Ascitic fluid adenosine deaminase insensitivity in detecting tuberculous peritonitis in the United States

✍ Scribed by D J Hillebrand; B A Runyon; W G Yasmineh; G P Rynders

• Publisher: John Wiley and Sons
• Year: 1996
• Tongue: English
• Weight: 155 KB
• Volume: 24
• Category: Article
• ISSN: 0270-9139
• DOI: 10.1002/hep.510240617

✦ Synopsis

rently available ascitic fluid diagnostic tests are insensitive Tuberculous peritonitis, although common in Third in diagnosing tuberculous peritonitis. Culture of ascitic fluid World countries, remains an uncommon cause of ascites or culture of peritoneum obtained at laparoscopy is the gold in the United States. Ascitic fluid adenosine deaminase standard for the diagnosis of tuberculous peritonitis. 19 How-(ADA) activity has been proposed as a useful diagnostic ever, several weeks are usually required before the culture test. The aim of this retrospective study was to deterdemonstrates growth of mycobacteria. The high mortality mine the clinical utility of ascitic fluid ADA activity in rate in untreated patients (e.g., 50% in the prechemotherapy diagnosing tuberculous peritonitis in a U.S. patient popera) warrants a continued search for a rapid noninvasive ulation. A total of 368 ascitic fluid specimens from a wellscreening test for tuberculous peritonitis. characterized ascitic fluid bank, including tuberculous Adenosine deaminase (ADA) is an enzyme found in erythperitonitis (n Å 7), tuberculous peritonitis in the setting rocytes, lymphocytes, and the cerebral cortex. 20 Its activity of cirrhosis (n Å 10), and consecutive specimens of in body fluids is related primarily to the number, maturation, widely varied etiologies (n Å 351) were analyzed for ADA and level of stimulation of lymphocytes. 20,21 ADA activity has activity by ultraviolet spectrophotometry at 265 nm. The been used as a diagnostic test for tuberculous meningitis, overall sensitivity of the ADA determination in diagnospericarditis, and pleural effusions. [22][23][24][25][26][27] Previous studies pering tuberculous peritonitis was only 58.8%, and the specformed outside the United States in patients with tubercuificity was 95.4%. The accuracy of ADA determination lous peritonitis have suggested its usefulness as a diagnostic (93.8%) compared favorably with that of the common asassay. 8,24,[28][29][30][31][32] However, these studies were performed in councitic fluid tests of white blood cell (WBC) count (ú500/ tries in which tuberculous is endemic. The present study inmm 3 ), total protein (ú2.5 g/dL), and combined WBC vestigated the clinical utility of the ascitic fluid ADA activity count and total protein (45.8%, 74.4%, and 81.3%, respecin diagnosing tuberculous peritonitis in a patient population tively). However, ADA was only 30% sensitive in dein the United States. tecting tuberculous peritonitis in the setting of cirrhosis, and cirrhosis was present in 59% of the tuberculous peri-PATIENTS AND METHODS tonitis patients in our population. In addition, malig-Ascitic fluid samples were collected prospectively for a study of nancy-related ascites (13%) and bacterial peritonitis the serum-ascites albumin gradient. 33 These samples were main- specimens (5.8%) occasionally yielded false-positive retained at 070ЊC and tested retrospectively for ADA activity. The sults. In conclusion, our results indicate that the ascitic cause(s) of ascites formation were clearly delineated through gold standards including autopsy, laparotomy, laparoscopy, biopsy, cul-fluid ADA activity has good accuracy but poor sensitivture, and clinical outcome. 33 The diagnosis of tuberculous peritonitis ity and imperfect specificity in a U.S. patient population required Mycobacterium tuberculosis growth in a culture of ascitic in which the prevalence of tuberculosis is low and unfluid or peritoneal biopsy specimen. A total of 368 specimens were derlying cirrhosis is common. (HEPATOLOGY 1996;24: tested. Seven specimens were from patients with peritoneal tubercu-

1408-1412.)

losis in the absence of cirrhosis; these were labeled ''isolated tuberculous peritonitis.'' Ten additional specimens were from patients with tuberculous peritonitis and cirrhosis. Another 351 consecutive ascitic Tuberculous peritonitis is a common cause of ascites in fluid samples were assayed. The ascitic fluid total protein (AFTP) Third World countries. 1 In 1991, more than 26,000 cases of and cell counts had been previously determined.

tuberculosis were reported in the United States. 2 Tuberculo-ADA activity was determined by measuring the decrease in adenosis is increasing in the Western World because of increases sine concentration under the action of ADA. 34 The ascitic fluid speciin the numbers of homeless persons, prison inmates, immimens were labeled by code. Control and coded ascitic fluid specimens grants, and patients with human immunodeficiency virus were thawed and spun for 1 minute at 8,000 rpm. Working adenosine (HIV). [2][3][4] Extrapulmonary disease occurs in 70% of patients reagent (980 mL) and 20 mL of either control or sample supernatant with tuberculosis and the acquired immunodeficiency synwere mixed gently before being run through the Beckman DU-7 spec- drome (AIDS); the peritoneum is the sixth most common extrophotometer (Beckman Instruments, Inc., Irvine, CA) at 265 nm.

The absorbance changes secondary to the changes in adenosine con-trapulmonary site. 4 Symptoms of peritoneal tuberculosis are centration were monitored at 30-second intervals for 10 minutes. A nonspecific, including abdominal pain and fever. [5][6][7][8][9][10][11][12][13][14][15][16][17][18] Curunit of ADA activity was defined as the amount of ADA that produced 1 mmol of inosine per minute at 37ЊC. Activity was reported in units per liter with the cutoff for positivity at 7 U/L. This cutoff was established in October 1989 at the University of Minnesota Hospitals and Abbreviations: HIV, human immunodeficiency virus; AIDS, acquired immunodeficiency syndrome; ADA, adenosine deaminase; AFTP, ascitic fluid total protein; WBC, white blood Clinics laboratory (ú2 SD above the mean ascitic fluid ADA level of cell; PMN, polymorphonuclear leukocyte; RBC, red blood cell; RES, reticuloendothelial sys-39 consecutive ascitic fluid specimens with negative M. tuberculosis tem.