1
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Ye Q, Yan W. Adenosine deaminase from the cerebrospinal fluid for the diagnosis of tuberculous meningitis: A meta-analysis. Trop Med Int Health 2023; 28:175-185. [PMID: 36591905 DOI: 10.1111/tmi.13849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To comprehensively evaluate the diagnostic efficacy of adenosine deaminase in cerebrospinal fluid (CSF) for tuberculous meningitis (TBM), and the potential influence of patients' age groups and cutoffs of measured adenosine deaminase. METHODS Systematic review and meta-analysis of relevant studies retrieved from PubMed, Embase, and Web of Science databases. Pooled sensitivity and specificity were calculated with a random-effect model. RESULTS Overall, 43 studies with 1653 patients with TBM and 3417 controls without were included. Pooled results showed that adenosine deaminase in CSF is associated with satisfactory diagnostic efficacy for TBM, with a pooled sensitivity of 0.86 (95% confidence interval [CI]: 0.82-0.90), specificity of 0.89 (95% CI: 0.86-0.91), positive likelihood ratio of 7.70 (95% CI: 6.16-9.63), and negative likelihood ratio of 0.15 (95% CI: 0.12-0.20). The pooled receiver operating characteristic (AUC) was 0.94 (95% CI: 0.91-0.96), suggesting good performance. Subgroup analyses showed good diagnostic efficacies of adenosine deaminase in CSF for both adults (AUC 0.95) and children (AUC 0.96) with TBM. AUCs indicating the diagnostic accuracies of adenosine deaminase in CSF for TBM were 0.93 for studies with cutoffs <10 U/L and and 0.94 for a cutoff =10 U/L, but only 0.90 for studies with cutoffs >10 U/L. CONCLUSIONS Measuring adenosine deaminase of CSF shows satisfactory diagnostic efficacy for TBM in children and adults, particularly if using a cutoff ≤10 U/L.
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Affiliation(s)
- Qin Ye
- Department of Pulmonary Medicine, Ningbo HwaMei Hospital, Ningbo Institute of Life and Health Industry, University of Chinese Academy of Sciences, Ningbo, China
| | - Wang Yan
- Department of Neurology, Ningbo HwaMei Hospital, University of Chinese Academy of Sciences, Ningbo, China
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2
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Delemarre EM, van Hoorn L, Bossink AWJ, Drylewicz J, Joosten SA, Ottenhoff THM, Akkerman OW, Goletti D, Petruccioli E, Navarra A, van den Broek BTA, Paardekooper SPA, van Haeften I, Koenderman L, Lammers JWJ, Thijsen SFT, Hofland RW, Nierkens S. Serum Biomarker Profile Including CCL1, CXCL10, VEGF, and Adenosine Deaminase Activity Distinguishes Active From Remotely Acquired Latent Tuberculosis. Front Immunol 2021; 12:725447. [PMID: 34691031 PMCID: PMC8529994 DOI: 10.3389/fimmu.2021.725447] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/15/2021] [Indexed: 12/20/2022] Open
Abstract
Introduction There is an urgent medical need to differentiate active tuberculosis (ATB) from latent tuberculosis infection (LTBI) and prevent undertreatment and overtreatment. The aim of this study was to identify biomarker profiles that may support the differentiation between ATB and LTBI and to validate these signatures. Materials and Methods The discovery cohort included adult individuals classified in four groups: ATB (n = 20), LTBI without prophylaxis (untreated LTBI; n = 20), LTBI after completion of prophylaxis (treated LTBI; n = 20), and healthy controls (HC; n = 20). Their sera were analyzed for 40 cytokines/chemokines and activity of adenosine deaminase (ADA) isozymes. A prediction model was designed to differentiate ATB from untreated LTBI using sparse partial least squares (sPLS) and logistic regression analyses. Serum samples of two independent cohorts (national and international) were used for validation. Results sPLS regression analyses identified C-C motif chemokine ligand 1 (CCL1), C-reactive protein (CRP), C-X-C motif chemokine ligand 10 (CXCL10), and vascular endothelial growth factor (VEGF) as the most discriminating biomarkers. These markers and ADA(2) activity were significantly increased in ATB compared to untreated LTBI (p ≤ 0.007). Combining CCL1, CXCL10, VEGF, and ADA2 activity yielded a sensitivity and specificity of 95% and 90%, respectively, in differentiating ATB from untreated LTBI. These findings were confirmed in the validation cohort including remotely acquired untreated LTBI participants. Conclusion The biomarker signature of CCL1, CXCL10, VEGF, and ADA2 activity provides a promising tool for differentiating patients with ATB from non-treated LTBI individuals.
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Affiliation(s)
- Eveline M Delemarre
- Center for Translational Immunology (CTI), University Medical Center Utrecht, Utrecht, Netherlands.,Platform Immune Monitoring (PIM), University Medical Center Utrecht, Utrecht, Netherlands
| | - Laura van Hoorn
- Center for Translational Immunology (CTI), University Medical Center Utrecht, Utrecht, Netherlands.,Department of Respiratory Medicine and Tuberculosis, University Medical Center Utrecht, Utrecht, Netherlands
| | - Aik W J Bossink
- Department of Respiratory Medicine and Tuberculosis, Diakonessenhuis, Utrecht, Netherlands
| | - Julia Drylewicz
- Center for Translational Immunology (CTI), University Medical Center Utrecht, Utrecht, Netherlands
| | - Simone A Joosten
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - Tom H M Ottenhoff
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands
| | - Onno W Akkerman
- Department of Respiratory Medicine and Tuberculosis, University Medical Center Groningen, Groningen, Netherlands
| | - Delia Goletti
- Translational Research Unit, Department of Epidemiology and Preclinical Research, National Institute for Infectious Diseases-IRCCS L. Spallanzani, Rome, Italy
| | - Elisa Petruccioli
- Translational Research Unit, Department of Epidemiology and Preclinical Research, National Institute for Infectious Diseases-IRCCS L. Spallanzani, Rome, Italy
| | - Assunta Navarra
- Translational Research Unit, Department of Epidemiology and Preclinical Research, National Institute for Infectious Diseases-IRCCS L. Spallanzani, Rome, Italy
| | | | - Sanne P A Paardekooper
- Center for Translational Immunology (CTI), University Medical Center Utrecht, Utrecht, Netherlands
| | - Ineke van Haeften
- Department of Tuberculosis, Municipal Public Health Service, Utrecht, Netherlands
| | - Leo Koenderman
- Center for Translational Immunology (CTI), University Medical Center Utrecht, Utrecht, Netherlands.,Department of Respiratory Medicine and Tuberculosis, University Medical Center Utrecht, Utrecht, Netherlands
| | - Jan-Willem J Lammers
- Department of Respiratory Medicine and Tuberculosis, University Medical Center Utrecht, Utrecht, Netherlands
| | - Steven F T Thijsen
- Department of Medical Microbiology and Immunology, Diakonessenhuis, Utrecht, Netherlands
| | - Regina W Hofland
- Department of Respiratory Medicine and Tuberculosis, University Medical Center Utrecht, Utrecht, Netherlands.,Department of Respiratory Medicine and Tuberculosis, Diakonessenhuis, Utrecht, Netherlands
| | - Stefan Nierkens
- Center for Translational Immunology (CTI), University Medical Center Utrecht, Utrecht, Netherlands.,Platform Immune Monitoring (PIM), University Medical Center Utrecht, Utrecht, Netherlands
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3
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Doi A, Hasuike T, Shindo T, Nishioka H. Elevation of CSF adenosine deaminase in HIV patient with meningitis from retroviral rebound syndrome, a case report. Int J Infect Dis 2020; 98:297-298. [PMID: 32562847 DOI: 10.1016/j.ijid.2020.06.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/10/2020] [Accepted: 06/13/2020] [Indexed: 11/18/2022] Open
Abstract
Adenosine deaminase (ADA) in cerebrospinal fluid (CSF) is considered to be a useful biomarker in differentiating tuberculous meningitis (TBM) from other meningitis in non-HIV patients. However, its specificity decreases in patients with HIV, and other diseases such as cytomegalovirus encephalitis, toxoplasmosis or meningeal lymphomatosis can also elevate ADA in CSF. We here report a rare case of retroviral rebound syndrome in a HIV patient, whose ADA in CSF was elevated.
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Affiliation(s)
- Asako Doi
- Department of Infectious Diseases, Kobe City Medical Center General Hospital, Japan; Department of General Internal Medicine, Kobe City Medical Center General Hospital, Japan.
| | - Toshikazu Hasuike
- Department of Infectious Diseases, Kobe City Medical Center General Hospital, Japan; Department of General Internal Medicine, Kobe City Medical Center General Hospital, Japan
| | - Tatsuya Shindo
- Department of General Internal Medicine, Kobe City Medical Center General Hospital, Japan
| | - Hiroaki Nishioka
- Department of Infectious Diseases, Kobe City Medical Center General Hospital, Japan; Department of General Internal Medicine, Kobe City Medical Center General Hospital, Japan
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4
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Abstract
Central nervous system (CNS) disease caused by Mycobacterium tuberculosis (MTB) is highly devastating. Tuberculous meningitis (TBM) is the most common form of CNS tuberculosis (TB). Rapid, sensitive, and affordable diagnostic tests are not available. Ziehl-Neelsen (ZN) stain has a very low sensitivity in cases of TBM, the sensitivity rates is of about 10-20%.The detection rate can be improved by taking large volume CSF samples (>6 ml) and prolonged slide examination (30 min). Culture of MTB from the CSF is slow and insufficiently sensitive. The sensitivity is different, which varies from 36% to 81.8%. The microscopic observation drug susceptibility (MODS) assay was recommended by the World Health Organization in 2011. The sensitivity is 65%, which is more sensitive and faster than CSF smear. Commercial PCR assays were found to be insensitive at detecting MTB in CSF samples. Many research provided the value of ADA on the TBM diagnosis. Interferon-gamma release assays (IGRAs) are not recommended for diagnosis of active TB disease. Imaging is essential in diagnosis and showing complications of CNS TB. Thwaites criteria and the Lancet consensus scoring system (LCSS) were developed to improve the diagnosis of TBM. Clinicians will continue to make judgment based on clinical examination, inflammatory CSF examinations, imaging studies, and scoring systems.
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Affiliation(s)
- Yi-Yi Wang
- Department of Neurology, Tianjin Haihe Hospital, Tianjin, P.R. China.
| | - Bing-di Xie
- Department of Neurology, Tianjin Medical University General Hospital, Tianjin, P.R. China
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5
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Pormohammad A, Riahi SM, Nasiri MJ, Fallah F, Aghazadeh M, Doustdar F, Pouriran R. Diagnostic test accuracy of adenosine deaminase for tuberculous meningitis: A systematic review and meta-analysis. J Infect 2017; 74:545-554. [PMID: 28366687 DOI: 10.1016/j.jinf.2017.02.012] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 02/01/2017] [Accepted: 02/20/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The measurement of adenosine deaminase (ADA) level in cerebrospinal fluid (CSF) has generated as a suitable test for tuberculous meningitis (TBM) diagnosis. The main objective in the present meta-analysis focused on analyzing the ADA test accuracy in order to diagnose TBM. METHODS We searched several databases including Medline, Embase and Cochrane databases to identify studies addressing the diagnosis of TBM. The quality of included reports were assessed by RevMan5 software (via QUADS2 checklist). Accuracy measures of ADA test (sensitivity, specificity and others) pooled with random effects models. In addition, the data was elicited by using midas and metan packages in stata (version 12). RESULT Twenty studies were eligible for inclusion within the meta-analysis. The pooled sensitivity and specificity for TBM diagnosis hallmarks were 89% (95% CI: 0.84-0.92) and 91% (95% CI: 0.87-0.93), respectively. The positive likelihood ratio was 9.4 (95% CI: 7-12.8), negative likelihood ratio was 0.12 (95% CI: 0.09-0.17), and diagnostic odds ratio was 77 (95% CI: 45-132). Indeed, the area under the summary receiver operating characteristic (SROC) was 0.96. CONCLUSION It was magnificently attained that ADA test had a relatively high accuracy for TBM diagnosis.
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Affiliation(s)
- Ali Pormohammad
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Seyed-Mohammad Riahi
- Department of Epidemiology, Birjand University of Medical Sciences, Birjand, Iran; Department of Epidemiology, Faculty of Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Mohammad Javad Nasiri
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Fatemeh Fallah
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Mohammad Aghazadeh
- Department of Medical Microbiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Farahnoosh Doustdar
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Ramin Pouriran
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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6
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Ekermans P, Dusé A, George J. The dubious value of cerebrospinal fluid adenosine deaminase measurement for the diagnosis of tuberculous meningitis. BMC Infect Dis 2017; 17:104. [PMID: 28143441 PMCID: PMC5282858 DOI: 10.1186/s12879-017-2221-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 01/25/2017] [Indexed: 11/22/2022] Open
Abstract
Background The diagnosis of tuberculous meningitis (TBM) can be extremely difficult in the absence of culture confirmation. Cerebrospinal fluid (CSF) adenosine deaminase (ADA) can potentially assist in this regard, although its current value remains unclear. The literature on the usefulness of CSF ADA in TBM diagnosis is inconsistent, especially from an analytical point of view. Methods A retrospective analysis of clinical and laboratory data relating to all CSF ADA requests during 2009 and 2010 in a South African quaternary healthcare setting was performed. A CSF ADA cut-off for TBM diagnosis was calculated using receiver operating characteristic curve analysis. The performance of CSF ADA in different infective and non-infective categories was assessed. Results In total, 3548 CSF ADA requests were considered over the 2-year period. Of these, 1490 were for patients for whom both a CSF ADA and a mycobacterial culture were requested. The optimal cut-off was calculated at 2.0 U/L (AUC = 0.86; 95% CI = 0.82 – 0.89; p-value < 0.01; sensitivity of 85.9% (95% CI of 77.0 – 92.3) and specificity of 77.7% (95% CI of 75.4 – 79.8%); positive likelihood ratio = 3.85 and negative likelihood ratio = 0.18). At this cut-off 13 TBM cases were missed. Conclusion An optimal cut-off for routine use could not be established as too many TBM cases were missed. Specimen integrity, lack of ADA assay standardisation and overlap in performance of the assay in different diagnostic categories affect interpretation.
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Affiliation(s)
- Pieter Ekermans
- Department of Chemical Pathology, University of Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa. .,Department of Chemical Pathology and Department of Clinical Microbiology and Infectious Diseases, School of Pathology, Faculty of Health Sciences, University of Witwatersrand and National Health Laboratory Service, 7 York Road, Johannesburg, South Africa.
| | - Adriano Dusé
- Department of Clinical Microbiology and Infectious Diseases, University of Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
| | - Jaya George
- Department of Chemical Pathology, University of Witwatersrand and National Health Laboratory Service, Johannesburg, South Africa
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7
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Tanaka Y, Satomi K. Cryptococcal meningitis associated with increased adenosine deaminase in the cerebrospinal fluid. SPRINGERPLUS 2016; 5:2093. [PMID: 28028491 PMCID: PMC5153386 DOI: 10.1186/s40064-016-3767-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Accepted: 11/30/2016] [Indexed: 11/30/2022]
Abstract
Introduction Clinically, increased cerebrospinal fluid (CSF) adenosine deaminase (ADA) level is an important diagnostic clue of tuberculous meningitis. However, increased CSF ADA level can be caused by other neurological diseases. Case description We report a case of a 67-year-old woman with cryptococcal meningitis presented with increased ADA level of the CSF. In parallel with her recovery, the ADA level of CSF decreased steadily. This is the first case described the chronological change in CSF ADA level of the patient with cryptococcal meningitis in detail. Discussion and Evaluation Clinically, increased CSF ADA level is an important diagnostic clue of tuberculous meningitis. However, previously, it was reported that increased CSF ADA level can be caused by other neurological diseases. In this case, the patient was diagnosed with cryptococcal meningitis, and the possibility of coinfection with tuberculous meningitis has been discarded by the negative PCR, negative cultures and the clinical course. In addition, the chronological change in CSF ADA level was useful for follow-up assessment. Conclusions Cryptococcal meningitis should be considered for the differential diagnosis for diseases presented increased CSF ADA.
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Affiliation(s)
- Yuji Tanaka
- Department of Neurology, Gifu Municipal Hospital, 7-1 Kashima-Cho, Gifu City, 500-8513 Japan
| | - Kazuo Satomi
- Department of Neurology, Gifu Municipal Hospital, 7-1 Kashima-Cho, Gifu City, 500-8513 Japan
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9
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Ferreiro L, San José E, Valdés L. Tuberculous pleural effusion. Arch Bronconeumol 2014; 50:435-43. [PMID: 24721286 DOI: 10.1016/j.arbres.2013.07.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Revised: 07/12/2013] [Accepted: 07/12/2013] [Indexed: 12/28/2022]
Abstract
Tuberculous pleural effusion (TBPE) is the most common form of extrapulmonary tuberculosis (TB) in Spain, and is one of the most frequent causes of pleural effusion. Although the incidence has steadily declined (4.8 cases/100,000population in 2009), the percentage of TBPE remains steady with respect to the total number of TB cases (14.3%-19.3%). Almost two thirds are men, more than 60% are aged between 15-44years, and it is more common in patients with human immunodeficiency virus. The pathogenesis is usually a delayed hypersensitivity reaction. Symptoms vary depending on the population (more acute in young people and more prolonged in the elderly). The effusion is almost invariably a unilateral exudate (according to Light's criteria), more often on the right side, and the tuberculin test is negative in one third of cases. There are limitations in making a definitive diagnosis, so various pleural fluid biomarkers have been used for this. The combination of adenosine deaminase and lymphocyte percentage may be useful in this respect. Treatment is the same as for any TB. The addition of corticosteroids is not advisable, and chest drainage could help to improve symptoms more rapidly in large effusions.
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Affiliation(s)
- Lucía Ferreiro
- Servicio de Neumología, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, La Coruña, España
| | - Esther San José
- Servicio de Análisis Clínicos, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, La Coruña, España; Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, La Coruña, España
| | - Luis Valdés
- Servicio de Neumología, Complejo Hospitalario Clínico-Universitario de Santiago, Santiago de Compostela, La Coruña, España; Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, La Coruña, España.
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10
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Cherian A, Thomas SV. Central nervous system tuberculosis. Afr Health Sci 2011; 11:116-127. [PMID: 21572867 PMCID: PMC3092316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023] Open
Abstract
Central nervous system (CNS) involvement, one of the most devastating clinical manifestations of tuberculosis (TB) is noted in 5 to 10% of extrapulmonary TB cases, and accounts for approximately 1% of all TB cases. Definitive diagnosis of tuberculous meningitis (TBM) depends upon the detection of the tubercle bacilli in the CSF. Every patient with TBM should preferably be evaluated by imaging with contrast enhanced CT either before or within the first 48 hours of treatment. An extra-neural focus of tuberculosis should be sought clinically and radiologically in all patients with CNS TB as it may indicate safer and more accessible sites for diagnostic samplings. A minimum of 10 months treatment is warranted, prompted by the uncertain influences of disease severity, CNS drug penetration, undetected drug resistance and patient compliance. All patients with TB meningitis may receive adjunctive corticosteroids at presentation regardless of disease severity even for those with HIV infection. Drug resistance is strongly associated with previous treatment. The key principle of managing drug-resistant TB is never to add a single drug to a failing regimen. Early ventriculo-peritoneal shunting should be considered in those with hydrocephalus failing medical management. The single most important determinant of outcome is the stage of tuberculous meningitis at which treatment has been started.
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Affiliation(s)
- A Cherian
- Department of Neurology, Government Medical College, Trivandrum, Kerala, India, PIN-695011.
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11
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Tuon FF, Higashino HR, Lopes MIBF, Litvoc MN, Atomiya AN, Antonangelo L, Leite OM. Adenosine deaminase and tuberculous meningitis--a systematic review with meta-analysis. ACTA ACUST UNITED AC 2010; 42:198-207. [PMID: 20001225 DOI: 10.3109/00365540903428158] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Tuberculous meningitis (TBM) is a severe infection of the central nervous system, particularly in developing countries. Prompt diagnosis and treatment are necessary to decrease the high rates of disability and death associated with TBM. The diagnosis is often time and labour intensive; thus, a simple, accurate and rapid diagnostic test is needed. The adenosine deaminase (ADA) activity test is a rapid test that has been used for the diagnosis of the pleural, peritoneal and pericardial forms of tuberculosis. However, the usefulness of ADA in TBM is uncertain. The aim of this study was to evaluate ADA as a diagnostic test for TBM in a systematic review. A systematic search was performed of the medical literature (MEDLINE, LILACS, Web of Science and EMBASE). The ADA values from TBM cases and controls (diagnosed with other types of meningitis) were necessary to calculate the sensitivity and specificity. Out of a total of 522 studies, 13 were included in the meta-analysis (380 patients with TBM). The sensitivity, specificity and diagnostic odds ratios (DOR) were calculated based on arbitrary ADA cut-off values from 1 to 10 U/l. ADA values from 1 to 4 U/l (sensitivity >93% and specificity <80%) helped to exclude TBM; values between 4 and 8 U/l were insufficient to confirm or exclude the diagnosis of TBM (p = 0.07), and values >8 U/l (sensitivity <59% and specificity >96%) improved the diagnosis of TBM (p < 0.001). None of the cut-off values could be used to discriminate between TBM and bacterial meningitis. In conclusion, ADA cannot distinguish between bacterial meningitis and TBM, but using ranges of ADA values could be important to improve TBM diagnosis, particularly after bacterial meningitis has been ruled out. The different methods used to measure ADA and the heterogeneity of data do not allow standardization of this test as a routine.
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Affiliation(s)
- Felipe Francisco Tuon
- Department of Infectious and Parasitic Diseases, Hospital das Clinicas, School of Medicine, University of Sao Paulo, SP, Brazil
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Thwaites G, Fisher M, Hemingway C, Scott G, Solomon T, Innes J. British Infection Society guidelines for the diagnosis and treatment of tuberculosis of the central nervous system in adults and children. J Infect 2009; 59:167-87. [PMID: 19643501 DOI: 10.1016/j.jinf.2009.06.011] [Citation(s) in RCA: 313] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2009] [Revised: 06/26/2009] [Accepted: 06/26/2009] [Indexed: 12/14/2022]
Abstract
SUMMARY AND KEY RECOMMENDATIONS: The aim of these guidelines is to describe a practical but evidence-based approach to the diagnosis and treatment of central nervous system tuberculosis in children and adults. We have presented guidance on tuberculous meningitis (TBM), intra-cerebral tuberculoma without meningitis, and tuberculosis affecting the spinal cord. Our key recommendations are as follows: 1. TBM is a medical emergency. Treatment delay is strongly associated with death and empirical anti-tuberculosis therapy should be started promptly in all patients in whom the diagnosis of TBM is suspected. Do not wait for microbiological or molecular diagnostic confirmation. 2. The diagnosis of TBM is best made with lumbar puncture and examination of the cerebrospinal fluid (CSF). Suspect TBM if there is a CSF leucocytosis (predominantly lymphocytes), the CSF protein is raised, and the CSF:plasma glucose is <50%. The diagnostic yield of CSF microscopy and culture for Mycobacterium tuberculosis increases with the volume of CSF submitted; repeat the lumbar puncture if the diagnosis remains uncertain. 3. Imaging is essential for the diagnosis of cerebral tuberculoma and tuberculosis involving the spinal cord, although the radiological appearances do not confirm the diagnosis. A tissue diagnosis (by histopathology and mycobacterial culture) should be attempted whenever possible, either by biopsy of the lesion itself, or through diagnostic sampling from extra-neural sites of disease e.g. lung, gastric fluid, lymph nodes, liver, bone marrow. 4. Treatment for all forms of CNS tuberculosis should consist of 4 drugs (isoniazid, rifampicin, pyrazinamide, ethambutol) for 2 months followed by 2 drugs (isoniazid, rifampicin) for at least 10 months. Adjunctive corticosteroids (either dexamethasone or prednisolone) should be given to all patients with TBM, regardless of disease severity. 5. Children with CNS tuberculosis should ideally be managed by a paediatrician with familiarity and expertise in paediatric tuberculosis or otherwise with input from a paediatric infectious diseases unit. The Children's HIV Association of UK and Ireland (CHIVA) provide further guidance on the management of HIV-infected children (www.chiva.org.uk). 6. All patients with suspected or proven tuberculosis should be offered testing for HIV infection. The principles of CNS tuberculosis diagnosis and treatment are the same for HIV infected and uninfected individuals, although HIV infection broadens the differential diagnosis and anti-retroviral treatment complicates management. Tuberculosis in HIV infected patients should be managed either within specialist units by physicians with expertise in both HIV and tuberculosis, or in a combined approach between HIV and tuberculosis experts. The co-administration of anti-retroviral and anti-tuberculosis drugs should follow guidance issued by the British HIV association (www.bhiva.org).
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Affiliation(s)
- Guy Thwaites
- Centre for Molecular Microbiology and Infection, Imperial College, Exhibition Road, South Kensington, London, UK.
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13
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Central nervous system tuberculosis: pathogenesis and clinical aspects. Clin Microbiol Rev 2008; 21:243-61, table of contents. [PMID: 18400795 DOI: 10.1128/cmr.00042-07] [Citation(s) in RCA: 356] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Tuberculosis of the central nervous system (CNS) is a highly devastating form of tuberculosis, which, even in the setting of appropriate antitubercular therapy, leads to unacceptable levels of morbidity and mortality. Despite the development of promising molecular diagnostic techniques, diagnosis of CNS tuberculosis relies largely on microbiological methods that are insensitive, and as such, CNS tuberculosis remains a formidable diagnostic challenge. Insights into the basic neuropathogenesis of Mycobacterium tuberculosis and the development of an appropriate animal model are desperately needed. The optimal regimen and length of treatment are largely unknown, and with the rising incidence of multidrug-resistant strains of M. tuberculosis, the development of well-tolerated and effective antibiotics remains a continued need. While the most widely used vaccine in the world largely targets this manifestation of tuberculosis, the BCG vaccine has not fulfilled the promise of eliminating CNS tuberculosis. We put forth this review to highlight the current understanding of the neuropathogenesis of M. tuberculosis, to discuss certain epidemiological, clinical, diagnostic, and therapeutic aspects of CNS tuberculosis, and also to underscore the many unmet needs in this important field.
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Nishida Y, Komachi H, Mizusawa H. A case of Listeria meningitis associated with increased adenosine deaminase in cerebrospinal fluid. Diagn Microbiol Infect Dis 2006; 57:435-7. [PMID: 17141462 DOI: 10.1016/j.diagmicrobio.2006.09.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2006] [Revised: 09/11/2006] [Accepted: 09/17/2006] [Indexed: 11/19/2022]
Abstract
We present, to the best of our knowledge, the first case of listeria meningitis with increased adenosine deaminase (ADA) in cerebrospinal fluid. Although some cases of other etiologies were also reported, this report informs those who manage patients with meningitis that not only Mycobacterium and Brucella spp. but also other facultative agents can increase ADA levels in cerebrospinal fluid, possibly through monocyte-macrophage activation.
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Affiliation(s)
- Yoichiro Nishida
- Department of Neurology and Neurological Science, Graduate School, Tokyo Medical and Dental University, Tokyo 113-8519, Japan.
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Andreasyan NA, Hairapetyan HL, Sargisova YG, Mardanyan SS. ADA2 isoform of adenosine deaminase from pleural fluid. FEBS Lett 2005; 579:643-7. [PMID: 15670822 DOI: 10.1016/j.febslet.2004.11.109] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2004] [Revised: 11/03/2004] [Accepted: 11/08/2004] [Indexed: 11/21/2022]
Abstract
Adenosine deaminase isoenzyme 2 (ADA2) was isolated from human pleural fluid for the first time. Molecular and kinetic properties were characterized. It was shown that the inhibitors of adenosine deaminase isoenzyme 1 (ADA1), adenosine, and erithro-9-(2-hydroxy-3-nonyl)adenine (EHNA) derivatives are poor inhibitors of ADA2. Comparison of the interaction of ADA2 and ADA1 with adenosine and its derivative, 1-deazaadenosine, indicates that the isoenzymes have similar active centers. The absence of ADA2 inhibition by EHNA is evidence of a difference of these active centers in a close environment. The possible role of Zn2+ ions and the participation of acidic amino acids Glu and Asp in adenosine deamination catalyzed by ADA2 were shown.
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Affiliation(s)
- Nune A Andreasyan
- H. Buniatian Institute of Biochemistry, Armenia NAS, 5/1 Sevak Str, Yerevan 375014, Republic of Armenia
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Gaga M, Papamichalis G, Bakakos P, Latsi P, Samara I, Koulouris NG, Alchanatis N, Orphanidou D. Tuberculous Effusion: ADA Activity Correlates with CD4+ Cell Numbers in the Fluid and the Pleura. Respiration 2005; 72:160-5. [PMID: 15824526 DOI: 10.1159/000084047] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2003] [Accepted: 07/23/2004] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Adenosine deaminase (ADA) is a commonly used marker in the diagnosis of tuberculous effusion and there is evidence that its production is linked to T cells and monocytes. Data on the correlation between ADA and T cells or macrophages in tuberculous effusions are conflicting. Furthermore, no studies have examined a possible correlation between pleural tissue infiltration and ADA. OBJECTIVES We undertook this study to examine cell subsets in the fluid and the pleura in tuberculous effusion and their correlation to ADA. The use of cell subsets as a marker in the differential diagnosis was also examined. METHODS Pleural fluid from 36 patients with tuberculous and 34 patients with malignant effusion as well as pleural tissue biopsies from 16 patients with tuberculous pleurisy were examined. The APAAP and the avidin-biotin complex immunocytochemical methods were used to examine CD4+ T cells and macrophages (CD68+), while ADA activity was measured by the Giusti colorimetric method. RESULTS Our results showed that, in pleural fluid, CD4+ cells and ADA were significantly higher in tuberculous compared to malignant effusion (p<0.001 for all measurements). In pleural tissue biopsies, macrophages were the predominant cells but CD4+ T cells were also abundant. A significant correlation was found between ADA and CD4+ numbers in pleural fluid and tissue (r=0.45, p<0.01; r=0.75, p<0.001, respectively). ADA had high sensitivity and specificity for differential diagnosis while cell subsets did not. CONCLUSIONS These results indicate that ADA activity correlates to CD4+ T cell infiltration in the pleura and the fluid. Moreover, ADA but no cell subsets may be used as markers of tuberculous effusion.
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MESH Headings
- Adenosine Deaminase/metabolism
- Adult
- Aged
- Aged, 80 and over
- Antigens, CD/immunology
- Antigens, Differentiation, Myelomonocytic/immunology
- Biomarkers/metabolism
- Biopsy
- CD4 Lymphocyte Count
- CD4-Positive T-Lymphocytes/immunology
- CD4-Positive T-Lymphocytes/pathology
- Diagnosis, Differential
- Extracellular Fluid/cytology
- Extracellular Fluid/enzymology
- Female
- Humans
- Immunohistochemistry
- Macrophages/immunology
- Male
- Middle Aged
- Pleura/pathology
- Pleural Effusion/enzymology
- Pleural Effusion/etiology
- Pleural Effusion/pathology
- Pleural Effusion, Malignant/enzymology
- Pleural Effusion, Malignant/pathology
- Sensitivity and Specificity
- Severity of Illness Index
- Tuberculosis, Pulmonary/complications
- Tuberculosis, Pulmonary/enzymology
- Tuberculosis, Pulmonary/pathology
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Affiliation(s)
- M Gaga
- Respiratory Medicine Department, Medical School, Athens University, Athens, Greece.
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