Tuberculous pleurisy with false negative adenosine deaminase level- Case report.

Yıl 2023, Cilt: 1 Sayı: 2, 1 - 8, 29.09.2023

Ünal Şahin Songül Özyurt Dilek Karaoğlan Enes Ahmetoğlu Oğuzhan Okcu

Öz

Background and a_m: Tuberculous pleural effusion is a common disease entity with a spectrum of presentations from a largely benign effusion, The World Health Organization (WHO) recognized 6.3 million new tuberculosis (TB) cases in 2017, 16% corresponding to extrapulmonary forms; pleural tuberculosis is the most common extrapulmonary form in adults. Diagnostic thoracentesis with thorough pleural fluid analysis including biomarkers such as adenosine deaminase (ADA) and gamma interferon achieves high accuracy in the correct clinical context. Definitive diagnosis may require invasive procedures to demonstrate histological evidence of caseating granulomas or microbiological evidence of the organism on smear or culture. Case: We report the case of a 30- year old male patient admitted to the outpatient setting of the hospital with fever, nonproductive cough and pleuritic pain. He had these symptoms for four weeks. His chest x-ray revealed massive pleural effusion on the left hemithorax. The patient comes from an area with a high incidence of tuberculosis, so our diagnostic strategy was combined with a lymphocyte / neutrophil ratio of exudative pleural fluid greater than 0.75 plus closed needle biopsy tissue. Empirical anti-TB treatment was initiated due to the most likely diagnosis of TB. Conclus_on: In this patient who was negative for ADA, the diagnosis was obtained by pleural biopsy. TB should be considered in cases that may be false negative ADA, and pleural biopsy should be performed primarily for pathological diagnosis in all pleural effusions where clinical suspicion for TB persists. In cases where diagnostic delays may occur, empirical treatment should be started in the presence of strong diagnostic suspicion.

Anahtar Kelimeler

Tuberculous pleural effusion, adenosine deaminase, empirical anti-TB treatment, false negative ADA

Kaynakça

• 1. Shaw JA, Diacon AH, Koegelenberg CFN. Tuberculous pleural effusion. Respirology. 2019 Oct;24(10):962-971. doi: 10.1111/resp.13673. Epub 2019 Aug 16. PMID: 31418985.
• 2. Antonangelo L, Faria CS, Sales RK. Tuberculous pleural effusion: diagnosis & management. Expert Rev Respir Med. 2019 Aug;13(8):747-759. doi: 10.1080/17476348.2019.1637737. Epub 2019 Jul 3. PMID: 31246102.
• 3. Baumann MH, Nolan R, Petrini M, Lee YC, Light RW, Schneider E. Pleural tuberculosis in the United States: incidence and drug resistance. Chest. 2007 Apr;131(4):1125-32. doi: 10.1378/chest.06-2352. PMID: 17426219.
• 4. Porcel JM. Tuberculous pleural effusion. Lung. 2009 Sep-Oct;187(5):263-70. doi: 10.1007/s00408-009- 9165-3. Epub 2009 Aug 13. PMID: 19672657.
• 5. Diacon AH, Van de Wal BW, Wyser C, Smedema JP, Bezuidenhout J, Bolliger CT, Walzl G. Diagnostic tools in tuberculous pleurisy: a direct comparative study. Eur Respir J. 2003 Oct;22(4):589-91. doi: 10.1183/09031936.03.00017103a. PMID: 14582908.
• 6. Berger HW, Mejia E. Tuberculous pleurisy. Chest. 1973 Jan;63(1):88-92. doi: 10.1378/chest.63.1.88. PMID: 4630686.
• 7. Light RW. Update on tuberculous pleural effusion. Respirology. 2010 Apr;15(3):451-8. doi: 10.1111/j.1440-1843.2010.01723.x. Epub 2010 Mar 21. PMID: 20345583.
• 8. Wang Z, Xu LL, Wu YB, Wang XJ, Yang Y, Zhang J, Tong ZH, Shi HZ. Diagnostic value and safety of medical thoracoscopy in tuberculous pleural effusion. Respir Med. 2015 Sep;109(9):1188-92. doi: 10.1016/j.rmed.2015.06.008. Epub 2015 Jul 3. PMID: 26166016.
• 9. Valdés L, Alvarez D, San José E, Penela P, Valle JM, García-Pazos JM, Suárez J, Pose A. Tuberculous pleurisy: a study of 254 patients. Arch Intern Med. 1998 Oct 12;158(18):2017-21. doi: 10.1001/archinte.158.18.2017. PMID: 9778201.
• 10. Kim HJ, Lee HJ, Kwon SY, Yoon HI, Chung HS, Lee CT, Han SK, Shim YS, Yim JJ. The prevalence of pulmonary parenchymal tuberculosis in patients with tuberculous pleuritis. Chest. 2006 May;129(5):1253- 8. doi: 10.1378/chest.129.5.1253. PMID: 16685016.
• 11. Porcel JM. Advances in the diagnosis of tuberculous pleuritis. Ann Transl Med. 2016 Aug;4(15):282. doi: 10.21037/atm.2016.07.23. PMID: 27570776; PMCID: PMC4980363.
• 12. Kim HJ, Lee HJ, Kwon SY, Yoon HI, Chung HS, Lee CT, Han SK, Shim YS, Yim JJ. The prevalence of pulmonary parenchymal tuberculosis in patients with tuberculous pleuritis. Chest. 2006 May;129(5):1253-8. doi: 10.1378/chest.129.5.1253. PMID: 16685016.
• 13. Gopi A, Madhavan SM, Sharma SK, Sahn SA. Diagnosis and treatment of tuberculous pleural effusion in 2006. Chest. 2007 Mar;131(3):880-889. doi: 10.1378/chest.06-2063. PMID: 17356108.
• 14. Light RW. Pleural diseases. 6th ed. Philadelphia: Pleural Diseases 6th (sixth) Edition by Light MD, Richard W. published by Lippincott Williams & Wilkins (2013).
• 15. Valdés L, Alvarez D, Valle JM, Pose A, San José E. The etiology of pleural effusions in an area with high incidence of tuberculosis. Chest. 1996 Jan;109(1):158-62. doi: 10.1378/chest.109.1.158. PMID: 8549179.
• 16. Piras MA, Gakis C, Budroni M, Andreoni G. Adenosine deaminase activity in pleural effusions: an aid to differential diagnosis. Br Med J. 1978 Dec 23-30;2(6154):1751-2. doi: 10.1136/bmj.2.6154.1751-a. PMID: 737480; PMCID: PMC1610017.
• 17. Goto M, Noguchi Y, Koyama H, Hira K, Shimbo T, Fukui T. Diagnostic value of adenosine deaminase in tuberculous pleural effusion: a meta-analysis. Ann Clin Biochem. 2003 Jul;40(Pt 4):374-81. doi: 10.1258/000456303766477011. PMID: 12880538.
• 18. Gui X, Xiao H. Diagnosis of tuberculosis pleurisy with adenosine deaminase (ADA): a systematic review and meta-analysis. Int J Clin Exp Med. 2014 Oct 15;7(10):3126-35. PMID: 25419343; PMCID: PMC4238476.
• 19. Abrao FC, de Abreu IR, Miyake DH, Busico MA, Younes RN. Role of adenosine deaminase and the influence of age on the diagnosis of pleural tuberculosis. Int J Tuberc Lung Dis. 2014 Nov;18(11):1363-9. doi: 10.5588/ijtld.14.0257. Erratum in: Int J Tuberc Lung Dis. 2014 Dec;18(12):1526. Miyaki, D H[corrected to Miyake, D H]. PMID: 25299872.
• 20. Lee YC, Rogers JT, Rodriguez RM, Miller KD, Light RW. Adenosine deaminase levels in nontuberculous lymphocytic pleural effusions. Chest. 2001 Aug;120(2):356-61. doi: 10.1378/chest.120.2.356. PMID: 11502629.
• 21. Jiménez Castro D, Díaz Nuevo G, Pérez-Rodríguez E, Light RW. Diagnostic value of adenosine deaminase in nontuberculous lymphocytic pleural effusions. Eur Respir J. 2003 Feb;21(2):220-4. doi: 10.1183/09031936.03.00051603. PMID: 12608433.
• 22. Sivakumar P, Marples L, Breen R, Ahmed L. The diagnostic utility of pleural fluid adenosine deaminase for tuberculosis in a low prevalence area. Int J Tuberc Lung Dis. 2017 Jun 1;21(6):697-701. doi: 10.5588/ijtld.16.0803. PMID: 28482965.
• 23. Baba K, Hoosen AA, Langeland N, Dyrhol-Riise AM. Adenosine deaminase activity is a sensitive marker for the diagnosis of tuberculous pleuritis in patients with very low CD4 counts. PLoS One. 2008 Jul 30;3(7):e2788. doi: 10.1371/journal.pone.0002788. PMID: 18665218; PMCID: PMC2464737.
• 24. Valdés L, San José E, Alvarez D, Valle JM. Adenosine deaminase (ADA) isoenzyme analysis in pleural effusions: diagnostic role, and relevance to the origin of increased ADA in tuberculous pleurisy. Eur Respir J. 1996 Apr;9(4):747-51. doi: 10.1183/09031936.96.09040747. PMID: 8726940.
• 25. Lee SJ, Kim HS, Lee SH, Lee TW, Lee HR, Cho YJ, Jeong YY, Kim HC, Lee JD, Hwang YS. Factors influencing pleural adenosine deaminase level in patients with tuberculous pleurisy. Am J Med Sci. 2014 Nov;348(5):362-5. doi: 10.1097/MAJ.0000000000000260. PMID: 24762755.
• 26. Porcel JM. Pearls and myths in pleural fluid analysis. Respirology. 2011 Jan;16(1):44-52. doi: 10.1111/j.1440-1843.2010.01794.x. PMID: 20573057.
• 27. Wang J, Liu J, Xie X, Shen P, He J, Zeng Y. The pleural fluid lactate dehydrogenase/adenosine deaminase ratio differentiates between tuberculous and parapneumonic pleural effusions. BMC Pulm Med. 2017 Dec 4;17(1):168. doi: 10.1186/s12890-017-0526-z. PMID: 29202740; PMCID: PMC5715489.
• 28. Blakiston M, Chiu W, Wong C, Morpeth S, Taylor S. Diagnostic Performance of Pleural Fluid Adenosine Deaminase for Tuberculous Pleural Effusion in a Low-Incidence Setting. J Clin Microbiol. 2018 Jul 26;56(8):e00258-18. doi: 10.1128/JCM.00258-18. PMID: 29793967; PMCID: PMC6062806.
• 29. Lee SJ, Kim HS, Lee SH, Lee TW, Lee HR, Cho YJ, Jeong YY, Kim HC, Lee JD, Hwang YS. Factors influencing pleural adenosine deaminase level in patients with tuberculous pleurisy. Am J Med Sci. 2014 Nov;348(5):362-5. doi: 10.1097/MAJ.0000000000000260. PMID: 24762755.
• 30. Valdés L, Alvarez D, San José E, Penela P, Valle JM, García-Pazos JM, Suárez J, Pose A. Tuberculous pleurisy: a study of 254 patients. Arch Intern Med. 1998 Oct 12;158(18):2017-21. doi: 10.1001/archinte.158.18.2017. PMID: 9778201.
• 31. von Groote-Bidlingmaier F, Koegelenberg CF, Bolliger CT, Chung PK, Rautenbach C, Wasserman E, Bernasconi M, Friedrich SO, Diacon AH. The yield of different pleural fluid volumes for Mycobacterium tuberculosis culture. Thorax. 2013 Mar;68(3):290-1. doi: 10.1136/thoraxjnl-2012-202338. Epub 2012 Aug 4. PMID: 22863812.
• 32. Casalini AG, Mori PA, Majori M, Anghinolfi M, Silini EM, Gnetti L, Motta F, Larini S, Montecchini S, Pisi R, Calderaro A. Pleural tuberculosis: medical thoracoscopy greatly increases the diagnosticaccuracy. ERJ Open Res. 2018 Jan 5;4(1):00046-2017. doi: 10.1183/23120541.00046-2017. PMID: 29318136; PMCID: PMC5754561.
• 33. Christopher DJ, Dinakaran S, Gupta R, James P, Isaac B, Thangakunam B. Thoracoscopic pleural biopsy improves yield of Xpert MTB/RIF for diagnosis of pleural tuberculosis. Respirology. 2018 Jul;23(7):714-717. doi: 10.1111/resp.13275. Epub 2018 Feb 27. PMID: 29486527.