WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES

Saurabh et al. World Journal of Pharmacy and Pharmaceutical Sciences

SJIF Impact Factor 6.647

Volume 6, Issue 3, 867-873 Research Article ISSN 2278 – 4357

SERUM VITAMIN D LEVELS IN PULMONARY TUBERCULOSIS

Saurabh Kumar Deo*, Neeru Bhaskar1 and Sameer Singhal2

*
Ph. D. Scholar (Medical Biochemistry), Maharishi Markandeshwar University, Mullana,
Ambala, Haryana, India.
1
Professor, Department of Biochemistry, Maharishi Markandeshwar University, Mullana,
Ambala, Haryana, India.
2
Professor & Head, Department of Respiratory Medicine, Maharishi Markandeshwar
University, Mullana, Ambala, Haryana, India.

Article Received on
07 Jan. 2017,
Revised on 26 Jan. 2017,
Accepted on 16 Feb. 2017
DOI: 10.20959/wjpps20173-8759
ABSTRACT
Vitamins are known to be associated with immunity and nutrition.
Moreover, vitamin deficiency can affect host immunity to various
infectious diseases, including tuberculosis. We performed a case-
control study to investigate the serum vitamin D concentrations in 100

*Corresponding Author
patients with pulmonary tuberculosis (PTB) and 100 control subjects
Saurabh Kumar Deo and it was found that the mean serum vitamin D levels in pulmonary
Ph. D. Scholar (Medical tuberculosis (PTB) patients were 24.08 ± 14.59 ng/ ml with a range of
Biochemistry), Maharishi
5.7 – 98.3 ng/ml and in control subjects the mean serum vitamin D
Markandeshwar
levels were 31.08 ± 11.31 ng/ml with a range of 14.2 – 85.5 ng/ml and
University, Mullana,
Ambala, Haryana, India.
the difference between two groups found to be statistically highly
significant (p<0.001). The mean serum vitamin D levels in male and
female hypovitaminosis D within PTB groups were 18.44 ± 7.31 and 18.93 ± 6.49 ng/ml,
respectively. In conclusion, vitamin D deficiency is common in patients with PTB.

KEYWORDS: Vitamin D, pulmonary tuberculosis, immunity, hypovitaminosis.

INTRODUCTION
Tuberculosis
Tuberculosis (TB), one of the oldest diseases known to affect humans, is a major cause of
death worldwide. It is caused by Mycobacterium tuberculosis complex and usually affects the
lungs, although other organs are involved in up to one-third of cases. If properly treated,

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tuberculosis caused by drug-susceptible strains is curable. If untreated, the disease is fatal

within 5 years in 50-65% of cases. Transmission usually occurs through the airborne spread
of droplet nuclei produced by patients with infectious pulmonary TB (PTB).[1]

Tuberculosis is classified as pulmonary TB and extra pulmonary TB or both.[1] The most

common extra pulmonary sites are lymph nodes, pleura, genitourinary tract, bones and joints,
meninges, peritoneum, and pericardium.[1] Another way to classify TB is whether the disease
is latent (hidden) or active (overt):- Latent TB is asymptomatic because the bacteria remain
inactive in the body. However, it can turn into active TB. An estimated one-third of the
world's population has latent TB.[2] Active TB is the clinically manifested form of TB. It can
occur in the first few weeks after infection with mycobacteria, or it might occur years later.[2]

TB occurs in every part of the world. In 2012, the largest number of new TB cases occurred
in Asia, accounting for 60% of new cases globally. However, sub-Saharan Africa carried the
greatest proportion of new cases with over 255 cases per 100 000 population. India accounts
for the largest burden of tuberculosis (TB) worldwide, with nearly 25% of the world's
cases.[3,4] Of the total number of tuberculosis cases in the world, 2-2.5 million cases are from
India alone.

Vitamin D
Vitamin D is a lipid soluble vitamin found in small amounts in few foods, including fatty
fish. The active form of vitamin D is calcitriol (Fig. 1). Most of the vitamin D is obtained
through exposure to sunlight. There are two forms of vitamin D- vitamin D2 (ergocalciferol)
which is of plant origin and vitamin D3 (cholecalciferol) which is of animal origin. Vitamin
D3 is synthesized in the skin from 7-dehydrocholesterol by ultraviolet irradiation.[5] Vitamin
D is used for preventing and treating rickets, osteoporosis, bone pain (osteomalacia), bone
loss in patients with hyperparathyroidism, and an inherited disease- osteogenesis imperfecta,
in which the bones are especially brittle and easily broken. It is also used for boosting the
immune system, and preventing autoimmune diseases and cancer.[6]

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Fig 1: Activation of vitamin D.

Tuberculosis and Vitamin D

Immune responses to Mycobacterium tuberculosis are complex and incompletely understood.
However, there is increasing epidemiological evidence to support the role of vitamin D in the
immune response to TB. Many immune cells express the vitamin D receptor (VDR),
including T and B cells, dendritic cells, as well as macrophages. Initial studies found that
calcitriol stimulates antimicrobial activity, but it is only recently that the possible mechanism
has been described. Ligation of the innate immune pattern recognition receptors, Toll-like
receptors (TLRs) on human macrophages, causes upregulation of the intracellular VDR and
vitamin D hydroxylase genes, resulting in induction of cathelicidin and/or β-defensin, both of
which are potent antimicrobial peptides. Cathelicidin induces fusion of the phagolysosome,
which is essential for the containment, degradation and subsequent killing of mycobacteria.[7]
Calcitriol also exerts its effects on innate immune responses by the promotion of autophagy
and the suppression of tissue remodeling and lung matrix breakdown. Autophagy is a potent
mechanism by which the host defends against mycobacterial infection, by degradation of
cellular components through the lysosomal machinery.

Keeping in view the above facts, the present study was planned to evaluate serum vitamin D
levels in pulmonary TB.

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AIMS AND OBJECTIVES

 To evaluate serum vitamin D levels in pulmonary tuberculosis.

MATERIALS AND METHOD

The study was conducted in the Department of Biochemistry in collaboration with the
Department of Respiratory Medicine, MM Institute of Medical Sciences and Research,
Mullana, Ambala, Haryana.

The study was conducted in 100 patients (age 15 years and above of either sex) of pulmonary
TB attending OPD and wards of Respiratory Medicine of MM Institute of Medical Sciences
and Research, Mullana, Ambala. They were selected by simple random sampling. 100
healthy subjects aged 15 years and above of either sex served as controls.

INCLUSION CRITERIA
1. Patients of sputum smear positive/mycobacterial culture positive pulmonary tuberculosis.
2. Age 15 years and above.
3. Either sex.

EXCLUSION CRITERIA
1. Sputum smear negative pulmonary tuberculosis.
2. Extra pulmonary tuberculosis.
3. Age <15 years.
4. Pregnancy and lactation.
5. Subjects on vitamin D and/or calcium supplements.
6. Drugs that affect bone metabolism, e.g. antiepileptic drugs.
7. Patients with known skeletal disease and parathyroid disorders.
8. Chronic kidney/liver disease.
9. HIV positive.

ESTIMATION OF SERUM VITAMIN D [25(OH)D] LEVELS:

It was assayed by direct competitive chemiluminescence immunoassay (CLIA).[8] 3 ml of
venous blood sample was aseptically collected as per the standard guidelines and protocol.
Serum was allowed to separate and subsequently analyzed for serum vitamin D level.

Reference range: 30 - 100 ng/ml.[8]
 Hypovitaminosis D: <30 ng/ml.

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RESULT
The present study was conducted to assess the serum vitamin D levels in patients suffering
from pulmonary tuberculosis at Department of Biochemistry in collaboration with
Department of Respiratory Medicine, MMIMSR, Mullana, Ambala, Haryana. One hundred
clinically diagnosed patients (age 15 years and above of either sex) of pulmonary TB
attending OPD and wards of Respiratory Medicine of MM Institute of Medical Sciences and
Research, Mullana, Ambala were selected to serve as subjects for the study. Equal number of
healthy subjects aged 15 years and above of either sex served as controls.

The age of TB patients and control subjects was almost comparable with difference between
two groups being statistically insignificant (p>0.05) (Table 1).

Table 1: Showing age distribution amongst TB patients and control subjects.

Range Mean± SD
p- Value
(Years) (Years)
TB Patients 15- 75 44.17±15.81
0.070
Control Subjects 18- 73 40.51±12.37

Out of 100 TB patients, 73 were males and 27 were females and among control subjects, 62
were males and 38 were females.

In the present study, 77 PTB patients were found to have low serum vitamin D levels, out of
which 57 were males and 20 were females (Table 2). In case of control subjects, 55 subjects
were suffering from hypovitaminosis D out of which 32 were males and 23 were females
(Table 2).

Table 2: Showing vitamin D distribution in TB subjects and control subjects

Normal Vit D Hypovitaminosis D
Range
% of Normal Vit % of
(ng/mL) Frequency Frequency
D Hypovitaminosis D
Male = 16 Male = 16% Male = 57 Male = 57%
TB
5.7- 98.3 Female = 7 Female = 7% Female = 20 Female = 20%
Subjects
Total = 23 Total = 23% Total = 77 Total = 77%
Male = 30 Male = 30% Male = 32 Male = 32%
Control
14.2- 85.5 Female = 15 Female = 15% Female = 23 Female = 23%
Subjects
Total = 45 Total = 45% Total = 55 Total = 55%

The PTB patients had mean serum vitamin- D levels of 24.08 ± 14.59 ng/ ml with a range of
5.7 – 98.3 ng/mL and for control subjects, the mean serum vitamin- D levels were 31.08 ±
11.31 ng/ml with a range of 14.2 – 85.5 ng/ml (Table 2) and the difference was found to be
statistically highly significant (p<0.001) as revealed in “Fig.” 2.

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Fig. 2: Showing serum vitamin D levels amongst TB patients and Control subjects.

DISCUSSION
There could be three possible reasons for the deficiency in the population. i) Poor intake of
vitamin D containing food items was the primary cause and not decreased sunlight exposure.
It therefore implies that there is need to get both sunlight as well as a balanced diet for
adequacy of vitamin D. This is possible by consuming a vegetarian diet with a combination
of “Cereals + Pulses + Vegetables + fruits” in the right proportions everyday (non-
vegetarians could take egg, fish or meat instead of the pulses). Though there are no data to
support, it is a common observation that very few people know what constitutes a balanced
diet, and some beliefs and wrong concepts about diet prevent many from taking dietary items
which contain Vitamin D. There are only very few who regularly get all these in their diet
due to lack of awareness about what constitutes a balanced diet. Even if they are made aware
of and motivated many have no access to balanced diet due to poverty.[9] ii) Reduced
cutaneous biosynthesis of vitamin D could be another reason, due to the increased melanin in
skin which could be interfering with ultraviolet light mediated vitamin D synthesis.[10] iii) To
compound the problem further, it could be possible that the poor intake of vegetables, which
is a very common issue in most people of our country, and the resultant magnesium
deficiency might lead to reduced parathyroid hormone (PTH) secretion and the consequent
reduction of 1- hydroxylation of vitamin D,[11] since PTH is needed for this step in Vitamin D
biosynthesis.

CONCLUSION
Thus, the present study was observed Vitamin D deficiency in PTB patients. Even apparently
healthy people may have Vitamin D deficiency. These results suggest a therapeutic role for
vitamin D in the treatment of TB.

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