Letter to the Editor
High adenosine deaminase level in the pleural effusion of a case with leukemia
Nivel alto de adenosina desaminasa en el derrame pleural de un caso con leucemia
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Elevated levels of adenosine deaminase (ADA) in patients with pleural effusion help clinicians to diagnose areas where tuberculosis is endemic. We present a case of T-cell leukemia associated with elevated ADA in a pleural effusion in a patient presenting with massive pleural effusion.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 21-year-old female patient was admitted to our outpatient clinic with dyspnea and weight loss of 8<span class="elsevierStyleHsp" style=""></span>kg in 3 months. She had no cough, sputum, hemoptysis or fever. Although the patient migrated from Syria, which had a high prevalence of TB, she had no contact with TB. Her family history revealed that her sister was diagnosed with leukemia. On her physical examination, a mobile, 2<span class="elsevierStyleHsp" style=""></span>cm sized lymphadenopathy extending to the thyroid was found in the left supraclavicular fossa. On examination of the respiratory system, the left hemithorax was less involved in breathing and there was a matite up to the upper zone. Abdominal examination revealed splenomegaly and mild ascites, no hepatomegaly. In the laboratory findings; the blood white cell count was 8410 per microliter (mcL) and 71.5% were neutrophils and 19.1% were lymphocytes. The erythrocyte sedimentation rate was 10<span class="elsevierStyleHsp" style=""></span>mm/h. On chest X-ray, diffuse opacity reaching the apex was observed on the left. Computed tomography of the thorax which was taken four days ago in another health center; bilateral left greater pleural effusion, pericardial effusion close to 1<span class="elsevierStyleHsp" style=""></span>cm, and conglomerated lymphadenopathies surrounding the vascular structures of the mediastinum were observed. The patient was hospitalized and thoracentesis was performed on the left side. The pleural fluid was yellow in color, exudative, LDH level value was found 1959 units per liter (U/L) and white blood cell count was 59<span class="elsevierStyleHsp" style=""></span>310<span class="elsevierStyleHsp" style=""></span>mcL and the device could not distinguish lymphocytes. The right pleural fluid ADA level was reported as >150<span class="elsevierStyleHsp" style=""></span>U/L. Right thoracentesis was performed two days later, pleural fluid was yellow, exudative, LDH value 2444<span class="elsevierStyleHsp" style=""></span>U/L, white cell count was 37<span class="elsevierStyleHsp" style=""></span>680 mcL, 71.8% lymphocyte predominance. The left pleural fluid ADA level was reported as >150<span class="elsevierStyleHsp" style=""></span>U/L. Bilateral pleural fluid gram staining showed no bacterial and no culture growth. Acid-resistant bacilli (ARB) test and <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> polymerase chain reaction examination were negative and their cultures were negative. Interferon gamma release test for latent TB was negative. Cytological examination of fluid showed atypical T-cell proliferation and was found to be compatible with T-cell lymphoma or leukemia. Excisional biopsy of the left supraclavicular lymphadenopathy was performed for definitive diagnosis, reported as T-lymphoblastic type leukemia and treatment was initiated. Hematoxylin–Eosin stained preparations of lymph node showed diffuse infiltration of lymphoid blastic cells. In the immune-histochemical study, blastic cells were positive for CD3, CD4, CD5, CD7, Bcl-2 and TdT.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Written informed consent was obtained from the patient who participated in this case.</p><p id="par0020" class="elsevierStylePara elsevierViewall">In adults, tuberculosis and parapneumonic effusions are the most common causes of benign pleural effusions, but malignant causes should be kept in mind. Lympho-proliferative diseases, especially lymphoma, are among the causes of massive pleural effusion.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Adult T-cell leukemia; the rate of chronic leukemia in adults is 2% and clinical findings include B-symptoms, conglomerated lymph nodes. Pleural or peritoneal effusion can be seen in the diagnosis at a rate of 25%.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">ADA is an enzyme involved in purine metabolism, especially in T-lymphocyte proliferation and maturation, which has an effect on the immune system in all cells. In diseases such as leukemia and lymphoma, ADA may be elevated in pleural fluid. Intracellular microorganisms such as Mycobacterium tuberculosis increase ADA secretion by stimulating lymphocytes.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> Therefore, ADA is used as a biomarker in the diagnosis of tuberculous pleurisy. In a study, pleural effusion was detected in 30% of patients with Large B-cell lymphoma, and ADA level >35<span class="elsevierStyleHsp" style=""></span>U/L was found in 35% of fluids.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">ADA in pleural fluid has a very high sensitivity for tuberculosis. When pleural fluid is tested for TB, it is an extremely valuable biomarker for the clinician with high diagnostic sensitivity, specificity, positive probability ratio and negative probability ratio (92%, 90%, 9.03 and 0.10) according to the results of meta-analysis.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Although pleural effusion cases with ADA elevation have been reported with lymphoma, there are no case reports of leukemia. In conclusion, in patients with lymphocytic pleural effusion with ADA elevation, other causes must be ruled out before diagnosis of tuberculosis, especially for the diseases that cause lymphocyte cell proliferation such as lymphoma and leukemia.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0025" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Consensus criteria for diagnosis, staging, and treatment response assessment of T-cell prolymphocytic leukemia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P.B. Staber" 1 => "M. Herling" 2 => "M. Bellido" 3 => "E.D. Jacobsen" 4 => "M.S. Davids" 5 => "T.M. 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