Association of Helicobacter Pylori Infection and Diabetes Mellitus Type 2 Subjects in Yaounde Cameroon Using a Panel of Serum Biomarkers ( PGII , HpIgG ) : A Case Control Study

Introduction: Infection to Helicobacter pylori has been associated to many gastrointestinal diseases including gastritis, peptic ulcer disease, gastroesophageal reflux disease, atrophic gastritis and gastric cancer. Chronic infections are frequent and severe in patients with diabetes mellitus (DMT2), probably due to the impairment of their immune status. The link between H. pylori infection and diabetes mellitus (DM) remains controversial. This study aimed at detection and comparison of anti H. pylori antibodies (IgG) in serum of diabetes mellitus type 2 (DMT2) and non-diabetic dyspepsia subjects and also to find if there exists any significant correlation between H. pylori infection and DMT2. Materials and methods: This case control study of 82 patients (51 diabetics and 31 non-diabetic subjects) was carried out in Yaounde Cameroon during the period January-April 2017. Clinical and sociodemographic information of both groups were recorded 5 ml of blood was aseptically collected for H. pylori IgG antibodies. Assay parameters were analysed using a software application GastroSoft (www.GastroPanel.com). Data was analysed using Epi info 7.0. All statistics were realized at 95% CI. Authorizations were obtained at the Yaounde Central Hospital, the Cite Verte District Hospital. Ethical clearance was also obtained from the National Ethics Committee. Results: Significantly raised Anti H. pylori antibodies (IgG) were found in diabetics (88.2%) than in the non-diabetic control group (67.7%), (P = 0.015) showing strong correlation between the association of H. pylori and DMT2. Dyspepsia was very common in anti H. pylori positive cases (83.6%). The most common diabetic complications observed in H. pylori positive diabetic subjects were retinopathy (81.0%), neuropathy (33.3%), diabetic foot (19.0%) and nephropathy (9.5%). The major diabetic risk factors in H. pylori positive subjects were obesity (39.5%), overweight (31.6%) and hypertension (31.7%). Significantly raised anti H. pylori antibodies were observed in almost all age groups in the diabetic groups. Conclusion: The result showed that diabetics are more prone to H. pylori infection and need continuous monitoring.


Introduction
Infection to spiral rod-shaped gram-negative bacterium, Helicobacter pylori (H.pylori) is associated to many gastrointestinal diseases including gastritis, peptic

RESEARCH ARTICLE
Check for updates low up at Yaounde Central Hospital, the Cite Verte District Hospital and the Etouge-Ebe Baptist Hospital were included during the three-month period January-April 2017.The control group consisted of 31 healthy students and health personnel with no history of diabetes and hypertension, none of the controls included was on antimicrobial agents, H2 receptor antagonist or proton-pump inhibitor for at least last 4 weeks.Age, sex, height, weight, and body mass index of all the participants were recorded.History of dyspepsia was recorded.The diabetic subjects were also enquired for intake of non-steroidal anti-inflammatory drugs, history of treatment of H. pylori infection, use of proton pump inhibitors, H2 receptor antagonist and antacids.5 ml of venous blood was aseptically collected in dry tubes, which was kept undisturbed for 1 hour for clot formation.The serum was transferred into sterile cryotubes and stored at -20 °C, for estimation of specific IgG anti H. pylori antibodies and pepsinogen II levels using the HPIgG Elisa and PGII Elisa respectively of the GastroPanel (Biohit plc Finland, www.biohithealthcare.com).All patients with H. pylori IgG ≥ 30 EIU and PGII > 15 μg/l were considered positive for active Helicobacter pylori infection.All the diabetic subjects in study group were observed for various diabetes mellitus related complications like diabetes retinopathy, nephropathy, neuropathy, and diabetic foot.Assay parameters were analysed using a software application GastroSoft (www.GastroPanel.com).Data was interpreted using Epi Info software 7.0.Chi-square test was applied to test the difference between two proportions; student (t) test was applied to test the difference between two means; Fisher (F) test was applied to test the difference of more than two means and P value less than 0.05 was regarded as significant (P < 0.05).Ethical clearance was obtained from the National Ethics committee.All patients signed an informed consent form.

Results
In total, 82 subjects were recruited aged 19-77 yrs, ulcer disease, gastroesophageal reflux disease, atrophic gastritis and gastric cancer [1,2].H. pylori infection has been estimated in up to half of the world's population and mainly acquired in childhood by the feco-oral, orooral or gastro-oral routes [3].H. pylori infection has also been implicated in other non-gastrointestinal diseases like diabetes mellitus, ischemic heart disease, neurological disorder, hypertension, thyroiditis, dermatological, rheumatological and cerebrovascular disease [4].Diabetes mellitus (DM) is a common, chronic and progressive disease characterized by chronic hyperglycemia with disturbances in carbohydrate, fat and protein metabolism resulting from either absolute or a relative deficiency of insulin and/or action [5].The chronic hyperglycemia in DM patients is associated with long-term damage, dysfunction, and failure of various organs including the eyes, kidneys, nerves, heart as well as blood vessels.H. pylori has been implicated on cardiovascular conditions, insulin resistance, and metabolic syndrome potentially mediated by elevations in inflammatory markers such as C-reactive protein (CRP) and Interlukin-6 (IL-6) [6].Several studies all over the world have reported high H. pylori prevalence amongst DM patients although the link between H. pylori infection and diabetes remains controversial.Impairment of cellular and humoral immunity, reduction of gastrointestinal motility and acid secretion, altered glucose metabolism and increased susceptibility of pathogens as they regularly attend hospital settings have been implicated in increased susceptibility to infection in diabetic patient [1].H. pylori IgG antibodies and pepsinogen II are well known markers for Helicobacter pylori infection and gastric inflammation respectively.Thus, the aim of this study was to evaluate the prevalence of H. pylori infection in DMT2 patients in Yaounde and also to find if there exists any significant correlation between H. pylori infection and DMT2.

Material and Methods
A total of 51 type 2 diabetic patients undergoing fol-  1).
H. pylori seropositivity (IgG ≥ 30 EIU) was higher in participants presenting with dyspepsia complaints (86.4%) than non-dyspepsia subjects (71.4%)Table 1.However, H. pylori prevalence was not associated with dyspepsia in both the diabetic and control groups (p > also reported similar results in a group diabetic patients and healthy controls. Significantly raised pepsinogen II levels were observed in H. pylori positive (25.2 ± 15.2 µg/l) t = 2.1; p = 0.03 and a strong positive correlation was obtained between IgG and PGII levels r = 0.98, p = 0.001.Pepsinogen II levels are known to be strongly associated to Helicobacter pylori antibodies [19,20] (www.biohithealthcare.com).Raised pepsinogen II levels (PGII > 15 μg/l) were observed in all aged groups of the diabetics (F = 3.1; p = 0.02) than in the non-diabetic group (F = 2.2; p = 0.09) and in the diabetics presenting with dyspepsia (29.0 ± 17.0 μg/l) than non-diabetics dyspepsia subjects (14.0 ± 8.1 μg/l).This difference is as a result the increased susceptibility of H. pylori infection in diabetic patients.Pepsinogen II is a known marker of gastric inflammation due to Helicobacter pylori and prolonged use of anti-inflammatory drugs [2,20] (www.biohithealthcare.com).

Conclusion
The study indicates that diabetics are more prone to H. pylori infection and the growing need for continuous monitoring of H. pylori infection in diabetic patients.However more extensive well-designed cohort studies are needed to definitely conclude the relationship of H. pylori infection with diabetes mellitus and its complications.
Patients with diabetes mellitus are often affected by chronic infections [1].Many studies have evaluated the prevalence of H. pylori infection in diabetic patients and the possible role of this condition in their metabolic control.The present study found that diabetic patients are more prone to acquire H.pylori infection (88.2%) than the control group (67.7%, p = 0.001) (statistically significant).Jeon, et al. [13], in a prospective cohort showed that infection of H. pylori leads to an increased incidence of diabetes.Sherwal, et al. [4] and Taher, et al. [14], also observed higher prevalence of H. pylori in diabetic dyspeptic patients than in non-diabetic.Many other authors across the world including Ali and Sarkis [1], Kimiaki, et al. [15], Oldenburg, et al. [9] Quadri, et al. [16] Gulcelik, et al. [17] have also observed statistically significant association of H. pylori with diabetes mellitus.Several reasons have been advanced as to the increased susceptibility to infection in diabetic patients.These include, diabetes-induced impairment of cellular and humeral immunity, diabetes-induced reduction of gastrointestinal motility and acid secretion may promote pathogen colonization and infection rate in the gut, altered glucose metabolism may produce chemical changes in the gastric mucosa that promote H. pylori colonization and frequently exposed to pathogens by diabetics than their healthy counterparts as they regularly attend hospital settings [1,4].

Figure 1 :
Figure 1: Correlation between HP IgG antibodies and Pepsinogen II levels.