Correspondence

Case 3-1998: Tuberculous Peritonitis

N Engl J Med 1998; 338:1701-1702June 4, 1998

Article

To the Editor:

With respect to the January 22 Case Records,1 we would like to point out several limitations to the diagnostic value of an assay of adenosine deaminase activity. Some studies have shown that the specificity of an adenosine deaminase assay for the diagnosis of tuberculous pleuritis is 100 percent. However, in a review of the topic, Bañales et al.2 found that the specificity ranged from 76 percent to 100 percent. Burgess et al.,3 who reported a specificity of 81 percent, emphasized that elevated adenosine deaminase activity may be associated with a number of other diseases, including malignant conditions (especially those of hematologic origin), bacterial infections, empyema, and collagen vascular diseases. On the other hand, the sensitivity of the assay for the diagnosis of tuberculous ascites has ranged from 58 percent 4 to 100 percent.5 In addition, the presence of cirrhosis markedly decreases the sensitivity of the assay for the diagnosis of tuberculous peritonitis (sensitivity, 30 percent).4 Several authors have concluded that determination of adenosine deaminase activity in peritoneal fluid has a limited role in the diagnosis of tuberculous peritonitis.6

Alicia Conde, M.D., Ph.D.
Hospital El Sabinal, 35017 Las Palmas, Spain

Joaquín Marchena, M.D., Ph.D.
University Hospital El Pino, 35005 Las Palmas, Spain

6 References

1. 1

   Case Records of the Massachusetts General Hospital (Case 3-1998). N Engl J Med 1998;338:248-254
   Full Text | Web of Science | Medline

2. 2

   Banales JL, Pineda PR, Fitzgerald JM, Rubio H, Selman M, Salazar-Lezama M. Adenosine deaminase in the diagnosis of tuberculous pleural effusions: a report of 218 patients and review of the literature. Chest 1991;99:355-357
   CrossRef | Web of Science | Medline

3. 3

   Burgess LJ, Maritz FJ, Le Roux I, Taljaard JJ. Combined use of pleural adenosine deaminase with lymphocyte/neutrophil ratio: increased specificity for the diagnosis of tuberculous pleuritis. Chest 1996;109:414-419
   CrossRef | Web of Science | Medline

4. 4

   Hillebrand DJ, Runyon BA, Yasmineh WG, Rynders GP. Ascitic fluid adenosine deaminase insensitivity in detecting tuberculous peritonitis in the United States. Hepatology 1996;24:1408-1412
   CrossRef | Web of Science | Medline

5. 5

   Dwivedi M, Misra SP, Misra V, Kumar R. Value of adenosine deaminase estimation in the diagnosis of tuberculous ascites. Am J Gastroenterol 1990;85:1123-1125
   Web of Science | Medline

6. 6

   Harlan WR III, Grimm IS. Tuberculous peritonitis: can ADA keep the laparoscope away? Gastroenterology 1997;113:687-689
   CrossRef | Medline

To the Editor:

In the January 22 Case Records, Smith states that it is unclear how sensitive and specific the adenosine deaminase assay for tuberculous peritonitis would be in areas with a low prevalence of the disease. The sensitivity and specificity would remain unchanged. The lower prevalence would decrease the assay's positive predictive value and increase the negative predictive value.

Rajeev Jain, M.D.
University of Texas Southwestern Medical Center, Dallas, TX 75235

Author/Editor Response

Dr. Sheets replies:

To the Editor: Because of space limitations, I was not able fully to discuss adenosine deaminase activity in patients with Mycobacterium tuberculosis. I appreciate Drs. Conde and Marchena's further review of the literature. Understanding the part that adenosine deaminase activity plays in the diagnosis of tuberculosis in either peritoneum or pleura is useful to physicians involved in the management of this disease.

As Dr. Jain indicates, the sensitivity and specificity of the adenosine deaminase assay for the diagnosis of tuberculous peritonitis would remain unchanged in areas with a low prevalence of the disease, but the positive and negative predictive values of the assay would change.

Ellen E. Sheets, M.D.
Brigham and Women's Hospital, Boston, MA 02115

Citing Articles (1)

Citing Articles

1. 1

   DAVID W JOHNSON, NICK GRAY, PAUL SNELLING. (2003) A peritoneal dialysis patient with fatal culture-negative peritonitis. Case Discussion. Nephrology 8:1, 49-55
   CrossRef