Use of pleural fluid levels of adenosine deaminase and interferon gamma in the diagnosis of tuberculous pleuritis:

Tuberculous and Malignant Pleural Effusions With Adenosine Deaminase Levels of 40-70 IU/L: Trends in New Cases Over Time and Differentiation Between Groups

BACKGROUND

The diagnosis of tuberculous pleural effusion (TPE) often relies on pleural fluid adenosine deaminase (ADA) levels. The diagnostic utility of ADA, however, is influenced by the prevalence of tuberculosis (TB) in local populations. Malignant pleural effusion (MPE) cases can exhibit moderately elevated ADA levels comparable to those seen in TPE. As population aging potentially impacts ADA levels, global TB incidence is decreasing whereas the burden of malignancy is on the rise. Consequently, epidemiological shifts and temporal changes in ADA distribution complicate the differential diagnosis between TPE and MPE when ADA levels are within the 40-70 IU/L range. Nonetheless, data specific to this subset are scarce.

METHODS

This retrospective study included consecutive patients aged > 18 years with confirmed TPE and MPE, spanning from 2012 to 2023. ADA levels in pleural fluid were categorized into three groups: < 40 IU/L, 40-70 IU/L, and > 70 IU/L. The study examined annual trends in the frequency of new cases and ADA level distributions over time and identified discriminating factors between TPE and MPE in cases with ADA levels of 40-70 IU/L.

RESULTS

In total, 297 TPE and 369 MPE cases were included in this study. Over the study period, the frequency of TPE progressively declined, while that of MPE increased. In the most recent four-year period, new TPE and MPE cases with ADA levels of 40-70 IU/L occurred at comparable numbers. Multivariable analysis identified pleural fluid carcinoembryonic antigen (CEA) levels and the number of focal pleural nodules as independent predictors for MPE. Specifically, the presence of either CEA levels > 15.7 ng/mL or more than eight pleural nodules yielded the highest diagnostic accuracy with a sensitivity of 88%, specificity of 100%, and an area under the curve of 0.95.

CONCLUSION

The differential diagnosis between TPE and MPE with pleural ADA levels of 40-70 IU/L has become increasingly critical due to evolving epidemiological patterns and ADA distribution changes over time. Pleural fluid CEA levels and the characteristics of pleural nodules may offer valuable guidance in distinguishing between TPE and MPE within this diagnostic gray zone.

Clinical profiles of Mycoplasma pneumoniae pneumonia in children with different pleural effusion patterns: a retrospective study

BACKGROUND

The clinical significance of the presence or absence of Mycoplasma pneumoniae (MP) in pleural effusion in Mycoplasma pneumoniae pneumonia (MPP) children has not yet been elucidated. Herein, we investigated the clinical implication of pleural fluid MP positive in children with MPP.

METHODS

A total of 165 MPP children with pleural effusion requiring thoracocentesis were enrolled in this study. They were subsequently divided into two groups according to the presence or absence of MP in pleural effusion, namely positive group (n = 38) and negative group (n = 127). Information on their clinical manifestations, laboratory findings, radiological characteristics and treatment modalities was retrospectively collected from medical chart reviews.

RESULTS

The length of hospitalization (15.00 (10.75-19.25) vs. 11.00 (9.00-14.00) days, p=0.001) and total course of illness (23.00 (18.00-28.00) vs. 20.00 (17.00-24.00) days, p=0.010) were significantly longer in the positive group than in the negative group. The occurrence of pericardial effusion (23.7% vs. 7.9%, p=0.017), atelectasis (73.7% vs. 53.5%, p=0.027) and necrotizing pneumonia (23.7% vs. 7.9%, p=0.017) were more frequent in the positive group compared to the negative group. The levels of neutrophil percentages (82.35% (75.40%-85.78%) vs. 72.70% (64.30%-79.90%), p<0.001), C-reactive protein (CRP) (71.12 (37.75-139.41) vs. 31.15 (13.54-65.00) mg/L, p<0.001), procalcitonin (PCT) (0.65 (0.30-3.05) vs. 0.33 (0.17-1.13) ng/ml, p=0.005), serum lactate dehydrogenase (LDH) (799.00 (589.00-1081.50) vs. 673.00 (503.00-869.00) U/L, p=0.009), D-dimer (6.21 (3.37-16.11) vs. 3.32 (2.12-6.62) mg/L, p=0.001) on admission were significantly higher in the positive group than in the negative group. These pronounced differences significantly contributed to the identification of MPP with MP positive pleural effusion, as evidenced by the ROC curve analysis. Marked elevations in adenosine deaminase (49.25 (36.20-60.18) vs. 36.20 (28.10-46.50) U/L, p<0.001) and LDH levels (2298.50 (1259.75-3287.00) vs. 1199.00 (707.00-1761.00) U/L, p<0.001) were observed in pleural fluid of the positive group when compared to the negative group. Meanwhile, the number of patients on low molecular weight heparin (LMWH) therapy (9 (23.7%) vs. 12 (9.4%), p=0.028) was higher in the positive group. Multivariate logistic regression analysis revealed that D-dimer > 7.33 mg/L was significantly associated with the incidence of MP positive pleural effusion in MPP (OR=3.517).

CONCLUSIONS

The presence of MP in pleural fluid in MPP children with pleural effusion indicated a more serious clinical course. D-dimer > 7.33 mg/L was a related factor for MP positive pleural effusion in MPP. The results of the present study would help in the creation of a therapeutic plan and prediction of the clinical course of MPP in children.

Correlation of serum adenosine deaminase activity with disease activity in patients with primary Sjögren's syndrome

BACKGROUND

Primary Sjögren's syndrome (pSS) is a chronic inflammatory autoimmune disease primarily affecting the exocrine glands, which has a variety of clinical manifestations and unclear pathogenic mechanisms. Adenosine deaminase (ADA) is an enzyme involved in the breakdown of purines, and changes in its activity have been associated with a number of autoimmune diseases. This study aims to investigate the relationship between serum ADA activity and disease activity in patients with pSS.

METHODS

In this study, 196 patients with pSS and 196 healthy controls were enrolled. Serum ADA activity and clinical laboratory parameters were collected and analyzed in both groups. Pearson correlation analysis was used to examine the correlation between ADA activity and clinical laboratory parameters, as well as the correlation between ADA activity and the disease activity score.

RESULTS

Compared with healthy controls, the activity of ADA in the serum of pSS patients was significantly increased (P < 0.0001), and the ADA activity was significantly decreased after immunosuppressive treatment (P < 0.0001). Correlation analysis revealed that the activity of ADA was significantly positively correlated with erythrocyte sedimentation rate (ESR) (r = 0.3, P < 0.0001) and serum immunoglobulin G (IgG) levels (r = 0.5, P < 0.0001), and significantly negatively correlated with high-density lipoprotein (HDL) (r = -0.4, P < 0.0001). Furthermore, there was a significant positive correlation between ADA activity and the disease activity score as measured by the Sjögren's Syndrome Disease Activity Index (SSDAI) (r = 0.4, P < 0.0001).

CONCLUSION

This study found that patients with pSS have higher activity of ADA in serum, which is associated with disease activity as measured by SSDAI. These results suggest that ADA activity may be a potential biomarker for evaluating disease activity and treatment efficacy in pSS patients.Additionally, ADA may be a potential target for the treatment of pSS patients.

Drug transdermal delivery by electrophonophoresis can increase the concentration of rifampicin in the pleural effusion of patients with tuberculous pleurisy but has no effect on the concentration of rifampicin in plasma

BACKGROUND

Electrophonophoresis (EP) has been widely used in various clinical fields. The purpose of this study was to evaluate the dermal permeability of rifampicin (RIF) in patients with tuberculous pleurisy assisted by EP and to verify the clinical application of this percutaneous drug delivery system in the treatment of tuberculous pleurisy, verify the system's influencing factors, and determine whether plasma drug concentration was increased.

METHOD

Patients were given oral isoniazid 0.3-0.4 g, rifampicin 0.45-0.60 g, pyrazinamide 1.0-1.5 g and ethambutol 0.75 g according to their body weight once a day. After 5 days of anti-tuberculosis treatment, 3 ml of rifampicin was delivered transdermally with EP. Pleural effusion and peripheral blood samples in patients were collected at and after dosing. The drug concentration in the samples was determined by high-performance liquid chromatography.

RESULT

The median plasma concentration (interquartile ranges) of RIF in 32 patients was 8.80 (6.65, 13.14) μg/ml before RIF transdermal injection plus EP and decreased to 8.09 (5.58, 11.82) μg/ml after 30 min of RIF transdermal injection plus EP. The RIF concentration in pleural effusion was higher than that before RIF-transdermal plus EP. In patients who received RIF via EP transdermal administration, the concentration of the drug at the local site was statistically higher than the concentration at the local site prior to penetration. However, no such enhancement was observed in plasma after transdermal administration of RIF.

CONCLUSION

EP can effectively increase the concentration of rifampicin in the pleural effusion of tuberculous pleurisy and has no effect on the circulating plasma concentration. The increased concentration of the drug in the lesion helps to destroy the bacteria.

Adenosine deaminase-based measurement in the differential diagnosis of pleural effusion: a multicenter retrospective study

INTRODUCTION

The differential diagnosis of pleural effusion is difficult, and studies have reported on the potential role of adenosine deaminase (ADA) in the differential diagnosis of undiagnosed pleural effusion. This retrospective study aimed to investigate the diagnostic role of ADA in pleural effusion.

METHODS

266 patients with pleural effusion from three centers were enrolled. The concentrations of ADA and lactate dehydrogenase (LDH) were measured in pleural fluids and serum samples of the patients. The diagnostic performance of ADA-based measurement for tuberculous pleural effusion (TPE), malignant pleural effusion (MPE), and parapneumonic effusion (PPE) was examined by receiver operating characteristic (ROC) curve analysis.

RESULTS

An area under the ROC curve (AUC) value of 0.909 was obtained using the pleural ADA values as the indicator for TPE identification (sensitivity: 87.50%, specificity: 87.82%). The ratio of serum LDH to pleural ADA (cancer ratio) provided the predictive capacity with an AUC of 0.879 for MPE diagnosis (sensitivity: 95.04%, specificity: 67.06%). At a cut-off value of 14.29, the pleural ADA/LDH ratio showed a sensitivity and specificity of 81.13% and 83.67%, respectively, and a high AUC value of 0.888 for the differential diagnosis of PPE from TPE.

CONCLUSION

ADA-based measurement is helpful for the differential diagnosis of pleural effusion. Further studies should be performed to validate these results.

Investigating the appropriate adenosine deaminase cutoff value for the diagnosis of tuberculous pleural effusion in a country with decreasing TB burden

As the burden of tuberculosis (TB) in South Korea decreases while that of malignancy increases with an aging society, the composition of etiology for pleural effusion is changing. The aim of this study was to investigate the diagnostic value of adenosine deaminase (ADA) for diagnosis of tuberculous pleural effusion (TPE) in this circumstance. Medical records of patients who underwent medical thoracoscopy from May 2015 to September 2020 in Incheon St. Mary Hospital, Korea were retrospectively reviewed. TPE was diagnosed if one of the following criteria was met: (1) granuloma in pleura, (2) positive TB polymerase chain reaction or culture in pleural fluid or tissue with non-specific pathologic findings in pleura, or (3) bacteriologically confirmed pulmonary TB with non-specific pathologic findings in pleura. A total of 292 patients, including 156 with malignant pleural effusion (MPE), 52 with TPE, and 84 with other benign effusion, were analyzed. Among 206 patients with lymphocyte dominant pleural effusion, the area under receiver characteristic curve of ADA for diagnosis of TPE was 0.971. The sensitivity and specificity of a current cutoff value of 40 IU/L were 1.00 and 0.61, respectively, whereas those of a raised cutoff value of 70 IU/L were 0.93 and 0.93, respectively. Among 54 patients with ADA levels of 40–70 IU/L, 30 (55.6%) patients were diagnosed as MPE, 21 (38.9%) as other benign effusion, and only 3 (5.6%) as TPE. Caution is needed in clinical diagnosis of TPE with current ADA cutoff value in countries with decreasing TB incidence, due to many false positive cases.

Laboratory and radiological discrimination between tuberculous and malignant pleural effusions with high adenosine deaminase levels

BACKGROUND/AIMS

Pleural fluid adenosine deaminase (ADA) levels are useful in discriminating tuberculous pleural effusions (TPEs) from malignant pleural effusions (MPEs). However, some patients with MPE exhibit high-ADA levels, which may mimic TPEs. There is limited data regarding the differential diagnosis between high-ADA MPE and high-ADA TPE. This study aimed to identify the predictors for distinguishing high-ADA MPEs from high-ADA TPEs.

METHODS

Patients with TPE and MPE with pleural fluid ADA levels ≥ 40 IU/L were included in this study. Clinical, laboratory, and radiological data were compared between the two groups. Independent predictors and their diagnostic performance for high-ADA MPEs were evaluated using multivariate logistic regression analysis and receiver operating characteristic curve.

RESULTS

A total of 200 patients (high-ADA MPE, n = 30, and high-ADA TPE, n = 170) were retrospectively included. In the multivariate analysis, pleural fluid ADA, pleural fluid carcinoembryonic antigen (CEA), and pleural nodularity were independent discriminators between high-ADA MPE and high-ADA TPE groups. Using pleural ADA level of 40 to 56 IU/L (3 points), pleural CEA level ≥ 6 ng/mL (6 points), and presence of pleural nodularity (3 points) for predicting high-ADA MPEs, a sum score ≥ 6 points yielded a sensitivity of 90%, specificity of 96%, positive predictive value of 82%, negative predictive value of 98%, and area under the receiver operating characteristic curve of 0.965.

CONCLUSION

A scoring system using three parameters may be helpful in guiding the differential diagnosis between high-ADA MPEs and high-ADA TPEs.

Diagnostic accuracy of adenosine deaminase for pleural tuberculosis in a low prevalence setting: A machine learning approach within a 7-year prospective multi-center study

OBJECTIVE

To analyze the performance of adenosine deaminase in pleural fluid combined with other parameters routinely measured in clinical practice and assisted by machine learning algorithms for the diagnosis of pleural tuberculosis in a low prevalence setting, and secondly, to identify effusions that are non-tuberculous and most likely malignant.

PATIENTS AND METHODS

We prospectively analyzed 230 consecutive patients diagnosed with lymphocytic exudative pleural effusion from March 2013 to June 2020. Diagnosis according to the composite reference standard was achieved in all cases. Pre-test probability of pleural tuberculosis was 3.8% throughout the study period. Parameters included were: levels of adenosine deaminase, pH, glucose, proteins, and lactate dehydrogenase, red and white cell counts and lymphocyte percentage in pleural fluid, as well as age. We tested six different machine learning-based classifiers to categorize the patients. Two different classifications were performed: a) tuberculous/non-tuberculous and b) tuberculous/malignant/other.

RESULTS

Out of a total of 230 patients with pleural effusion included in the study, 124 were diagnosed with malignant effusion and 44 with pleural tuberculosis, while 62 were given other diagnoses. In the tuberculous/non-tuberculous classification, and taking into account the validation predictions, the support vector machine yielded the best result: an AUC of 0.98, accuracy of 97%, sensitivity of 91%, and specificity of 98%, whilst in the tuberculous/malignant/other classification, this type of classifier yielded an overall accuracy of 80%. With this three-class classifier, the same sensitivity and specificity was achieved in the tuberculous/other classification, but it also allowed the correct classification of 90% of malignant cases.

CONCLUSION

The level of adenosine deaminase in pleural fluid together with cell count, other routine biochemical parameters and age, combined with a machine-learning approach, is suitable for the diagnosis of pleural tuberculosis in a low prevalence scenario. Secondly, non-tuberculous effusions that are suspected to be malignant may also be identified with adequate accuracy.

Clinical and Epidemiological Features of Tuberculous Pleural Effusion in Alicante, Spain

We aimed to (1) evaluate the incidence of tuberculous pleural effusion (TPE) over 25 years in our centre; (2) measure the yield of different diagnostic techniques; (3) compare TPE features between immigrant and native patients. Retrospective study of patients who underwent diagnostic thoracentesis and pleural biopsy in our hospital between 1995 and 2020. TPE was diagnosed in 71 patients (65% natives, 35% immigrants). Onset was acute in 35%, subacute in 26% and prolonged in 39%. Radiological features were atypical in 42%. Thoracentesis specimens were lymphocyte-predominant in 84.5% of patients, with elevated adenosine deaminase in 75% of patients. Diagnostic yield of pleural biopsy was 78%. Compared with native patients, more immigrants had previous contact with TB (54% vs. 17%, p = 0.001), prior TB (21% vs. 4%, p < 0.02) and atypical radiological features (58% vs. 34%, p < 0.03). TPE incidence was six times higher in the immigrant population (6.7 vs. 1.1 per 100,000 person-years, p < 0.001). TPE has an acute onset and sometimes atypical radiological features. Pleural biopsy has the highest diagnostic yield. Reactivation, prior contact with TB, atypical radiological features, complications, and positive microbiology results are more common in immigrant patients.

Elevated Adenosine Deaminase in Pleural Effusion A Case of Non-Hodgkin Lymphoma Misdiagnosis

Despite a recent decline, tuberculosis (TB) infection is still a frequent diagnosis in Portugal. Adenosine deaminase (ADA) measurement has become an important tool in the timely diagnosis of this infection. However, ADA elevation in bodily fluids is not pathognomonic of TB infection.

We present the case of a 70-year-old woman, undergoing treatment for pleural TB, diagnosed based on elevated ADA levels in a pleural effusion. Due to worsening symptoms she was readmitted, and the previous diagnosis was reconsidered. Thoracocentesis was repeated and cytometry analysis of the fluid was performed, showing the presence of diffuse large B cell lymphoma (DLBCL).

DLBCL is the most frequently occurring non-Hodgkin lymphoma (NHL). Pleural involvement is rare in the initial stages. ADA elevation >250 U/l should raise suspicion of malignancy, especially in association with markedly elevated LDH levels. The purpose of this case report is to highlight that in the absence of microbiologic or histologic confirmation, a presumptive TB diagnosis should not be lightly made, and alternative diagnoses should be systematically ruled out.

Influence of age on the diagnostic accuracy of soluble biomarkers for tuberculous pleural effusion: a post hoc analysis

BACKGROUND

Accurately diagnosing pleural effusion is a frequent and significant problem in clinical practice. Combining pleural biomarkers with patients' age may be a valuable method for diagnosing TPE. We sought to evaluate the influence of age on diagnostic values of pleural adenosine deaminase (ADA), interferon-gamma (IFN-γ), and interleukin 27 (IL-27) for tuberculous pleural effusion (TPE).

METHODS

Two hundred seventy-four consecutive adult patients with pleural effusion were selected from Beijing and Wuhan between January 1, 2014 and June 30, 2015, and their pleural fluid concentrations of ADA, IFN-γ, and IL-27 were tested. Biomarker performance was analyzed by standard receiver operating characteristic (ROC) curves according to different ages.

RESULTS

Data from the Beijing cohort showed that ADA, IFN-γ, and IL-27 could all accurately diagnose TPE in young patients (≤ 40 years of age). With a cutoff of 21.4 U/L, the area under the curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ADA for diagnosing TPE were 1.000 (95% confidence interval: 0.884-1.000), 100.0, 100.0%, 100.0, and 100.0, respectively. In older patients (> 40 years of age), IL-27 and IFN-γ were excellent biomarkers for discriminating TPE versus non-TPE cases. With a cutoff of 591.4 ng/L, the AUC, sensitivity, specificity, PPV, and NPV of IL-27 for diagnosing TPE were 0.976 (95% confidence interval: 0.932-0.995), 96.3, 99.0%, 96.3, and 99.0, respectively. Similar diagnostic accuracy among the three pleural biomarkers was validated in the Wuhan cohort.

CONCLUSIONS

Among young patients, ADA is reliable for diagnosing TPE. Conversely, in older patients, IL-27 and IFN-γ are excellent biomarkers to differentiate TPE versus non-TPE cases.

Systemic Administration of Calea pinnatifida Inhibits Inflammation Induced by Carrageenan in a Murine Model of Pulmonary Neutrophilia

Objective

The aim of this study was to investigate the anti-inflammatory effects of the crude extract (CE), derived fraction, and isolated compounds from Calea pinnatifida leaves in a mouse model of pulmonary neutrophilia.

Methods

The CE and derived fractions, hexane, ethyl acetate, and methanol, were obtained from C. pinnatifida leaves. The compounds 3,5- and 4,5-di-O-E-caffeoylquinic acids were isolated from the EtOAc fraction using chromatography and were identified using infrared spectroscopic data and nuclear magnetic resonance (¹H and ¹³C NMR). Leukocytes count, protein concentration of the exudate, myeloperoxidase (MPO) and adenosine deaminase (ADA), and nitrate/nitrite (NO _x ), tumor necrosis factor-alpha (TNF-α), interleukin-1-beta (IL-1β), and interleukin-17A (IL-17A) levels were determined in the pleural fluid leakage after 4 h of pleurisy induction. We also analyzed the effects of isolated compounds on the phosphorylation of both p65 and p38 in the lung tissue.

Results

The CE, its fractions, and isolated compounds inhibited leukocyte activation, protein concentration of the exudate, and MPO, ADA, NO _x , TNF-α, IL-1β, and IL-17A levels. 3,5- and 4,5-di-O-E-caffeoylquinic acids also inhibited phosphorylation of both p65 and p38 (P < 0.05).

Conclusion

This study demonstrated that C. pinnatifida presents important anti-inflammatory properties by inhibiting activated leukocytes and protein concentration of the exudate. These effects were related to the inhibition of proinflammatory mediators. The dicaffeoylquinic acids may be partially responsible for these anti-inflammatory properties through the inhibition of nuclear transcription factor kappa B and mitogen-activated protein kinase pathways.

Laboratory testing of extravascular body fluids: National recommendations on behalf of the Croatian Society of Medical Biochemistry and Laboratory Medicine. Part I - Serous fluids

Extravascular body fluids (EBF) analysis can provide useful information in the differential diagnosis of conditions that caused their accumulation. Their unique nature and particular requirements accompanying EBF analysis need to be recognized in order to minimize possible negative implications on patient safety. This recommendation was prepared by the members of the Working group for extravascular body fluid samples (WG EBFS). It is designed to address the total testing process and clinical significance of tests used in EBF analysis. The recommendation begins with a chapter addressing validation of methods used in EBF analysis, and continues with specific recommendations for serous fluids analysis. It is organized in sections referring to the preanalytical, analytical and postanalytical phase with specific recommendations presented in boxes. Its main goal is to assist in the attainment of national harmonization of serous fluid analysis and ultimately improve patient safety and healthcare outcomes. This recommendation is intended to all laboratory professionals performing EBF analysis and healthcare professionals involved in EBF collection and processing. Cytological and microbiological evaluations of EBF are beyond the scope of this document.

Cell-free Mycobacterium tuberculosis DNA test in pleural effusion for tuberculous pleurisy: a diagnostic accuracy study

OBJECTIVES

Tuberculous pleurisy (TP) diagnosis remains difficult, with the sensitivity of Xpert MTB/RIF (Xpert) and mycobacterial culture (culture) only about 30-50%. We aimed to assess the diagnostic performance of a cell-free Mycobacterium tuberculosis DNA test (cf-TB) in pleural effusion for TP.

METHODS

Adults (≥18 years) with suspected TP presenting with pleural effusion were consecutively recruited, and pleural effusion specimens were prospectively collected in Beijing Chest Hospital, Beijing, China. After centrifuging pleural effusion, sediments were used for culture, Xpert and T-SPOT.TB assay, whereas supernatants were used for cf-TB and adenosine deaminase assay. The diagnostic performance was assessed against a composite reference standard.

RESULTS

From June 2015 to December 2018, we prospectively evaluated 286 adults with suspected TP. One hundred twenty-two participants were classified as definite TP based on the prespecified composite reference standard. The cf-TB produced a sensitivity of 79.5% (97/122, 95% confidence interval (CI) 72.4- 86.7) for definite TP, which was superior to Xpert (38.5% (29.9-47.2); 47/122; p < 0.001) and culture (27.1% (19.2-34.9); 33/122; p < 0.001). With pleural effusion Xpert and/or culture as the reference standard, cf-TB showed 96.6% (57/59, 95% CI 92.0-100.0) sensitivity, which was also significantly higher than Xpert (79.7%, 95% CI 69.4-89.9; 47/59; p 0.004) and culture (55.9%, 95% CI: 43.3-68.6; 33/59; p < 0.001).

CONCLUSIONS

The cf-TB clearly showed improved sensitivity compared with Xpert and culture. We recommend cf-TB as the first-line test for TP diagnosis.

Central Venous Catheter Based Closed Thoracic Drainage in the Treatment of Tuberculous Pleuritis

Objective:

To explore the clinical effect of central venous catheter closed thoracic drainage in the treatment of tuberculous pleurisy.

Methods:

One hundred and four patients with tuberculous pleurisy who were admitted to Binzhou People’s Hospital from August 2016 to August 2017 were divided into a control group and a treatment group according to random number table method, 52 each. The control group was treated with conventional pleural puncture and drainage, while the treatment group was treated with closed central venous catheter based thoracic drainage. The clinical efficacy, improvement time of clinical symptoms, total volume of drainage, pleural thickness, and improvement of quality of life and occurrence of adverse reactions were compared between the two groups.

Results:

Pleural effusion, fever and chest tightness of the treatment group disappeared earlier (P<0.05); the hospitalization time in the treatment group was less than that in the control group (P<0.05); the total amount of drainage in the treatment group was lower than that in the control group (P<0.05); the pleural thickness of the treatment group was higher than that in the control group (P<0.05); the quality of life score in the treatment group was significantly higher than that in the control group (P<0.05). The total effective rates of the treatment group and the control group were 93.5% and 85%, respectively, with a significant difference (P<0.05). The incidence of adverse reactions in the treatment group was significantly lower than that in the control group, with a significant difference (P<0.05).

Conclusion:

Central venous catheter based closed thoracic drainage is more effective than conventional thoracic puncture and drainage in the treatment of tuberculous pleurisy. It can accelerate the improvement of clinical symptoms, improve the quality of life of patients, and reduce the incidence of complications. It is worth popularizing and applying.

Improved early diagnosis of difficult cases of tuberculous pleural effusion by combination of thoracoscopy with immunological tests

INTRODUCTION

Although pleural effusion is a common clinical manifestation, the differential diagnosis of the cause of pleural effusion is often challenging, especially in the early differentiation of tuberculous pleurisy (TP) from other pleural effusion. The aim of this study was to evaluate the performance of commonly used laboratory tests for the early diagnosis of difficult cases of pleural effusion.

METHODS

Patients with undiagnosed pleural effusion were enrolled and subjected to five laboratory tests including thoracoscopy, pleural fluid adenosine deaminase assay (ADA), serum tuberculosis antibody test (TB-antibody), tuberculin skin test (TST), and T-SPOT.TB assay. The diagnosis of TP was established based on pleural histology and mycobacterial culture. The different tests were compared for diagnostic performance.

RESULTS

A total of 106 patients were enrolled; their mean age was 53 years and 70.8% were male. Seventy-two (68%) of them were confirmed to have TP. When used individually, the five laboratory tests showed highly variable performance parameters, including sensitivity ranging from 46% to 92% and specificity ranging from 33% to 82%. When used in different combinations, thoracoscopy combined with TST or TB-antibody showed the optimal performance parameters, with a sensitivity of 80.8% and a specificity of 85.7%.

CONCLUSIONS

The results of this study suggest that the combination of thoracoscopy with TST or TB-antibody test is the best choice for the early diagnosis of difficult cases of TP in high TB burden countries.

Pleural IFN-γ release assay combined with biomarkers distinguished effectively tuberculosis from malignant pleural effusion

BACKGROUND

Tuberculosis (TB) remains a major public health concern on a global scale, especially in developing nations. So far, no formal guidelines are available for the diagnosis and treatment of tuberculosis pleurisy. The diagnosis of TB is worsened by the immense difficulty in differential determination of tuberculosis pleural effusion (TPE) and malignant pleural effusion (MPE). The purpose of this investigation is to assess the differential diagnostic efficiencies of the pleural IFN-γ release assay (IGRA) and widely-used biochemical parameters in the distinction analysis of TPE and MPE.

METHODS

A cohort of 222 patients with pleural effusion was examined, comprising of 143 TPE and 58 MPE patients. The patients were examined with IGRA, and the widely-used biomarkers in the pleural effusion and peripheral blood.

RESULTS

Our results show that the TPE patients have significantly higher M. tuberculosis (Mtb) antigen-specific IFN-γ responses to ESAT-6 protein and peptide pool in the blood compared to MPE patients. TPE patients were also shown to have enriched Mtb antigen-specific IFN-γ responses in pleural effusion than in peripheral blood. Among the widely-used biomarkers, the adenosine deaminase (ADA) and carcinoembryonic antigen (CEA) in pleural effusion were better biomarkers with high sensitivity and specificity to discriminate TPE and MPE. In addition, pleural IGRA could not be affected by the pleural adhesion, and the applications of the pleural IGRA together with ADA and CEA provide a promising approach for the TPE and MPE differential identification.

CONCLUSIONS

Our study proposes that the integration of pleural IGRA and ADA, CEA detection could add to more effective diagnosis stratagems in the discernment between TPE and MPE.

Impact of age on the diagnostic yield of four different biomarkers of tuberculous pleural effusion

The diagnostic value of pleural fluid biomarkers in tuberculous pleurisy (TP) is firmly established. However, it is less clear whether patients' age affects the diagnostic accuracy of TP biomarkers. The aim of the study was to assess the impact of age, on the predictive value of ADA, IFN-γ, IP-10 and Fas ligand in patients with pleural effusion. The study included 222 patients, median age 64.5 (54-77) years, 58.6% men, with pleural effusion: TPE (60 patients; 27.0%), malignant PE (90 patients; 40.5%), parapneumonic effusion/pleural empyema (35 patients; 15.8%), pleural transudate (30 patients, 13.5%) and other causes of PE (7 patients; 3.2%). The odds ratio for the diagnosis of TPE significantly decreased with increasing age (OR = 0.62/10 years) and significantly increased with increasing level of all evaluated pleural fluid biomarkers. Age affected the diagnostic accuracy of ADA with a trend towards reduction in OR for TPE in older patients (P = 0.077, 95% CI 0.59-1.03). Younger age and high pleural fluid ADA level are associated with very high probability of TP. This probability significantly decreases not only with decreasing pleural fluid ADA, but also with increasing age. Patient's age does not affect the diagnostic yield of pleural fluid IFN-γ, IP-10 and sFas.

Diagnostic accuracy of interleukin-22 and adenosine deaminase for tuberculous pleural effusions

OBJECTIVE

Reliable markers for accurately diagnosing tuberculous pleural effusions (TPE) are needed. This study sought to investigate the diagnostic potential of pleural interleukin-22 (IL-22) and compare it with the performance of adenosine deaminase (ADA).

METHOD

This prospective study involved 49 patients with TPE and 60 patients with pleural effusion of other causes. Pleural levels of IL-22 and ADA were determined, respectively, using ELISA or an enzymatic method. A receiver operating characteristic curve was constructed and the area under the curve (AUC) was calculated to summarize the diagnostic accuracy of single markers or marker combinations.

RESULTS

Levels of IL-22 in pleural effusion were significantly higher in TPE patients than in other patients (322.36 ± 406.65 vs. 83.13 ± 22.15 pg/ml, P < 0.05). With a cut-off value of 97.82 pg/ml, the diagnostic sensitivity of IL-22 for TPE was 71.42%, specificity was 81.67%, and the area under the curve (AUC) was 0.83. ADA levels were also increased in TPE, and its AUC for diagnosing TPE was 0.90. The combination of IL-22 and ADA enhanced diagnostic accuracy, offering sensitivity of 83.67%, specificity of 91.67%, and an AUC of 0.93.

CONCLUSION

IL-22 may be useful for diagnosing TPE, and combining it with ADA may further enhance diagnostic accuracy. Our results justify more rigorous studies with larger samples to confirm the diagnostic potential of IL-22 for TPE.

Misdiagnosis of primary pleural DLBCL as tuberculosis: A case report and literature review

Diffuse large B-cell lymphoma (DLBCL) is the most common type of non-Hodgkin lymphoma (NHL). DLBCL presents with pleural involvement at an advanced stage; however, primary pleural lymphomas without any other site of involvement are rare, and the possibility of misdiagnosis is high, particularly in developing countries, where tuberculosis or other severe pulmonary infections remain a major health concern. Furthermore, lymphoma and tuberculosis share a number of common clinical characteristics, such as fever, night sweats, feeling of satiety after a small meal, fatigue and unexplained weight loss, among others. We herein describe a case of misdiagnosis of primary pleural lymphoma as tuberculosis in a 49-year-old male patient who presented with pleural effusion and high adenosine deaminase (ADA) level in the pleural fluid. Anti-tuberculosis treatment was administered for 1 month, but the patient's condition deteriorated. A surgical biopsy was performed and was diagnostic of DLBCL. CHOP chemotherapy was administered with a significant delay due to the misdiagnosis, and it was not efficient, as rituximab was not added to the regimen. The therapeutic efficacy was monitored by computed tomography scans, which revealed that the lesion had shrunk slightly. The overall survival of the patient was ~1 year and he eventually succumbed to severe thoracic infection and pleural effusion. Suspicion should be raised when a patient presents with pleural effusion and extremely high ADA levels, as ADA activity of >250 U/L should raise the suspicion of empyema or lymphoma rather than tuberculosis.

The pleural fluid lactate dehydrogenase/adenosine deaminase ratio differentiates between tuberculous and parapneumonic pleural effusions

Background

Although pleural fluid lactate dehydrogenase (LDH) and adenosine deaminase (ADA) levels are often used to distinguish between tuberculous pleural effusion (TPE) and parapneumonic pleural effusion (PPE), this can be challenging as the LDH level may vary from normal to severely increased in PPE and a significantly elevated ADA is frequently measured in both conditions. In this study, we evaluated use of the pleural fluid LDH/ADA ratio as a new parameter to discriminate TPE from PPE.

Methods

A retrospective study was conducted in patients with pathologically-confirmed TPE (n = 72) and PPE (n = 47) to compare pleural fluid LDH and ADA levels and LDH/ADA ratios between the 2 groups. A receiver operating characteristic (ROC) curve was constructed for identifying TPE.

Results

The median pleural fluid LDH and ADA levels and LDH/ADA ratios in the TPE and PPE groups were: 364.5 U/L vs 4037 U/L (P < .001), 33.5 U/L vs 43.3 U/L (P = .249), and 10.88 vs 66.91 (P < .0001), respectively. An area under the ROC curve of 0.9663 was obtained using the LDH/ADA ratio as the indicator for TPE identification, and the sensitivity, specificity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR) were, respectively, 93.62%, 93.06%, 13.48, and 0.068 at a cut-off level of 16.20.

Conclusions

The pleural fluid LDH/ADA ratio, which can be determined from routine biochemical analysis, is highly predictive of TPE at a cut-off level of 16.20. Measurement of this parameter may be helpful for clinicians in distinguishing between TPE and PPE.

Electronic supplementary material

The online version of this article (10.1186/s12890-017-0526-z) contains supplementary material, which is available to authorized users.

Diagnosis of tuberculous pleurisy with combination of adenosine deaminase and interferon-γ immunospot assay in a tuberculosis-endemic population: A prospective cohort study

The aim of this study was to identify the optimal cut-off value of T cell enzyme-linked immunospot assay for tuberculosis (T-SPOT.TB) and evaluate its diagnostic performance alone (in the peripheral blood) or in combination with the adenosine deaminase (ADA) activity test (in peripheral blood and the pleural fluid) in patients with tuberculous pleurisy.Adult patients presenting with pleural effusion were included in this prospective cohort study. Tuberculous pleurisy was diagnosed by T-SPOT.TB in peripheral blood and a combination of T-SPOT.TB and ADA activity test in pleural fluid and peripheral blood. Receiver operating characteristic (ROC) curve in combination with multivariate logistic regression was used to evaluate the diagnostic performance of the assays.Among a total of 189 patients with suspected tuberculous pleurisy who were prospectively enrolled in this study, 177 patients were validated for inclusion in the final analysis. ROC analysis revealed that the area under the ROC curve (AUC) for T-SPOT.TB in pleural fluid and peripheral blood was 0.918 and 0.881, respectively, and for the ADA activity test in pleural fluid was 0.944. In addition, 95.5 spot-forming cells (SFCs)/2.5 × 10 cells were determined as the optimal cut-off value for T-SPOT.TB in pleural fluid. Parallel combination of T-SPOT.TB and ADA activity test in pleural fluid showed increased sensitivity (96.9%) and specificity (87.5%), whereas serial combination showed increased specificity (97.5%). The combination of 3 assays had the highest sensitivity at 97.9%, with an AUC value of 0.964.T-SPOT.TB in pleural fluid performed better than that in peripheral blood and the ADA activity test in pleural fluid for tuberculous pleurisy diagnosis. The optimal cut-off value of T-SPOT.TB in pleural fluid was 95.5 SFCs/2.5 × 10 cells. Combination of 3 assays might be a promising approach for tuberculous pleurisy diagnosis.

Pleural fluid tests to diagnose tuberculous pleuritis

PURPOSE OF REVIEW

This article summarizes current data regarding the accuracy of pleural fluid tests assisting the diagnosis of tuberculous pleuritis (TBP).

RECENT FINDINGS

No pleural fluid test reliably rules-in TBP in settings with low TBP prevalence. Interferon-γ) alone or in combination with adenosine deaminase (ADA) is more reliable than ADA for this purpose in nonlow prevalences. ADA can reliably rule-out TBP in prevalences of less than 40% although in higher prevalences the product of interleukin-27 and ADA is the most accurate rule-out test.

SUMMARY

The definite diagnosis of TBP requires the isolation of Mycobacterium tuberculosis from pleural fluid or biopsies. Because of the low sensitivity of pleural fluid cultures and the invasiveness of pleural biopsy techniques, the concept of a pleural fluid test that accurately establishes or excludes TBP diagnosis has been proposed. Numerous pleural fluid tests have been evaluated for this purpose with ADA being the most widely accepted one. During the last years, it has been demonstrated that the ability of ADA to rule-in or rule-out TBP is affected by the prevalence of TBP in the setting where the test is used. The complementary use of interferon-γ or interleukin-27 increases the ability of ADA to rule-in or rule-out the disease, respectively.

An unexpected finding in a man with multiple pulmonary nodules, a pleural effusion and respiratory failure

We report the case of a 47-year old Caucasian man with a history of depression and high alcohol intake who presented with a one-month history of weight loss, dry cough and abdominal pain. He had no smoking history of note. The patient was treated for a suspected chest infection, however developed respiratory failure and was intubated. A CT showed multiple pulmonary nodules, left pleural thickening extending to the mediastinum and bilateral pleural effusions-larger on the left, suggestive of disseminated malignancy. A broncho-alveolar lavage surprisingly contained numerous acid-fast bacilli and no malignant cells. Treatment for tuberculosis was initiated and the patient recovered gradually. After several weeks, a pyrazinamide-resistant organism was cultured and subsequently identified to be Mycobacterium Bovis. We discuss this unexpected finding and review the literature on Bovine Tuberculosis in humans.

Pleural fluid adenosine deaminase/serum C-reactive protein ratio for the differentiation of tuberculous and parapneumonic effusions with neutrophilic predominance and high adenosine deaminase levels

PURPOSE

Tuberculous pleural effusion (TPE) and parapneumonic effusion (PPE) are usually distinguished by cellular predominance and pleural fluid adenosine deaminase (ADA) levels. However, both diseases may occasionally show similar neutrophilic predominance and high ADA levels. In such cases, the differential diagnosis between TPE and PPE is challenging and has been rarely investigated.

METHODS

A retrospective study was conducted on TPE and PPE patients with neutrophilic exudate and pleural fluid ADA levels ≥40 U/L. Individual and combined parameters of routine blood and pleural fluid tests were compared between the two groups, and receiver operating characteristic (ROC) curves were constructed for identifying TPE.

RESULTS

Thirty-six TPE and 41 PPE patients were included. White blood cell counts, serum C-reactive protein (S-CRP), and pleural fluid pH, lactate dehydrogenase, and ADA levels showed significant difference between the two groups (p < 0.001). Among multiple parameters, pleural fluid ADA/S-CRP ratio, which best reflected different local and systemic characteristics between TPE and PPE, provided the highest diagnostic accuracy with an area under the ROC curve of 0.93. At a cutoff value of 5.62, ADA/S-CRP ratio had a sensitivity of 89 %, specificity of 88 %, positive likelihood ratio of 7.29, and negative likelihood ratio of 0.13 for identifying TPE. Additionally, more than half of TPE patients had a ratio above 15.82, while none of PPE patients showed such findings.

CONCLUSIONS

Pleural fluid ADA/S-CRP ratio, as a simple method using routine laboratory tests, may be helpful in discriminating between TPE and PPE patients with neutrophilic predominance and ADA ≥40 U/L.

Nucleotide Metabolism and DNA Replication

The development and application of a highly versatile suite of tools for mycobacterial genetics, coupled with widespread use of "omics" approaches to elucidate the structure, function, and regulation of mycobacterial proteins, has led to spectacular advances in our understanding of the metabolism and physiology of mycobacteria. In this article, we provide an update on nucleotide metabolism and DNA replication in mycobacteria, highlighting key findings from the past 10 to 15 years. In the first section, we focus on nucleotide metabolism, ranging from the biosynthesis, salvage, and interconversion of purine and pyrimidine ribonucleotides to the formation of deoxyribonucleotides. The second part of the article is devoted to DNA replication, with a focus on replication initiation and elongation, as well as DNA unwinding. We provide an overview of replication fidelity and mutation rates in mycobacteria and summarize evidence suggesting that DNA replication occurs during states of low metabolic activity, and conclude by suggesting directions for future research to address key outstanding questions. Although this article focuses primarily on observations from Mycobacterium tuberculosis, it is interspersed, where appropriate, with insights from, and comparisons with, other mycobacterial species as well as better characterized bacterial models such as Escherichia coli. Finally, a common theme underlying almost all studies of mycobacterial metabolism is the potential to identify and validate functions or pathways that can be exploited for tuberculosis drug discovery. In this context, we have specifically highlighted those processes in mycobacterial DNA replication that might satisfy this critical requirement.

Atypical Pleural Fluid Profiles in Tuberculous Pleural Effusion: Sequential Changes Compared with Parapneumonic and Malignant Pleural Effusions

Objective Although tuberculous pleural effusion (TPE) is commonly characterized by lymphocytic predominance and high adenosine deaminase (ADA) levels, it may present with neutrophilic predominance or low ADA levels, which are more commonly found in parapneumonic effusion (PPE) or malignant pleural effusion (MPE), respectively. A few studies have observed that the atypical pleural fluid profiles of these cases of TPE may resolve at follow-up thoracentesis. However, these observations were incompletely analyzed and lacked comparison with proper control groups. Thus, limited data are available comparing the sequential pleural fluid changes between TPE and PPE or MPE with similar pleural fluid profiles. Methods TPE, PPE, and MPE patients who underwent sequential thoracentesis were retrospectively reviewed. The sequential changes in the pleural fluid profiles were compared between neutrophilic TPE and PPE, and lymphocytic TPE and MPE with low ADA levels. Results Twenty-three TPE patients (16 with neutrophilic exudates, seven with lymphocytic exudates), 72 cases of PPE with neutrophilic exudates, and 18 cases of MPE with lymphocytic exudates were included in the analysis. A sequential shift to lymphocytic exudates occurred significantly more often in TPE than in PPE cases. The initial and follow-up ADA levels in TPE cases with a lymphocytic shift were significantly higher than those in PPE cases with a lymphocytic shift. The ADA levels in the TPE cases with initial lymphocytic exudates and low ADA levels significantly increased at follow-up thoracentesis. For the TPE and MPE cases with initial lymphocytic exudates and ADA levels <40 U/L, the frequency of effusion with ADA levels ≥40 U/L at the second thoracentesis was significantly higher in the TPE cases. Conclusion Follow-up thoracentesis may provide useful information for clinical decision-making in suspected atypical TPE cases with neutrophilic exudates or low ADA levels.

Adenosine deaminase is a useful biomarker to diagnose pleural tuberculosis in low to medium prevalence settings

Adenosine deaminase (ADA) activity measurement in pleural fluid is a relevant test to diagnose pleural tuberculosis (pTB) in high tuberculosis prevalence settings. We investigated the diagnostic utility of pleural ADA using a retrospective analysis of patients admitted with newly diagnosed pleural effusion without identified etiology between 2001 and 2008 in Paris suburb, a low to medium tuberculosis prevalence area. 104 adults (mean age 55 years; 34 with pTB, 70 with other diagnoses) were analyzed. Median follow-up was 15.6 months. Mean [interquartile range] pleural ADA was 119 U/L [IQR: 83-143] in pTB and 24 U/L [IQR: 15-31] in non-tuberculous effusions (P<0.001). With an optimal pleural ADA cut-off value of 41.5 U/L for pTB diagnosis, sensitivity and specificity were 97.1% and 92.9%, while positive and negative predictive values were 86.8% and 98.5%, respectively. We conclude that pleural ADA activity could be integrated in the diagnostic procedures of pTB in low to medium tuberculosis prevalence settings.

Tuberculous pleural effusions: advances and controversies

On a global scale, tuberculosis (TB) remains one of the most frequent causes of pleural effusions. Our understanding of the pathogenesis of the disease has evolved and what was once thought to be an effusion as a result of a pure delayed hypersensitivity reaction is now believed to be the consequence of direct infection of the pleural space with a cascade of events including an immunological response. Pulmonary involvement is more common than previously believed and induced sputum, which is grossly underutilised, can be diagnostic in approximately 50%. The gold standard for the diagnosis of tuberculous pleuritis remains the detection of Mycobacterium tuberculosis in pleural fluid, or pleural biopsy specimens, either by microscopy and/or culture, or the histological demonstration of caseating granulomas in the pleura along with acid fast bacilli (AFB). In high burden settings, however, the diagnosis is frequently inferred in patients who present with a lymphocytic predominant exudate and a high adenosine deaminase (ADA) level, which is a valuable adjunct in the diagnostic evaluation. ADA is generally readily accessible, and together with lymphocyte predominance justifies treatment initiation in patients with a high pre-test probability. Still, false-negative and false-positive results remain an issue. When adding closed pleural biopsy to ADA and lymphocyte count, diagnostic accuracy approaches that of thoracoscopy. The role of other biomarkers is less well described. Early pleural drainage may have a role in selected cases, but more research is required to validate its use and to define the subpopulation that may benefit from such interventions.

Role of medical thoracoscopy and closed-blind pleural biopsy in undiagnosed exudative pleural effusions: a single-center experience of 348 patients

BACKGROUND

Medical thoracoscopy (MT) performed either with rigid or the semirigid thoracoscope has been shown to have diagnostic accuracy superior to closed-blind pleural biopsy (CBPB) in exudative pleural effusions (EPE), which remain undiagnosed after thoracentesis. However, in resource-constrained settings, CBPB continues to be performed. In this study, we compare the outcome of thoracoscopy with CBPB.

METHODS

This was a retrospective analysis of data collected over a 10-year period (2004 to 2014) of patients who underwent pleural biopsy for the evaluation of undiagnosed EPE. We report the comparative procedural yield and safety of CBPB and MT.

RESULTS

During the study period, 84 and 264 patients (mean age, 49.8 y) underwent CBPB and MT, respectively. No clinical or radiologic finding could predict the correct histologic diagnosis with reasonable certainty in patients with undiagnosed EPE. The procedural yield of MT was significantly higher than CBPB (93.2% vs. 84.5%, P=0.02). The yield of MT significantly improved when chest ultrasound was used to guide the choice and point of entry of the thoracoscope (98.7% vs. 90.6%, P=0.04). Thoracoscopy was associated with mortality and complication rates of 0.37% and 5.6%, respectively, whereas the complication rate with CBPB was 8.3% with no mortality.

CONCLUSIONS

MT is the procedure of choice in the evaluation of undiagnosed EPE, due to its higher success rate and an acceptable safety profile. However, in centers where thoracoscopy is not feasible, CBPB should be performed in preference to initiating empiric treatment.

[Surgery for thoracic tuberculosis]

Tuberculosis is mainly a medical disease. Surgery has been the unique therapeutic tool for a long time before the advent of specific antituberculous drugs, and the role of surgery was then confined to the treatment of the sequelae of tuberculosis and their complications. The resurgence of tuberculosis and the emergence of multidrug-resistant TB combined to immunosuppressed patients represent a new challenge for tuberculosis surgery. Surgery may be indicated for a diagnostic purpose in patients with pulmonary, pleural, mediastinal or thoracic wall involvement, or with a therapeutic purpose (drainage, resection, residual cavity obliteration). Modern imaging techniques and the advent of video-assisted thoracic surgery allowed a new approach of this pathology; the majority of diagnostic interventions and selected cases requiring lung resection can be performed through a mini-invasive approach. Patients proposed for aggressive surgery may be treated with the best results thanks to a good evaluation of the thoracic lesions, of the patients' nutritional, infectious and general status combined with a good coordination between the specialized medical team for an optimal preparation to surgery.

Factors influencing pleural adenosine deaminase level in patients with tuberculous pleurisy

BACKGROUND

Adenosine deaminase (ADA) activity is useful for diagnosing tuberculous (TB) pleurisy in regions with a high prevalence of tuberculosis. However, some cases of TB pleural effusion show decreased ADA activity. Therefore, we evaluated factors influencing pleural ADA levels in patients with TB pleurisy.

METHODS

We retrospectively evaluated 182 patients with TB pleural effusion who were admitted to Gyeongsang National University Hospital from January 2004 to September 2008. Patients were dichotomized into 2 groups: a low-ADA (<40 IU/L) group (n = 22) and a high-ADA (≥40 IU/L) group (n = 160). Age, sex, ADA level of pleural effusion, smoking status, history of tuberculosis and comorbid diseases were evaluated in each group.

RESULTS

The median age of the patients was 50.5 years, with a male to female ratio of 1.72:1. Patients with a low-ADA level were significantly older than those with a high ADA level (66.9 ± 12.0 versus 49.4 ± 21.2 years, P < 0.001). A history of tuberculosis and hypertension was more common in the low-ADA group than in the high-ADA group (31.8% versus 15.0%, P = 0.049 and 36.4% versus 16.9%, P = 0.03, respectively). A multivariate analysis revealed that older age and current smoking were predictive of TB pleurisy with a low ADA level (odds ratios, 1.053 and 4.848; P = 0.002 and 0.028, respectively).

CONCLUSIONS

Physicians should be careful when interpreting pleural ADA levels in elderly patients and/or current smokers for the diagnosis of TB pleurisy.

Development and Evaluation of the New Predictive Models in Tuberculous Pleuritis

Different pleural fluid biomarkers have been found useful in the discrimination between tuberculous pleural effusion (TPE) and non-TPE, with interferon gamma (IFN-γ) showing the highest single marker diagnostic accuracy. The aim of the present study was to develop predictive models based on clinical data and pleural fluid biomarkers, other than IFN-γ, which could be applied in differentiating TPE and non-TPE. Two hundred and forty two patients with newly diagnosed pleural effusion were prospectively enrolled. Upon completion of the diagnostic procedures, the underlying disease was identified in 203 patients (117 men and 86 women, median age 65 years; 44 patients with TPE and 159 with non-TPE) who formed the proper study group. Pleural fluid level of ADA, IFN-γ, IL-2, IL-2sRα, IL-12p40, IL-18, IL-23, IP-10, Fas-ligand, MDC, and TNF-α was measured and then ROC analysis and multivariate logistic regression were used to construct the predictive models. Two predictive models with very high diagnostic accuracy (AUC > 0.95) were developed. The first model included body temperature, white blood cell count, pleural fluid ADA and IP-10. The second model was based on age, sex, body temperature, white blood cell count, pleural fluid lymphocyte percentage, and IP-10 level. We conclude that two new predictive models based on clinical and laboratory data demonstrate very high diagnostic performance and can be potentially used in clinical practice to differentiate between TPE and non-TPE.

Radiologic and laboratory differences in patients with tuberculous and parapneumonic pleural effusions showing non-lymphocytic predominance and high adenosine deaminase levels

PURPOSE

Tuberculous pleural effusion (TPE) is characterized by lymphocytic predominance and high adenosine deaminase (ADA) levels. However, TPEs sometimes present non-lymphocytic predominance, and parapneumonic effusion (PPE) often exceeds the cutoff value of ADA for TPE. Thus, the differential diagnosis of cases with pleural fluid (PF) showing non-lymphocytic predominance and high ADA levels is challenging. However, limited data concerning the clinical differences in these patients are available.

METHODS

A retrospective study was conducted on TPE and PPE patients with PF showing non-lymphocytic predominance and ADA levels ≥40 U/L in 2009-2013 in a South Korean tertiary referral hospital. The clinical, laboratory, and computed tomography (CT) findings between the groups were analyzed using multivariate logistic regression to develop a prediction model with independent factors for TPE.

RESULTS

Among 353 patients with TPE, 24 (6.8 %) showed PF with non-lymphocytic predominance and ADA levels of ≥40 U/L. Twenty-eight PPE patients who presented PF findings comparable with those of TPE patients were included in the control group. In the final analysis, PF ADA levels >58 U/L and nodular lung lesions on CT were independent positive predictors, while loculated effusion was an independent negative predictor for TPE. Using the prediction model, a score ≥ +3 provided a sensitivity of 88 %, specificity of 93 %, positive predictive value of 91 %, and negative predictive value of 90 % for TPE.

CONCLUSION

PF ADA levels, nodular lung lesions, and loculated pleural effusion may help differentiate TPE from PPE in patients with PF showing non-lymphocytic predominance and ADA levels ≥40 U/L.

Diagnostic utility of adenosine deaminase in exudative pleural effusions

Objective:

To determine the diagnostic utility of adenosine deaminase (ADA) in exudative pleural effusions of different etiologies.

Setting and Design:

It was an observational study conducted at a tertiary care teaching institute.

Materials and Methods:

Of a total of 171 pleural fluid samples, 122 were found to be exudates and were included in the study. Pleural fluid ADA was done for all included patients. Pleural fluid ADA ≥40 U/l was taken as diagnostic cut off for TB effusion.

Statistical Analysis:

Sensitivity, specificity positive and negative predictive value of pleural fluid ADA for diagnosing TB was calculated by using clinical calculator – 1, Richard Lowry 2001-2013.

Results:

There were 171 patients with pleural effusion, out of which 122 (71.8%) were found to be exudative and were studied further. There were 49 (40.1%), 36 (29.5%) and 33 (27%) cases of TB, malignancy and para pneumonic effusion respectively, whereas 4 (3.3%) cases remained undiagnosed. Median ADA values for TB, malignancy and para pneumonic effusion were 55.8 U/l (range 9.7-756 U/l), 18 U/l (6.5-81 U/l) and 25 U/l (3.4-172 U/l) respectively. Pleural fluid ADA >40U/l yielded 85.7% sensitivity, 80.8% specificity, 75% positive predictive value and 89.5% negative predictive value.

Conclusion:

Pleural fluid ADA remains useful in diagnosing tuberculosis pleural effusion. The median ADA for TB effusion in present cohort was 51.8 IU/ml. Pleural fluid ADA of 40 U/L yielded 89.5% negative predictive value and 75% positive predictive value. Pleural fluid ADA is cost effective and good screening test for diagnosis of TB.

A case of pleural paragonimiasis confused with tuberculous pleurisy

Here, we report a case of pleural paragonimiasis that was confused with tuberculous pleurisy. A 38-year-old man complained of a mild febrile sensation and pleuritic chest pain. Radiologic findings showed right pleural effusion with pleural thickening and subpleural consolidation. Adenosine deaminase (ADA) activity in the pleural effusion was elevated (85.3 IU/L), whereas other examinations for tuberculosis were negative. At this time, the patient started empirical anti-tuberculous treatment. Despite 2 months of treatment, the pleural effusion persisted, and video-assisted thoracoscopic surgery was performed. Finally, the patient was diagnosed with pleural paragonimiasis based on the pathologic findings of chronic granulomatous inflammation containing Paragonimus eggs. This case suggested that pleural paragonimiasis should be considered when pleural effusion and elevated ADA levels are observed.

Tuberculous pleurisy: an update

Tuberculous pleurisy is the most common form of extrapulmonary tuberculosis in Korea. Tuberculous pleurisy presents a diagnostic and therapeutic problem due to the limitations of traditional diagnostic tools. There have been many clinical research works during the past decade. Recent studies have provided new insight into the tuberculous pleurisy, which have a large impact on clinical practice. This review is a general overview of tuberculous pleurisy with a focus on recent findings on the diagnosis and management.

Tuberculous pleural effusion

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.

Pleural, peritoneal and pericardial effusions - a biochemical approach

The pathological accumulation of serous fluids in the pleural, peritoneal and pericardial space occurs in a variety of conditions. Since patient management depends on right and timely diagnosis, biochemical analysis of extravascular body fluids is considered a valuable tool in the patient management process. The biochemical evaluation of serous fluids includes the determination of gross appearance, differentiation of transudative from exudative effusions and additional specific biochemical testing to assess the effusion etiology. This article summarized data from the most relevant literature concerning practice with special emphasis on usefulness of biochemical tests used for the investigation of pleural, peritoneal and pericardial effusions. Additionally, preanalytical issues concerning serous fluid analysis were addressed and recommendations concerning acceptable analytical practice in serous fluid analysis were presented.

Evaluation of pleural effusion sCD26 and DPP-IV as diagnostic biomarkers in lung disease

In this study, we measured ADA and DPP-IV enzymatic activity and sCD26 concentration in 150 pleural effusion (PE) samples and tested for correlations between these and other cellular and biochemical measures. We found that DPP-IV in particular might improve the specificity (but not the sensitivity) of the ADA test for diagnosis of pulmonary tuberculosis, since half of the false ADA positive results in non-tuberculous PE were also DPP-IV positive. A percentage of patients with malignant PE were sCD26 or DPP-IV positive; however, some patients with benign PE also tested positive. As a pattern associated with DPP-IV (but not the CD26 protein) was observed in PE, we searched for a finding that might increase the value of these biomarkers for diagnosis of malignancy. The observed pattern was related to the presence of leukocytes, as indicated by correlations with the cell count, and to a band of 180 kDa, detected by immunoblotting.

Gamma interferon immunospot assay of pleural effusion mononuclear cells for diagnosis of tuberculous pleurisy

Diagnosis of tuberculous pleurisy remains a challenge in the clinic. In this study, we evaluated the usefulness of a previously developed Mycobacterium tuberculosis antigen-specific gamma interferon enzyme-linked immunospot (ELISPOT) assay in the diagnosis of tuberculous pleurisy by testing a cohort of 352 patients with pleural effusion. We found that M. tuberculosis antigen-specific gamma interferon-producing cells were enriched four to five times in pleural fluid compared with their levels in peripheral blood from patients with tuberuclous pleurisy assayed in parallel. The sensitivity, specificity, positive predictive value, and negative predictive value of the pleural fluid mononuclear cell ELISPOT assay for the diagnosis of tuberculous pleurisy were 95.7%, 100%, 100%, and 81.0%, respectively. In comparison, the sensitivity and specificity of the ELISPOT assay using peripheral blood mononuclear cells were 78.3% and 86.3%, respectively. The sensitivity and specificity of the pleural fluid adenosine deaminase activity test were 55.5% and 86.3%, respectively. These results demonstrate that the M. tuberculosis antigen-specific ELISPOT assay performed on pleural fluid mononuclear cells provides an accurate, rapid diagnosis of tuberculous pleurisy.

Reexpansion pulmonary edema in children

OBJECTIVE To present a case of a patient with clinical and radiological features of reexpansion pulmonary edema, a rare and potentially fatal disease. CASE DESCRIPTION An 11-year-old boy presenting fever, clinical signs and radiological features of large pleural effusion initially treated as a parapneumonic process. Due to clinical deterioration he underwent tube thoracostomy, with evacuation of 3,000 mL of fluid; he shortly presented acute respiratory insufficiency and needed mechanical ventilation. He had an atypical evolution (extubated twice with no satisfactory response). Computerized tomography findings matched those of reexpansion edema. He recovered satisfactorily after intensive care, and pleural tuberculosis was diagnosed afterwards. COMMENTS Despite its rareness in the pediatric population (only five case reports gathered), the knowledge of this pathology and its prevention is very important, due to high mortality rates. It is recommended, among other measures, slow evacuation of the pleural effusion, not removing more than 1,500 mL of fluid at once.