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Communications to the Editor |

Adenosine Deaminase Levels in Nontuberculous Lymphocytic Pleural Effusions FREE TO VIEW

José Manuel Porcel, MD, FCCP; Manuel Vives, MD
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University Hospital Arnau de Vilanova Lleida, Spain

Correspondence to: José Manuel Porcel, MD, FCCP, Department of Internal Medicine, University Hospital Arnau de Vilanova, Alcalde Rovira Roure 80, 25198 Lleida, Spain; e-mail: jporcelp@medynet.com



Chest. 2002;121(4):1379-1380. doi:10.1378/chest.121.4.1379
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To the Editor:

We would like to support the points raised in the otherwise excellent article in CHEST by Lee et al (August 2001)1 with a larger series of patients. Those authors stated that adenosine deaminase (ADA) levels in patients with nontuberculous lymphocytic effusions seldom exceeded the diagnostic cutoff for tuberculous pleurisy. Thus, only two patients with lymphomas and one with a complicated parapneumonic effusion (2.8%) among 106 patients with lymphocytic effusions had ADA levels of > 40 U/L. This percentage remained practically unmodified (3.6%) if only exudates (n = 82) were considered.

We reviewed the medical records of 293 patients whose pleural fluid data showed a level of > 50% of lymphocytes, after convincingly excluding their tuberculous origin. The study was conducted at a 480-bed teaching hospital in Lleida, Spain, during the last 7 years. The clinical diagnoses of the patients were defined by known predetermined criteria.1Specifically, transudates and exudates were defined by the criteria of Light et al,2 and the categorization of pleural fluid as malignant relied on either a positive result of cytology or biopsy specimen testing or a known cancer without an alternative explanation for the effusion. The final diagnoses of pleural effusions were as follows: malignancy (139 patients); transudates (86 patients); parapneumonic (2 patients); pericardial disease (19 patients); abdominal surgical procedures (10 patients); pulmonary embolism (6 patients); trauma (5 patients); Dressler syndrome (4 patients); connective tissue diseases (3 patients); and postcoronary artery bypass surgery (1 patient). The primary tumors in the malignant group included the following: lung (54 patients); breast (31 patients); lymphoma (13 patients); ovary (12 patients); and miscellaneous (29 patients). In our hospital, ADA activity is determined by Giusti’s colorimetric method, with 40 U/L serving as the cutoff for the identification of tuberculous effusions. Eight patients (2.7%) in our population surpassed this cutoff as follows: non-Hodgkin lymphomas, three patients (ADA levels, 67.5, 46, and 45.9 U/L); acute lymphoid leukemia, one patient (ADA level, 346 U/L); colorectal cancer, one patient (ADA level, 47.1 U/L); small cell lung cancer, one patient (ADA level, 45.9 U/L); and uncomplicated parapneumonic effusions, two patients (ADA levels, 58.9 and 40.5 U/L). If we excluded transudates, the percentage of false-positive elevations was raised insignificantly (3.9%).

In conclusion, our findings are nearly identical to those reported by Lee et al,1 namely, that false-positive elevation is rare (ie, < 4%) when the criterion of ADA levels is applied to lymphocytic exudates only. Due to its high sensitivity and specificity, measurement of the pleural fluid ADA level is an excellent test both for ruling out and ruling in a suspected diagnosis of tuberculous effusion, at least in areas with a high prevalence of tuberculosis.,34

Lee, YCG, Rogers, JT, Rodriguez, RM, et al (2001) Adenosine deaminase levels in nontuberculous lymphocytic pleural effusions.Chest120,356-361. [PubMed] [CrossRef]
 
Light, RW, Macgregor, MI, Luchsinger, PC, et al Pleural effusions: the diagnostic separation of transudates and exudates.Ann Intern Med1972;77,507-513. [PubMed]
 
Roth, BJ Searching for tuberculosis in the pleural space.Chest1999;116,3-5. [PubMed]
 
Kataria, YP Adenosine deaminase in the diagnosis of tuberculous pleural effusion.Chest2001;120,334-336. [PubMed]
 

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References

Lee, YCG, Rogers, JT, Rodriguez, RM, et al (2001) Adenosine deaminase levels in nontuberculous lymphocytic pleural effusions.Chest120,356-361. [PubMed] [CrossRef]
 
Light, RW, Macgregor, MI, Luchsinger, PC, et al Pleural effusions: the diagnostic separation of transudates and exudates.Ann Intern Med1972;77,507-513. [PubMed]
 
Roth, BJ Searching for tuberculosis in the pleural space.Chest1999;116,3-5. [PubMed]
 
Kataria, YP Adenosine deaminase in the diagnosis of tuberculous pleural effusion.Chest2001;120,334-336. [PubMed]
 
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