Differential diagnosis between lymphoma-associated malignant pleural effusion and tuberculous pleural effusion

Abstract

Background: Lymphoma-associated malignant pleural effusions (L-MPE) can mimic tuberculous pleural effusion (TPE) characterized by lymphocytic exudate with high adenosine deaminase (ADA) levels. Furthermore, the low cytological yield of L-MPE makes differentiation between L-MPE and TPE more challenging. However, there are few data regarding differential diagnosis of L-MPE and TPE. Methods: All consecutive patients diagnosed with L-MPE or TPE between January 2011 and December 2016 were retrospectively recruited using the Electronic Medical Record database. Clinical symptoms and laboratory and pleural fluid data [including serum lactate dehydrogenase (LDH), C-reactive protein, and pleural fluid ADA levels] were compared between L-MPE and TPE. Useful variables in the differential diagnosis of L-MPE and TPE were evaluated by multivariate logistic regression analysis. Results: Seventeen patients with L-MPE and 216 patients with TPE were included in this study. In the multivariate analysis, fever was negatively associated with L-MPE [odds ratio (OR): 0.175, 95% confidence interval (CI): 0.033-0.941, P=0.042], while serum LDH levels were positively associated with L-MPE (OR: 1.005, 95% CI: 1.003-1.007, P<0.001). Serum LDH >460 U/L provided a sensitivity of 76% and a specificity of 81% to distinguish L-MPE and TPE. In contrast, serum C-reactive protein and pleural fluid ADA levels were not significantly different between the groups. Conclusions: Patients with L-MPE and TPE present very similar clinical, laboratory, and pleural fluid characteristics. Fever and serum LDH levels may be helpful in guiding the differential diagnosis of L-MPE and TPE. Lymphoma should be kept in mind in the differential diagnosis in patients with lymphocytic pleural effusion and high ADA levels.

Diagnostic Procedures, Diagnoses, and Treatment Outcomes of Patients with Presumptive Tuberculosis Pleural Effusion in Uzbekistan

“…In our study, 10.7% of TPE cases had a histological confirmation of TB, which was similar to a South Korean study showing that 13.9% of patients had a positive histological diagnosis of TPE [ 21 ]. Of interest, while there is little evidence in the literature about using cytological examination for diagnosing TPE, a high proportion of our study participants (43.0%) were confirmed to have TPE cytologically.…”

“…Among our study participants, eight (4.3%) were confirmed to have a malignant disease. The proportion of presumptive TPE with cancer varies from 7.3% to 55.4% across the published literature [ 21 , 22 , 23 ]. The differences between our study and the other studies are explained by the specific study populations.…”

“…The ADA has been long considered a highly accurate marker for diagnosing TPE and, especially, in moderate to high TB burden countries like Uzbekistan, the detection of high ADA levels can help confirm TB diagnosis and justify the timely initiation of relevant treatment. [ 16 , 21 , 22 , 28 ].…”

Diagnostic significance of adenosine deaminase in pleural effusate for primary effusion lymphoma–like lymphoma

“…This level was much higher than ADA levels previously reported in lymphoma cases with pleural effusion and tuberculous pleural effusion cases. 1 Our case and review of the literature suggests the possibility that pleural effusate ADA levels in patients with PEL-LL might be much higher than those in patients with other types of lymphomas and those with tuberculous pleural effusion. More data are needed to validate our observation.…”

“…Tuberculous pleural effusion and lymphoma are included in the differential diagnosis of patients with high adenosine deaminase (ADA) levels in pleural effusate. Previous reports showed that median ADA levels in pleural fluid were 73 IU/L (interquartile range 44‐124 IU/L) and 84 IU/L (interquartile range 64‐110 IU/L) in patients with lymphoma‐associated malignant effusion (n = 17) and tuberculous pleural effusion (n = 216), respectively 1 . Our patient with primary effusion lymphoma (PEL)–like lymphoma (PEL‐LL) had extremely high ADA levels in pleural fluid.…”