title: A diagnostic algorithm for tuberculous pleurisy using the ELISPOT assay on peripheral blood and pleural effusion.
abstract: BACKGROUND
  Diagnosis of tuberculous (TB) pleurisy remains challenging due to the paucibacillary nature of the disease. We prospectively assessed the diagnostic usefulness of the T-cell based ELISPOT assay, and created a clinical algorithm for differentiating TB pleurisy from other diagnoses.
  
  
  METHODS
  All adult patients with suspicion for TB pleurisy were enrolled in a tertiary hospital in Seoul, South Korea, over a 7-year period. ELISPOT assays were performed using mononuclear cells from peripheral blood and pleural effusion.
  
  
  RESULTS
  Seventy-seven patients with suspected TB pleurisy were enrolled. Of these, 33 (43%) patients, comprising 27 confirmed and 6 probable TB pleurisy, were classified as TB pleurisy, and 36 (47%) were classified as not TB. The remaining 8 with possible TB pleurisy were excluded from the final analysis. The sensitivities and specificities, respectively, of the diagnostic methods were as follows: pleural fluid adenosine deaminase (ADA) level 32 U/L, 81% and 79%; peripheral blood mononuclear cells (PBMC) ELISPOT assay, 82% and 73%; pleural effusion-mononuclear cells (PE-MC) ELISPOT assay, 58% and 87%. When the diagnostic algorithm was applied, PBMC ELISPOT ≥6 spots or ADA ≥32 U/L' as a rule-out test safely excluded 46% (12/26) of the not TB patients, and 'PE-MC ≥6 spots' as a rule-in test accurately classified 23% (7/31) of the patients with TB pleurisy.
  
  
  CONCLUSIONS
  A diagnostic algorithm combining ELISPOT assays and ADA levels in pleural fluid appears to be a promising and non-invasive approach for patients with suspected TB pleurisy.
authors.affiliation: a Department of Infectious Diseases , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea.
authors.forename: Min-Chul
authors.initials: MC
authors.lastname: Kim
authors.affiliation: a Department of Infectious Diseases , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea.
authors.forename: Sun-Mi
authors.initials: SM
authors.lastname: Kim
authors.affiliation: a Department of Infectious Diseases , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea.
authors.forename: Sang-Oh
authors.initials: SO
authors.lastname: Lee
authors.affiliation: a Department of Infectious Diseases , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea.
authors.forename: Sang-Ho
authors.initials: SH
authors.lastname: Choi
authors.affiliation: a Department of Infectious Diseases , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea.
authors.forename: Yang Soo
authors.initials: YS
authors.lastname: Kim
authors.affiliation: a Department of Infectious Diseases , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea.
authors.forename: Jun Hee
authors.initials: JH
authors.lastname: Woo
authors.affiliation: a Department of Infectious Diseases , Asan Medical Center, University of Ulsan College of Medicine , Seoul , Republic of Korea.
authors.forename: Sung-Han
authors.initials: SH
authors.lastname: Kim
mesh_terms: D000243:Adenosine Deaminase / Q000032:analysis; D000328:Adult; D000368:Aged; D000465:Algorithms; D058501:Enzyme-Linked Immunospot Assay / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009169:Mycobacterium tuberculosis / Q000276:immunology*; D010996:Pleural Effusion / Q000175:diagnosis* / Q000201:enzymology / Q000276:immunology*; D011446:Prospective Studies; D013601:T-Lymphocytes / Q000276:immunology; D014396:Tuberculosis, Pleural / Q000175:diagnosis* / Q000201:enzymology / Q000276:immunology*
chemical_list: D000243:Adenosine Deaminase
keywords: Diagnosis; ELISPOT; TB-specific T lymphocytes; tuberculous pleurisy