ABSTRACT Background: Tuberculosis (TB) remains a major health problem across the world and commonly involves the lungs. Analysis of adenosine deaminase activity is a very useful diagnostic approach to achieve a more rapid and precise diagnosis in serosal fluids and serum of pulmonary tuberculosis.  Objectives: To estimate the serum adenosine deaminase (ADA) levels in pulmonary tuberculosis and other common respiratory diseases & to evaluate the role of serum ADA estimation in differentiation of tubercular and common non tubercular respiratory diseases. Methods:  The study was a hospital based, non randomized comparative study conducted at Kempegowda Institute of Medical Sciences, Bangalore and DOT centres of RNTCP, BBMP, Bangalore.                                        We measured serum adenosine deaminase levels in 3 groups, group Ι: 41 cases of pulmonary tuberculosis, group ΙΙ: 30 cases of tubercular pleural effusion, group ΙΙΙ: 49 cases of non tubercular respiratory diseases viz, bronchiectasis, chronic bronchitis in the age group of 20 – 64 years over a period of one year. Age and sex matched 30 healthy volunteers, were taken as controls. Estimation of serum ADA was done by sensitive colorimetric method described by Giusti and Galanti m Results: Mean serum ADA levels in cases of pulmonary tuberculosis (50.93 ± 9.22 U/L), tubercular pleural effusion (42.48 ± 8.2 U/L), non tubercular respiratory diseases (21.03±3.64 U/L) were significantly more than controls (17.07±2.71U/L). But the mean serum ADA value between  pulmonary  tuberculosis and non tubercular respiratory diseases shows higher significant mean difference and was  statistically significant with a p value < 0.01. The mean difference of serum ADA levels between the tubercular pleural effusion and non tubercular respiratory diseases was also statistical significant with a p value < 0.01. Conclusion: We conclude that elevated serum ADA level in pulmonary tuberculosis is statistically significant compared to non tubercular respiratory diseases and healthy controls.

Key words

Tuberculosis(TB), Adenosine deaminase(ADA)

 

 

FULL TEXT    :               INTRODUCTION

Tuberculosis (TB) continues to be a major cause of morbidity and mortality world wide. Tuberculosis remains the single largest infectious disease causing high mortality in humans, leading  to  ~1.7 million deaths annually, accounting to 26 deaths per lakh population. India is the highest TB burden country accounting for one fifth of the global annual incidence.1,2

The most important part of the tuberculosis struggle is the early detection and treatment.  The diagnosis is usually based on clinical presentation, radiologic findings, sputum for acid fast bacilli(AFB) and positive tuberculin tests. But clinical, radiological features are variable and the later tests may be false negative. Therefore it becomes imperative for some rapid and useful tests for the analysis of tuberculosis.3

The measurement of serum adenosine deaminase is one of the biochemical methods. Determination of Adenosine deaminase (ADA) is a useful surrogate marker for tuberculosis in pleural, pericardial, and peritoneal fluids. Studies have confirmed high sensitivity and specificity of Adenosine  deaminase  for the early diagnosis of extrapulmonary tuberculosis. 4,5

Adenosine deaminase (ADA) an enzyme involved in purine metabolism, is found ten times higher in concentration in lymphocytes than erythrocytes. ADA is a significant indicator of active cellular immunity. The level of serum ADA increases in various diseases in which cell mediated immunity is stimulated such as tuberculosis, typhoid fever, infectious mononucleosis, brucellosis and brochogenic carcinoma.6,7

The level of ADA in tuberculosis is higher than any other non tubercular pulmonary diseases. Its sensitivity and specificity are very high. The serum ADA value is sufficiently useful in identifying those patients in whom the diagnosis of pulmonary tuberculosis should be actively considered .8,9

MATERIALS AND METHODS: The study was a hospital based study conducted at Kempegowda Institute of Medical Sciences and Research Centre, Bangalore and DOT centre’s of RNTCP in Bruhat Bangalore  Mahanagara  Palike.

Study duration: 1 year

Study design: Non randomized comparative study

Sample design: Purposive sampling

         The study comprised of 120 cases. The patients were divided into 3 groups, Group Ι: 41 cases of newly diagnosed pulmonary tuberculosis, Group ΙΙ: tubercular pleural effusion 30 cases and Group ΙΙΙ:  49 cases of non tubercular pulmonary diseases (chronic bronchitis & bronchiectasis), in the age group of 20-64 years were included. Thirty, age and sex matched healthy volunteers were taken as controls.

All the patients were clinically examined and various investigations like sputum examination for AFB,  chest  X-ray, pleural fluid analysis, pulmonary function tests were carried out to confirm the diagnosis.

Patients  with  Liver cirrhosis, HIV-AIDS, psoriasis, pregnancy, diabetes,  and  all  other conditions in which serum ADA is increased were not included in this study.

Serum Adenosine  Deaminase  in patients as well as in controls was estimated by sensitive colorimetric method as described by Giusti & Galanti.10

 

Table  1: Various study groups and the number of patients included in each group

 

Group.

Study Group

No. of Patients

Total

Ι

Pulmonary tuberculosis (PTB)
  Pulmonary Tuberculosis Sputum AFB + ve

26

41

  Pulmonary Tuberculosis Sputum AFB – ve

15

ΙΙ

Tubercular Pleural Effusion

30

30

ΙΙΙ

Non tubercular respiratory diseases
  Chronic Obstructive   Pulmonary Disease

30

49

 

 

Bronchiectasis

19

Total

120

  Healthy controls

30

30

 

 

                                    RESULTS     &   DISCUSSION 

Among thirty healthy controls in the age group of 20-64 years with 19 males (63.3%) and 11 females (36.7%) , the mean serum ADA level was 17.07±2.7U/L.The mean value of serum ADA activity was 16.50±2.67 U/L, for males and 18.04±2.62 U/L for females in the control group. These findings are similar to those reported by Jhamaria et.al, 16.8±10.2U/L, for males and 19.09±2.99 U/L, for females. In the present study there was no significant variation in the mean serum ADA level in relation to age and sex in healthy controls as were made by Jhamaria et.al, study.11

The study group consisted of 120 cases, in which 75 males (62.5%) and 45 females (37.5%) were present. The mean serum ADA activity in this study group was 36.61±15.15U/L as compared to 17.07±2.72U/L in control group showing a significant mean difference. No significant mean difference was observed in the serum ADA level in relation to age and sex among these patients. Meena Verma et al, had also found similar observation. 7

41 cases of pulmonary tuberculosis were divided according to sputum status into sputum +ve for AFB(26cases) and sputum –ve  for AFB(15 cases).  The mean serum ADA levels in 41 patients of pulmonary tuberculosis (both sputum +ve and sputum -ve ) was 50.93  ±9.22 U/L when compared with mean value of 17.07±2.72U/L,  in control group, which is statistically highly significant  with p < 0.01.The mean serum ADA levels in pulmonary tuberculosis sputum AFB +ve and sputum AFB                   –ve cases of PTB were 51.09± 9.44 U/L and 50.64 ± 9.13U/L  respectively, showing  no statistical significant mean difference between them, but were significantly higher when compared to controls. Meena Verma et al , had also reported no difference in mean serum ADA activity in patients of  pulmonary tuberculosis  sputum AFB +ve and  pulmonary tuberculosis sputum AFB –ve cases .

In this study, the mean serum ADA value in patients of pulmonary tuberculosis (sputum AFB +ve and –ve) was 50.93 ± 9.22 U/L, and when compared to mean serum ADA value of 21.03±3.64 U/L in patients of non tubercular respiratory diseases group, showed higher significant mean difference between these groups and was also statistical highly significant with a p value < 0.01. Meena Verma et al, K.Srinivas Rao et.al, Jhamaria Jp et.al, also showed in their study significant higher mean difference of serum ADA levels between pulmonary tuberculosis and non tubercular respiratory disease with a statistically significant raised serum ADA values in the former group that is pulmonary tuberculosis.7, 12, 11

In our study, mean serum ADA levels in Pulmonary tuberculosis sputum AFB +ve patients were compared to non tubercular respiratory diseases group (COPD & Bronchiectasis) and higher statistical significant mean difference was found similar to the results of Khalid Hassanein et.al study.13  In this study, mean serum ADA levels in Pulmonary tuberculosis sputum AFB -ve patients were compared to non tubercular respiratory diseases group (COPD & Bronchiectasis) and higher statistical significant mean difference was found. This finding is in good agreement with the M. K. Agarwal et.al study. 6

Table  2: Descriptive Statistics serum ADA levels in various study groups and healthy control groups

Study Groups

No.

Range

Mean

SD

PTB Sputum  AFB+ve

26

38.92 – 72.50

51.09

9.44

PTB Sputum  AFB-ve

15

36.86 -66.75

50.64

9.13

TB PEF

30

25.91 -59.72

42.48

8.19

COPD

30

16.30 -29.18

21.07

3.22

Bronchiectasis

19

14.89 -31.62

20.96

4.31

Healthy Controls

30

10.36 -22.00

17.07

2.72

 

Fig. 1:   Mean  serum ADA levels in various study groups and controls.

Table 3: Comparison of serum ADA levels in Pulmonary Tuberculosis (Sputum AFB smear +ve & -ve) with  non tubercular respiratory diseases and controls.

Group N Mean Std dev SE of Mean F P value Sig diff between
PTB 41 50.93 9.22   1.44 370.747 < 0.01 PTB vs Non TB
Non TB 49 21.03 3.64   0.52 PTB vs Control
Control 30 17.07 2.72   0.50 Non TB vs Control

Fig 2.With ANOVA there is statistical significant mean difference between PTB group compared with controls and  Non TB respiratory diseases, p < 0.01

       Table 4: Comparison of serum ADA levels in Tubercular Pleural effusion with non tubercular respiratory diseases.

 

Group   No. Mean    Std. Deviation     t       P
 TB PEF     30   42.48      8.19   13.54     < 0.01
Non TB respiratory diseases     49   21.03      3.64

 

Fig.3

Mean serum ADA levels in Tubercular pleural effusion  compared with non tubercular respiratory diseases group.

The mean serum ADA levels 21.03±3.64 U/L in patients of Non tubercular respiratory diseases group (COPD and Bronchiectasis) were compared to 17.07±2.72U/L in control group, though the mean serum ADA was slightly higher than the control value, it also showed  statistical significance,& also significant statistical mean difference was obtained when COPD & Bronchiectasis individual groups were compared to healthy controls, and when these individual sub division groups of Non tubercular respiratory diseases were compared to Pulmonary tuberculosis group showed highly statistical significant mean difference. These findings are in accordance with Jhamaria Jp et.al and Mukesh Kumar Agarwal et.al studies.11,6

The mean serum ADA levels in 30 cases of tubercular pleural effusion was 42.48 ± 8.2 U/L, when compared to control value a statistically significant  p value < 0.01 is obtained. When the mean serum ADA value of tubercular pleural effusion patients were compared to mean serum ADA activity of Pulmonary tuberculosis, it also showed statistical significant mean difference with p<0.01.

When the mean serum ADA value in patients of tubercular pleural effusion ( 42.48 ± 8.2 U/L), were compared to mean serum ADA value of 21.03±3.64 U/L in patients of non tubercular respiratory diseases group  showed higher significant mean difference between these groups and was also highly statistically significant with a p value < 0.01. Lamsal M et al, Smach MA et al, Al-Shammary FJ, had also found that mean serum ADA activity was significantly increased in patients with tubercular pleural effusion compared to non tubercular respiratory diseases and healthy controls, they concluded that the measurement of ADA in patients of tubercular pleural effusion has a utility in the diagnosis of tuberculosis when other clinical and laboratory tests are negative. 9, 14,15

Stevanoic G et al, study regarding the significance of adenosine deaminase  serum concentrations in the diagnosis of extra pulmonary tuberculosis (EPTB) had concluded that increased concentrations of serum adenosine deaminase have shown the potential of usable screening test as an indicative EPTB parameter. However to fully assess its diagnostic significance, it require further clinical research.  16

In  this study taking 33 U/L as cut off value, none of the patients of non tubercular respiratory diseases showed ADA value above that and none of the patients of pulmonary tuberculosis showed a lower value than 33U/L. K.Srinivas Rao et al, Jhamaria et. al. using 33 U/L as the cut off limit, had found 100% specificity and 98% sensitivity of serum ADA level test for diagnosis of pulmonary tuberculosis. 12,11

The results of the present study are in good agreement with those of  Meena Verma et al, Mukesh Kumar Agarwal et.al, K Srinivas Rao et.al, Khalid Hassanein et.al, Jhamaia JP et.al, that ADA value rises in serum of pulmonary tuberculosis patients, with a significant higher mean difference between patients of pulmonary tuberculosis and non tubercular respiratory diseases, so we can use serum ADA to differentiate between pulmonary tuberculosis and non tubercular respiratory diseases. 7,6,12,13, 11

CONCLUSION:

As determination of ADA is highly specific, sensitive, cost effective, not time consuming and is relatively easy to do, it can be routinely employed to differentiate pulmonary tuberculosis from non tubercular respiratory diseases, particularly if the diagnosis of tuberculosis is in doubt as in cases of suspected sputum AFB smear negative pulmonary tuberculosis.

                    

 

 

          

                                                      REFERENCES

1. World health organization (WHO) Report 2010: Global Tuberculosis Control.

2. Tuberculosis India 2010.RNTCP STATUS REPORT.  Central TB Division,

Directorate General of Health Sciences,Ministry of Health and Family Welfare; Nirman Bhavan ,New Delhi.

3. Saeed Aminiafshar, Masoomeh Alimagham, Maryam Keshtkar Jahromi, et al ;Serum Adenosine Deaminase Level as an Indicator of Pulmonary Tuberculosis Activity versus Other Infectious DiseasesTanaffos (2004) 3(12), 19-23.

4. P C Mathur, K K Tiwari, Sushma Trikha and Dharmendra Tiwari; Indian J Tuberc ; Diagnostic value of adenosine Deaminase (ADA) activity in tubercular serositis. 2006; 53:92-95

5.Ungerer JP, Oosthuizen HM, Retief JH, Bissbort SH: Significance of adenosine deaminase activity and its isoenzymes in tuberculous effusions. Chest; 1994;106:33-7.

6. Agarwal MK, Jitendra Nath, Mukerji PK, V.M.L Srivastava: A study of serum Adenosine Deaminase activity in Sputum Negative patients of Pulmonary Tuberculosis; Ind J.Tub; 1991; 38: 139-141.

7. Meena Verma, Sanjeev Narang, Ashish Moonat and Akshra Verma : Study of adenosine deaminase activity in pulmonary tuberculosis and common respiratory diseases. Indian journal of clinical  biochemistry; 2004;19, (1);129-131

8. Lakshmi V, Rao R R, Joshi N, Rao P N : Serum adenosine deaminase activity in bacillary or paucibacillary pulmonary tuberculosis; Indian pathol microbial; 1992 Jan;35(1);48-52

9. Lamsal M, Gautam N, Bhatta N, Majhi S, Baral N, Bhattacharya SK : Diagnostic utility of Adenosine Deaminase (ADA) activity in pleural fluid and serum of tuberculous and non-tuberculous respiratory disease patients; Southeast Asian J Trop Med Public Health; 2007 Mar; 38(2):363-9.

10. Giusti G, Galanti B: Adenosine deaminase colorimetric method In:Bergmeyer Hu, editors. Methods of enzymatic analysis, Vol 4, 3rd edition. Weinhem : verlag chemie, 1984 : 315 -23.

11. Jhamaria JP, Jena, RK, Lutada, SK, Mathur, D.K Pari-har H.L and sharma, SK: Serum ADA in differential diagnosis of Pulmonary Tuberculosis and common non Tuberculosis respiratory diseases. Indian J.Tuberculosis. 1988; 35:  25-29.

12. K. Srinivasa Rao, H. Anand Kumar, B.M.Rudresh, T. Srinivas, K. Harish Bhat :  A Comparative study and evaluation of serum adenosine deaminase activity in the diagnosis of pulmonary tuberculosis :  Biomedical Research 2010 (2): 189-194

13. Khalid Hassanein, Hossam Hosny, Randa Mohamed, Wagdy Abd El- Moneim: role of adenosine deaminase (ADA) in the diagnosis of pulmonary tuberculosis: Egyptian Journal of Bronchology : Vol. 4, No. 1, June, 2010.

14. Smach MA, Garouch A, Charfeddine B et al; Serum and Pleural fluid  Adenosine Deaminase Activity in  Tuberculous  pleurisy:Ann Bio Clin(Paris):2006 May-Jun;64(3);265-70.

15. Al-Shammary F.J: Adenosine Deaminase Activity in Serum and Pleural Effusions of Tuberculous and Non-Tuberculous Patients.Biochem. Mol. Biol. Int.,Nov: 43(4): 1997;

763-779

16. Stevanovic G Pelemis M, Pavlovic M, Lavadinovic L, Dakic Z, Milosevic I,Milosevic B; Significance of Adenosine deaminase serum concentrations in the diagnosis of extra-pulmonary tuberculosis: J of IMAB 2011; 17(1):130-134.

 

 

 

 

 

Dr. VEENA.S.RATHOD*: Senior Medical Officer, Legislative Home Dispensary,

Legislative Home, Bangalore

 

DR.S.SUNITHA**           :  Associate Professor, Department of Biochemistry, Kempegowda

Institute of Medical Sciences,  Banashankari 2nd stage,    Bangalore

 

DR. HULIRAJ.N***       :   Professor & Head,

Department of TB & Chest diseases, Kempegowda Institute of        Medical Sciences, Bangalore

 

 

 

 

 

 

 


 

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