Elevated Adenosine Deaminase Levels Research Articles

Demographic, clinical and laboratory characteristics of extrapulmonary tuberculosis: Eight-year results of a multicenter retrospective study in Turkey.

Extrapulmonary tuberculosis (EPTB) is an important public health problem due to its diverse clinical presentations, diagnostic complexities, and significant impact on patient outcomes and public health. Our study aimed to understand the sociodemographic, clinical, and laboratory characteristics as well as diagnostic and treatment modalities of adult patients with EPTB. This is a multicentric retrospective study that covers patients with EPTB cases followed up from January 2015 to December 2022 among tuberculosis (TB) dispensaries and Infectious Diseases and Clinical Microbiology clinics of 15 hospitals located in various regions of Turkey. The study included 64.6% women with a mean age of 44 years and a mortality rate of 3.5% within 1 year of diagnosis. Initial constitutional symptoms were predominantly fatigue (57%) and anorexia (53.7%). The most commonly affected sites were the lymph nodes (49.1%) and pleura (9.7%). The lumbar region was particularly involved in cases with spinal TB. Diagnostic findings included acid-fast bacilli positivity in 27.5% of cases, tuberculosis polymerase chain reaction positivity in 41%, elevated adenosine deaminase levels in 91.2% (especially in pleural and peritoneal fluids), and mycobacterial culture positivity in 40.9%. Pathology slides showed granulomatous inflammation in 97.7%. Increased C-reactive protein (CRP) levels correlated with the number of organs affected. Anti-TB treatment-related hepatotoxicity was detected in 8.9% of patients. In this study, it is important to note that the lumbar region is predominantly affected with involvement in spinal region. CRP level was consistent with the number of organ involvements and was one of the most critical results of this study.

Cerebrospinal Fluid Parameters Predicting Contralateral Isolated Lateral Ventricle in Adult Tuberculous Meningitis with Hydrocephalus Post-Ventriculoperitoneal Shunt

Hydrocephalus, a major complication in tuberculous meningitis (TBM) patients, often necessitates treatment via ventriculoperitoneal shunt (VPS). However, post-VPS, some patients develop a complication called contralateral isolated lateral ventricle (CILV), leading to persistent hydrocephalus symptoms. This study aims to evaluate cerebrospinal fluid (CSF) parameters in predicting CILV occurrence post-VPS in adult TBM patients. A retrospective analysis was conducted, focusing on the relationship between preoperative CSF parameters and the development of CILV in 40 adult TBM patients who underwent VPS. The study compared CSF parameters from lumbar puncture after admission with those from ventricular CSF post-external ventricular drainage tube insertion. CILV was observed in 6 of the 40 patients following VPS. Statistical analysis showed no significant difference between the CSF parameters obtained via lumbar and ventricular punctures. Notably, the mean CSF glucose level in patients with CILV was significantly lower (1.92mmol/L) compared to the non-CILV group (3.03mmol/L). Conversely, the median adenosine deaminase (ADA) level in the CILV group was higher (5.69 U/L) compared to the non-CILV group (3.18 U/L). The optimal cutoff values for CSF glucose and ADA levels were 1.90mmol/L and 4.80 U/L, respectively, with a sensitivity of 66.67% and 83.33% and a specificity of 88.24% and 79.41%. The study identified elevated ADA levels and decreased glucose levels in CSF as potential risk factors for CILV development in adult TBM patients post-VPS. These findings suggest the necessity for more tailored surgical approaches, in patients with altered CSF parameters to mitigate the risk of CILV.

Observation of Clinical Profile of Different Types of Meningitis in a Tertiary Care Hospital

Background: Meningitis, an inflammation of the membranes surrounding the brain and spinal cord, presents significant diagnostic challenges due to its varied etiologies and overlapping clinical symptoms. This study aims to observe and document the clinical and laboratory characteristics of viral, bacterial, and tubercular meningitis in a tertiary care hospital setting. Methods: This descriptive observational study was conducted at the Department of Neuromedicine, Cumilla Medical College Hospital, Bangladesh, from January 2020 to December 2020. We enrolled 159 patients diagnosed with meningitis based on clinical, biochemical, and investigative criteria. Detailed demographic data, clinical examination findings, and relevant investigations, including cerebrospinal fluid (CSF) studies, were recorded. Data analysis was performed using SPSS software version 20 and MS-Excel 2016. Results: Among the 159 participants, 36.7% were diagnosed with bacterial meningitis, 32.5% with viral meningitis, and 24.9% with tubercular meningitis. Fever was a universal symptom, while headache was reported by 87.3% of viral, 87.1% of bacterial, and 95.2% of tubercular meningitis patients. Vomiting was more prevalent in tubercular (57.1%) and bacterial (50%) meningitis. Laboratory findings showed the highest mean white blood cell count in bacterial meningitis (11803.18±2905.55 cells/cmm). C-reactive protein levels were also highest in bacterial meningitis (21.23±16.20 mg/dl). Elevated adenosine deaminase levels were a distinguishing feature of tubercular meningitis (14.18±10.60 Unit/L). Conclusion: This study highlights the distinct clinical and laboratory profiles associated with different types of meningitis. The findings emphasize the importance of comprehensive evaluations for accurate diagnosis and effective management of meningitis. Further research should aim to refine diagnostic criteria and explore advanced diagnostic tools to improve patient outcomes. , , , , , ,

Observation of Clinical Profile of Different Types of Meningitis in a Tertiary Care Hospital

Background: Meningitis, an inflammation of the membranes surrounding the brain and spinal cord, presents significant diagnostic challenges due to its varied etiologies and overlapping clinical symptoms. This study aims to observe and document the clinical and laboratory characteristics of viral, bacterial, and tubercular meningitis in a tertiary care hospital setting.Methods: This descriptive observational study was conducted at the Department of Neuromedicine, Cumilla Medical College Hospital, Bangladesh, from January 2020 to December 2020. We enrolled 159 patients diagnosed with meningitis based on clinical, biochemical, and investigative criteria. Detailed demographic data, clinical examination findings, and relevant investigations, including cerebrospinal fluid (CSF) studies, were recorded. Data analysis was performed using SPSS software version 20 and MS-Excel 2016.Results: Among the 159 participants, 36.7% were diagnosed with bacterial meningitis, 32.5% with viral meningitis, and 24.9% with tubercular meningitis. Fever was a universal symptom, while headache was reported by 87.3% of viral, 87.1% of bacterial, and 95.2% of tubercular meningitis patients. Vomiting was more prevalent in tubercular (57.1%) and bacterial (50%) meningitis. Laboratory findings showed the highest mean white blood cell count in bacterial meningitis (11803.18±2905.55 cells/cmm). C-reactive protein levels were also highest in bacterial meningitis (21.23±16.20 mg/dl). Elevated adenosine deaminase levels were a distinguishing feature of tubercular meningitis (14.18±10.60 Unit/L).Conclusion: This study highlights the distinct clinical and laboratory profiles associated with different types of meningitis. The findings emphasize the importance of comprehensive evaluations for accurate diagnosis and effective management of meningitis. Further research should aim to refine diagnostic criteria and explore advanced diagnostic tools to improve patient outcomes.

Tuberculous polyserositis in endemic areas with an emphasis on empiric therapy

Abstract Rationale: Polyserositis describes contemporaneous inflammation of multiple serous membranes accompanied by effusions in serous cavities. It has been associated with different aetiologies, including autoimmune diseases, endocrine diseases, neoplasia, drug-associated cases, and infectious diseases, such as tuberculosis. Patient concerns: We report the case of a 34-year-old woman who presented with abdominal swelling for 8 months, fatigability, and shortness of breath for 2 months. She denied a history of lower-limb swelling, orthopnea, paroxysmal nocturnal dyspnoea, or right upper quadrant pain. She had no history of cigarette smoking, prior treatment for tuberculosis, malignancy, or contact with someone known to have tuberculosis (TB). On examination, she had a weak pulse, muffled heart sounds, and ascites. Diagnosis: Polyserositis was suspected following visualization of fluid in the peritoneal, pleural, and pericardial cavities on imaging. Interventions: The patient underwent pericardiocentesis and ascitic taps. The patient also received spironolactone, prednisolone, and paracetamol. Despite repeated ascitic tapping and use of diuretics, fluid continued to accumulate until the initiation of empiric anti-TB drugs (rifampicin, isoniazid, pyrazinamide, and ethambutol), as noted from the elevated levels of adenosine deaminase (pleural fluid-46.30U/L) and living in an endemic area for tuberculosis (Kenya). Outcomes: Three weeks after the initiation of anti-TB drugs, the ascites and pericardial and pleural effusions resolved. Two months after discharge, the patient showed marked improvement, with no residual fluid noted in the serous cavities on imaging. Lessons learnt: We report a case of extrapulmonary TB presenting with polyserositis (pericardial, pleural, and ascitic fluid) with elevated adenosine deaminase levels when the traditional Ziehl Neelsen staining yielded negative results. Good clinical judgment and more novel diagnostic tools are necessary to avoid unnecessary delays in initiating definitive management.

Study of cerebrospinal fluid levels of lactate, lactate dehydrogenase and adenosine deaminase in the diagnosis and outcome of acute meningitis

ABSTRACT Background Meningitis is a serious clinical health issue in most developing countries. Late diagnosis and treatment result in significant morbidity and mortality. This research aims to study the utility of CSF lactate, lactate dehydrogenase (LDH), and adenosine deaminase (ADA) as diagnostic markers in acute meningitis, and to differentiate among varied aetiologies of acute meningitis and their outcomes. Method A cross-sectional observational case–control study was conducted in 30 patients of suspected meningitis of varied aetiologies and 30 controls without any pre-existing neurological disorder and who underwent lumbar puncture during spinal anesthesia. A fresh CSF sample was collected in a heparinized vial following an aseptic lumbar puncture. The levels of lactate, LDH and ADA were estimated and recorded. Result CSF lactate was significantly elevated in bacterial meningitis (BM) and cryptococcal meningitis, with 100% sensitivity when compared to controls. Elevated LDH was found only in BM, hence elevated LDH levels may strongly signify bacterial etiology. Significantly elevated ADA levels were noted in tuberculous meningitis. Significantly elevated levels of lactate and ADA were suggestive of slower clinical recovery and a prolonged hospital stay (p < 0.001). Conclusion Estimation of CSF lactate, LDH, and ADA levels is a rapid, inexpensive and simple procedure and can play a major role in the early differentiation of bacterial, viral, tuberculous, and fungal meningitis. This would facilitate the initiation of appropriate treatment as early as possible, thereby decreasing mortality and complications.

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.LEARNING POINTSElevated ADA levels are not pathognomonic of TB infection.Lymphocytic pleural effusion requires a systematic diagnostic approach.Very high levels of ADA should arouse suspicion of lymphoma.

Progression of Acute Myeloid Leukemia Manifested as New Onset Ascites With Elevated Adenosine Deaminase

A 77-year-old male with AML and non- ischemic cardiomyopathy presented to our hospital with one month history of dyspnea on exertion and exercise intolerance. Review of systems was remarkable for abdominal pain, poor appetite, and increased abdominal girth for two weeks. Physical examination revealed a well-nourished, elderly male with decreased breath sounds over the posterior lung bases, and periumbilical tenderness with a distinct fluid wave. Laboratory studies were significant for WBC-11.3 x103, Hgb-8.9g/dL, Plt-106 x 103, Blast %-32, BNP-275 pg/mL, AST-21 U/L, ALT-14 U/L, and an indeterminate Quantiferon gold. CT abdomen/pelvis revealed hepatosplenomegaly with engorgement of the portal vein, new onset ascites, and a peripherally enhancing pelvic fluid collection (Figure 1). A paracentesis was performed. Analysis of the ascitic fluid revealed WBC -34,850 cells/μL with 45% blasts, total protein-4g/dL, LDH- 974 U/L (serum 383 U/L), albumin 2.7 g/dL (serum, 3.6 g/dL) and adenosine deaminase 102 U/L. Cytologic examination of the fluid showed a markedly cellular fluid with high nuclear to cytoplasmic ratio, nuclear contour abnormalities, and abundant mitotic figures consistent with myeloid cells (Figure 2). No microorgamisms were identified, including mycobacterium. Flow cytometry demonstrated cells that expressed CD13, CD33, CD15, CD11b, CD11c, CD64, CD34, CD117, HLA-DR, CD71 and CD38. These findings were consistent with AML and the patient was started on Hydroxyurea and Ruxolitinib. Malignant ascites is a common complication of solid tumors, but is rarely witnessed in hematologic malignancies. In particular, leukemic ascites is an exceedingly rare phenomenon manifesting at initial presentation or late extramedullary relapse following bone marrow transplantation. There have been very few cases of leukemic ascites reported in the literature, however this is the first case of leukemic ascites with elevated adenosine deaminase levels. Although the pathophysiology in this case is not fully understood, it is speculated to be the result of leukemic infiltration of the lymphatics or peritoneal deposition of tumor cells. However infectious etiologies should be thoroughly excluded prior to making this diagnosis and planning on treatment. This report also emphasizes the importance of prompt evaluation of new onset ascites and the performance of flow cytometry and cytologic analysis especially in a patient with known history of malignancy.Figure: CT Abdomen/Pelvis Image of Peripherally Enhnacing Pelvic Fluid.Figure: Ascitic Fluid cellular fluid with myeloid cells.

A Case of Pleural TB

SESSION TITLE: Other Infections SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Extra-pulmonary Tuberculosis (TB) comprises a quarter of the initial TB presentations but can be challenging to diagnosis. Reactivation of latent TB infection (LTBI) is seen in the immunocompromised population. Initial screening for TB with tuberculosis skin test (TST) can be falsely negative in them. Interferon gamma release assay (IGRA) is now the preferred TB screening test. CASE PRESENTATION: 43-year-old male with history of Crohn’s disease with negative TST on adalimumab and mercaptopurine presented with progressively worsening shortness of breath, fevers, night sweats, productive cough and pleuritic chest pain for three weeks duration. He was seen by his primary care physician and given azithromycin for bronchitis. However, symptoms persisted prompting an ER evaluation. He was found febrile, tachycardic, tachypneic and hypoxic. On exam he had diminished breath sounds and dullness to percussion of the right lung field. Chest x-ray showed large right pleural effusion. Laboratory studies were unremarkable. He was started on antibiotics for pneumonia with parapneumonic effusion. A thoracentesis showed exudative fluid process. The adenosine deaminase (ADA) level was low and bacterial culture was negative. However, his Quantiferon test was positive. He continued to worsen so he underwent video-assisted thoracotomy with pleural biopsy given concern for TB. He was found to have numerous pleural implants. The tissue culture was positive for acid fast bacilli. The pathology of the pleural biopsies showed multiple non-necrotizing epithelioid granulomata with histiocytes and giant cells. He was started on RIPE therapy for extra-pulmonary TB. DISCUSSION: Extrapulmonary TB can present as primary TB or in reactivation of LTBI. Tuberculous pleuritis develops from direct infection of the pleura and lymph nodes as a result of a ruptured sub-pleural caseous area in the lung. A delayed hypersensitivity reaction ensues resulting in the development of a tuberculous pleural effusion. In these cases, TB can be detected by sampling the pleural fluid. The pleural fluid has lymphocyte pre-dominance and elevated ADA level. The reliability of this biomarker in detecting TB depends on the prevalence of TB in the area. ADA levels can be falsely low in the early part of tuberculous pleurisy and in the immunocompromised. CONCLUSIONS: This case highlights the high false negative rate of TST among immunosuppressed individuals due to anergy. Our patient was initially tested for TB with TST while on oral steroids during a Crohn's flare. This test was false negative. He had underlying LTBI that became reactivated while on immunosuppressive therapy. IGRA testing would have been a more sensitive method of detecting LTBI. This case also emphasizes the gold standard of diagnosing extra-pulmonary TB with thoracotomy and pleural biopsy. Reference #1: Vorster M., et al. Tuberculous pleural effusions: advances and controversies. Journal of Thoracic Disease. 2015; 7(6): 981-91. DISCLOSURE: The following authors have nothing to disclose: Rohini Manaktala, Ricardo Perez, Prashant Grover No Product/Research Disclosure Information

A clinical study of diagnostic efficacy of adenosine deaminase levels in tubercular pleural effusion

Background: Tuberculosis is a common cause of pleural effusion in countries like India where it is highly endemic. However, the organism mycobacterium tuberculosis is seldom detectable in pleural fluid. The diagnosis of pleural tuberculosis has been greatly improved by the use of biochemical markers. The pleural fluid activity of adenosine deaminase (ADA) is one of the best providing reliable bases for a treatment decision, particularly in excluding the diagnosis of tuberculosis, due to its high sensitivity. The present study was aimed to evaluate the diagnostic efficacy of ADA levels in tubercular pleural effusion. Methods: The study is a clinical, prospective and observational study of 50 Patients of pleural effusion consecutively admitted in Government Medical College and Hospital, Kannouj from Dec 2008 to Dec 2009. Macroscopic findings, cytological, microbiological and biochemical analysis of pleural fluid were performed, including ADA levels in all patients. Results: Mean age group was 31 years and common in men. In our study, out of 30 patients with tuberculosis pleural fluid ADA was done in them and 28 (93.33%) of them had a level more than 40IU/L. Using a cut off of greater 40IU/L we got a sensitivity and specificity of 93.3% and 90% respectively and positive predictive value 93.3% and Negative predictive value 90%. Conclusions: All patients with TB pleural effusion had elevated ADA levels and there was a statistical significant association (p value <0.05) of ADA levels in differentiating TB pleural effusion from Non-TB pleural effusion.

Cystic Mesenteric Inflammatory Pseudotumor Associated to Multidrug-Resistant Meningeal Tuberculosis and a Cerebrospinal Fluid Shunt: An Unusual Case

Abdominal masses in childhood have a very large spectrum of benign and malignant causes. Inflammatory pseudotumor (IP) arising from intra-abdominal sites has only rarely been designated previously in children. We report the case of a 21-year-old HIV-negative man, in whom a cystic mesenteric IP appeared after 46 months of diagnosis of tuberculous meningitis (TBM) complicated with brain infarcts, tuberculoma, hydrocephalus and multiple neurosurgical procedures including ventriculoperitoneal (VP) cerebrospinal fluid (CSF) shunt placement, shunt exchanges and endoscopic ventricular septostomies. At diagnosis, primary antituberculous drugs were administered and mycobacterial CSF cultures were persistently negative; nevertheless, follow-up elevated adenosine deaminase levels in CSF suggested multidrug-resistant (MDR) tuberculosis and moxifloxacin and aminoglycoside were added with improvement. Repeated formation of abdominal cystic masses with shunt obstructions, abdominal distention and pain lead us to conclude that the peritoneum was no longer useful for CSF derivation and a ventriculo-atrial shunt was placed. After laparoscopic excision of an abdominal mass, microscopic examination showed a cystic tumor formed by proliferation of fibroblasts, myofibroblasts and inflammatory cells. Focally a granuloma with multinucleated giant cells (Langerhans cells) was observed and Ziehl-Neelsen staining showed acid-fast bacilli. Diagnosis of IP associated to MDR tuberculosis was made. This complication is probably under-recognized since histopathological study of abdominal masses related with CSF VP shunts is not performed systematically. Our case illustrates the importance of microscopic tissue examination to detect MDR and extensively drug-resistant (XDR) tuberculosis and the difficult treatment of these cases. J Neurol Res. 2015;5(3):225-229 doi: http://dx.doi.org/10.14740/jnr333w

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.

Pleuro-peritoneal lymphomatosis with concurrent tonsillar involvement in T-cell nonHodgkin′s lymphoma: Clinical presentation mimicking disseminated tuberculosis

A young male patient had been evaluated for pleural effusion at another center wherein on the basis of exudative, lymphocyte predominant pleural effusion with high pleural fluid adenosine deaminase (ADA) levels and tuberculin skin test (TST) reactivity, antituberculous medications had been administered. Reevaluation in view of worsening symptoms led to confirmation of the diagnosis of T-cell lymphoblastic lymphoma with pleuro-peritoneal lymphomatosis and tonsillar involvement. This case highlights the fact that elevated ADA levels should not be taken as surrogate for a diagnosis of TB in the absence of histopathological/microbiological confirmation even in countries with high tuberculosis (TB) prevalence. Tonsil in an uncommon site of involvement in patients with T-cell lymphoma. As the diagnosis in our patient was confirmed from biopsy of a tonsillar mass, a thorough physical examination should be performed in all patients with a suspected diagnosis of lymphoma.

Clinical relevance and characteristics of pleural effusion in patients with Mycoplasma pneumoniae pneumonia

Data regarding parapneumonic pleural effusion in Mycoplasma pneumoniae pneumonia (MP) patients are limited. In this study MP patients with pleural effusion tended to be younger and had longer hospital stays and more common use of systemic steroids compared to those without pleural effusion. In 5 of the 6 patients for whom pleural fluid data were available, the pleural effusion was lymphocyte-predominant rather than polymorphonuclear leukocyte-predominant; these patients also had elevated adenosine deaminase levels. Taken together, these results indicate that MP patients with pleural effusion may have a more severe form compared to those without pleural effusion. M. pneumoniae should be considered an aetiological agent of lymphocyte-predominant pleural effusion.

Serum Adenosine deaminase (ADA) levels in surgically treated hydatid cyst patients

Adenosine deaminase (ADA) is an essential enzyme in the monocytes - macrophage system and in the proliferation and differentiation of lymphocytes. ADA activity is routinely used in the differentiation of other etiologies of tuberculosis pleurisy in clinical practice and elevated ADA levels are stated to indicate the severity of the disease. In this study the purpose was to compare the serum ADA levels between patients operated due to hydatid cyst and healthy individuals (control group). The serum ADA levels of surgically treated patient with hydatid cyst were analyzed and a significant decrease was observed in comparison with the control group (10.98±6.53 vs 21.11±14.07, p<0.05). Decreasing of ADA levels on surgical treated hydatid cyst patients can be interpreted as the inhibition of tissue damage or cessation of lymphocyte proliferation as a result of the elimination of the parasite by means of surgical treatment and breaking the relation between the parasite and immune cells of the host. Determination of ADA activity in hydatid cyst patients might be a diagnostic tool if further clinical trials are carried out. Key words: Adenosine deaminase, hydatid cyst, operated patients.

Elevated adenosine deaminase levels in celiac disease

Celiac disease (CD) is a genetically based chronic inflammatory disorder of the small bowel induced by the dietary gluten and possibly other environmental cofactors. The objective of this study was to investigate the relation of adenosine deaminase (ADA), a cytoplasmic enzyme involved in the catabolism of purine bases, as an index of altered immune response, with adult CD patients. ADA has been shown to increase in several inflammatory conditions, but there is no literature data indicating an alteration in CD. Serum levels of ADA were investigated in newly diagnosed 20 CD patients. ADA levels were compared in patients with CD and in healthy controls. Correlation analysis was also performed between ADA and other serum markers of CD (anti-gliadin and anti-endomysial antibodies) Mean serum ADA levels were significantly elevated in CD patients compared with control group. ROC curve analysis suggested that the optimum ADA level cut-off point for CD was 12.27 U/l. At a cut-off value of 12.27 U/l, the sensitivity was 80% and specificity was 100%. There was no statistically significant correlation between ADA and anti-gliadin and anti-endomisium antibodies. Serum ADA levels elevated significantly in CD patients, suggesting a partial role in activated T-cell response in the disease pathophysiology. ADA can be used as a supportive diagnostic marker in patients with CD.

Use of anabolic-androgenic steroids masking the diagnosis of pleural tuberculosis: a case report

IntroductionTuberculous pleural effusions are not always easy to diagnose but the presence of a lymphocyte-rich exudate associated with an increased adenosine deaminase level and a positive skin test result are highly sensitive diagnostic signs.Case presentationWe report a case of pleural tuberculosis in a 31-year-old white male patient from Caracas, Venezuela who was negative for human immunodeficiency virus and presented 2 weeks after injecting the anabolic-androgenic steroid nandrolone decanoate, in whom all the tests for tuberculosis were initially negative; an eosinophilic pleural effusion with a low adenosine deaminase level, a negative tuberculin skin test and negative for acid-fast bacilli staining and culture of the pleural fluid. After excluding other causes of eosinophilic pleural effusion malignant pleural effusion was suspected. The patient did not return until 4 months later. The second thoracentesis obtained a pleural fluid suggestive for tuberculosis, with a predominance of lymphocytes, an elevated adenosine deaminase level (51 U/l) and a positive tuberculin skin test. Culture of pleural fragments confirmed pleural tuberculosis.ConclusionThis case suggests that the use of an anabolic-androgenic steroid masks the definitive diagnosis of pleural tuberculosis by changing the key diagnostic parameters of the pleural fluid, a finding not previously reported. Available evidence of the effects of anabolic steroids on the immune system also suggests that patients using anabolic-androgenic steroids might be susceptible to developing tuberculosis in either reactivating a latent infection or facilitating development of the disease after a recent infection.

Assessment of adenosine deaminase levels in rheumatoid arthritis patients receiving anti-TNF-α therapy

Anti-TNF-alpha agents are increasingly used in rheumatoid arthritis (RA) treatment and that is known to increase the risk of tuberculosis (TB) reactivation. Adenosine deaminase (ADA) levels are shown to increase to high levels in TB patients. Our aim is to investigate the serum ADA levels in RA patients being treated with anti-TNF-alpha and to compare the results with the patients on DMARD therapy. The study groups comprised of 56 RA patients (45 female, mean age 49) who were treated either with two or three DMARDs, 32 RA patients with anti-TNF-alpha treatment (26 female, mean age 46) and 20 healthy controls (10 female, mean age 48). All patients fulfilled the 1987 ACR criteria for RA. DAS28 score was calculated for all subjects. When compared to healthy controls, ADA levels were measured statistically higher both in patient groups (P = 0.046, 0.002). ADA levels in anti-TNF-alpha group were similar to conventional therapy (11.3 +/- 2.7, 10.9 +/- 4.01; P = 0.76). PPD was positive in 17 RA patients in the anti-TNF-alpha treatment group (%53). The ADA levels were found to be similar in the anti-TNF-alpha group when compared according to the PPD positivity (positive, 12.4 +/- 3.7; negative, 10.5 +/- 2.1; P = 0.02). No correlation was found between the ADA levels and age, disease duration, ESR, CRP, DAS 28 and HAQ score. In this study, we observed that RA patients at remission taking DMARD or anti-TNF-alpha therapy have similar levels of serum ADA. Although serum ADA levels during TB infection increase much higher, in our study, ADA levels of all RA patients were lower than 15 IU/L. Elevated ADA levels may be a clue for diagnosis of TB in patients who were on anti-TNF-alpha therapy.

Serum adenosine deaminase activities during acute attacks and attack-free periods of familial Mediterranean fever

Background Familial Mediterranean Fever (FMF) is a systemic relapsing autoinflammatory disorder. Adenosine deaminase (ADA) is an enzyme widely distribute in tissues and body fluids. Circulating levels of ADA have been shown to increase in several inflammatory conditions. This study was designed to evaluate the serum ADA in patients with FMF during acute attacks and attack-free periods. Methods The study groups comprised 23 FMF patients in attack-free period (male/female: 11/12), 30 FMF patients in attack period (male/female: 11/19) and 20 healthy control (male/female:10/10). The groups were similar for age, gender and disease duration. Results The mean age of FMF patients in attack-free period, patient with acute attack were 34.3 ± 11.7 and 29.4 ± 11.1 respectively. The disease durations were 13.1 ± 10.2 and 8.2 ± 7.6 years for patients in attack-free periods and patients with acute FMF attack, respectively. Patients with acute attack had significantly higher ADA levels than both patients with attack-free periods and healthy controls (for each, p < 0.001). Conclusion In this study we demonstrated that FMF patients with acute attacks had higher serum ADA levels than attack-free periods and healthy controls. It is likely that ADA may have a role in the cytokine network of the inflammatory cascade of FMF. Also, elevated ADA levels may be a part of the activated Th1 response in the disease. ADA may be used as a supportive marker to differentiate FMF attacks from attack-free periods. Further larger-scale studies are needed to support this result.

Tuberculous Pericarditis

The incidence of tuberculous pericarditis is increasing in Africa as a result of the human immunodeficiency virus (HIV) epidemic. The primary objective of this article was to review and summarize the literature on the pathogenesis, diagnosis, and management of tuberculous pericarditis. We searched MEDLINE (January 1966 to May 2005) and the Cochrane Library (Issue 1, 2005) for information on relevant references. A "definite" diagnosis of tuberculous pericarditis is based on the demonstration of tubercle bacilli in pericardial fluid or on a histological section of the pericardium; "probable" tuberculous pericarditis is based on the proof of tuberculosis elsewhere in a patient with otherwise unexplained pericarditis, a lymphocytic pericardial exudate with elevated adenosine deaminase levels, and/or appropriate response to a trial of antituberculosis chemotherapy. Treatment consists of the standard 4-drug antituberculosis regimen for 6 months. It is uncertain whether adjunctive corticosteroids are effective in reducing mortality or progression to constriction. Surgical resection of the pericardium remains the appropriate treatment for constrictive pericarditis. The timing of surgical intervention is controversial, but many experts recommend a trial of medical therapy for noncalcific pericardial constriction, and pericardiectomy in nonresponders after 4 to 8 weeks of antituberculosis chemotherapy. Research is needed to improve the diagnosis, assess the effectiveness of adjunctive steroids, and determine the impact of HIV infection on the outcome of tuberculous pericarditis.