By dr kartik sood

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By dr kartik sood

  1. 1. ALKALINE PHOSPHATASE:<br />DISTINGUISHING BETWEEN TUBERCULOUS AND NON TUBERCULOUS PLEURAL EFFUSION<br />BY DR KARTIK SOOD JUNIOR RESIDENT DEPARTMENT OF PULMONARY MEDICINE ELMCH<br />ORIGINAL ARTICLE-LUNG INDIA VOL-26,ISSUE 3,SEPT 2009<br />JAYASHREE SUHAS<br />ASHISH JADHAV<br />
  2. 2. INTRODUCTION<br />Tuberculosis is one of the important causes of exudative pleural effusion in our country.<br />Other causes- <br />Neoplasticdiseases<br /><ul><li>Metastatic disease
  3. 3. Mesothelioma</li></ul>Infectious diseases <br /><ul><li>Bacterial infections
  4. 4. Fungal infections
  5. 5. Viral infections
  6. 6. Parasitic infections</li></li></ul><li>Pulmonary embolization<br />Gastrointestinal disease <br /> Esophageal perforation <br /> Pancreatic disease <br />Intraabdominal abscesses <br /> Diaphragmatic hernia <br /> After abdominal surgery <br /> Endoscopic varicealsclerotherapy<br /> After liver transplant<br />Collagen-vascular diseases<br /> Rheumatoid pleuritis<br /> Systemic lupus erythematosus<br /> Drug-induced lupus <br />Immunoblasticlymphadenopathy<br />Sjögren's syndrome <br /> Wegener's granulomatosis<br />Churg-Strauss syndrome<br />
  7. 7. <ul><li>Asbestos exposure
  8. 8. Sarcoidosis
  9. 9. Uremia
  10. 10. Meigs' syndrome
  11. 11. Yellow nail syndrome
  12. 12. Drug-induced pleural disease
  13. 13. Nitrofurantoin
  14. 14. Dantrolene
  15. 15. Methysergide
  16. 16. Bromocriptine
  17. 17. Procarbazine
  18. 18. Amiodarone
  19. 19. Trapped lung
  20. 20. Radiation therapy
  21. 21. Post-cardiac injury syndrome
  22. 22. Hemothorax
  23. 23. Iatrogenic injury
  24. 24. Pericardial disease
  25. 25. Chylothorax
  26. 26. Post-coronary artery bypass surgery </li></li></ul><li><ul><li>Light’s criteria
  27. 27. Pleural fluid protein/serum protein >0.5
  28. 28. Pleural fluid LDH/serum LDH >0.6
  29. 29. Pleural fluid LDH more than two-thirds normal upper limit for serum
  30. 30. Modified light’s criteria:
  31. 31. Pleural fluid cholesterol level > 60mg/dl
  32. 32. Serum albumin minus pleural fluid albumin level ≤ 1.2g/dl</li></li></ul><li><ul><li>Various parameters have been used to differentiate tuberculous from nontuberculous pleural effusion.
  33. 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</li></ul>Alkaline phosphatase (ALP) is one of the biochemical markers found in pleural effusion. Previous studies have used ALP to differentiate between exudates and transudates.<br />
  34. 34. <ul><li>This study was thus undertaken to confirm</li></ul>the usefulness of ALP activity in differentiating tuberculous from nontuberculous pleural effusion.<br /><ul><li>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.</li></li></ul><li>the study was divided into two groups:<br />tuberculous (30) and nontuberculous pleural effusion (30). Nontuberculous group consist of malignant<br />effusion, parapneumonic effusion, empyema, rheumatoidarthritis, systemic lupus erythematosus, liver abscess,nephrotic syndrome, acute glomerulonephritis, cirrhosis of liver, congestive cardiac failure, severe hypoproteinemia,<br />and chronic renal failure.<br /><ul><li>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</li></li></ul><li>RESULTS WERE<br />In the group of patients with tuberculous<br /> pleural effusion, mean P ALP was significantly higher as compared to nontuberculous pleural effusion .<br />Patients with tuberculous pleural effusion had a<br />significantly higher mean P/S ALP ratio than with nontuberculous pleural effusion. <br />However,such significant difference was not observed for S ALP levels.<br />
  35. 35. VALUES<br />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 . <br />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<br />
  36. 36. DISCUSSION<br />Result confirms that alkphsactivity is useful in differentiating tuberculous and non tuberculous effusion<br />a cut-off value of ≥71 IU/L for pleural alkaline phosphatase activity; and a cut-off value of <br /> ≥0.51 for pleural fluid/serum alkaline phosphatase ratio.<br />

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