Adenosine deaminase: A sensitive and cost-effective method for the detection of tuberculous pleural effusion in a developing state like Bihar, India


Background: Tuberculosis remains a worldwide public health hazard even today. To diagnose tuberculosis in exudative pleural effusion still remains a challenge. Tests such as Tuberculin test, direct AFB demonstration by microscope, Acid Fast Bacili (AFB) culture and PCR have low sensitivity in pleural effusion. In a poor state like Bihar (India) a panel of investigations is not possible for the patient. Aim: The aim of this study is to diagnose tuberculous pleural effusion by estimating Adenosine Deaminase in the pleural effusion fluid that is both cost-effective and sensitive. Setting and Design: 100 cases of pleural effusion were studied in Patna Medical College and ADA values were estimated. For tuberculosis, the cut-off value was taken as 40U/L at 37°C. Statistical analysis: The sensitivity and specificity of ADA were 97.05% and 95.83% respectively. Material and Method: Alongwith physical, chemical and microscopical examination of pleural fluid, culture for AFB was also done and ADA was estimated by Galanti and Giusti’s colorimetric method. Results: ADA is highly sensitive and specific and its value is significant in detection of tuberculous pleural effusion. Conclusion: ADA is a useful method to diagnose tuberculous pleural effusion among the people in a developing state like Bihar.

Keywords: Adenosine deaminase (ADA), pleural effusion, tuberculosis

How to cite this article:
Mallik M, Bhartiya R, Singh R, Kumar M, Bariar NK. Adenosine deaminase: A sensitive and cost-effective method for the detection of tuberculous pleural effusion in a developing state like Bihar, India. Ann Trop Med Public Health 2016;9:170-3


How to cite this URL:
Mallik M, Bhartiya R, Singh R, Kumar M, Bariar NK. Adenosine deaminase: A sensitive and cost-effective method for the detection of tuberculous pleural effusion in a developing state like Bihar, India. Ann Trop Med Public Health [serial online] 2016 [cited 2017 Nov 14];9:170-3. Available from:



Tuberculosis still remains a public health hazard worldwide even though the causative organism i.e. Mycobacterium tuberculosis was discovered more than 100 years ago. Effective vaccines and drugs are also available to make tuberculosis a preventable and curable disease. According to the World Health Organization (WHO), 9.4 million incidence (137/100,000 population) and 14 million prevalence (299/100,000 population) is present worldwide. In India also, according to the WHO, the incidence is 2.5 million1.[1] Tuberculosis was discovered 2000 years ago and was known as kyshya rog (corroding disease). With the advent of human immunodeficiency virus (HIV) there has been a resurgence of tuberculosis. A total of 58,000 tuberculous cases were recorded in Bihar in 2014.[2] Bihar is one of the poorest states of India with around 40% of people living below poverty line.[3],[4]

This disease primarily affects the lungs. It also affects intestine, bones and joints, meninges, lymph nodes, skin, and other tissues. Pleural effusion is one of the serious complications of tuberculosis as far as morbidity and mortality are concerned. The identification of tuberculosis in body fluid still remains a common clinical problem. The definitive diagnosis of tuberculosis is demonstration of acid fast bacilli either by light microscopic or by culture. But sensitivity of AFB is 1% in light microscopy and 42% in culture.[5] PCR though normally a very sensitive method has a relatively low sensitivity in pleural fluid and it is also costly and not done in common laboratories.[5]

In this condition, ADA activity in pleural fluid will be a very good parameter for diagnosis of tuberculous pleural effusion.[5] ADA has two principal isoenzymes – ADA1 and ADA2. ADA2 is found in macrophages and monocytes. Its release is stimulated in the presence of live microorganism inside the cell.

Materials and Methods

A total of 100 cases of pleural effusion were studied in Patna Medical College and Hospital. Informed consent was taken from the patients. Patient’s history, clinical examination, and routine examination were performed. Pleural effusion fluid were collected in the medicine ward and sent to the pathology department for further evaluation. Patient’s complete blood count was also done.

The pleural fluid was examined under the following heading:

  1. Physical examination.
    1. Appearance of fluid.
    2. Cobweb present or not.
    3. Volume of fluid.
    4. Specific gravity of fluid.
  2. Chemical examination.
    1. Total protein estimation.
    2. Pleural fluid ADA estimation by Galanti and Giusti’s colorimetric method.[6]
    3. Glucose.
  3. Microscopic examination.
    1. Total WBC count.
    2. Total RBC count.
    3. Gram staining and AFB stain (Ziehl–Neelsen staining).
    4. Papanicolaou (PAP) staining in cases of suspected cases of malignancy.
    5. Culture.

A total of 100 patients were then grouped as follows:

Group 1 – This group had eight cases of transudative pleural effusion.

These cases were considered as the control group for ADA activity value.

Group 2 – This group had 68 cases of tuberculous pleural effusion.

The diagnosis was obtained by the Mantoux test (induration more than 10 mm in diameter) and compatible history and cytological examination of pleural fluid (plenty of lymphocytes and paucity of mesothelial cells.) confirmed by and/or response to anti-Koch’s therapy.

Group 3 – This group included 20 cases of malignant effusion.

The diagnosis was obtained by compatible history, clinical feature, and finding of malignant cell by PAP stain.

Group 4 – This included four cases of pneumonic effusion.


Out of 100 cases, 68 were of tubercular, 20 cases were malignant and 12 cases benign non-tubercular.

Protein content were high, meaning to say that more than 3 gm/dL in tuberculous, malignant & pneumonic effusion. Protein content were less than 3 gm/dL in malnutrition and in congestive cardiac failure (CCF). Out of 68 tubercular cases, tuberculin test were positive in 48 cases, AFB direct demonstrated in 2 cases and AFB grown in LJ media in 13 cases. ADA value in malnutrition and CCF was 1.9 U/L. ADA mean in tuberculosis was 93.2 U/L and, in malignancy 14.7 U/L and in pneumonia 18.08 U/L noted.

In tubercular cases, ELISA (Enzyme Linked Immuno Sorbent Assay) was positive in 81.3% cases, PCR in 86.9% cases whereas ADA was positive in 97% cases.


[Table 1] shows the appearance of pleural fluid. Majority of tuberculous fluid were clear and straw colored. A total of 54 cases (79.4%) had straw colored aspirate. Nine (13.2%) had turbid and 5 (7%) had hemorrhagic fluid. This finding was in agreement with Onadeko et al. who found that tuberculous pleural fluid was predominantly straw coloured or turbid.[7]

Table 1: Showing appearance of fluid in different cases of effusion

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[Table 2] shows 59 cases that have protein content in between 3 and 6 gm per 100 mL. Nine cases had protein content more than 6 gm per 100 mL. Cases of malignancy also had protein content more than 3 gm/100 ml. Malnutrition and congestive cardiac failure had protein content less than 3 gm per 100 mL. Similar finding were recorded by Light et al.[8] and Crofton.[9]

Table 2: Showing distribution of aspirated fluid protein content in the cases examined

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[Table 3] shows tuberculin test to be positive in 48 cases that is 70.5%, direct demonstration of mycobacterium tuberculosis is seen in two cases that is 2.9% and 13 (19.1%) cases AFB grown in culture same as by Triman et al of US National Library of Medicine.[5]

Table 3: Showing the criteria followed for the confirmation of tuberculous pleural effusion from suggested clinical and radiological diagnoses

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[Table 4] shows ADA concentration in different pleural transudative effusions. In the three cases of pleural effusion due to malnutrition and five cases due to congestive cardiac failure the range of ADA activity in pleural fluid was 0.5-3.5 U/L at 37°C, the mean range being 1.9 at 37°C. The mean value is more or less consistent with Ocana et al.[10] and Singh et al.[11]

Table 4: Showing ADA concentration in transudative pleural effusion

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[Table 5] shows ADA value in different pleural effusion. Out of 68 cases, ADA activity was found in the range between 38 U/L and 151 U/L at 37°C, the mean being 93.2 ± 25.3 U/L. In this study, ADA cutoff value for tuberculous effusion was 40 U/L at 37°C. But two cases (false negative) had ADA of less than 40 U/L that were 38 U/L and 38.4 U/L, respectively.

Table 5: Showing ADA value in different exudative pleural effusion

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A total of 20 cases of malignant pleural effusion with ADA activity in the range of 5-40.6 U/L at 37°C, the mean being 14.7 ± 5.7 U/L. One case of malignant pleural effusion had ADA value 40.6 U/L (false positive) rest all the cases had values between 5 U/L and 22.6 U/L.

Four cases of pneumonic pleural effusion with ADA activity between 12.5 U/L and 26.0 U/L with a mean of 18.08 ± 4.95 U/L. From this table, it is clear that ADA activity found in tuberculous pleural effusion was much higher than that found in other exudative groups.

The ADA activity reported by other authors are as followed
The above table shows that the result of the present study is similar to study by other authors such as Bharat et al.,[12] Susmita et al.,[13] Sharma et al.,[14] Asmita et al..[15]

[Table 6] shows the comparative study between the different diagnostic protocols of tuberculous effusion. The table showed only 48 cases (70.5%) were Mantoux positive (>10 mm induration), only two cases (2.9%) were M. tuberculosis were demonstrated by direct microscopy. Culture was positive in only 13 cases (19.1%). Enzyme Linked Immuno Sorbent Assay (ELISA) was positive in 39 cases out of 48 patients who went for ELISA that was 81.3%. PCR was positive in 20 cases out of 23 cases who opted for PCR that was 86.9%. But ADA was positive in 66 out of 68 cases that was 97%. This is similar to the study by Triman et al.[5]

Table 6: Showing comparative study between different types of diagnostic method for tuberculosis in exudative pleural effusion

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The burden of tuberculosis is high in Bihar with the majority of cases present in the low socioeconomic strata. This population is unable to go for costly tests such as PCR. The sensitivity of the other tests such as Tuberculin test and direct AFB demonstration by light microscopy are low in pleural effusion cases.

The above study shows that ADA still remains a cheaper and sensitive method to diagnose tuberculous pleural effusion where other costly test are beyond the reach of the poor.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.



World Health Organization. Global Tuberculosis Control-WHO Report 2012. Geneva, Switzerland: World Health Organization; 2012. p. 18-20.
Times of India. Patna: Rajendra Memorial Research Institute; 2015. p. 2.
Number and percentage of population below poverty line. Reserve Bank of India: Government of India 2015. p. 162.
Rangarajan Panel C. The Economics Times. 2014. p. 11.
Trajman A, Kaisermann C, Luiz RR, Sperhacke RD, Rossetti ML, Féres Saad MH, et al. Pleural fluid ADA, IgA-ELISA and PCR sensitivities for the diagnosis of pleural tuberculosis. Scand J Clin Lab Invest 2007;67:877-84.
Guisti G, Galanti B. Colorimetric method. In: Bergmeyer HU, editor. Method of Enzymatic Analysis. 3rd ed. Berlin, Weinheim, Germany: Verlag Chemie; 1984. p. 315-23.
Onadeko BO. Tuberculous pleural effusion: Clinical pattern and management in a Nigerians. Tubercle 1978;59:269-75.
Light RW. Pleural Diseases. Baltimore: Lippincot Williams & Wilkins; 2001. p. 182-95.
Reider HL, Chen-Yuan C, Gie RP, Enarson DA, editors. Crofton’s Clinical Tuberculosis. 3rd ed. Caribbean: Macmillan; 2009. p. 92-4.
Ocaña I, Martinez-Vazquez JM, Segura RM, Fernandez-De-Sevilla T, Capdevila JA. Adenosine deaminase in pleural fluids. Test for diagnosis of tuberculous pleural effusion. Chest 1983;84:51-3.
Singh RP. Tuberculous pleural effusion. J Assoc Physicians India 1989;34:421.
Gupta BK, Bharat V, Bandyopadhyay D. Role of adenosine deaminase estimation in differentiation of tuberculous and non-tuberculous exudative pleural effusions. J Clin Med Res 2010;2:79-84.
Chaudhary S, Patel AK. Role of pleural fluid adenosine deaminase (ADA) for the diagnosis of tuberculous pleural effusion. Calicut Med J 2010;8:e4.
Sharma SK, Suresh V, Mohan A, Kaur P, Saha A, Kumar A, et al. A prospective study of sensitivity and specificity of adenosine deaminase estimation in the diagnosis of tuberculous pleural effusion. Indian J Chest Dis Allied Sci 2001;43:149-55.
Mehta AA, Gupta AS, Ahmed S, Rajesh V. Diagnostic utility of adenosine deaminase in exudative pleural effusions. Lung India 2014;31:142-4.

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1755-6783.181661


[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

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