Diagnostic Value of Adenosine Deaminase (ADA) in Ascitic Fluid for Peritoneal Tuberculosis: an Evidence-based Case Report

Author : dr. Juliyanti Chief of Ward: dr. Mulia Supervisor: dr. Nadia Ayu Mulansari, SpPD

Introduction

Tuberculosis causes some 2 million deaths per year world wide and is increasing in incidence in developed and developing countries. The peritoneum is the sixth most common extra pulmonary site. The reported incidence of peritoneal TB among all forms of TB varies from 0.1% to 0.7% worldwide and it can be expected to increase with the increasing incidence of TB worldwide.

Peritoneal tuberculosis

Usually results from the reactivation of latent TB in peritoneal foci that were established after hematogenous spread from a primary lung focus. Manifested as ascites of insidious onset, abdominal pain and fever. The non-specific symptoms associated with PTB and its challenging clinical course can interfere with a definitive diagnosis, and TB peritonitis is often confused with other intra-abdominal diseases. Delayed diagnosis increases the morbidity and mortality of PTB.

Diagnosis of PTB

Diagnostic tests for PTB are difficult and time-consuming because of paucity of M. tuberculosis in peritoneal fluid. It requires histological confirmation of caseous granulomas or bacteriological confirmation, by using ascitic fluid-derived acidfast bacilli (AFB) smears as well as cultures for M. tuberculosis. Cultures for M. tuberculosis require 4 weeks and AFB smears are too insensitive to meet current needs. A laparoscopy-guided biopsy can be used to obtain a rapid diagnosis of PTB; however it is associated with risks related to anesthesia and potential injury and bleeding.

Adenosine deaminase (ADA)

ADA is a purine-degrading enzyme that catalyses the deamination of adenosine, resulting in the production of inosine ADA is widely distributed in tissues and body fluids, and its levels can be used to differentiate T cells from B cells; ADA levels are 1012 times higher in T cells than in B cells; its level vary with the proliferative status and the maturity of cells. ADA is increased in tuberculous ascitic fluid because of the stimulation of T cells by the mycobacterial antigens. Its levels in body fluids can be measured rapidly, provide an alternative for the diagnosis of TB.

Case resume

Female, 51 years old, with chief complaint of progressive abdominal swelling since 2 months prior to admission.

She had abdominal pain occasionally, malaise, anorexia and weight loss but had no history of night sweat or fever.
She had no history of prior liver disease or alcoholic abuse, denied symptoms of dyspnea, cough, chest pain or leg swelling She was diagnosed with diabetes mellitus and hypertension since 3 years before and was regularly on lisinopril and metformin. She was non-smoker, menopause 6 years ago and had no complaint of vaginal bleeding.

Case resume (2)

Physical examination revealed normal vital sign, dullness

on percussion of left lower thorax with decreased breath sound, positive shifting dullness on abdomen, no stigmata of hepatic cirrhosis and no peripheral edema. elevated ESR, moderate hyponatremia, hyperglycemia, normal kidney and liver function test, elevated CA 125 level (537 U/mL), normal albumin and increased globulin. Serological test for HIV, hepatitis B and C were negative. Fecal and urine analysis were normal

Laboratory result showed leukocytosis, thrombocytosis,

Case resume (3)

Chest x-ray revealed left sided pleural effusion with no

sign of parenchymal involvement. Abdominal ultrasounds showed free peritoneal fluid with no significant finding in abdominal viscera. An abdominal CT scan showed abundant free fluid but no other sign of abnormality. Gynecological study revealed normal result except adhesive fibrin on ascitic fluid.
yellowish ascitic fluid was obtained that contained 1650 cells/ul, 99.9 % of which were mononuclear cells (lymphocyte). LDH was very high, proteins were increased, serum-asites albumin gradient was < 1,1 g/dl (0,5 g/dl) and A Ziehl-Neelsen stain was negative. Ascitic ADA level was high (107,1 U/L).

A diagnostic paracentesis was carried out, and a clear

Formulate clinical question

In practice, we are facing with diagnostic problem of this patient with exudative asites and lymphocyte predominant pleiocytosis her ascitic fluid that suggestive a peritoneal tuberculosis but ascitic fluid revealed negative for AFB Gold standard for diagnosis of PTB either time consuming or invasive, so we tried to find other rapid diagnostic tool

We were informed that ADA level can be used to determine whether her ascites was due to TB infection or not, but we still did not know about the accuracy of this assay
Therefore, we formulate clinical question: What is the value of ascitic fluid ADA for the diagnosis of peritoneal tuberculosis?

Searching the evidence

Result
5 articles included:

Riquelme et al, 2006

Saleh et al, 2012 Sharma et al, 2006 Burgess et al, 2001 Sathar et al, 1995

Meta-analysis was appraised using Q-FAST tool Other 4 prospective studies was appraised for its

VIA

Critical appraisal
Item Q-question F-finding Summary of Riquelme et al, 2006 The study was based on clear clinical question and it is similar to ours Inclusion criteria and search methods are stated in the methods section, inclusion criteria were based on the clinical question. A primary search of the literature was conducted including MEDLINE (PubMed) and hand searching, no limits regarding language 4 prospective studies were included in the meta-analysis

A-appraise

Individual prospective studies were critically appraised by two independent reviewers, agreement between reviewers for article selection was measured as kappa coefficient of only 0.43 (moderate), probable due to small number of selected articles.

S-synthesis

The paper includes a clear summary table of the included studies and heterogeneity analysis was done. Four individual studies were homogen.

T-transferability

The result of study was applicable on our patient because similarity in the domain, determinant and outcome.

Validity
Study Independent and blind comparison Appropriate spectrum of patient Reference standard ascertained regardless of the index test result

Saleh et al, 2012 Sharma et al, 2006

Yes Yes

Yes Yes

Yes Yes

Burgess et al, 2001

Sathar et al, 1995

Yes
Yes

Yes
Yes

Yes
Yes

Importance
Study N Best ROC curve cut-off ADA value (IU/L) AUC Sn (%) Sp (%) LRs (+) PPV (%) NPV (%)

Riquelme, et al Saleh et al, 2012 Sharma et al, 2006

264 41 119

39 35 37

0.99 0.99 0.98

100 100 97

97 92,6 94

26.8 N/A N/A

N/A 87,5 N/A

N/A 100 N/A

Burgess et al, 2001

178

30

0.92

94

92

N/A

57

99

Sathar et al, 1995

92

30

0.95

93

96

N/A

93

96

Applicability
Study The test is available, affordable, accurate and precise in our setting Ability to generate an estimate of patients pre-test probability The resulting post-test probabilities will affect management and help patient

Saleh et al, 2012 Sharma et al, 2006

Yes Yes

Yes Yes

Yes Yes

Burgess et al, 2001

Yes

Yes

Yes

Sathar et al, 1995

Yes

Yes

Yes

Discussion

All studies agreed that ADA is increased in tuberculous ascitic fluid because of the stimulation of T cells by the mycobacterial antigens, sensitivity and specificity levels over 90% have been reported in all studies. We admit that we might have missed relevant articles, we excluded all hits that were not in English publication and not available with full text on the Internet, which can be a negative contributor. When applying the results of best available evidence to our patient, we have to consider that the meta-analysis included population from Chile and India, where a higher frequency of TB was observed and was similar to ours, where TB is endemic. Therefore, we can extrapolate the result on our patient.

Discussion
Our patient with clinical

features suggestive of PTB, has a 50% pretest probability of having PTB. an ADA level of 107 IU/L (>39, LR+ 26.8) she therefore has a 96 % posttest probability of having PTB.

If the ascites fluid study shows

The clinical relevance of this

test is evident ever because it may avoid the need to confirm the diagnosis with invasive techniques such as laparoscopy.

Discussion
Then, we decide to treat our patient with a 4-drug

combination of anti-tuberculosis.

However, the CDC in United State insists the need

of a sensitivity in vitro test in every patient with PTB to determine the epidemiology of MTB.

It is known that even using the most advanced

techniques to isolate the Mycobacterium, the rate of positive test is still low and we consider ADA activity is a practical and useful approach to make therapeutic decision in patients suspected PTB.

Discussion
After 8 weeks of anti-tuberculosis treatment, on

the follow up of our patient, she recovered from constitutional symptoms and her abdominal circumference was reduced from 112 cm to 102 cm.
anti-tuberculosis drugs that consist of 2 months of initial phase and 7 months of continuation phase.

She was planned to have a 9-month course of

Conclusion
Measurement of an ascitic ADA activity yields a high

rate of diagnostic accuracy for PTB and it is an easy available test.

It may help clinicians to decide whether or not to treat

patients with ascites who clinically suspicious for PTB. value in ascitic fluid seems to be a good approach while waiting for the results of cultures or biopsies. diagnostic work-up of patients with suspected PTB.

To start empirical treatment on a patient with high ADA

We do recommend the utilization of this test in the

Thank you