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Association of low serum vitamin D level among pulmonary tuberculosis patients

Background: Recent studies suggest that the incidence and severity of tuberculosis is associated with low levels of Vitamin D, this is especially important in developing countries like India which carries a major portion of global Tuberculosis burden. Therefore, this study aimed to determine the prevalence of Vitamin D deficiency in newly diagnosed tuberculosis patients in our institute. Aims and objective is to study the deficiency of Vitamin D In newly diagnosed sputum positive pulmonary TB and to compare the level of Vitamin d with that of age matched healthy control population. Methods: This was a descriptive cross-sectional case control study to asses Vitamin D deficiency among 140 cases which included 2 categories of patients (a) Group 1: 70 sputum AFB positive newly diagnosed pulmonary TB patients, (b) Group 2: 70 apparently healthy people who came to the hospital with regular checkup. Results: Mean age of study groups and control in years were, Control: 40.3857±10.231, Cases: 36.885±11.076. Mean BMI was significantly higher in controls when compared with new TB cases (19.27±2.455 vs 15.215±1.774) kg/m p <0.05). There was significant decrease in mean Vitamin D3 value when new cases TB patients were compared with controls (18.212±9.3027 vs 36.1267±8.410 p <0.05). Conclusions: Patients with tuberculosis are significantly Vitamin D deficient as compared to normal people. This deficiency is more marked in females and those with low BMI. The present finding favours the role of Vitamin D in the prevention and treatment of tuberculosis in developing countries like India.


INTRODUCTION
Tuberculosis is most common cause of death world over due to single infectious agent in adult and account for over a quarter of all avoidable death globally. India accounts for nearly one third of global burden of tuberculosis. As per the Global TB report 2017 the estimated incidence of TB in India was approximately 2.8 million accounting for about a quarter of world TB cases. 1 Major factor that contribute to resurgence of tuberculosis in developing countries include common site for the development of TB; 85% of patients with TB present with pulmonary complaints. The typical lesion in tuberculosis is an epithelioid granuloma with central caseation necrosis. 4 There is evidence to suggest that hypovitaminosis D increases the risk of tuberculosis (TB). Vitamin D binds to nuclear receptors in macrophages, leading to an oxidative burst which is important for the intracellular antimycobacterial activity, and vitamin D metabolites also upregulates nitric oxide synthase which serves to suppress mycobacterial growth. 5,6 The major natural source of the vitamin is synthesis of cholecalciferol in the skin from cholesterol through a chemical reaction that is dependent on sun exposure (specifically UVB radiation). There were reports of association between lower levels of Vitamin D and Tuberculosis. 6,7 The role of vitamin D in modifying the treatment course of pulmonary tuberculosis is still a matter of debate.
Aim and objective is to study the deficiency of Vitamin D in newly diagnosed sputum positive pulmonary TB and to compare the level of vitamin D with that of age matched healthy control population.

METHODS
This present study was conducted in the department of respiratory medicine, New Medical College, Kota on 70 newly diagnosed sputum AFB positive pulmonary TB patients and 70 apparently healthy control subjects over a period of one year (July 2016-June 2017). It's a Descriptive case control study.

Inclusion criteria
Include 2 categories of patients  Group 1:70 sputum AFB positive newly diagnosed pulmonary TB patients  Group 2:70 apparently healthy people who came to the hospital with regular checkup.

Exclusion criteria
 Authors excluded patients with extrapulmonary TB, HIV, Diabetes, alcoholic liver disease, Chronic Kidney disease, malabsorption, patients on immunosuppressive therapy, intake of drugs that can alter vitamin D Level.
After taking an informed consent, through history was taken, physical examination and relevant investigation were done to rule out exclusion criteria and detect other comorbidities. Age, gender, weight and height of the patient were noted. Their clinical details including the symptoms of hypovitaminosis D were recorded.
Nutritional intake was assessed. Samples for Vitamin D were collected and sent for Lab and all the samples are analysed in duplicate for 25OH vit D3 Using a sensitive RIA technique. All data were tabulated and analysed using IBM SPSS version 16 software.  Forward association study between low serum Vitamin D and Pulmonary tuberculosis could be explained by two facts firstly, the active form of vitamin D enhances the ability of macrophages to suppress the intracellular growth of Mycobacterium tuberculosis. 11,12 Secondly, on triggering of toll-like receptors by molecules of the tubercle bacillus, the production of microbe-killing catholicising is impaired in the absence of adequate. 13 Our findings raise the possibility that adequate 25(OH)D levels may protect against primary infection due to Mycobacterium Tuberculosis, and this is supported by the work of Martineau et al, in which a single dose of vitamin D improved immunity to Mycobacteria in vitro in contacts of patients with TB serum vitamin D. 14

CONCLUSION
Patients with tuberculosis are significantly Vitamin D deficient as compared to normal people. Low serum Vitamin D along with Low BMI could be important predictor of Tuberculosis is susceptible individuals the present finding favors the role of Vitamin D in the prevention and treatment of tuberculosis in developing countries like India.