LungIndia.2008JulSep25(3):109110.

PMCID:PMC2822331

doi:10.4103/09702113.44121

AdenosineDeaminase(ADA)LevelinTubercularPleuralEffusion
S.K.Verma, 1A.L.Dubey, 1P.A.Singh, 2S.L.Tewerson, 2andDavashishSharma3
1
DepartmentofTB&ChestDiseases,CSMMedicalUniversity,Lucknow,India
2
DepartmentofPathology,CSMMedicalUniversity,LucknowM.L.N.MedicalCollege,Allahabad,India
3
DepartmentofStatistics,CSMMedicalUniversity,LucknowM.L.N.MedicalCollege,Allahabad,India
Correspondence:Dr.S.K.Verma,AssociateProfessor,DepartmentofPulmonaryMedicine,CSMMedicalUniversity,UP,Lucknow226003.Tel.:91
05222254346
Received2007SepAccepted2008Mar.
CopyrightLungIndia
ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionLicense,whichpermitsunrestricteduse,distribution,and
reproductioninanymedium,providedtheoriginalworkisproperlycited.

ThisarticlehasbeencitedbyotherarticlesinPMC.

Abstract

Goto:

STUDYOBJECTIVE:

Tostudythevalueofadenosinedeaminaselevelintubercularpleuraleffusion.
DESIGN:

Ahospitalbasedobservationalstudy.
SETTING:

OutandInpatientsserviceofdepartmentofTuberculosis&ChestDiseases,MLNMedicalCollegeAllahabad.
PATIENTS:

50consecutivepatientsofpleuraleffusion,whowereabovetheageof12years,werestudied.
RESULTS:

Pleuralfluidadenosinedeaminasewasmorethan36IU/L(36to229.7IU/L)intubercularpleuraleffusion(34
patients).Incaseofmalignancyno.ofpatientswas08andpleuralfluidadenosinedeaminasewasmorethan18.5
IU/L(18.5to87.6IU/L).Whileinonecaseofhypoprotenemieapleuralfluidadenosinedeaminasewas8.21IU/L.
If36IU/ListakenascutoflimitthesensitivityandspecificityofADAfortuberculosisis100%and77.7%.
Morethan100IU/Lwasexclusivelyseenintubercularpleuraleffusion.
CONCLUSION:

ADA>100IU/LwasobservedinTBonly.
Keywords:TubercularPleuraleffusion,PleuralfluidADAlevel
INTRODUCTION

Goto:

Pleuraleffusionisacommonchestproblem,yetitisdifficulttoestablishtheaetiologicaldiagnosisinasmanyas
20%casesinspiteofgoodhistory,thoroughclinical,radiological,fullexaminationofaspiratedfluidandpleural
biopsy1.Sothereisaneedofsimple,rapidandreliablediagnostictesttoestablishtheaetiologyofpleuraleffusion.
Consideringthisaprospectivehospitalbasedstudywasdesignedtocomparepleuralfluidadenosinedeaminase
levelandpleuralbiopsyinestablishingthediagnosisoftubercularpleuraleffusion.
MATERIALANDMETHOD

Goto:

Thestudycomprisedof50consecutivepatientsofpleuraleffusion,bothmaleandfemale,abovetheageof12
yearswhoattendedtheSwaroopRaniNehruHospitalofMotilalNehruMedicalCollege,Allahabad,U.P.India.
Patientsinwhomhistoryoftyphoidfever,acuteviralhepatitisandactivecirrhosiswerepresent,wereexcluded.
Detailedhistorywastakenandthoroughclinicalexaminationwasdoneineachandeverypatientsandtheywere
thensubjectedtoabatteriesofinvestigationwhichincludedroutinehaemogram,urineexamination,skiagramchest
PAandlateralview,sputumsmearexaminationforAFBandsputumcultureformycobacteriumtuberculosis,

pleuralfluidforprotein,glucose,cellcount,malignantcells,Gram'sstain,pleuralfluidexaminationforAFB,
pleuralfluidcultureformycobacteriumtuberculosisandotherrelevantinvestigationasperneedofcases.ADA
wasmeasuredinpleuralfluidbycolorimetricmethodofGuistiandGalanti2.Pleuralbiopsywasdonethrough
Abraham'spunchbiopsyneedle3.
RESULTS

Goto:

50patientsabovetheageof12yearswerestudied.Malewere34andfemalewere16.
Outof50patientstuberculosiswasdiagnosedin34cases(byhistory+sputumresults+pleuralfluidresults
+pleuralbiopsy)19(46%)patientswerediagnosedbypleuralbiopsy11werediagnosedbyAFBinpleuralfluid
and4byAFBinsputumsmearexamination.Similarly8casesofmalignancywerediagnosed(4bydirect
histologyofpleuraltissueand4bytissuebiopsyfromlungparenchymamassorlymphnode).PleuralfluidADA
levelwasmorethan36IU/Lincasesoftubercularpleuraleffusion.Itranged36to229.7IU/L.Whileincaseof
malignancyitwasmorethan18.5IU/L(18.5to87.6IU/L).Inonecaseofhypoproteinemiaitwas9.21IU/L.
When36IU/Listakenascutoffpoint,sensitivityandspecificityofADAforTBis100%and77.7%.Wefound
thatwhenmorethan100IU/lwastakenascutoflimitofADAlevel,itwasseenintuberculosisonly.
DISCUSSION

Goto:

PresentstudyconfirmsthattADAlevelintubercularpleuraleffusionisincreasedandinnontubercularpleural
effusionADAleveldidnotexceedto100IU/L.Tuberculosisisacommoncauseofpleuraleffusion4especiallyin
countrieslikeIndia.Moreoverincidenceoftuberculosisisincreasingworldwide5.Althoughtubercularpleural
effusioncanresolvespontaneouslybutupto65%untreatedtubercularpleuraleffusioncandevelopactive
tuberculosis6.Sorapidandaccuratediagnosisandprompttreatmentisnecessaryfortubercularpleuraleffusion.
Wheneverapatientofpleuraleffusionpresentsweusuallyinvestigateonlineofgross,microscopicandbiochemical
parameters(excludingADAlevel).Althoughlymphocyticpredominantfluidisusuallyseenintubercularpleural
effusionbutalllymphocyticpredominantfluidcan'tbetubercular,itcouldbemalignant.Sothereisaneedto
differentiateamongvariouscausesofpleuraleffusion.Definitivediagnosisoftubercularisoftendifficultasinmore
than50%ofpatients,pleuraistheonlysiteofinfection7.Tuberculintestisnonspecificandfindingcanbe
negative8.Becausebacterialloadisless9sopleuralfluidcultureformycobacteriumtuberculosisisalsolow(<20)
10
.PleuralfluidADAestimationisquickandrelativelyinexpensive.
InpresentstudyADAlevelintuberculosiscaseswasmorethan36IU/LinagreementwithNiwaetal.(1985)11
>38IU/LRodziguez(1962)12>37U/LandJindaletal(1993)13>40U/l.Incaseofmalignantpleuraleffusionour
findingscorelatewithmostoftheauthors.ADAlevelinmalignancywasupto87.6IU/L.ADAlevelmorethan
100IU/LobservedonlyincasesoftubercularpleuraleffusionsofromthestudyweconcludedthatifADAlevelof
morethan100IU/Listakenascutoffpointitisexclusivelyseenincasesoftubercularpleuraleffusion.Sowecan
saythatestimationofADAlevelinpleuralfluidisextremelyhelpfulinestablishingtheaetiologyoftubercular
pleuraleffusionandtoruleoutotherdiagnosisespeciallyofotherdiseasesinwhichlymphocytepredominanceof
pleuraleffusionisseensuchasmalignancyandcollagenvasculardiseases(i.e.rheumatoidarthritisandsystemic
erythematosus).
Limitationofstudy:

Numberofpatientsstudiedissmall.Sodefinitivecriteriacan'tbeestablishedonthissamplesize.Alargenumberof
patientsarerequiredtoconfirmourfindingsfurtherandestablishthedefinitivecriteria.
REFERENCES

Goto:

1.KatariaYP,ImtiazK.Adenosinedeaminaseinthediagnosisoftuberculouspleuraleffusion.Chest.20012:298
300.[PubMed]
2.GuistiG,GalantiB.Colorimetricmethod.In:BergmeyerHU,editor.MethodofEnzymaticanalysis.3rded.
Berlin:GermanyVerlagChemie,Weinheim1984.pp.315323.
3.AbramsLD.Apleuralbiopsypunch.TheLancet.1958:3031.[PubMed]
4.LightRW.Pleuraldiseases.3rded.Baltimore,MD:Williamsandwilkins1995.
5.DolinPJ,RaviglioneMC,KochiA.Globaltuberculosisincidenceandmortalityduring19002000.Bullworld
heathorgan.199472:21320.[PMCfreearticle][PubMed]
6.RoperWH,WaringJJ.Primaryserofibrinouspleuraleffusioninmilitarypersonnel.AMRevRespirDis.
199571:61634.[PubMed]
7.SeibertAF,HaynesJ,MiddletonR,etal.Tuberculouspleuraleffusion:twentyyearexperience.Chest.
19911999:88386.[PubMed]

8.RothBJ.searchingfortuberculosisinpleuralspace.Chest.1999116:35.[PubMed]
9.BothamleyGH.TuberculousPleurisyandadenosinedeminase.Thorax.199550:59394.[PMCfreearticle]
[PubMed]
10.BergerHW,MijiaE.TuberculousPleurisy.Chest.197368:8892.[PubMed]
11.NiwaY,KishimotoH,ShimokataK.Carcinomatousandtuberculouspleuraleffusion.Chest.198587:35155.
[PubMed]
12.RodriquizEP,FerrandoC,FlonderJ,etal.ADAinpleuraleffusion.Chest.1992102:325.[PubMed]
13.JindalSK.ADAinpleuraleffusion.JAssocPhysicianIndia.199341:41620.[PubMed]
ArticlesfromLungIndia:OfficialOrganofIndianChestSocietyareprovidedherecourtesyofMedknow
Publications