialised country.
M E T H O D S : This is a population-based study in adults
diagnosed with TB between 2000 and 2013 in Barce-
lona. We studied potentially associated sociodemo-
graphic and clinical/epidemiological factors. Logistic
regression was used to calculate odds ratios (ORs) and
their 95% confidence intervals (CIs).
R E S U LT S : Of 5849 TB patients, 349 (5.9%) had DM.
The annual prevalence of DM ranged from 4.0% to
7.2%. Factors associated with DM were being Spanish-
born (OR 1.46, 95%CI 1.111.96), age 740 years (OR
6.08, 95%CI 4.368.66), cavitary patterns on chest X-
ray (OR 1.42, 95%CI 1.081.86), experiencing more
side effects due to anti-tuberculosis treatment (OR 1.86,
95%CI 1.282.64) and hospitalisation at the time of
diagnosis (OR 1.8, 95%CI 1.402.31). Human immu-
nodeficiency virus infection was associated with a lower
probability of DM in both subjects with a history of
injection drug use (OR 0.27, 95%CI 0.100.57) and
those without (OR 0.04, 95%CI 0.0020.19).
C O N C L U S I O N S : DM prevalence among adults with TB
in Barcelona is low and remained stable over the 14-year
study period. However, TB patients with DM were
potentially more infectious and their clinical manage-
ment was more complicated.
K E Y W O R D S : age; HIV infection; injection drug users;
side effects; cavitary pattern

THE INTERNATIONAL DIABETES Federation
estimated that by 2011 over 366 million people aged
2079 years, representing 8.3% of the worlds
population, would have diabetes mellitus (DM). It
is expected that by 2030, DM will become the seventh
greatest cause of death worldwide.1
The association between DM and tuberculosis (TB)
is well known.2 However, the dramatic increase in
obesity and DM in recent decades, particularly in
some low-income, high TB prevalence areas of Asia
such as India and China, has led to more extensive
analyses of this association.3,4 Although some studies
have shown that the risk of DM patients acquiring TB
is up to three times higher than among non-
diabetics,3 and even higher among insulin-dependent
cases,5 prevalence is variable. DM prevalence among
TB cases ranges from around 50%, reported by some
studies in India, to under 10% in parts of the United
States, or even lower in certain African countries,
with nearly 30% prevalence in Mexico.2,4,610 In
Spain, according to official statistics, DM prevalence
was 6.4% in 2009 among the general population
aged .16 years, and has been rising since 1993.
A recent population-based study showed a DM
prevalence in adults of 13.8%, with approximately
6% of cases remaining undiagnosed.11 In Barcelona,
DM prevalence among TB cases in 2013 was 6.6%.
The increasing prevalence is related to an aging
population, low income levels, changes in lifestyles,
obesity and improvements in diagnosis and notifica-
tion,12 changes that are occurring ever more rapidly
in low- and middle-income countries.13 Our hypoth-
esis was that the epidemiological profile of industri-
alised countries is different from that of low-income
countries due to better monitoring and control of
DM.
The present study aimed to assess the relationship
between DM and TB in an industrialised country with
an intermediate TB burden and to help establish
priorities for epidemiological control of both diseas-
es, as suggested by other authors.2,3,6,14,15 The study
also aimed to analyse the evolution of DM prevalence
and identify associated factors among adults with TB

Correspondence to: Antonio Moreno-Martnez, Epidemiology Service, Agencia de Salut Publica de Barcelona, Barcelona,
Spain. Tel: (34) 932 384 555. Fax: (34) 932 182 275. e-mail: amoreno@aspb.cat
Article submitted 29 January 2015. Final version accepted 28 June 2015.
1508 The International Journal of Tuberculosis and Lung Disease
Figure Trend and evolution of the percentage of diabetes
mellitus cases among adults with tuberculosis by year of
diagnosis. Barcelona, 20002013. Line trend P 0,351.
in Barcelona, north eastern Spain (population 1.6
million16 and TB incidence, 20 per 100 000 popula-
tion).17
MATERIAL AND METHODS
Study design
This was a retrospective, population-based, cross-
sectional study conducted in the city of Barcelona.
Subjects
All cases aged 718 years diagnosed with active TB
between 1 January 2000 and 31 December 2013,
residing in Barcelona and detected by the Programme
for Prevention and Control of Tuberculosis of
Barcelona (PPCTB), were included in the study.
Variables
We analysed sociodemographic, clinical and treat-
ment data that had been collected systematically
using PPCTB epidemiological questionnaires routine-
ly administered by nursing personnel of the Barcelona
Public Health Agency (Agencia de Salut Publica de
Barcelona, ASPB) Epidemiology Service and their
evolution.
Definitions
A diagnosis of DM was based on information
provided by the patient, recorded in medical charts
and systematically reviewed by public health person-
nel and/or fasting plasma glucose .126 mg/dl.18 TB
cases were defined in accordance with epidemiolog-
ical criteria. A TB patient was defined as anyone who
had been prescribed and had received anti-tubercu-
losis treatment, except for those who had died or
defaulted from treatment due to side effects. Diag-
nosed TB cases were classified according to the
European Surveillance Network criteria: a possible
TB case was defined as a subject who met the clinical
criteria for TB; a probable case as one who met
clinical criteria for TB, and was also smear-positive or
presented granulomas on histological testing, or was
positive on a nucleic acid amplification test (NAAT);
a confirmed TB case was defined as a case who, in
addition to being smear-positive, was also culture- or
NAAT-positive.19 Subjects were considered to have
multidrug-resistant TB (MDR-TB) if their strains
were resistant to at least isoniazid (INH) and
rifampicin (RMP), or extensively drug-resistant TB
when, in addition to MDR-TB, they were also
resistant to all fluoroquinolones and at least one of
the three injectable second-line drugs. Cases with
non-tuberculous mycobacteria were excluded.
Statistical analysis
We conducted a descriptive study to calculate DM
prevalence among the patients included. We also
calculated frequency distributions for qualitative
variables, and measures of central tendency and
precision for quantitative variables. Potential factors
associated with DM were analysed at bivariate level
by comparing proportions between groups using the
v2 test. At multivariate level, we fitted a logistic
regression model using the stepwise-selection method
and included those factors found to be associated at
bivariate level with P , 0.1. We calculated odds
ratios (ORs) and their associated 95% confidence
intervals (CIs). Model fit was assessed using the
Hosmer-Lemeshow test. In all analyses, P , 0.05 was
considered statistically significant. Analyses were
performed using IBM Statistical Package for the
Social Sciences Statistics, version 19 (IBM Corp,
Armonk, NY, USA) and the compareGroups package
of the R statistical system (R Computing, Vienna,
Austria). DM trends were obtained using the classical
v2 test for trends in proportions (as implemented in
the R function prop.trend.test).
Ethical considerations
As the data were obtained from questionnaires
administered by ASPB Epidemiology Service nursing
personnel as part of routine monitoring of notifiable
diseases, ethics approval was not considered neces-
sary, and subjects were not required to provide
informed consent. Data were processed anonymous-
ly, respecting strict confidentiality in accordance with
the ethics principles of the 1964 Helsinki Declaration
(revised in 2000 by the World Medical Association)
and in accordance with the 1999 Spanish Data
Protection Act.
RESULTS
Of the 5849 adult TB patients included in the study,
349 (5.97%) had DM. The proportion with DM
among the included patients rose slightly over the 14-
year study period, from 6.2% in 2000 to 6.7% in
2013 (P 0.351) (Figure). The median age of the DM
patients was 63 years (Quartile [Q] 1 50, Q3 74);

237 (67.9%) were male and 275 (78.8%) were
Spanish-born; 87.4% were aged 740 years, 71.6%
presented with pulmonary TB, and 14.6% died
during anti-tuberculosis treatment.
At bivariate level, factors associated with DM were
being Spanish-born, previous immunosuppressive
treatment, age 740 years, death during anti-tuber-
culosis treatment, more adverse effects due to anti-
tuberculosis drugs, hospitalisation and cavitation on
chest X-ray (CXR). Human immunodeficiency virus
(HIV) infection was associated with a low probability
of DM in both subjects with and those without a
history of injection drug use (IDU). In contrast, no
differences were found with regard to any of the
following: year of TB diagnosis (5.8% during 1999
2006 vs. 6.2% during 20072013), type of TB case
(new or relapse/reinfection), history of incarceration,
susceptibility of isolated strains to INH or RMP,
presence of MDR-TB strains, or microbiological
confirmation in pulmonary forms of TB (Table).
Multivariate analysis confirmed the association
between DM and being Spanish-born, age 740 years,
having more adverse effects to anti-tuberculosis
drugs, cavitation on CXR and requiring hospitalisa-
tion. HIV infection was associated with a lower
probability of DM, regardless of history of IDU
(Table).
DISCUSSION
The study shows that DM prevalence in Barcelona
among adults diagnosed with TB has remained stable
since 2000, with an average prevalence during the
period of 6%. Having DM is associated with being
Spanish-born, age 740 years, cavitation on CXR,
having more adverse effects on anti-tuberculosis
treatment and requiring hospitalisation at the time
of diagnosis. HIV infection was associated with a low
probability of DM, regardless of history of IDU.
Although a higher proportion of DM than non-DM
subjects died during anti-tuberculosis treatment, this
difference was not statistically significant at multi-
variate level.
Despite the increasing worldwide trend in DM,1
DM prevalence among TB patients varies consider-
ably between countries, depending on economic,
demographic, geographic and epidemiological fac-
tors, and ranging from slightly over 4% to around
50%.4,68,20 This study found that DM prevalence
among adult TB patients in Barcelona had remained
stable in recent years. The prevalence observed in
2013 was similar to the estimate for the general
population, between 4.8% and 18.7%,15 and lower
than the 13.8% observed in a population-based
survey conducted in Spain.11 In 2006, however, a
study carried out in Madrid among the TB population
aged .64 years concluded that DM was the second
greatest risk factor for TB, with a prevalence of
DM among adults with TB 1509
12.3%.21 Other chronic health-affecting behaviour,
such as smoking, or new treatment regimens using
immunosuppressors, have also been identified as risk
factors for the development of TB.21,22 This study
found no differences on multivariate analysis, al-
though immunosuppressive treatment was more
common among adults with DM, and no differences
were found on the basis of smoking, homelessness, or
history of incarceration or of previous TB.
One of the factors found to be associated with DM
among TB patients included being Spanish-born.
Differences between the Spanish-born (8.1%) and
the immigrant population (3%) may be due to the
lower prevalence of overweight subjects and perhaps
also lower DM prevalence among immigrants, who
tend to be younger than native Spaniards with
TB.12,13 According to Spains National Health System
Strategy for DM (Estrategia en Diabetes del Sistema
Nacional de Salud), DM, especially type 2 DM, was
related to obesity, age .68 years, lower physical
activity and low education level, and the non-Spanish
born seem to have a lower prevalence of DM.12 More
studies should be performed to analyse the reasons
for these differences.
Sex was not associated with DM, while age 740
years was. Although we could not determine the type
of DM in subjects analysed in this study due to the
manner in which data for this variable were collected,
it is known that the prevalence of type 2 DM
increases with age.12
Adults with DM were more likely to require
hospitalisation and present with adverse effects than
non-diabetics. Infections can contribute to glycaemic
imbalance and may occasionally require the admin-
istration of insulin during the initial phases. It should
also be noted that some anti-tuberculosis drugs may
favour the appearance of disorders associated with
DM, as is the case with INH, or may alter the
metabolism of other chronic treatment drugs and
increase glucose levels, as is the case with RMP.5
Although DM has been related to M. tuberculosis
resistance5 and to delayed sputum conversion,20 this
study did not find DM to be associated with INH or
RMP resistance or MDR-TB, nor to the degree of
positivity of sputum cultures at the initiation of anti-
tuberculosis treatment. The reason may be the low
prevalence of resistance in our setting, particularly
among native Spaniards. In 2012, the rate of INH
resistance was 6.4% among native Spaniards and
8.6% among immigrants; the corresponding figures
for RMP were respectively 0.9% and 1.7%.17
Contrary to reports from India,6 we found no clear
association between extra-pulmonary or purely pul-
monary forms of TB (in comparison to mixed forms)
among adults with DM. However, we did find an
association between presence of cavitation on CXR,
as reported by some authors,5,22 and the number of
cases for which no CXR information was available.
1510 The International Journal of Tuberculosis and Lung Disease

Table Factors associated with diabetes mellitus in 5849 adult patients with tuberculosis. Barcelona, 20002013
Diabetes mellitus Bivariate analysis Multivariate analysis
Total
(n 5849) No Yes
n n (%) n (%) OR (95%CI) P value OR (95%CI) P value
Clinical form of TB
Pulmonary, smear-positive 2146 2012 (93.8) 134 (6.2) Reference Reference
Pulmonary, smear-negative,
culture-positive 1498 1415 (94.5) 83 (5.5) 0.88 (0.661.17) 0.379
Extra-pulmonary 1597 1498 (93.8 99 (6.2) 0.99 (0.761.30) 0.957
Pulmonary, culture-negative 606 573 (94.6) 33 (5.4) 0.87 (0.581.27) 0.474
Sex
Female 2105 1993 (94.7) 112 (5.3) Reference Reference
Male 3744 3507 (93.7) 237 (6.3) 1.20 (0.961.52) 0.117
Age group, years
1839 2897 2853 (98.5) 44 (1.5) Reference Reference
740 2952 2647 (89.7) 305 (10.3) 7.45 (5.4610.4) ,0.001 6.08 (4.368.66)* ,0.001*
Country of birth
Foreign 2461 2387 (97) 74 (3) Reference Reference
Spain 3388 3113 (91.9) 275 (8.1) 2.84 (2.203.72) ,0.001 1.46 (1.111.96)* 0.008*
New case
Yes 5343 5024 (94) 319 (6) Reference Reference
No 506 476 (94.1) 30 (5.9) 1.00 (0.661.44) 0.989
Chest X-ray
Cavitation 1309 1219 (93.1) 90 (6.9) 1.27 (0.971.64) 0.079 1.42 (1.081.86)* ,0.001*
Abnormal, no cavitation 3409 3221 (94.5) 188 (5.5) Reference Reference
Unknown 98 89 (90.8) 9 (9.2) 1.76 (0.813.37) 0.143 2.36 (1.064.71)* 0.021*
Normal 1033 971 (94) 62 (6) 1.10 (0.811.46) 0.548 1.16 (0.851.58)* 0.317*
Homelessness
Yes 428 405 (94.6) 23 (5.4) Reference Reference
No 5421 5095 (94) 326 (6) 1.12 (0.741.78) 0.606
Alcoholism
Yes 1212 1129 (93.2) 83 (6.8) Reference Reference
No 4637 4371 (94.3) 266 (5.7) 0.83 (0.641.07) 0.150
Smoker
Yes 2418 2268 (93.8) 150 (6.2) Reference Reference
No 3431 3232 (94.2 199 (5.8 0.93 (0.751.16) 0.521
History of incarceration
Yes 161 156 (96.9) 5 (3.1) Reference Reference
No 5672 5329 (94) 343 (6) 1.95 (0.885.58) 0.106
IDU/HIV status
IDU, HIV 5143 4808 (93.5) 335 (6.5) Reference Reference
IDU, HIV 300 299 (99.7) 1 (0.3) 0.05 (0.000.24) ,0.001 0.04 (0.0020.19)* 0.001*
IDU, HIV 336 330 (98.2) 6 (1.8) 0.27 (0.100.55) ,0.001 0.27 (0.100.57)* 0.002*
IDU, HIV 70 63 (90) 7 (10) 1.63 (0.673.35) 0.259 1.85 (0.743.99)* 0.144*
Hospitalisation
No 2398 2300 (95.9) 98 (4.1) Reference Reference
Yes 3355 3108 (92.6) 247 (7.4) 1.86 (1.472.38) ,0.001 1.80 (1.402.31)* ,0.001*
Unknown 96 92 (95.8) 4 (4.2) 1.06 (0.312.60) 0.915 1.11 (0.312.82)* 0.833*
Prior immunosuppressive treatment
No 5627 5303 (94.2) 324 (5.8) Reference Reference
Yes 222 197 (88.7) 25 (11.3) 2.09 (1.333.15) 0.002
Adverse effects of treatment
No 5460 5152 (94.4) 308 (5.6) Reference Reference
Yes 389 348 (89.5) 41 (10.5) 1.98 (1.382.76) ,0.001 1.86 (1.282.64)* ,0.001*
Died
No 5381 5083 (94.5) 298 (5.5) Reference Reference
Yes 468 417 (89.1) 51 (10.9) 2.09 (1.512.84) ,0.001
* Statistically significant.
OR odds ratio; CI confidence interval; TB tuberculosis; IDU injection drug use;  negative; HIV human immunodeficiency virus; positive.

Some studies have suggested that DM increases not
only the risk of acquiring TB but also the severity of
the disease, the number of relapses and the risk of
death due to TB.5,2325 However, this study did not
find the rate of any-cause mortality during anti-
tuberculosis treatment to be significantly associated
with DM. The lack of clinical and analytical data did
not permit us to establish a relationship between these
events and poor DM control, as suggested in some
studies.5,26
In this study, HIV infection was associated with a
lower probability of DM, in contrast to the results of

another published study.27 In our study, this applied
to both patients with a history of IDU and those
without. While some studies have shown that HIV
infection could be a risk factor,28 this could be related
to the use of certain antiretroviral drugs, particularly
some protease inhibitors.2931 No data were available
on the antiretroviral drugs used. More studies are
needed to clarify the relationship between HIV
infection, antiretroviral therapy, IDU, DM and TB.
In the light of the differences between the various
studies, it is important to understand the relationship
between TB and DM in different regions around the
world to establish priorities and adapt the needs of
prevention and control programmes. In high DM
prevalence, high TB burden countries with weak
public health programmes, the current recommenda-
tion is to rule out TB and latent tuberculous infection
among diabetics, and rule out DM among TB
patients. This recommendation could be extended
to immigrants from areas with a high prevalence of
both diseases.
We found no population-based studies from
industrialised countries analysing the relationship
between DM and TB; this study therefore provides
relevant information about this dual problem. Our
study included all cases detected through a city TB
control programme with very high coverage and
notification rates, and active epidemiological surveil-
lance, including monitoring of microbiological test
results, hospital discharges and record linkage be-
tween mortality, HIV-TB and other registries. The
analysis was restricted to adults to avoid bias.
Limitations
The lack of clinical, analytical and body mass index
data precluded any analysis of the relationship
between insufficient DM control and the evolution
of TB. The majority of diabetic cases were classified
as such and included in the analysis on the basis of
information provided either by the patient or by the
patients family, or obtained from patient clinical
records systematically reviewed by public health
personnel and reported by epidemiological surveys.
Although DM may have been underestimated, these
methods should be valid for chronic diseases.32 As the
questionnaires used by the Barcelona TB Programme
do not differentiate by type of DM, it was not
possible to analyse the two diseases separately. Time
to sputum conversion could not be analysed as
neither data on sputum culture during treatment
nor results from samples obtained at the end of the
intensive phase were available.
CONCLUSIONS
DM prevalence among adults with TB in Barcelona
was low and remained stable over the 14-year study
period. In Barcelona, DM is associated with age 740
DM among adults with TB 1511
years, being Spanish-born, hospitalisation, cavitation
on CXR and adverse effects due to anti-tuberculosis
treatment. HIV infection was associated with a lower
probability of DM.
The DM prevalence and profile in a large
industrialised city may differ from those in develop-
ing countries, but TB in DM patients is always more
complicated. All of this ought to be taken into
consideration when developing TB control pro-
grammes to achieve better coordination among
programmes targeting DM, smoking, HIV, etc.
Acknowledgements
Other members of TB-Diabetes Working Group of the Barcelona
TB Investigation Unit (Unidad de Investigacion en Tuberculosis de
Barcelona, UITB): M L De Souza-Galvao, M A Jimenez-Fuentes
(Unitat de Tuberculosi, Vall dHebron-Drassanes Hospital Uni-
versitari, Vall dHebron, Barcelona); I Molina, A Curran (Infectious
Diseases Department, Hospital Universitari de la Vall dHebron,
Barcelona); M A Sambeat, V Pomar (Infectious Diseases Unit,
Hospital de la Santa Creu i Sant Pau, Barcelona); H Knobel, F
Sanchez-Martnez (Hospital del Mar, Instituto Hospital del Mar de
Investigaciones Medicas, Barcelona); J A Martnez, J M Miro
(Infectious Diseases Service, Hospital Clnic de Barcelona, Barce-
lona, Spain).
Conflicts of interest: none declared.
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CADRE : Le diab ete (DM) peut contribuer au
developpement de la tuberculose (TB).
O B J E C T I F : Analyser la prevalence du DM et ses
facteurs associes parmi les adultes atteints de TB dans
une grande ville dun pays developpe.
P A T I E N T S E T M E T H O D E : Etude en population chez
des adultes ayant eu un diagnostic de TB entre 2000 et
2013 a Barcelone. Nous avons etudie les facteurs
sociodemographiques et cliniques/epidemiologiques
potentiellement associes. La regression logistique a ete 0,27 ; IC95% 0,100,57) et ceux sans ces antecedents
utilisee pour calculer les odds ratios (OR) et leurs
intervalles de confiance (IC) a 95%.
R E S U LT A T S : Sur un total de 5849 patients TB, 349
(5,9%) avaient un DM. La prevalence annuelle du DM
allait de 4,0% a 7,2%. Les facteurs associes au DM ont
ete naissance en Espagne (OR 1,46 ; IC95% 1,111,96) ;
M A R C O D E R E F E R E N C I A: La diabetes mellitus (DM)
puede contribuir al desarrollo de tuberculosis (TB).
O B J E T I V O: Analizar la prevalencia de DM entre los
adultos con TB y los factores asociados en una gran
ciudad de un pas industrializado.
M E T O D O S: Estudio poblacional realizado en adultos
diagnosticados de TB entre 2000 y 2013 en Barcelona.
Se estudiaron factores sociodemograficos, clnicos y
epidemiologicos potencialmente asociados. Se utilizo
regresion logstica para calcular odds ratios (OR) con
intervalos de confianza (IC) del 95%.
R E S U LT A D O S: De un total de 5849 pacientes con TB,
349 (5,9%) tenan DM. La prevalencia anual de DM fue
del 4,0% al 7,2%. Los factores asociados con DM
fueron ser espanol (OR 1,46; IC95% 1,111,96); tener
740 anos (OR 6,08; IC95% 4,368,66); cavitacion en
DM among adults with TB i
RESUME
age de 740 ans (OR 6,08 ; IC95% 4,368,66) ; profil
cavitaire de la radiographie pulmonaire (OR 1,42 ;
IC95% 1,081,86) ; survenue de plus deffets
secondaires au traitement anti-tuberculeux (OR 1,86 ;
IC95% 1,282,64) ; et hospitalisation au moment du
diagnostic (OR 1,8 ; IC95% 1,402,31). Linfection a
virus de limmunodeficience humaine a ete associee avec
une probabilite plus faible de DM, chez les sujets ayant
des antecedents dutilisation de drogues injectables (OR
(OR 0,04 ; IC95% 0,0020,19).
C O N C L U S I O N : La prevalence du DM parmi les adultes
atteints de TB a Barcelone est faible et est restee stable
tout au long des 14 annees. Cependant, les patients TB
avec DM ont ete potentiellement plus contagieux et plus
compliques en termes de prise en charge clinique.
RESUMEN
la radiografa de torax (OR 1,42; IC95% 1,081,86);
presentar mas efectos secundarios del tratamiento
antituberculoso (OR 1,86; IC95% 1,282,64); y
hospitalizacion en el momento del diagnostico (OR
1,8; IC95% 1,402,31). La infeccion por virus de la
inmunodeficiencia humana se asocio con una baja
probabilidad de tener DM, tanto con antecedentes de
abuso de drogas inyectadas (OR 0,27; IC95% 0,10
0,57) como en su ausencia (OR 0,04; IC95% 0,002
0,19).
C O N C L U S I O N E S: La prevalencia de DM entre los
adultos con TB en Barcelona es baja y ha permanecido
estable entre 2000 y 2013. Sin embargo, los pacientes
con TB y DM son potencialmente mas contagiosos y su
manejo clnico mas complicado.