Skip to main content

Advertisement

SpringerLink
Log in

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

  • Original Paper
  • Published:
Infection Aims and scope Submit manuscript

Abstract

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Porcel JM, Vives M. Etiology and pleural fluid characteristics of large and massive effusions. Chest. 2003;124:978–83.

    Article  PubMed  Google Scholar 

  2. Maji A, Maikap MK, Jash D, Saha K, Kundu A, Saha D, et al. Role of common investigations in aetiological evaluation of exudative pleural effusions. J Clin Diagn Res. 2013;7:2223–6.

    PubMed  PubMed Central  Google Scholar 

  3. Lin MT, Wang JY, Yu CJ, Lee LN, Yang PC. Mycobacterium tuberculosis and polymorphonuclear pleural effusion: incidence and clinical pointers. Respir Med. 2009;103:820–6.

    Article  PubMed  Google Scholar 

  4. Colice GL, Curtis A, Deslauriers J, Heffner J, Light R, Littenberg B, et al. Medical and surgical treatment of parapneumonic effusions: an evidence-based guideline. Chest. 2000;118:1158–71.

    Article  CAS  PubMed  Google Scholar 

  5. Liang QL, Shi HZ, Wang K, Qin SM, Qin XJ. Diagnostic accuracy of adenosine deaminase in tuberculous pleurisy: a meta-analysis. Respir Med. 2008;102:744–54.

    Article  PubMed  Google Scholar 

  6. Krenke R, Korczynski P. Use of pleural fluid levels of adenosine deaminase and interferon gamma in the diagnosis of tuberculous pleuritis. Curr Opin Pulm Med. 2010;16:367–75.

    Article  CAS  PubMed  Google Scholar 

  7. Ruan SY, Chuang YC, Wang JY, Lin JW, Chien JY, Huang CT, et al. Revisiting tuberculous pleurisy: pleural fluid characteristics and diagnostic yield of mycobacterial culture in an endemic area. Thorax. 2012;67:822–7.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Porcel JM, Vives M, Esquerda A, Ruiz A. Usefulness of the British Thoracic Society and the American College of Chest Physicians guidelines in predicting pleural drainage of non-purulent parapneumonic effusions. Respir Med. 2006;100:933–7.

    Article  Google Scholar 

  9. Porcel JM, Esquerda A, Bielsa S. Diagnostic performance of adenosine deaminase activity in pleural fluid: a single-center experience with over 2100 consecutive patients. Eur J Intern Med. 2010;21:419–23.

    Article  CAS  PubMed  Google Scholar 

  10. Trajman A, da Silva Santos Kleiz de Oliveira EF, Bastos ML, Belo Neto E, Silva EM, da Silva Lourenco MC, et al. Accuracy of polymerase chain reaction for the diagnosis of pleural tuberculosis. Respir Med 2014;108:918–23.

  11. Kiropoulos TS, Kostikas K, Oikonomidi S, Tsilioni I, Nikoulis D, Germenis A, et al. Acute phase markers for the differentiation of infectious and malignant pleural effusions. Respir Med. 2007;101:910–8.

    Article  PubMed  Google Scholar 

  12. Lee J, Lee SY, Lim JK, Yoo SS, Cha SI, Park JY, et al. Radiologic and laboratory differences in patients with tuberculous and parapneumonic pleural effusions showing non-lymphocytic predominance and high adenosine deaminase levels. Infection. 2015;43:65–71.

    Article  CAS  PubMed  Google Scholar 

  13. Lee J, Lim JK, Lee SY, Yoo SS, Cha SI, Park JY, et al. Neutrophilic loculated tuberculous pleural effusion: incidence, characteristics and differentiation from complicated parapneumonic effusion. Am J Med Sci. 2016;351:153–9.

    Article  PubMed  Google Scholar 

  14. Gabay C, Kushner I. Acute-phase proteins and other systemic responses to inflammation. N Engl J Med. 1999;340:448–54.

    Article  CAS  PubMed  Google Scholar 

  15. Bielsa S, Valencia H, Ruiz-Gonzalez A, Esquerda A, Porcel JM. Serum C-reactive protein as an adjunct for identifying complicated parapneumonic effusions. Lung. 2014;192:577–81.

    Article  CAS  PubMed  Google Scholar 

  16. Daniil ZD, Zintzaras E, Kiropoulos T, Papaioannou AI, Koutsokera A, Kastanis A, et al. Discrimination of exudative pleural effusions based on multiple biological parameters. Eur Respir J. 2007;30:957–64.

    Article  CAS  PubMed  Google Scholar 

  17. Porcel JM, Vives M, Cao G, Bielsa S, Ruiz-Gonzalez A, Martinez-Iribarren A, et al. Biomarkers of infection for the differential diagnosis of pleural effusions. Eur Respir J. 2009;34:1383–9.

    Article  CAS  PubMed  Google Scholar 

  18. World Health Organization. Global tuberculosis report 2015. http://www.who.int/tb/data.

  19. Bielsa S, Palma R, Pardina M, Esquerda A, Light RW, Porcel JM. Comparison of polymorphonuclear- and lymphocyte-rich tuberculous pleural effusions. Int J Tuberc Lung Dis. 2013;17:85–9.

    Article  CAS  PubMed  Google Scholar 

  20. Jeon D. Tuberculous pleurisy: an update. Tuberc Respir Dis (Seoul). 2014;76:153–9.

    Article  Google Scholar 

  21. Morley JJ, Kushner I. Serum C-reactive protein levels in disease. Ann N Y Acad Sci. 1982;389:406–18.

    Article  CAS  PubMed  Google Scholar 

  22. Porcel JM. Pleural fluid tests to identify complicated parapneumonic effusions. Curr Opin Pulm Med. 2010;16:357–61.

    Article  PubMed  Google Scholar 

  23. Porcel JM. Tuberculous pleural effusion. Lung. 2009;187:263–70.

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

This research was supported by Kyungpook National University Research Fund, 2016 and by Basic Science Research Program through the National Research Foundation of Korea funded by the Ministry of Science, ICT & Future Planning (2015R1C1A2A01052502).

Author information

Authors and Affiliations

  1. Department of Internal Medicine, School of Medicine, Kyungpook National University, 680 Gukchaebosang-ro, Jung-gu, Daegu, 700-842, Republic of Korea

    Jaehee Lee, Seung Soo Yoo, Shin Yup Lee, Seung Ick Cha, Jae Yong Park & Chang Ho Kim

Authors
  1. Jaehee Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Seung Soo Yoo
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Shin Yup Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Seung Ick Cha
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jae Yong Park
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Chang Ho Kim
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Chang Ho Kim.

Ethics declarations

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (PPTX 80 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Lee, J., Yoo, S.S., Lee, S.Y. et al. 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. Infection 45, 59–65 (2017). https://doi.org/10.1007/s15010-016-0928-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s15010-016-0928-5

Keywords

Search

Navigation