Egyptian Journal of Chest Diseases and Tuberculosis (2017) 66, 299–305

H O S T E D BY
The Egyptian Society of Chest Diseases and Tuberculosis

Egyptian Journal of Chest Diseases and Tuberculosis

www.elsevier.com/locate/ejcdt
www.sciencedirect.com

Comparison of the diagnostic utility of ADA and

CA125 in tuberculous effusion
M.S. El Hoshy a,*, A.A. Abdallah a, S.M. Abd Elhamid b

a
Chest Diseases Department, Faculty of Medicine, Alexandria University, Egypt
b
Micorobiology and Immunology Department, Damanhur University, Egypt

Received 29 August 2016; revised 29 September 2016; accepted 3 October 2016

Available online 11 November 2016

Abstract Background: Pleural effusion can be due to various pleural infections like TB as well as
neoplasia. CA125 is a tumor marker found on the surface of ovarian and other normal cells as pleu-
ral cells. CA125 has been found to increase in serum and hence pleural fluid of patients with pleural
effusion due to malignancy as well as due to TB.
This study was conducted to evaluate the utility of CA125 in the diagnosis of pleural effusion
resulting from TB, malignancy and pneumonia as well as to evaluate and compare the diagnostic
utility of CA125 and ADA in the diagnosis of TB effusion.
Patients and methods: 20 patients with tuberculous effusion (group I), 20 patients with malignant
effusion (group II) and 20 patients with parapneumonic effusions (group III) were evaluated for the
levels of CA125 and ADA in their pleural fluid. In malignant cases, diagnosis was made through
microscopic inspection of pleural biopsy samples and cytology of pleural fluid. For diagnosis of
tuberculosis, Ziehl Neelsen sputum smear, pleural fluid smear and/ or culture. Parapneumonic effu-
sions were confirmed by pleural fluid cell count and culture & sensitivity.
Results: The mean ± SD level of CA125 in pleural fluid was 41.732 ± 20.744 U/ml, 309.27
± 79.564 U/ml and 7.040 ± 5.601 U/ml in tuberculous, malignant and parapneumonic effusions
respectively; which showed a statistically significant difference between the three groups (p < 0.01).
Pleural fluid CA125 was significantly higher in group II than group I (P1 = 0.000), and group III
(P3 = 0.000). Pleural fluid CA125 was significantly higher in group I than group III (P2 = 0.000).
Pleural fluid ADA was significantly higher in group I than group II (P1 = 0.000) and group III
(P2 = 0.000). For diagnosing TB, CA125 showed a sensitivity and specificity of 74.1%, 76.9%,
respectively while ADA demonstrated a sensitivity and specificity of 75% and 75% respectively.
Conclusion: CA-125 levels in pleural fluid may be used for differentiation between TB, pneumonic,
and malignancy-induced effusions.
Also CA125 may be added to the diagnostic workup of pleural fluid for accurate diagnosis of TB
effusion.
Ó 2016 The Egyptian Society of Chest Diseases and Tuberculosis. Production and hosting by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-
nd/4.0/).

* Corresponding author.
Peer review under responsibility of The Egyptian Society of Chest Diseases and Tuberculosis.
http://dx.doi.org/10.1016/j.ejcdt.2016.10.003
0422-7638 Ó 2016 The Egyptian Society of Chest Diseases and Tuberculosis. Production and hosting by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
300
Introduction
In absence of inflammation, pleural space contains little tran-
sudate fluid with small amounts of protein, LDH and few cells,
which are mainly lymphocytes, macrophages and endothelial
cells. Pleural effusion may occur due to an inflammatory or
non-inflammatory etiology. In non-inflammatory etiologies,
there might be a decrease in oncotic pressure or an increase
in hydrostatic pressure. Otherwise, changes in lymphatic drai-
nage may play an important role. However, changes in the per-
meability of veins in the pleura result from cross reaction
between infectious organisms and defensive inflammatory cells
and the secreted cytokines and chemokines. Thus, diagnosis of
the underlying cause is not simple in some cases. It is essential
to keep this fact in mind for an appropriate treatment
approach [1].
Mechanism of accumulation of pleural fluid in tuberculosis
is somewhat chronic, just the same as in malignancy. This sim-
ilarity makes differentiation of the cause of pleural effusion
whether due to malignancy or TB difficult to detect. This
makes the process of appropriate management also difficult
despite the use of several parameters and techniques. Discrim-
inating the etiology of pleural effusion in tuberculosis and
malignant cases plays an important role in patients’ treatment
[1].
CA125 is glycoprotein with a high molecular weight,
mucin-like, exists on the surface of ovarian, and some inflam-
matory and non-inflammatory cells like pleural cells. Prolifer-
ation of these cells causes this antigen to be released in serum.
CA-125 was first known as a specific tumor marker that is the
basis for a widely used serum assay for the monitoring of the
ovary. Gradually it was found that inflammation even without
polymorphism (as in the early stage of pregnancy, menstrual
cycle, PID, and endometriosis) causes this tumor marker to
increase. Increased CA-125 levels in response to tuberculosis
were first observed in 1980’s. Later, it was revealed that tuber-
culosis in various sites of the body causes increase in serum
Antigen level [2–6].
This study was performed in order to investigate the ability
of CA-125 levels to differentiate pleural effusion due to tuber-
culosis, pneumonias and malignancies. Also to compare the
validity of the use of CA125 and ADA for the diagnosis of
tuberculous effusion.
Aim of the work
The aim of the present study is to evaluate the diagnostic valid-
ity of CA125 and compare the diagnostic utilities of ADA and
CA125 in tuberculous effusion.
Study population
This study included 60 patients who were admitted to Alexan-
dria University Hospital during the period between December
2015 and July 2016. Patients were divided into 3 groups as fol-
lows: group I included 20 patients with tuberculous effusion,
group II included 20 patients with malignant effusion and
group III included 20 patients with pneumonic effusion.
Informed consent was obtained from all the participants
before the study.
M.S. El Hoshy et al.
Patients and methods
All patients were subjected basically to thorough history-
taking and clinical examination, routine laboratory investiga-
tions, plain chest radiography (posteroanterior and lateral
views), CT chest and thoracocentesis. The pleural fluid
obtained was examined for the following: gross appearance
and nature of the fluid, total and differential cell count, total
protein and albumin content (g/dl), lactate dehydrogenase
enzyme, and bacteriological examination by culture and sensi-
tivity. In malignant cases, diagnosis was made through micro-
scopic inspection of biopsy samples and cytology of pleural
fluid. For diagnosis of tuberculosis, Ziehl Neelsen smear
and/ or culture of pleural fluid or in some cases pleural biopsy.
Pneumonic effusions were confirmed by pleural fluid cell count
and culture and sensitivity. CA125 was measured in pleural
fluid in U/ml using the commercially available ELISA kit
(CA125 Test System, Monobind Inc., CA, USA). Pleural fluid
ADA measurements were done using Adenosine Deaminase
BioAssayTM ELISA Kit, US Biological Life Sciences, Michigan,
USA). By utilizing several different serum references of known
antigen values, a dose response curve was generated from
which the antigen concentration of the samples was
ascertained.
ROC (receiver operating characteristic) curves were used to
determine the optimal cut-off value of ADA and serum CA125
which could distinguish TB from other pulmonary infections
with the highest sensitivity, specificity, and predictive values
[7]. The curve obtained, allowed the calculation of the slope
and the area under the curve (AUC).
The association between categorical variables was per-
formed using Chisquared tests. Mann Whitney U test and
SPSS ver. 11.5 software were used for statistical analysis to
compare CA125 in the three groups and p-values < 0.05 were
considered to be statistically significant.
Results
The study comprised 3 groups: group I which included 20
patients with confirmed diagnosis of tuberculous effusions.
In group II, 20 patients had confirmed malignant effusion
through positive cytology of pleural fluid or biopsy samples.
In group III, 20 patients had a confirmed diagnosis of para-
pneumonic effusion.
Table 1 shows that the age of the studied patients ranged
from 26 to 60 years with a mean of 44.87 ± 13.557 in group
I, while it ranged from 24 to 68 years with a mean of 47.15
± 12.963 in group II and it ranged from 23 to 66 years with
a mean of 43.00 ± 14.008 in group III, with no statistically sig-
nificant difference between the three groups as regards age.
Regarding gender, 12 patients (60%) were males whereas 8
patients (40%) were females in group I. 11 patients (55%) were
males whereas 9 patients (45%) were females in group II, and
12 patients (60%) were males whereas 8 patients (40%) were
females in group III with no statistically significant difference
between the three groups as regards gender.
Regarding radiological findings, left pleural effusion was
detected in 9 (45%) patients in group I, in 7 (35%) patients
in group II and in 10 (50%) patients in group III. Right pleural
effusion was detected in 11 (55%) patients in group I, in 13
(65%) patients in group II and in 10 (50%) patients in group
Comparison of the diagnostic utility of ADA and CA125 in tuberculous effusion 301

Table 1 Comparison between studied groups as regards Age, gender, radiological findings, pleural fluid ADA and CA125.
Group (I) Group (II) Group (III) P value
tuberculous effusion malignant effusion parapneumonic effusion
Age 26–60 24–68 23–66 P1 = 0.561,
44.87 ± 13.557 47.15 ± 12.963 43.00 ± 14.008 P2 = 0.632
P3 = 0.355,
P = 0.644
Gender
Male 12 (60%) 11 (55%) 12 (60%) P1 = 1.000,
P2 = 1.000
P3 = 1.000,
P = 1.000
Female 8 (40%) 9(45%) 8 (40%)
Radiological findings
Left 9 (45%) 7 (35%) 10 (50%) P1 = 0.780,
Pleural P2 = 0.596
Effusion P3 = 0.523,
P = 0.631
Right 11 (55%) 13 (65%) 10 (50%)
Pleural
Effusion
Pleural 76–120 12–36 10–34 P1 = 0.000*,
Fluid 93.30 ± 12.103 23.65 ± 6.515 22.55 ± 7.430 P2 = 0.000*
ADA P3 = 0.758,
P = 0.000*
Pleural 23.8–98.7 212.6–454 1.1–21 P1 = 0.000*,
Fluid 41.732 ± 20.744 309.27 ± 79.564 7.040 ± 5.601 P2 = 0.000*
CA125 P3 = 0.000*,
P = 0.000*
P1 = Comparison between Group (I) and Group (II).
P2 = Comparison between Group (I) and Group (III).
P3 = Comparison between Group (II) and Group (III).
P = Comparison between the three groups.

III. There was no statistically significant difference between the
three groups as regards radiological findings.
Regarding pleural fluid ADA, it ranged from 76 to 120 IU/L
with a mean of 93.30 ± 12.103 in group I, whereas it ranged
from 12 to 36 IU/L with a mean of 23.65 ± 6.515 in group II
and it ranged from 10 to 34 IU/L with a mean of 22.55
± 7.430 in group III. Pleural fluid ADA was significantly
higher in group I than the other 2 groups (P = 0.000,
P1 = 0.000, P2 = 0.000).
Regarding pleural fluid CA125, it ranged from 23.8 to
98.7 IU/ml with a mean of 41.732 ± 20.744 in group I,
whereas it ranged from 212.6 to 454 IU/ml with a mean of
309.27 ± 79.564 in group II and it ranged from 1.1 to
21 IU/ml with a mean of 7.040 ± 5.601 in group III with sta-
tistically significant difference between the three studied
groups (P = 0.000). Pleural fluid CA125 was significantly
higher in group II than group I (P1 = 0.000) and group III
(P3 = 0.000). Pleural fluid CA125 was significantly higher in
group I than group III (P2 = 0.000).
Table 2 shows that the sensitivity and specificity of pleural
fluid ADA in the tuberculous group were 75% and 75%
respectively with positive predictive and negative predictive
values of 64 and 30.2 respectively. The sensitivity and speci-
ficity of pleural fluid CA125 in the tuberculous group were
74.1% and 76.9% respectively with positive predictive and
negative predictive values of 70 and 33.3 respectively.
ROC (receiver operating characteristic) curves for diagnosis
of TB by ADA and serum CA125 are shown in Fig. 1 and
Fig. 2, respectively. Comparison between sensitivity, specificity
and accuracy of both ADA and CA125 for TB diagnosis is
shown in Fig 3. As compared to ADA, CA125 is more specific
and slightly less sensitive for the diagnosis of TB effusion.
Discussion
CA125 antigen is a glycoprotein marker that is primarily pro-
duced by amnion, coelomic epithelium of the featus, but can
also be produced by epithelium of fallopian tube, endome-
trium, endocervix, pleura or peritoneum. CA125 was found
in high levels in serum in many benign conditions including
infections of the peritoneum and pleura, during menstruation,
pregnancy, endometriosis, liver diseases (like cirrhosis), benign
ovarian tumors, pancreatitis, renal and hepatic insufficiencies,
pelvic irradiation, post-menopausal period, pelvic inflamma-
tory disease and tuberculosis [8,11–15].
High serum CA125 levels have also been demonstrated in
many malignant processes including several tumors. Classi-
cally it has been used to monitor the course of ovarian carci-
noma. CA125 levels are also increased in other neoplastic
conditions, such as pulmonary, pancreatic, hepatobiliary, gas-
tric, and colorectal neoplasias [9–11].
302
Table 2 Comparison between sensitivity and specificity of ADA and CA125.
Sensitivity Specificity
ADA 75% 75%
CA125 74.1% 76.9%
ADA
Fig. 1 Receiver operating characteristic (ROC) curve for diagnosis of TB by ADA.
In a study to evaluate the level of CA125 in serum of
patients with history of previous surgery, heart failure, pul-
monary disease, cirrhosis and intrabdominal disease, Mirales
et al. have reported increased CA125 levels (>35 IU/ml) [16].
Other studies have reported high serum CA125 levels in
tuberculosis, mainly in extrapulmonary locations with abdom-
inal involvement [17–25].
Aoki and his colleagues compared the amounts of ADA in
pleural fluid, CA125 in serum, and pleural fluid gamma inter-
feron in TB pleurisy and non-tuberculosis cases and stated that
there was a considerable overlap between the amounts of pleu-
ral fluid ADA and serum CA125 in the two groups. However,
the average value of CA125 in tuberculous pleuritis cases was
higher compared with other infections [26].
In the present study, the amount of CA125 in pleural fluid
of malignant patients was found to be significantly higher than
in tuberculous pleural fluid.
This is in agreement with the same results of Shervin et al.
who stated that estimating pleural fluid CA125 in patients with
M.S. El Hoshy et al.
AUC PPV NPV Accuracy
0.500 64 30.2 50%
0.486 70 33.3 57.5 %
an unidentified and unclassical history is very useful. This is
because, the chronic nature of this disease whether malignant
or tuberculosis makes it very difficult to distinguish these
two from each other requiring costly tests which may be
avoided by using this method [27,28].
Also, Tomita et al. compared the level of pleural fluid
CA125 in 51 patients affected by pleural effusion secondary
to malignancy and 38 patients affected by benign effusion in
a study to examine the histological distribution of CA125 in
patients affected by pleural effusion. They determined, as in
agreement with the present study, that the amount of CA125
in malignant effusion is remarkably higher than in the other
cases in which effusion is due to other causes. They confirmed
that CA125 in pleural effusion is produced by both malignant
cells and active mesothelial cells [31].
On the other hand, Hirose and his colleagues reported a
case of tuberculous effusion in which the level of serum
CA125 was 1150 units per ml [30]. Their study showed that
pleural cells were covered with antibodies against CA125 and
Comparison of the diagnostic utility of ADA and CA125 in tuberculous effusion 303

CA125

Fig. 2 Receiver operating characteristic (ROC) curve for diagnosis of TB by CA125.

ADA CA125

80

70

60

50

40
%

30

20

10

0
Sensivity Specificity Accuracy

Fig. 3 Comparison between sensitivity, specificity and accuracy of both ADA and CA125 for TB diagnosis.

that CA125 originated from pleural cells. They then concluded
that malignant morphologic changes in the cells are not neces-
sary for secretion of CA125. The amount of CA125 in both
infection (TB) and malignant cases increases and can be a use-
ful diagnostic guide [30].
Thakur and his colleagues mentioned that abdominal and
peritoneum tuberculosis can result in an increase in the
amount of serum CA-125, which can be reduced by using
the right treatment approach [29].
304
In the present study, the amount of CA125 was measured in
pleural fluid while in most of the previous studies
[5,6,26,28,32], the amount of CA125 was considered only in
serum.
ADA is an enzyme involved in purine catabolism, found in
the majority of cells, but particularly in lymphocytes. It has
been reported to have high sensitivity and reasonably good
specificity for the diagnosis of pleural TB [33–37]. Since mea-
surement of ADA is simple and inexpensive, it has a great
diagnostic potential in the diagnosis of pleural TB in develop-
ing countries.
In the present study, pleural fluid ADA was significantly
higher in TB group than the malignant and parapneumonic
groups which is in agreement with other previous studies
[38–42]. 4 of the non-TB pleural fluid samples had increased
ADA, 3 of which were from group II and in 1 from group
III, but these results were not statistically significant.
The sensitivity and specificity of pleural fluid ADA at a cut-
off of 45 IU/L in the tuberculous group of the present study
were 75% and 75% respectively i.e. ADA has similar sensitiv-
ity and specificity for diagnosing TB effusion.
The sensitivity and specificity of pleural fluid CA125 at a
cut-off of 90 IU/L in the tuberculous group of the present
study were 74.1% and 76.9% respectively i.e. CA125 is more
specific than sensitive in diagnosing TB effusion (Fig. 3).
As compared to ADA, in the present study, CA125 is more
specific and slightly less sensitive in the diagnosis of TB
effusion.
Ambade et al. reported a sensitivity and specificity of ADA
of 80% and 76%, respectively, at a cut-off of 71 IU/L which is
quite comparative to the present study.
Similarly, Shalaby el al. reported that pleural CA-125 was
more specific than sensitive in the detection of exudates
because of tuberculosis, whereas serum CA-125 is more sensi-
tive [43].
Aoki et al. reported that the sensitivity, specificity were
81
8%, 89
3%, respectively, when pADA values of more than
45 U ml 1 were considered, and they were 100%, 75
0%,
respectively, when sCA125 values of more than 35 U ml 1 -
were considered [26].
Fortun et al. concluded that serum CA125 values increased
in patients with pulmonary TB and not in patients with non-
TB pulmonary infections. The sensitivity and specificity were
68.6% and 77.8%, respectively at cut-off for pulmonary tuber-
culosis 32.5 IU/ml (Pulmonary TB was the only factor associ-
ated with a Ca-125 level >32.5) [44].
Burgess et al. have reported higher sensitivities and speci-
ficities of tuberculous PF ADA in the range of 91–100% and
81–94%, respectively [45], while Goto et al. in his meta-
analysis of 40 studies reported a sensitivity range of 47.1–
100%, and specificity range of 0–100%, and also suggested
that the difference was due to different methods of estimation.
They added that choosing a lower value increases sensitivity at
the expense of specificity [46].
To conclude, raised CA125 in pleural fluid can be due to
diverse aetiologies as tuberculosis and malignancy i.e. benign
as well as malignant reasons have to be ruled out in cases of
raised fluid CA125 levels.
Also, the use of pleural ADA levels provides a rapid and
accurate means of detecting tuberculous effusion and hence
early proper treatment. The study advocates a strategy of using
M.S. El Hoshy et al.
ADA as a screening test in all patients presenting with an
exudative pleural effusion of uncertain origin.
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