https://imcjms.com/public Ibrahim Medical College Journal of Medical Science https://imcjms.com/public/registration/journal_full_text/40 Tue, 02 Aug 2016 10:08:02 +0000 Diagnosis of tuberculous pleural effusion (TPE) is difficult because of its non-specific clinical presentation and insufficient efficiency of conventional diagnostic methods. The study was carried out to evaluate the utility of adenosine deaminase (ADA) activity in pleural fluid for the diagnosis of TPE. ADA activity was measured in pleural fluid of 103 pleural effusion patients by colorimetric method using a commercial ADA assay kit. The diagnosis of TPE was made from pleural fluid examinations (including cytology, biochemistry, and bacteriology) and pleural biopsy. Patient with negative result of this methods were diagnosed by response of empirical treatment. Out of 130 cases, 62 (61.1%) had TPE and the remaining 41 (39.8%) had pleural effusion due to non tuberculous diseases. There was statistically significant difference (p < 0.001) between the mean of pleural fluid ADA levels (70.82±22.54 U/L) in TPE group and (30.07±22.93 U/L) in non-TPE group. Of 62 TPE cases, microscopy for AFB and culture for M.tuberculosis in pleural fluid revealed positivity in 9.6% and 22.5% cases respectively, and biopsy of pleura showed typical epithelioid granuloma in only 43.5% cases. The cut-off value of ADA for diagnosing TPE was 40 U/L using a ROC curve, with a sensitivity of 94% and specificity of 88%. Positive and negative predictive value of ADA assay were 92% and 90% respectively. The overall test accuracy was 90%. Pleural fluid ADA assay is therefore a simple, rapid, highly sensitive and specific adjunct test for diagnosis of TPE. Address for Correspondence:Dr. Sharmeen Ahmed, Associate Professor, Department of Microbiology and Immunology, Bangabandhu Sheikh Mujib Medical University(BSMMU), Shahbagh, Dhaka-1000   Bangladesh ranks sixth in the world of tuberculosis (TB) disease burden with estimated 300,000 new cases and 70,000 death per year.1 Pleural tuberculosis is a common manifestation of extrapulmonary TB and with or without pulmonary TB, is present in around 4% of all TB cases.2 If undetected, it may resolve spontaneously, but untreated pleural TB is a progressive disease with high recurrence rate. Diagnosis of pleural TB is difficult because of non-specific clinical presentation and insufficient efficiency of traditional diagnostic methods due to paucity of bacteria in pleural cavity.3,4 Pleural biopsy has been the gold standard in diagnosis but is invasive and often requires several attempts to locate the infectious loci.4 Present study tried to find out the significance of Adenosine deaminase activity in pleural fluid for the diagnosis of tuberculous pleural effusion. Materials and Methods This cross sectional type of comparative study conducted in 103 pleural effusion patients admitted to in-patient departments of Bangabandhu Shiekh Mujib Medical University (BSMMU) and National Institute of Disease of Chest and Hospital (NIDCH) during the period of January 2008 to December 2008. All patients underwent thoracentesis and parietal pleural biopsy with Abram’s needle by trained physicians. Patients with empyema thoracis, haemothorax and patients on anti-tuberculous treatment were excluded from the study. Laboratory methods Effusions were classified as transudates or exudates using Light’s criteria9 and this required a blood sample to be collected on the day of thoracentesis in order to measure total protein and LDH. Three pieces of pleural tissue were taken for histology. Diagnostic criteria Malignant pleural effusion was diagnosed when malignant tissue was shown by pleural tissue or cytopathology. Some of the malignant cases were diagnosed by fiber optic bronchoscopy. Effusion was considered parapneumonic when there was an acute febrile illness associated with pneumonia and complete response to antibiotic treatment. Rest of the non-tuberculosis patients (nephrotic syndrome, congestive cardiac failure and rheumatoid arthritis) were diagnosed by standard clinical procedure. Statistical analysis   Out of 103 pleural effusion cases, 62 (60.1%) were diagnosed as tuberculous pleural effusion (TPE) and 41 (39.1%) were non-TPE cases. The non-TPE cases group included 30 (29.1%) cases with malignant pleural effusion, 8(7.7%) patients with parapneumonic effusion and 3 cases of effusion due to nephrotic syndrome, cardiac failure and rheumatioid arthritis each. Among the 62 of TPE, 49 (79%) were male and 13 (21%) were female with a male female ratio 3.8:1. The mean age of all tuberculous cases was 35.85±14.59 years.   Fig-1. ROC plot of pleural fluid ADA activity. Dotted diagonal line indicates the line of no discrimination         Discussion TPE represent an immunological reaction to relatively few AFB in pleural space. Hence direct examination of pleural fluid by Ziehl-Neelsen (Z-N) staining has low sensitivity (0-10%).14,18,19 In the present study, Z-N staining of pleural fluid revealed positivity in 9.6% cases and pleural fluid culture yielded M.tuberculosis in 22.5% cases. Culture requires a minimum of 10-100 viable bacilli and, therefore, is more sensitive than Z-N staining.20 Majority of series showed diagnostic yields of <30%.18,21,22 Presence of granulomatous inflammation is frequently used as a diagnostic criteria for TPE,23,18 and biopsy of parietal pleura showed typical epithelioid granuloma in 50% to 84% of TPE cases.23,24,25 In this study, pleural biopsy showed diagnostic granuloma in only 43.5% of TPE cases. The low positivity might be due to non repetition of pleural biopsy in this series. Moreover, biopsy requires greater expertise and subject to sampling error to locate the infection foci.4     1.   WHO report 2008. Global tuberculosis control, country profile, Bangladesh. 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