Adenosine deaminase activity in the diagnosis of tuberculous peritonitis

Expression of Adenosine Deaminase and NLRP3 Inflammasome in Tuberculous Peritonitis and Their Relationship with Clinical Efficacy

Objective. Tuberculous peritonitis (TP) can cause multiple infections of surrounding organs and tissues, leading to organ failure and endangering life safety. In this research, the relationship between adenosine deaminase (ADA), NLRP3 inflammasome, and TP and its clinical significance will be deeply explored, so as to provide new directions and reliable reference opinions for future clinical diagnosis and treatment. Methods. Altogether, 59 TP patients (research group, RG) and 52 non-TP patients (control group, CG) who were admitted to our hospital from May 2014 to June 2018 were regarded as research objects. Ascites samples of RG before treatment (admission) and one month after treatment and CG before treatment were obtained, and the ADA and NLRP3 levels were tested to evaluate the clinical and prognostic significance of the two in TP. Results. Before treatment, ADA and NLRP3 in RG were higher than CG ( $P<0.05$ ), and the sensitivity and specificity of combined detection of the two in predicting TP occurrence were 89.83% and 73.08% ( $P<0.05$ ). In addition, ADA and NLRP3 in RG patients were positively correlated with the disappearance time of abdominal pain and ascites ( $P<0.05$ ) and had excellent predictive effect on the adverse reactions during treatment ( $P<0.05$ ). After treatment, both in RG patients decreased, which was inversely proportional to the clinical efficacy ( $P<0.05$ ). Prognostic follow-up manifested that ADA and NLRP3 in relapse patients were higher than those without recurrence after treatment ( $P<0.05$ ). Conclusion. The increase of ADA and NLRP3 in TP is relevant to the adverse reactions during treatment, clinical efficacy, and prognosis recurrence after treatment. It can be used as a disease marker to confirm, intervene, and evaluate TP progression promptly.

Long-term spontaneous remission with active surveillance in IgG4-related pleuritis: A case report and literature review

Pleural effusion is a relatively rare feature of IgG4-related disease (IgG4-RD). Here, we report a case of a 72-year-old woman who presented with pleural effusion. Although the pleural adenosine deaminase level was increased, surgical biopsy of the pleura and left inguinal lymph node indicated that the effusion was due to IgG4-RD. Active surveillance was initiated because serum IgG4 and pleural effusion naturally decreased and then completely disappeared. The patient has shown no recurrence for >4 years. This case suggests that pleural biopsy can be used to distinguish IgG4-RD from tuberculosis; moreover, some cases with pleural effusion could improve without treatment.

Tuberculous peritonitis following intestinal perforation in malignancy

Tuberculous peritonitis is one of the most common causes of exudative ascites, especially in the young, and is an important cause of extra-pulmonary disease. However, tuberculous peritonitis is challenging to diagnose because there are no pathognomonic clinical features or imaging findings. Therefore, it is commonly misdiagnosed as another type of peritoneal disease, especially so in elderly patients with malignant disease. In this report, we described two cases of tuberculous peritonitis that were observed after intestinal perforation in elderly patients with malignancies. These diagnoses were established by laparoscopic peritoneal biopsy or AFB cultures of the ascitic fluid. Both patients were treated with anti-TB medications.

Chylous Ascites: Evaluation and Management

Chylous ascites refers to the accumulation of lipid-rich lymph in the peritoneal cavity due to disruption of the lymphatic system secondary to traumatic injury or obstruction. Worldwide, abdominal malignancy, cirrhosis, and tuberculosis are the commonest causes of CA in adults, the latter being most prevalent in developing countries, whereas congenital abnormalities of the lymphatic system and trauma are commonest in children. The presence of a milky, creamy appearing ascitic fluid with triglyceride content above 200 mg/dL is diagnostic, and, in the majority of cases, unless there is a strong suspicion of malignancy, further investigations are not required in patients with cirrhosis. If an underlying cause is identified, targeted therapy is possible, but most cases will be treated conservatively, with dietary support including high-protein and low-fat diets supplemented with medium-chain triglycerides, therapeutic paracentesis, total parenteral nutrition, and somatostatins. Rarely, resistant cases have been treated by transjugular intrahepatic portosystemic shunt, surgical exploration, or peritoneovenous shunt.

Diagnostic accuracy of adenosine deaminase for tuberculous peritonitis: a meta-analysis

INTRODUCTION

Tuberculous peritonitis remains a diagnostic challenge for clinicians. Many studies have investigated the usefulness of adenosine deaminase (ADA) in ascites for the diagnosis of tuberculous peritonitis; however, the overall diagnostic accuracy of ADA for tuberculous peritonitis remains unclear. The aim of the present meta-analysis was to determine the overall accuracy of ADA measurements in the diagnosis of tuberculous peritonitis.

MATERIAL AND METHODS

We performed a systematic search in PubMed and Embase to identify published studies that evaluated the diagnostic role of ADA for tuberculous peritonitis. Quality was assessed according to standardized Quality Assessment of Diagnostic Accuracy Studies criteria. Sensitivity, specificity and other measures of accuracy of ADA assay in order to diagnose tuberculous peritonitis were pooled using random effects models. Summary receiver operating characteristic curve (SROC) was used to summarize overall test performance.

RESULTS

Sixteen studies met inclusion criteria for the present meta-analysis. The pooled sensitivity and specificity for diagnosing tuberculous peritonitis were 0.93 (95% CI: 0.89-0.95) and 0.96 (95% CI: 0.94-0.97), respectively. The positive likelihood ratio was 15.80 (95% CI: 10.87-22.95), negative likelihood ratio was 0.09 (95% CI: 0.05-0.16) and diagnostic odds ratio was 249.28 (95% CI: 113.11-549.39). The area under the SROC was 0.98.

CONCLUSIONS

Ascitic ADA determination is a relatively sensitive and specific test for the diagnosis of tuberculous peritonitis. Measurement of ADA in ascites is thus likely to be a useful diagnostic method for tuberculous peritonitis.

Adenosine deaminase activity in tuberculous peritonitis among patients with underlying liver cirrhosis

AIM: To investigate the value of adenosine deaminase (ADA) for early detection of tuberculous peritonitis (TBP) among cirrhotic patients.

METHODS: We retrospectively analyzed 22 patients with TBP from July 1990 to June 2010. Twenty-five cirrhotic patients with uninfected ascites were prospectively enrolled as the cirrhosis control group from July 2010 to June 2011. An additional group of 217 patients whose ascites ADA levels were checked in various clinical conditions were reviewed from July 2008 to June 2010 as the validation group.

RESULTS: The mean ascites ADA value of cirrhotic patients with TBP (cirrhotic TBP group, n = 8) was not significantly different from that of non-cirrhotic patients (non-cirrhotic TBP group, n = 14; 58.1 ± 18.8 U/L vs 70.6 ± 29.8 U/L, P = 0.29), but the mean ascites ADA value of the cirrhotic TBP group was significantly higher than that of the cirrhosis control group (58.1 ± 18.8 U/L vs 7.0 ± 3.7 U/L, P < 0.001). ADA values were correlated with total protein values (r = 0.909, P < 0.001). Using 27 U/L as the cut-off value of ADA, the sensitivity and specificity were 100% and 93.3%, respectively, for detecting TBP in the validation group.

CONCLUSION: Even with lower ADA activity in ascites among cirrhotic patients, ADA values were significantly elevated during TBP, indicating that ADA can still be a valuable diagnostic tool.

Role of ascites adenosine deaminase in differentiating between tuberculous peritonitis and peritoneal carcinomatosis

AIM: To investigate the usefulness of tumor markers and adenosine deaminase in differentiating between tuberculous peritonitis (TBP) and peritoneal carcinomatosis (PC).

METHODS: A retrospective analysis of data was performed on consecutive patients who underwent peritoneoscopic and abdominal computed tomography (CT) evaluations. Among 75 patients at the Seoul National University Hospital from January 2000 to June 2010 who underwent both tests, 27 patients (36.0%) and 25 patients (33.3%) were diagnosed with TBP and PC, respectively. Diagnosis was confirmed by peritoneoscopic biopsy.

RESULTS: Serum c-reactive protein (7.88 ± 6.62 mg/dL vs 3.12 ± 2.69 mg/dL, P = 0.01), ascites adenosine deaminase (66.76 ± 32.09 IU/L vs 13.89 ± 8.95 IU/L, P < 0.01), ascites lymphocyte proportion (67.77 ± 23.41% vs 48.36 ± 18.78%, P < 0.01), and serum-ascites albumin gradient (0.72 ± 0.49 g/dL vs 1.05 ± 0.50 g/dL, P = 0.03) were significantly different between the two groups. Among tumor markers, serum and ascites carcinoembryonic antigen, serum carbohydrate antigen 19-9 showed significant difference between two groups. Abdominal CT examinations showed that smooth involvement of the parietal peritoneum was more common in the TBP group (77.8% vs 40.7%) whereas nodular involvement was more common in the PC group (14.8% vs 40.7%, P = 0.04). From receiver operating characteristic (ROC) curves ascites adenosines deaminase (ADA) showed better discriminative capability than tumor markers. An ADA cut-off level of 21 IU/L was found to yield the best results of differential diagnosis; sensitivity, specificity, positive predictive value, and negative predictive value were 92.0%, 85.0%, 88.5% and 89.5%, respectively.

CONCLUSION: Besides clinical and radiologic findings, ascitic fluid ADA measurement is helpful in the differential diagnosis of TBP and PC.

Management of renal failure and ascites in patients with cirrhosis

Ascites and renal dysfunction in cirrhosis occur when the liver disease is decompensated and signify the presence of advanced liver failure. However, the precipitating causes should be looked for and treated. Although liver transplantation is the treatment of choice in patients with advanced liver failure, mild to moderate ascites can be treated effectively with medical management. Similarly, renal failure in cirrhotics is reversible if the precipitating causes can be treated effectively and by use of combination of vasoconstrictors and albumin. Transjugular intrahepatic portosystemic shunts also offer an effective therapy for refractory ascites and HRS. Such treatments may offer effective bridge to liver transplantation, by improving short and medium term survivals. Here, we shall discuss all the options available for the management of these complications of cirrhosis.

Tuberculous peritonitis in a German patient with primary biliary cirrhosis: a case report

Background

The number of cases of tuberculosis as a complication in people with immunodeficiency, people on immunosuppressive therapy and among the immigrant population is increasing in Germany. However, tuberculous peritonitis rarely occurs without these risks, particularly in Germans. The incidence of tuberculous peritonitis in Germany is very low; tuberculosis of the intestinal tract was found in approximately 0.8 % of tuberculosis cases in 2004. The diagnosis of tuberculous peritonitis is often delayed on account of non-specific clinical symptoms. The absence of specific biological markers, long incubation times for cultures and non-specific radiographic or ultrasonographic signs increase the morbidity associated with this treatable condition.

Case presentation

We report a case of tuberculous peritonitis in a 73-year-old female German patient. Her medical history revealed primary biliary cirrhosis (PBC) since 1992. On admission, she complained of abdominal pain, vomiting, ascites and peripheral edema. The patient has been in a seriously reduced general condition and had fever up to 39.6°C. A few weeks earlier, the patient was in another hospital with the same complaint. Inflammatory parameters were elevated, but the procalcitonin level was normal. Blood culture was always negative, as was the tuberculin test. Ultrasonography of the abdomen showed massive ascites with multiple septa. The patient underwent a computed tomography (CT) scan of the abdomen which showed a thickened intestinal wall in the sigmoid colon and a pronounced enhancement of the peritoneum. Computed tomography scans of the lung showed only slight bilateral pleural effusion. Because of the anaesthetic and bleeding risk due to thrombocytopenia, laparoscopy was not immediately undertaken. The culture from ascites was positive for M.tuberculosis after three weeks.

Conclusion

In primary biliary cirrhosis patients with non-specific clinical symptoms, such as vomiting, abdominal pain, ascites, weight loss, and fever, tuberculous peritonitis must be considered in the initial differential diagnosis, although these symptoms may be attributed to cirrhosis of the liver with spontaneous bacterial peritonitis. Ultrasonographic and CT scab findings are not specific for tuberculous peritonitis, but an awareness of the ultrasonographic features and the features of the CT scan may help in the diagnosis of tuberculous peritonitis and avoid clinical mismanagement.

Value of adenosine deaminase (ADA) in ascitic fluid for the diagnosis of tuberculous peritonitis: a meta-analysis

BACKGROUND AND GOALS

Adenosine deaminase (ADA) levels are used for diagnosing tuberculosis in several locations and although many studies have evaluated ADA levels in ascitic fluid. These studies have defined arbitrary cut-off points creating difficulties in the clinical application of the results. The goals of this study are: to determine the usefulness of ADA levels in ascitic fluid as a diagnostic test for peritoneal tuberculosis (PTB) and define the best cut-off point.

STUDY

A systematic review was done on the basis of 2 independent searches. We selected prospective studies that included consecutive patients. Diagnosis of PTB had to be confirmed by bacteriologic or histologic methods and ADA levels determined by the Giusti method. Inclusion/exclusion criteria were applied by 2 independent reviewers. A receiver operating characteristic curve was constructed to establish the optimal cut-off point and the likelihood ratios (LRs) estimated using fixed-effect pooled method.

RESULTS

Twelve prospective studies were found. Four of them met the inclusion criteria and were thus included in the meta-analysis. They included 264 patients, of which 50 (18.9%) had PTB. ADA levels showed high sensitivity (100%) and specificity (97%) using cut-off values from 36 to 40 IU/L. The included studies were homogeneous. Optimal cut-off point was determined at 39 IU/L, and LRs were 26.8 and 0.038 for values above and below this cut-off.

CONCLUSIONS

This study supports the proposition that ADA determination is a fast and discriminating test for diagnosing PTB with an optimal cut-off value of 39 IU/L.

Lymphomas and chylous ascites: review of the literature

Chylous ascites is a rare and challenging clinical condition that occurs as a result of disruption of the abdominal lymphatics. We include a review of the literature describing the etiology, diagnosis, and therapy of chylous ascites.

Systematic review: tuberculous peritonitis--presenting features, diagnostic strategies and treatment

The peritoneum is one of the most common extrapulmonary sites of tuberculous infection. Peritoneal tuberculosis remains a significant problem in parts of the world where tuberculosis is prevalent. Increasing population migration, usage of more potent immunosuppressant therapy and the acquired immunodeficiency syndrome epidemic has contributed to a resurgence of this disease in regions where it had previously been largely controlled. Tuberculous peritonitis frequently complicates patients with underlying end-stage renal or liver disease that further adds to the diagnostic difficulty. The diagnosis of this disease, however, remains a challenge because of its insidious nature, the variability of its presentation and the limitations of available diagnostic tests. A high index of suspicion is needed whenever confronted with unexplained ascites, particularly in high-risk patients. Based on a systematic review of the literature, we recommend: tuberculous peritonitis should be considered in the differential diagnosis of all patients presenting with unexplained lymphocytic ascites and those with a serum-ascites albumin gradient (SAAG) of <11 g/L; culture growth of Mycobacterium of the ascitic fluid or peritoneal biopsy as the gold standard test; further studies to determine the role of polymerase chain reaction, ascitic adenosine deaminase and the BACTEC radiometric system for acceleration of mycobacterial identification as means of improving the diagnostic yield; increasing utilization of ultrasound and computerized tomographic scan for the diagnosis and as a guidance to obtain peritoneal biopsies; low threshold for diagnostic laparoscopy; treatment for 6 months with the first-line antituberculous drugs (isoniazid, rifampicin, ethambutol and pyrazinamide) in uncomplicated cases.

Biochemical analysis of pleural, peritoneal and pericardial effusions

Body fluids other than blood, urine and cerebrospinal fluid are often submitted for biochemical analysis. Of these, pleural, peritoneal and pericardial fluids are the most common. Laboratory tests are a useful tool to assess the aetiology, pathophysiology and subsequent treatment of effusions. A wide range of biochemical tests may be requested. This review critically examines the various analytes that have been used to investigate these body fluids.

Adenosine deaminase levels in cerebrospinal fluid as a diagnostic test for tuberculous meningitis in children

Adenosine deaminase activity (ADA) was estimated in cerebrospinal fluid (CSF) of 30 patients of tuberculous meningitis (TBM) and 10 patients each of partially treated pyomeningitis (PTM), aseptic meningitis (AM) and pyogenic meningitis (PM). Mean ADA levels in CSF of TBM patients were higher (18.22 U/L) as compared to 6.28 U/L, 3.43 U/L and 7.98 U/L in PTM, AM and PM respectively. This difference of ADA values in CSF between TBM and other types of meningitis was statistically significant (p<0.01) different. Sensitivity and specificity of ADA levels in CSF of children to diagnose tuberculous meningitis was 66.6% and 90% respectively at 10 U/L cut off of ADA levels in CSF. ADA levels in CSF could also differentiate PTM, AM and PM from TBM with a specificity of 90%, 100% and 80% respectively.

Validation of an adenosine deaminase assay and its use in the evaluation of body fluids in dogs

Adenosine deaminase activity (ADA) (EC 3.5.4.4) was determined according to the method of Slaats and associates in the autoanalyzer Hitachi 705.(1) The analytical quality was controlled. Accuracy was tested by supplementing a sample with an ADA solution. The measured difference of ADA was close to the calculated one. The within-run and between-run precision of the method was sufficient. The detection limit was 1 U/l. ADA measurements were set in relation to a canine plasma pool and expressed as a percent to achieve reproducibility due to the lack of a commercial ADA standard. Body cavity effusions of 156 dogs were examined. The ADA of neoplastic effusions and the ADA of cardiac congestive effusions differed highly significantly (p < 0.001) in pleural and in peritoneal effusions. A discrimination value of 60% for pleural and a discrimination value of 100% ADA for peritoneal effusions separated neoplastic from cardiac congestive effusions. ADA determination in the serum of dogs did not contribute to the etiological differentiation of effusions. The elevation of ADA seemed to originate from the effusion, because the ratio of ADA (effusion/serum) was relatively high in cases of canine neoplasia. In this analysis the ADA in body cavity effusions of dogs was determined for the first time.

Tuberculous peritonitis in an endemic area

BACKGROUND

Tuberculous peritonitis is a fatal disease if not diagnosed in time.

AIMS

To identify the clinical, laboratory, and diagnostic features of tuberculous peritonitis in Iranian patients.

PATIENTS

Included in the study were all cases of tuberculous peritonitis with a definite diagnosis confirmed by pathology in four referral University Hospitals in Tehran between 1989 and 1999.

METHODS

All clinical, laboratory, and radiological findings as well as invasive procedures were reviewed.

RESULTS

A total of 50 patients (30 female, 20 male), mean age 33.5 years were studied. Main presenting symptoms included abdominal pain (84%), weight loss (72%) and fever (50%). In 24% of patients a positive tuberculin test was found. Erythrocyte sedimentation rate >50 mm/h was detected in 60% of patients and 4.4% had an Erythrocyte sedimentation rate >100 mm/h. Laparoscopy or laparotomy showed peritoneal seeding in 74% of patients.

CONCLUSIONS

Exudative ascites should give rise to clinical suspicion of tuberculous peritonitis in endemic areas or in immigrants from endemic areas. Laparoscopy is the most sensitive and specific diagnostic method.

The possible role of cerebrospinal fluid adenosine deaminase activity in the diagnosis of tuberculous meningitis in adults

We studied an adenosine deaminase (ADA) activity in the cerebrospinal fluid (CSF) of 182 patients with meningitis. The patients were subdivided into four groups, (1) 36 cases of tuberculous meningitis; (2) 130 cases of viral or aseptic meningitis; (3) nine cases of bacterial meningitis; (4) seven cases of cryptococcal meningitis. Mean+/-S.D. ADA activity was 12.76+/-7.53 U/l in group 1; 2.58+/-2.37 U/l in group 2; 7.38+/-3.27 U/l in group 3; 7.42+/-4.38 U/l in group 4. Comparing the ADA activity in each group with the other groups, the difference is significant (P<0.001), except between groups 3 and 4. The sensitivity of the test for group 1 compared with group 2 was 0.83 and the specificity was 0.95 when a cut-off value of 7 U/l was used. When group 1 was compared with groups 3 and 4, the sensitivity was 0.58 and the specificity was 0.89 and 0.71 with groups 3 and 4, respectively, when a cut-off value of 10 U/l was used. Values >15 U/l were not observed in any of the non-tuberculous meningitis patients; therefore, ADA activity >15 U/l could be a strong indication of tuberculous meningitis. We conclude that a determination of CSF ADA can aid in the early differential diagnosis of tuberculous meningitis.

The use of adenosine deaminase as a diagnostic tool for peritoneal tuberculosis

SETTING

Tygerberg Hospital, an academic hospital in the Western Cape, South Africa.

OBJECTIVE

To determine the diagnostic utility of ascitic fluid adenosine deaminase (ADA) in the diagnosis of tuberculous peritonitis.

DESIGN

A prospective study, carried out from February 1995 to February 1998, resulted in 178 paired ascites and serum specimens being collected from adult patients. Specimens were evaluated for biochemistry, ADA, microbiology and cytology; further investigations were done at the treating clinician's discretion. Diagnoses were made according the pre-determined criteria.

RESULTS

The median (range) ADA activity in the tuberculous group was 61.6 (17.5--115.0) U/L and was significantly higher than in any other diagnostic group (p<0.05). Using ROC curves, a cut-off level of 30 U/L for the diagnosis of tuberculous peritonitis was found to yield the best results; corresponding sensitivity and specificity was 94% and 92%, respectively. No statistically significant difference in ADA activity was observed when tuberculous ascites occurred in the absence or presence of cirrhosis.

CONCLUSIONS

Ascitic fluid ADA activity is useful in identifying those patients in whom the diagnosis of tuberculous peritonitis should be actively pursued to justify its routine use, at least in areas such as South Africa where TB is endemic. The presence or absence of underlying cirrhosis does not appear to distract from its diagnostic utility.

Tuberculous peritonitis--reports of 26 cases, detailing diagnostic and therapeutic problems

OBJECTIVE

To evaluate the clinical presentation, biochemical (ascites and serum) and laparoscopic findings, and to assess the efficacy of triple antituberculous therapy without rifampicin for 6 months in patients with tuberculous peritonitis.

METHODS

Twenty-six tuberculous peritonitis patients (11 male, 15 female) with a mean age of 34.8 +/- 3.4 years (range 14-77) were assessed with regard to diagnostic and therapeutic features.

RESULTS

The most common symptoms and signs were abdominal pain (92.3%) and ascites (96.2%), respectively. Tuberculin skin test (TST) was positive in all patients. An abnormal chest radiography suggestive of previous tuberculosis was present in five patients (19.2%), and two patients (7.7%) had extra-peritoneal (cerebral, pericardial) active tuberculous involvement. In 24 of the 25 patients who underwent laparoscopy with directed biopsy, whitish nodules suggested tuberculous peritonitis; 76% of the biopsy specimens revealed caseating, 20% non-caseating granulomatous inflammation, and 4% non-specific findings. The ascitic fluid of one patient (3.8%) was positive for acid-resistant bacilli, and culture was positive in two patients (7.7%). Twenty-four of the patients were treated for 6 months with isoniazid, streptomycin (total dose 40 g) and pyrazinamide (for the first 2 months and then substituted with ethambutol). Eighteen patients also received methyl prednisolone, initially 20 mg/day, for 1 month. The follow-up period was 19 +/- 1.7 months after the end of therapy (range 6-36). Ascites and abdominal pain abated earlier in patients on steroid therapy. All but two of the 24 patients responded to treatment.

CONCLUSION

Non-invasive tests such as acid-fast stain and culture of the ascitic fluid are usually insufficient, hence invasive laparoscopy and peritoneal biopsy are necessary for the diagnosis of tuberculous peritonitis if non-invasive tests such as ascites adenosine deaminase activity measurement are not easily available. Triple therapy without rifampicin for 6 months is sufficient to treat tuberculous peritonitis.

Tuberculous peritonitis defying diagnosis: report of a case

A case of tuberculous peritonitis, which has been scarcely encountered in clinical practice in recent years, is reported. A 32-year-old man was admitted to our hospital complaining of abdominal fullness, anorexia, and a 15 kg weight loss. His abdomen was distended. There was neither any previous history nor recent contact with tuberculosis. The laboratory data indicated increased C-reactive protein and erythrocyte sedimentation rate, but the white blood cell count was normal. A chest X-ray examination revealed no abnormalities. Abdominal X-ray showed scattered, small-intestinal gas shadows. Abdominal computed tomography scanning revealed a diffuse thickening of the dilated bowel wall, mainly adjacent to the mesentery. After a detailed examination a diagnosis of peritonitis carcinomatosa of unknown origin was suspected, and an exploratory laparotomy was done. Severe adhesions between the parietal peritoneum and the bowel were found. An excisional biopsy specimen was taken from the peritoneum, and a diagnosis of tuberculosis was thus made. Triple therapy with isoniazid, rifampicin, and kanamycin was started, and both the intestinal obstruction and anorexia were thus resolved.

The comparison of adenosine deaminase activity values with polymerase chain reaction results in patients with tuberculosis

Three methods in the diagnosis and treatment of tuberculosis have been compared in this study. Serum adenosine deaminase activities of patients with tuberculosis was compared with those of control groups with (+) and (-) PPD (purified protein derivative) results and were found to be higher than the controls. Within the controls the PPD (+) group displayed higher adenosine deaminase activities in comparison to the PPD (-) group. All patients had growth of B. Tuberculosis in the culture medium and all but one had positive polymerase chain reaction (PCR) results. Control patients were negative for culture and PCR. The sensitivity of ADA (adenosine deaminase) assay was 91.7% and specificity was 94.5%, whereas PCR had a sensitivity of 95.8% and a specificity of 100%. The ADA assay may be used in adjunction with other methods in the follow-up of tuberculosis with high sensitivity, specificity, and ease in applicability and specimen collection.

Abdominal tuberculosis in Ahmadi, Kuwait: a clinico-pathological review

For studying abdominal tuberculosis (TB) in Ahmadi, files off all patients admitted to our hospital with abdominal TB over 15 years (1981-1996) were reviewed. Nineteen patients are reported here. Young adults were predominant in our study. The non-Arab Asians were the most frequently affected group in relation to their population in Ahmadi, and Kuwaitis were the least frequently affected group. Abdominal pain, sweating, anorexia and fever were the most frequent presenting symptoms. Ascites and intestinal obstruction were the most frequent clinical presentations. Two patients presented with acute appendicitis and one patient had tuberculous pancreatitis. Abdominal lymph nodes, peritoneum, ileum and and caecum were the most frequently affected abdominal structures. We found laparoscopy very helpful in diagnosis of abdominal TB and we recommend it as the diagnostic method of choice. All our patients responded well to antituberculous chemotherapy. It should be kept in mind that abdominal TB still affects the indigenous and expatriate population of Kuwait.

Diagnostic features of tuberculous peritonitis in the absence and presence of chronic liver disease: a case control study

PURPOSE

To determine diagnostic features of tuberculous peritonitis (TBP) in the absence and presence of chronic liver disease.

PATIENTS AND METHODS

Thirty-four patients with TBP (13 without [Group I] and 21 with chronic liver disease [Group II] and 26 controls with cirrhosis and uninfected ascites (Group III) were studied.

RESULTS

The clinical features in Groups I and II were similar and all patients had elevated ascitic fluid total mononuclear cell count. In Groups I, II, and III, respectively, ascitic fluid protein was > 25 g/L in 100% (13/13), 70% (14/20), and 0% (0/26); serum-ascites albumin gradient (SAAG) was > 11 g/L in 0% (0/13), 52% (11/21), and 96% (25/26), (0% [0/13], 71% [15/21], and 96% [25/26] after correction for serum globulin); and ascitic fluid lactate dehydrogenase (LDH) level was > 90 U/L in 100% (12/12), 84% (16/19), and 0% (0/20), respectively. In Groups I and II combined, ascitic fluid acid-fast stain was negative in all but Mycobacterium tuberculosis culture was positive in 45% (10/22); peritoneal nodules occurred in 94% (31/33), granulomas in 93% (28/30), and positive peritoneal M tuberculosis culture in 63% (10/16).

CONCLUSIONS

In patients with suspected TBP, ascitic fluid protein of > 25 g/L, SAAG of < 11 g/L and LDH of > 90 U/L have high sensitivity for the disease. With coexistent chronic liver disease, a lower protein level and higher SAAG are usually not helpful but LDH > 90 U/L is a useful parameter for screening. Diagnosis is best confirmed by laparoscopy with peritoneal biopsy and M tuberculosis culture.

Validation of the determination of the activity of adenosine deaminase in the body effusions of cats

In order to identify parameters differentiating exudative from transudative effusions, it was postulated that the activity of adenosine deaminase (AD) (EC 3.5.4.4) might be highly correlated with granulomatous inflammatory processes of the serosa, and the activity of the enzyme in body effusions and serum from cats was examined. The method of Slaats et al (1985) for the determination of the enzyme was evaluated by using an Hitachi 705 autoanalyser, and its activity was measured in body cavity effusions of 174 cats. The activity of AD was high in effusions from cats with infectious serositis and bacterial or feline infectious peritonitis (FIP). In cases of FIP the activity of AD was very significantly different from all other cases of thoracic (P = 0.004) and abdominal (P < 0.0001) effusions. The determination of AD in the serum of cats did not contribute to the aetiological differentiation of hydrops. The increases in the activity of AD appeared to originate from the body effusion, because the ratio of the activity of the enzyme in the effusion to its activity in serum was relatively high in cases of FIP.

The value of adenosine deaminase (ADA) determination in the diagnosis of tuberculous ascites

In order to evaluate the role of the determination of adenosine deaminase activity (ADA) in ascitic fluid for the diagnosis of tuberculosis, 44 patients were studied. Based on biochemical, cytological, histopathological and microbiological tests, the patients were divided into 5 groups: G1-tuberculous ascites (n = 8); G2-malignant ascites (n = 13); G3-spontaneous bacterial peritonitis (n = 6); G4-pancreatic ascites (n = 2); G5-miscelaneous ascites (n = 15). ADA concentration were significantly higher in G1 (133.50 +/- 24.74 U/l) compared to the other groups (G2 = 41.85 +/- 52.07 U/l; G3 = 10.63 +/- 5.87 U/l; G4 = 18.00 +/- 7.07 U/l; G5 = 11.23 +/- 7.66 U/l). At a cut-off value of > 31 U/l, the sensitivity, specificity and positive and negative predictive values were 100%, 92%, 72% and 100%, respectively. ADA concentrations as high as in tuberculous ascites were only found in two malignant ascites caused by lymphoma. We conclude that ADA determination in ascitic fluid is a useful and reliable screening test for diagnosing tuberculous ascites. Values of ADA higher than 31 U/l indicate more invasive methods to confirm the diagnosis of tuberculosis.

Diagnosing ascites: value of ascitic fluid total protein, albumin, cholesterol, their ratios, serum-ascites albumin and cholesterol gradient

Ascitic fluid total protein, albumin, cholesterol, their ascites/serum ratios, serum-ascites albumin and cholesterol gradients were measured for their ability to differentiate cirrhotic, malignant and tuberculous ascites in 76 patients. The mean +/- s.d. ascitic fluid total protein, albumin, cholesterol, their respective ascitic fluid/serum ratios in cirrhotic ascites were lower than malignant and tuberculous groups (P < 0.001 for each). The difference between malignant and tuberculous groups was significant for ascitic fluid/serum total protein (P < 0.05) and ascitic fluid/serum albumin (P < 0.01) only. Mean serum-ascites albumin gradient in cirrhotics was higher than in the malignant and tuberculous groups (P < 0.001 for each). The difference between malignant and tuberculous groups was significant (P < 0.01). Mean +/- s.d. serum-ascites cholesterol gradient in cirrhotics was higher than that in malignant and tuberculous groups (P < 0.001 for each). The difference between malignant and tuberculous groups was also significant (P < 0.01). Both serum/ascitic fluid total protein less than 0.5 and ascitic fluid cholesterol less than 55 mg/dL had 94% diagnostic accuracy for differentiating cirrhotic from malignant and tuberculous differentiating cirrhotic from malignant and tuberculous ascites. Serum ascitic fluid albumin gradient greater than 1.1 g/dL, ascitic fluid/serum albumin less than 0.65 and ascitic fluid albumin less than 2 g/dL had diagnostic accuracy of 92, 92 and 91%, respectively. Ascitic fluid total protein had diagnostic accuracy of 88%. None of the tests was able to differentiate between malignant and tuberculous ascites. Measurement of ascitic fluid cholesterol concentration is a simple method of differentiating cirrhotic from non-cirrhotic ascites.

Ascitic fluid gamma interferon concentrations and adenosine deaminase activity in tuberculous peritonitis

The gamma interferon (gamma-IFN) concentration and the adenosine deaminase (ADA) activity were evaluated in 30 patients with tuberculous peritonitis, 21 patients with ascites due to a malignant disorder, and 41 patients with cirrhosis. The gamma-IFN concentrations were significantly higher (p < 0.0001) in tuberculous peritonitis patients (mean: 6.70 U/ml) than in the malignant (mean: 3.10 U/ml) and cirrhotic (mean: 3.08 U/ml) groups. Use of a cut off value of > or = 3.2 U/ml gave the assay a sensitivity of 93% (25 of 27), a specificity of 98% (54 of 55), positive (P+) and negative (P-) predictive values of 96% and a test accuracy of 96%. The ADA activity was significantly (p < 0.0001) higher in the tuberculous peritonitis group (mean: 101.84 U/l) than in the control groups (cirrhosis (mean: 13.49 U/l) and malignancy (mean: 19.35 U/l)). A cut off value of > 30 U/l gave the ADA test a sensitivity of 93% (26 of 28) a specificity of 96% (51 of 53), a (P+) value of 93%, a (P-) value of 96%, and a test accuracy of 95%. There was a significant (p < 0.0001) correlation (r = 0.72) between ADA activity and gamma-IFN values in patients with tuberculous peritonitis. These results show that a high concentration of gamma-IFN in ascitic fluid is as valuable as the ADA activity in the diagnosis of tuberculous peritonitis. Both are rapid non-invasive diagnostic tests for tuberculous peritonitis.

Increased CA 125 in a patient with tuberculous peritonitis: case report and review of published works

A case of a middle aged woman with weight loss, ascites, and a pleural effusion is presented where a clinical diagnosis of ovarian cancer was made. Her CA 125 was greatly increased at 873 IU/ml and the ascites was a lymphocytic exudate but cytology failed to show malignant cells. Operative biopsy showed numerous noncaseating granulomas in the omentum but no mycobacterial organisms were seen. Empiric antituberculous treatment was started before positive culture results were received and when treatment had ended both the ascites and pleural effusion had resolved and the CA 125 had fallen to 7 IU/ml. Review of published works showed several other examples of tuberculous peritonitis associated with increased CA 125 and the possible cause of raised CA 125 in this condition is discussed.

The role of laparoscopy in the evaluation of ascites of unknown origin

The role of laparoscopy in the diagnostic evaluation of ascites of unknown origin was studied in 129 patients. Laparoscopic results were as follows: (1) Carcinomatosis peritonei in 78 (60.5%). Peritoneal biopsies in 76 of these cases revealed malignancy in 67 (adenocarcinoma 62, lymphoma 4, mesothelioma 1) and tuberculosis in 5; specimens were inadequate for diagnosis in 4. (2) Tuberculous peritonitis in 26 (20.2%). Peritoneal biopsies in 24 of these cases revealed tuberculosis in 22 and non-specific chronic peritonitis in 2. (3) Cirrhosis in 7 (5.4%). (4) No gross abnormality in 18 (14.0%). Of the latter, causes of ascites had already been identified in 13 (72.2%), including chronic renal failure in 7, systemic lupus erythematosus in 2, constrictive pericarditis in 2, chronic pancreatitis with chylous ascites in 1, and retroperitoneal lymph node metastasis with chylous ascites in 1. Thus, laparoscopic observation in combination with biopsy established the cause of ascites of unknown origin in 111 (86.0%) of 129 patients. Most of the 18 patients without gross laparoscopic abnormality had underlying disease identified as a cause of ascites; laparoscopy was indicated in these cases to exclude other processes that may also cause ascites.

Abdominal tuberculosis

The abdomen is involved in 10% to 30% of patients with pulmonary tuberculosis. The diagnosis is not difficult in societies where the disease is common and clinicians are aware of it. While previously rare in Western countries, the incidence is now rising among immigrants, and patients with AIDS. In HIV-infected patients, the disease is of a rapidly progressive nature, often fatal through usually treatable, but the diagnosis is difficult and often delayed. Treatment is essentially medical but occasionally surgical operation is necessary.

Pleural fluid adenosine deaminase and lymphocyte proportion: clinical usefulness in the diagnosis of tuberculosis

Adenosine deaminase (ADA) and lymphocyte proportion are known to be independently elevated in tuberculous effusions, but are non-specific, and false positive results are frequent. To overcome this problem the combined use of both parameters was prospectively studied in 276 patients with pleural effusion seen at Porto Alegre, Brazil. Using a cut-off level of 40 U/l at 37 degrees C (method of Giusti19) for ADA activity and lymphocyte proportion of more than 50%, the correct diagnosis of tuberculosis (sensitivity) was made in 90.7% (CI 87.3-94.1%) of 54 patients. A specificity of 97.7% (CI 95.9-99.5%) was recorded. Five false positive diagnoses of tuberculous effusion were made. Five false negative diagnoses were made: three cases with haematogenous tuberculous dissemination with low ADA levels, and two other patients with low lymphocyte proportion. The combined use of ADA activity determination and lymphocyte proportion is a highly efficient diagnostic strategy of low cost, that merits wider use.

A radiological study of abdominal tuberculosis in a Saudi population, with special reference to ultrasound and computed tomography

The radiological appearances of abdominal tuberculosis are presented, which includes peritoneal, liver, spleen and pancreatic disease, but excludes renal and musculoskeletal involvement. Twenty-three patients were studied, 12 of whom had TB peritonitis. Barium studies remain valuable in gastrointestinal tract disease but for peritoneal, splenic, hepatic and pancreatic disease, ultrasound and computed tomography are indicated. Their diagnostic value is further enhanced by guided aspiration and biopsy techniques.

Diagnostic value of ascites gamma interferon levels in tuberculous peritonitis. Comparison with adenosine deaminase activity

The value of ascites gamma interferon concentration and ascites adenosine deaminase activity in distinguishing tuberculosis from other causes of ascites was examined in a prospective study of 86 patients with ascites, including 16 with tuberculous peritonitis. Gamma interferon concentration was higher in tuberculous peritonitis than in the other causes of ascites (p less than 0.0001), and a cut-off between 3 and 9 u/ml reached a sensitivity and a specificity of 100%. The mean (+/- SD) gamma interferon level in tuberculous ascites was 39.3 +/- 18.3 u/ml in patients seronegative for HIV and 14.2 +/- 4.7 u/ml in patients with AIDS (p = 0.01). Adenosine deaminase activity in tuberculous ascites was also higher than in the other causes of ascites (p less than 0.0001), and a cut-off of 40 u/l reached a sensitivity of 100% and a specificity of 97%. The two false positives for adenosine deaminase test were true negatives for the gamma interferon test. There was no significant correlation between gamma interferon concentration and adenosine deaminase activity either in tuberculous ascitis or in any other group. This study suggests that ascites gamma interferon determination may be very useful in the screening of tuberculous peritonitis, but its cost makes it advisable to use adenosine deaminase activity as a routine test, at least in areas where tuberculosis is endemic.

Adenosine deaminase (ADA) in peritoneal tuberculosis: diagnostic value in ascitic fluid and serum

Simultaneous determination of ascitic fluid and serum adenosine deaminase (ADA) activity was evaluated as a diagnostic aid in peritoneal tuberculosis. The ascites was due to peritoneal tuberculosis (group 1), cirrhosis of the liver (group 2), cirrhosis of the liver with spontaneous bacterial peritonitis (group 3), peritoneal malignancy (group 4), Budd-Chiari Syndrome (group 5) and miscellaneous conditions (group 6). Serum from patients of pulmonary tuberculosis and healthy volunteers was analysed for enzyme activity. In patients with peritoneal tuberculosis the ascitic fluid and serum ADA activity was significantly higher than for the other groups (P less than 0.001). Levels above 36 u/l in ascitic fluid and above 54 u/l in the serum suggest tuberculosis. The ascitic fluid/serum ADA ratio was also higher in patients with peritoneal tuberculosis than with other causes of ascites (P less than 0.01). A ratio of more than 0.984 was suggestive of tuberculosis.

Diagnostic value of ascites adenosine deaminase in tuberculous peritonitis

The value of ascitic fluid adenosine deaminase activity in distinguishing tuberculosis from other causes of ascites was examined in a retrospective study of 41 patients with bacteriologically confirmed tuberculous peritonitis and 41 control patients, matched for age and sex, with ascites of other causes (12 alcoholic cirrhosis, 5 cryptogenic cirrhosis, 12 malignant disorders, 3 pancreatitis, and 9 miscellaneous causes). The mean ascites adenosine deaminase activity was 99.8 (SD 49.1) in tuberculous patients and 14.8 (8.4) U/l in control patients (p less than 0.0001). A cutoff of 32.3 U/l had a sensitivity of 95% and specificity of 98% in distinguishing between the two groups. In a subsequent prospective study of 64 patients with ascites, 11 were found to have tuberculosis. Of the others, 23 had cirrhosis (18 alcoholic, 5 cryptogenic), 17 malignant disorders, 3 pancreatitis, 5 cor pulmonale, 3 congestive cardiac failure, 1 systemic mastocytosis, and 1 renal failure and hypothyroidism. The mean ascites adenosine deaminase activity was 112.6 (45.0) U/l in the patients with tuberculous ascites and 16.3 (36.7) U/l (p less than 0.0001) in those with ascites of other causes. In this study, adenosine deaminase had a sensitivity of 100% and specificity of 96% in discriminating tuberculosis from other causes of ascites. These findings suggest that the ascitic fluid adenosine deaminase activity may be used to identify patients in whom the diagnosis of abdominal tuberculosis must be pursued.