{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,15]],"date-time":"2026-09-15T19:02:41Z","timestamp":1789498961948,"version":"build-2803163510"},"reference-count":46,"publisher":"Public Library of Science (PLoS)","issue":"9","license":[{"start":{"date-parts":[[2026,9,15]],"date-time":"2026-09-15T00:00:00Z","timestamp":1789430400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000061","name":"Fogarty International Center","doi-asserted-by":"publisher","award":["5D43TW011817"],"award-info":[{"award-number":["5D43TW011817"]}],"id":[{"id":"10.13039\/100000061","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS One"],"abstract":"<jats:sec id=\"sec001\">\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Active tuberculosis (TB) infection can induce hyperglycaemia and insulin resistance, increasing the risk of type 2 diabetes mellitus and worsening TB disease severity. However, data on the dynamics of TB-associated hyperglycaemia and its effect on TB treatment outcomes among individuals not previously diabetic remain limited, particularly in high TB-burden settings. In this study, we aimed to investigate the prevalence and temporal patterns of TB-associated hyperglycaemia and its impact on disease presentation and TB treatment outcomes among a cohort of individuals not previously diabetic.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec002\">\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This was a five-month longitudinal prospective cohort study conducted at two urban specialized TB healthcare facilities in Kenya among adults aged &gt;18 years with bacteriologically confirmed pulmonary TB (PTB). Known diabetes mellitus (DM) or prediabetic individuals were excluded during enrolment. Glycaemic status was assessed at baseline and months two and five using glycated haemoglobin (HbA1c) according to the American Diabetes Association guideline. Hyperglycaemia was defined as HbA1c\u2009\u22655.7% and categorized as normoglycaemia, persistent, transient, or incident hyperglycaemia based on longitudinal measurements. Socio-demographic and clinical data were collected using a structured questionnaire and analysed using SPSS version 26.0 and GraphPad Prism version 9.0. Longitudinal trends in HbA1c levels and the association of hyperglycaemia with DM-related symptoms, as well as TB treatment outcomes, were assessed using the Friedman test and the Generalized Estimating Equations (GEE), respectively.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec003\">\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>We enrolled and followed 87 individuals newly diagnosed with PTB. Of these, 66 were tested for hyperglycaemia in month two after 7 died and 14 were lost to follow-up\/transferred out (LTFU\/TO), and 70 in month 5, after an additional death, 7 re-engagements, and 2 LTFU\/TO were reported. At enrolment, the cohort was predominantly male (76%), not married (53%), and HIV-negative (84%), with a median age of 37 years (IQR 29\u201344). Prevalence of hyperglycaemia at baseline was 75% (95% Confidence Interval [CI] 65\u201383), with 45% of the individuals presenting as prediabetic and 30% as diabetic. At the month-two and month-five time points, the proportion of participants with prediabetes (pre-DM) increased from 24% (16\/66) to 30% (21\/70), while the prevalence of DM declined from 21% (14\/66) to 9% (6\/70). Across the time points, HbA1c levels varied significantly (p\u2009&lt;\u20090.001). In GEE analysis, hyperglycaemic participants were more likely to experience classic symptoms of DM such as frequent micturition (adjusted Relative Risk [aRR] 1.76, 95% CI 1.12\u20132.77), increased thirst (aRR 2.37, 95% CI 1.38\u20134.05), unintentional weight loss (aRR 1.84, 95% CI 1.24\u20132.75), and blurred vision (aRR 1.95, 95% CI 1.20\u20133.18). After adjusting for age, BMI, HIV, alcohol use, and smoking, hyperglycaemia was independently associated with an increased risk of sputum positivity (aRR 4.22, 95% CI 2.09\u20138.52). Glycaemic variability was significantly associated with unfavourable TB treatment outcomes (p\u2009&lt;\u20090.001).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec id=\"sec004\">\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>New-onset hyperglycaemia was highly prevalent in adults newly diagnosed with TB and persisted through the fifth month of TB treatment. Hyperglycaemia was associated with classic diabetic symptoms and persisting sputum positivity, highlighting the need to integrate glycaemic monitoring and management into routine TB follow-up care.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1371\/journal.pone.0358593","type":"journal-article","created":{"date-parts":[[2026,9,15]],"date-time":"2026-09-15T18:04:57Z","timestamp":1789495497000},"page":"e0358593","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":0,"title":["Temporal patterns of tuberculosis-associated hyperglycaemia and its effect on treatment outcomes in individuals not previously diabetic: A prospective cohort study"],"prefix":"10.1371","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7523-2784","authenticated-orcid":true,"given":"Victor Moses","family":"Musyoki","sequence":"first","affiliation":[{"name":"University of Nairobi","place":["Kenya"],"department":["Department of Medical Microbiology and Immunology"]},{"name":"KAVI-Institute of Clinical Research, University of Nairobi","place":["Kenya"]},{"name":"Tuberculosis and HIV Co-infection Training Program","place":["Kenya"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marianne","family":"Mureithi","sequence":"additional","affiliation":[{"name":"University of Nairobi","place":["Kenya"],"department":["Department of Medical Microbiology and Immunology"]},{"name":"KAVI-Institute of Clinical Research, University of Nairobi","place":["Kenya"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Annamari","family":"Heikinheimo","sequence":"additional","affiliation":[{"name":"University of Nairobi","place":["Kenya"],"department":["Department of Medical Microbiology and Immunology"]},{"name":"University of Helsinki","place":["Finland"],"department":["Department of Veterinary Medicine"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elizabeth","family":"Maleche-Obimbo","sequence":"additional","affiliation":[{"name":"Tuberculosis and HIV Co-infection Training Program","place":["Kenya"]},{"name":"University of Nairobi","place":["Kenya"],"department":["Department of Paediatrics and Child Health"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dishon","family":"Maina","sequence":"additional","affiliation":[{"name":"Rhodes Chest Clinic","place":["Nairobi, Kenya"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Susan","family":"Musau","sequence":"additional","affiliation":[{"name":"University of Nairobi","place":["Kenya"],"department":["Department of Medical Microbiology and Immunology"]},{"name":"Tuberculosis and HIV Co-infection Training Program","place":["Kenya"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3007-7266","authenticated-orcid":true,"given":"Ruth","family":"Maganga","sequence":"additional","affiliation":[{"name":"University of Birmingham","place":["United Kingdom"],"department":["Department of Applied Health Sciences"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Omu","family":"Anzala","sequence":"additional","affiliation":[{"name":"University of Nairobi","place":["Kenya"],"department":["Department of Medical Microbiology and Immunology"]},{"name":"KAVI-Institute of Clinical Research, University of Nairobi","place":["Kenya"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kariuki","family":"Njaanake","sequence":"additional","affiliation":[{"name":"University of Nairobi","place":["Kenya"],"department":["Department of Medical Microbiology and Immunology"]},{"name":"KAVI-Institute of Clinical Research, University of Nairobi","place":["Kenya"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2026,9,15]]},"reference":[{"issue":"1","key":"pone.0358593.ref001","doi-asserted-by":"crossref","first-page":"13586","DOI":"10.1038\/s41598-024-64525-3","article-title":"Impact of hyperglycemia on tuberculosis treatment outcomes: a cohort study","volume":"14","author":"X Yanqiu","year":"2024","journal-title":"Sci Rep"},{"key":"pone.0358593.ref002","unstructured":"WHO. Global tuberculosis report. Geneva: World Health Organization; 2024."},{"key":"pone.0358593.ref003","unstructured":"National Tuberculosis, Leprosy and Lung Disease Program. Integrated guideline for tuberculosis, leprosy and lung disease. Ministry of Health, Kenya; 2021."},{"issue":"9","key":"pone.0358593.ref004","doi-asserted-by":"crossref","first-page":"2491","DOI":"10.3390\/nu12092491","article-title":"Association of dietary micronutrient intake with pulmonary tuberculosis treatment failure rate: acohort study","volume":"12","author":"K Xiong","year":"2020","journal-title":"Nutrients"},{"key":"pone.0358593.ref005","unstructured":"WHO. Implementing the end TB strategy: the essentials. Geneva: World Health Organization; 2022."},{"issue":"7","key":"pone.0358593.ref006","doi-asserted-by":"crossref","first-page":"102801","DOI":"10.1016\/j.dsx.2023.102801","article-title":"Effect of prediabetes on tuberculosis treatment outcomes: a study from South India","volume":"17","author":"V Viswanathan","year":"2023","journal-title":"Diabetes Metab Syndr"},{"issue":"1","key":"pone.0358593.ref007","doi-asserted-by":"crossref","first-page":"937","DOI":"10.1186\/s12879-020-05512-7","article-title":"The epidemiology of tuberculosis-associated hyperglycemia in individuals newly screened for type 2 diabetes mellitus: systematic review and meta-analysis","volume":"20","author":"S Menon","year":"2020","journal-title":"BMC Infect Dis"},{"key":"pone.0358593.ref008","doi-asserted-by":"crossref","first-page":"1134036","DOI":"10.3389\/fcimb.2023.1134036","article-title":"The cause-effect relation of tuberculosis on incidence of diabetes mellitus","volume":"13","author":"MK Bisht","year":"2023","journal-title":"Front Cell Infect Microbiol"},{"issue":"1","key":"pone.0358593.ref009","doi-asserted-by":"crossref","first-page":"8","DOI":"10.3390\/tropicalmed6010008","article-title":"The interaction of diabetes and tuberculosis: translating research to policy and practice","volume":"6","author":"R van Crevel","year":"2021","journal-title":"Trop Med Infect Dis"},{"key":"pone.0358593.ref010","doi-asserted-by":"crossref","first-page":"962","DOI":"10.3389\/fmicb.2019.00962","article-title":"Immunometabolism and pulmonary infections: implications for protective immune responses and host-directed therapies","volume":"10","author":"M Rao","year":"2019","journal-title":"Front Microbiol"},{"issue":"1","key":"pone.0358593.ref011","doi-asserted-by":"crossref","first-page":"570","DOI":"10.1186\/s12879-017-2657-5","article-title":"The association between tuberculosis and the development of insulin resistance in adults with pulmonary tuberculosis in the Western sub-district of the Cape Metropole region, South Africa: a combined cross-sectional, cohort study","volume":"17","author":"L Philips","year":"2017","journal-title":"BMC Infect Dis"},{"issue":"2","key":"pone.0358593.ref012","doi-asserted-by":"crossref","first-page":"147","DOI":"10.5588\/pha.16.0114","article-title":"Diabetes and pre-diabetes in tuberculosis patients in western Kenya using point-of-care glycated haemoglobin","volume":"7","author":"P Owiti","year":"2017","journal-title":"Public Health Action"},{"key":"pone.0358593.ref013","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1186\/s12878-015-0037-1","article-title":"Effect of anti-tuberculosis drugs on hematological profiles of tuberculosis patients attending at University of Gondar Hospital, Northwest Ethiopia","volume":"16","author":"E Kassa","year":"2016","journal-title":"BMC Hematol"},{"key":"pone.0358593.ref014","doi-asserted-by":"crossref","first-page":"1151528","DOI":"10.3389\/fimmu.2023.1151528","article-title":"Failure to decrease HbA1c levels following TB treatment is associated with elevated Th1\/Th17 CD4+ responses","volume":"14","author":"R Krause","year":"2023","journal-title":"Front Immunol"},{"key":"pone.0358593.ref015","doi-asserted-by":"crossref","first-page":"342","DOI":"10.3389\/fcimb.2019.00342","article-title":"Changes in host response to mycobacterium tuberculosis infection associated with type 2 diabetes: beyond hyperglycemia","volume":"9","author":"CA Segura-Cerda","year":"2019","journal-title":"Front Cell Infect Microbiol"},{"key":"pone.0358593.ref016","doi-asserted-by":"crossref","first-page":"2282","DOI":"10.3390\/microorganisms9112282","article-title":"Diabetes-associated susceptibility to tuberculosis: Contribution of hyperglycemia vs. dyslipidemia","volume":"9","author":"MD Ngo","year":"2021","journal-title":"Microorganisms"},{"issue":"1","key":"pone.0358593.ref017","first-page":"4","article-title":"Pulmonary tuberculosis and diabetes mellitus: epidemiology, pathogenesis and therapeutic management (Review)","volume":"4","author":"Y-F Peng","year":"2023","journal-title":"Med Int (Lond)"},{"key":"pone.0358593.ref018","unstructured":"IDF. Diabetes Atlas. International Diabetes Federation; 2021."},{"issue":"4","key":"pone.0358593.ref019","article-title":"Glucose metabolism disorder is associated with pulmonary tuberculosis in individuals with respiratory symptoms from Brazil","volume":"11","author":"JL Almeida-Junior","year":"2016","journal-title":"PLoS One"},{"key":"pone.0358593.ref020","doi-asserted-by":"crossref","first-page":"804173","DOI":"10.3389\/fmed.2021.804173","article-title":"Prevalence and clinical profiling of dysglycemia and HIV infection in persons with pulmonary tuberculosis in Brazil","volume":"8","author":"MB Arriaga","year":"2022","journal-title":"Front Med (Lausanne)"},{"issue":"11","key":"pone.0358593.ref021","article-title":"Differentiating transient from persistent diabetic range hyperglycemia in a cohort of people completing tuberculosis treatment in Dhaka, Bangladesh","volume":"16","author":"YMA Alkabab","year":"2021","journal-title":"PLoS One"},{"key":"pone.0358593.ref022","article-title":"Clinical, laboratory, and radiographic aspects of patients with pulmonary tuberculosis and dysglycemia and tuberculosis treatment outcomes","author":"LA Bezerra","year":"2022","journal-title":"J Bras Pneumol"},{"key":"pone.0358593.ref023","doi-asserted-by":"crossref","first-page":"293","DOI":"10.1016\/j.ijid.2022.01.012","article-title":"Persistent dysglycemia is associated with unfavorable treatment outcomes in patients with pulmonary tuberculosis from Peru","volume":"116","author":"RI Calderon","year":"2022","journal-title":"Int J Infect Dis"},{"issue":"1","key":"pone.0358593.ref024","doi-asserted-by":"crossref","first-page":"799","DOI":"10.1186\/s12879-019-4416-2","article-title":"High prevalence and heterogeneity of Dysglycemia in patients with tuberculosis from Peru: a prospective cohort study","volume":"19","author":"RI Calderon","year":"2019","journal-title":"BMC Infect 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Nathella","year":"2017","journal-title":"Immunology"},{"issue":"4","key":"pone.0358593.ref029","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0094890","article-title":"Diabetes mellitus, smoking status, and rate of sputum culture conversion in patients with multidrug-resistant tuberculosis: a cohort study from the country of Georgia","volume":"9","author":"MJ Magee","year":"2014","journal-title":"PLoS One"},{"issue":"22","key":"pone.0358593.ref030","doi-asserted-by":"crossref","first-page":"2539","DOI":"10.3390\/diagnostics14222539","article-title":"The complex relationship between tuberculosis and hyperglycemia","volume":"14","author":"M Byers","year":"2024","journal-title":"Diagnostics (Basel)"},{"issue":"3","key":"pone.0358593.ref031","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0282371","article-title":"Association between prior tuberculosis disease and dysglycemia within an HIV-endemic, rural South African population","volume":"18","author":"AC 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