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  • 1. ALKALINE PHOSPHATASE:
    DISTINGUISHING BETWEEN TUBERCULOUS AND NON TUBERCULOUS PLEURAL EFFUSION
    BY DR KARTIK SOOD JUNIOR RESIDENT DEPARTMENT OF PULMONARY MEDICINE ELMCH
    ORIGINAL ARTICLE-LUNG INDIA VOL-26,ISSUE 3,SEPT 2009
    JAYASHREE SUHAS
    ASHISH JADHAV
  • 2. INTRODUCTION
    Tuberculosis is one of the important causes of exudative pleural effusion in our country.
    Other causes-
    Neoplasticdiseases
    • Metastatic disease
    • 3. Mesothelioma
    Infectious diseases
    • Bacterial infections
    • 4. Fungal infections
    • 5. Viral infections
    • 6. Parasitic infections
  • Pulmonary embolization
    Gastrointestinal disease
    Esophageal perforation
    Pancreatic disease
    Intraabdominal abscesses
    Diaphragmatic hernia
    After abdominal surgery
    Endoscopic varicealsclerotherapy
    After liver transplant
    Collagen-vascular diseases
    Rheumatoid pleuritis
    Systemic lupus erythematosus
    Drug-induced lupus
    Immunoblasticlymphadenopathy
    Sjögren's syndrome
    Wegener's granulomatosis
    Churg-Strauss syndrome
  • 7.
    • Light’s criteria
    • 27. Pleural fluid protein/serum protein >0.5
    • 28. Pleural fluid LDH/serum LDH >0.6
    • 29. Pleural fluid LDH more than two-thirds normal upper limit for serum
    • 30. Modified light’s criteria:
    • 31. Pleural fluid cholesterol level > 60mg/dl
    • 32. Serum albumin minus pleural fluid albumin level ≤ 1.2g/dl
    • Various parameters have been used to differentiate tuberculous from nontuberculous pleural effusion.
    • 33. These include: Pleural fluid(PF) adenosine deaminase, PF lysozyme, PF gamma interferon, PF alpha 1 antitrypsin,PF protease inhibitors,PF CA 125, PF tumor necrosis factor, PF interleukin-1,PF polymerase chain reaction,and reported to be elevated in tuberculous pleural effusion
    Alkaline phosphatase (ALP) is one of the biochemical markers found in pleural effusion. Previous studies have used ALP to differentiate between exudates and transudates.
  • 34.
    • This study was thus undertaken to confirm
    the usefulness of ALP activity in differentiating tuberculous from nontuberculous pleural effusion.
    • Patients with pleural effusion and suffering from varying etiologies, were included and routine laboratory tests of pleural fluid were carried out (total proteins, glucose, and pleural fluid Cytology). Pleural fluid samples were cultured and pleural biopsy was done to obtain a definitive diagnosis.
  • the study was divided into two groups:
    tuberculous (30) and nontuberculous pleural effusion (30). Nontuberculous group consist of malignant
    effusion, parapneumonic effusion, empyema, rheumatoidarthritis, systemic lupus erythematosus, liver abscess,nephrotic syndrome, acute glomerulonephritis, cirrhosis of liver, congestive cardiac failure, severe hypoproteinemia,
    and chronic renal failure.
    • Studies performed on the pleural fluid and serum of all patients are: Pleural fluid ALP concentration (P ALP), serum ALP concentration (S ALP), pleural fluid/serum ALP ratio (P/S ALP ratio). Biochemical analysis of ALP was done
  • RESULTS WERE
    In the group of patients with tuberculous
    pleural effusion, mean P ALP was significantly higher as compared to nontuberculous pleural effusion .
    Patients with tuberculous pleural effusion had a
    significantly higher mean P/S ALP ratio than with nontuberculous pleural effusion.
    However,such significant difference was not observed for S ALP levels.
  • 35. VALUES
    PF ALP level greater than 71 was observed in 27 out of 30 cases of tuberculous pleural effusion and six out of 30 cases of nontuberculous pleural effusion .
    PF/S ALP ratio greater than 0.51 was observed in 27 out of 30 cases of tuberculous pleural effusion and 4 out of 30 of non tuberculous pleural effusion
  • 36. DISCUSSION
    Result confirms that alkphsactivity is useful in differentiating tuberculous and non tuberculous effusion
    a cut-off value of ≥71 IU/L for pleural alkaline phosphatase activity; and a cut-off value of
    ≥0.51 for pleural fluid/serum alkaline phosphatase ratio.