Methyl-prednisolone in pulmonary tuberculosis with diabetes mellitus.

Both diabetes mellitus and pulmonary tuberculosis were regarded as-contraindications to cortico-steroid therapy when such treatment first became available. Steroids have now become standard adjuvant therapy to the usual anti-tuberculous drugs in most cases of fulminant pulmonary tuberculosis and the Tuberculosis Society of Scotland report (I957, 1958) confirmed the value of such combined treatment. Even small doses of cortico-steroids seem to have a definite value as shown by Weinstein and Kohler ('959)-At the Dreadnought Seamen's Hospital, cases of advanced, bilateral or fulminant pulmonary tuberculosis are frequently seen, more especially among Indian and Pakistani seamen. The reasons for this are not pertinent to the present paper but experience has suggested that patients from the Indian sub-continent often have a poor response to tuberculous infection whilst amongst the Chinese the reverse seems to obtain. For these reasons we frequently have recourse to cortico-steroids and on more than one occasion we have seen diabetes mellitus diagnosed only after glycosuria has occurred, apparently as a direct result of a gluco-corticoid action. Diabetes mellitus has generally been regarded as contraindicating the use of cortico-steroids in any but the most compelling emergencies. Quite recently Oakley et al. (I959) have shown that in insulin resistant diabetes, due to insulin anti-bodies, steroids may counteract what is, perhaps, an auto-immune reaction and in this way overcome an insulin resistance. The present case presents the combination of pulmonary tuberculosis with diabetes mellitus, both proving resistant to standard treatment until steroids in the form of methyl-prednisolone were included in the therapeutic regime. He gave a history of diabetes of 20 years duration for which he had had only intermittent treatment with insulin. In 1957, a chest X-ray had been suspicious of tuberculosis but no further inivestigations had-been undertaken. For one week before admission he had noticed cough with bloodstained sputum and pain, pleuritic in character, in the right lower chest. On examination he was cachectic with temperature ioi°F. The urine contained 2 per cent. of sugar and ketone bodies were present. The sputum was purulent and blood streaked. Chest examination showed dullness to percussion and diminished breath sounds at the right lung base. There was tenderness of the muscles of the calves, the knee and ankle tendon reflexes were absent and vibration sense was absent at the ankles. Peripheral arterial pulses at the ankles were normal. Sputum examination on admission showed numerous acid-fast bacilli and Loewen-stein-Jensen culture subsequently proved positive for M. …