CID 1992; 15 (December)
J. Gomez Rodrigo, B. Padilla, A. Delgado-Iribarren, J. L. Dargallo, C. Pedroviejo, and J. Elviro Infectious Diseases Unit and Departments of Microbiology and Obstetrics. Hospital SeveroOchoa. Madrid. Spain
Cerebrospinal Fluid Adenosine Deaminase Levels in a Patient with Cryptococcal Meningitis SIR-The measurement of the adenosine deaminase activity (ADA) in CSF has been previously reported as a useful and reliable test for diagnosis oftuberculosis meningitis, and its specificity has been described to be as high as 99.4% [1]. Even in patients infected with human immunodeficiency virus (HIV), despite a selective depletion of blood T lymphocytes, raised ADA levels in CSF have been described as a helpful tool for diagnosing tuberculous meningitis [2]. There may be false-positive results, most often in cases of viral meningitis, although in a recent study of patients with bacterial meningitis due to Staphylococcus aureus and Streptococcus pneumoniae, ADA levels in CSF were significantly higher than normal and there were no differences between groups with bacterial and tuberculous meningitis [3]. Furthermore, opportunistic microorganisms other than Mycobacterium tuberculosis, such as Cryptococcus neoformans, may also produce meningitis in immunosuppressed patients. For the past 5 years, we have routinely measured CSF ADA levels, as described by Giusti [4], in patients with meningitis. In addition to patients with tuberculous meningitis, we have seen high CSF ADA levels in all those patients who are infected with HIV and who have cryptococcal meningitis in whom this parameter was measured (nine patients of 12; 75%). Among HIV-in-
Correspondence: Dr. Esteban Martinez, Department of Internal Medicine. Hospital de la Santa Creu i Sant Pau, Avda. Sant Antoni Maria Claret, 167,08025, Barcelona, Spain.
References I. Westh H, Skibsted L, Korner B. Streptococcus pneumoniae infections of the female genital tract and in the newborn child. Rev Infect Dis 1990;12:416-22. 2. Christopher GW, Hucker lA, White DW, Carter BL. Pneumococcal infections of the female genital tract. Rev Infect Dis 1990; 12:1203-4. 3. Bukovsky I, Neuman M, Ron-EI R, Langer R, Caspi E. Pneumococcal peritonitis in the presence of intra-uterine device-conservative treatment; a case report. Eur J Obstet Gynecol Reprod Bioi 1989;33:7982. 4. Goldman lA, Yeshaya A, Peleg D, Dekel A, Dicker D. Severe pneumococcal peritonitis complicating IUD: case report and review of the literature. Obstet Gynecol Surv 1986;41:672-4. 5. Muray JM, GalIi-Douani D, Ciraru-Vigneron N, BarrierJ. Pneumococcal peritonitis. An unusual diagnosis in gynecology. J Gynecol Obstet Bioi Reprod (Paris) 1982;11:829-32. 6. Browne MK, Cassie R. Spontaneous bacterial peritonitis during pregnancy. Case report. Br J Obstet Gynaecol 1981 ;88: I 158-60. 7. Fenoll A, Martin Bourgon C, Munoz R, Vicioso D, Casal J. Serotype distribution and antimicrobial resistance of Streptococcus pneumoniae isolates causing systemic infection in Spain, 1979-1989. Rev Infect Dis 1991;13:56-60.
fected patients, CSF ADA values were not significantly different between the group with tuberculous meningitis and the one with cryptococcal meningitis. CSF biochemical and cytological data from HIV-infected patients with cryptococcal meningitis are shown in table 1. The values for CSF ADA showed a close direct correlation with the number oflymphocytes in CSF (r = .689, P = .04). As far as we know, the association between cryptococcal meningitis and raised levels of CSF ADA has not been previously reported. There are at least two reasons. On the one hand, the incidence of cryptococcal meningitis is low, even among patients infected by HIV (4.5%; 12 of 269 patients with HIV infection diagnosed at our hospital), because it seems that severe immunosuppression is required (the mean CD4 lymphocyte count for our patients was 21 ± 13/mm 3, ranging from 3 to 47). Moreover, many laboratories do not routinely measure ADA levels in CSF. Although HIV-infected patients show a higher incidence of tuberculous meningitis than do non-HlV-infected patients [5], the former are also at risk for developing meningitis due to C. neoformans. Therefore, the previously described high specificity ofthe measurement ofADA in CSF for the diagnosis oftubercuTable 1. CSF biochemical and cytological data for nine infected patients with cryptococcal meningitis. Parameter Protein (g/L) Ratio ofCSF/blood glucose Leukocytes/mnr' * Adenosine deaminase (U/L)
Mean ± SD .64 ± .39 .44 ± .17 158 ± 167 14.7 ± 5.7 t
Range .08-1.5 .16-.73 20-426 8.2-25.2 t
* All the patients had a pleocytosis of lymphocytic predominance. t
The normal valve at our hospital is
J. Gomez Rodrigo, B. Padilla, A. Delgado-Iribarren, J. L. Dargallo, C. Pedroviejo, and J. Elviro Infectious Diseases Unit and Departments of Microbiology and Obstetrics. Hospital SeveroOchoa. Madrid. Spain
Cerebrospinal Fluid Adenosine Deaminase Levels in a Patient with Cryptococcal Meningitis SIR-The measurement of the adenosine deaminase activity (ADA) in CSF has been previously reported as a useful and reliable test for diagnosis oftuberculosis meningitis, and its specificity has been described to be as high as 99.4% [1]. Even in patients infected with human immunodeficiency virus (HIV), despite a selective depletion of blood T lymphocytes, raised ADA levels in CSF have been described as a helpful tool for diagnosing tuberculous meningitis [2]. There may be false-positive results, most often in cases of viral meningitis, although in a recent study of patients with bacterial meningitis due to Staphylococcus aureus and Streptococcus pneumoniae, ADA levels in CSF were significantly higher than normal and there were no differences between groups with bacterial and tuberculous meningitis [3]. Furthermore, opportunistic microorganisms other than Mycobacterium tuberculosis, such as Cryptococcus neoformans, may also produce meningitis in immunosuppressed patients. For the past 5 years, we have routinely measured CSF ADA levels, as described by Giusti [4], in patients with meningitis. In addition to patients with tuberculous meningitis, we have seen high CSF ADA levels in all those patients who are infected with HIV and who have cryptococcal meningitis in whom this parameter was measured (nine patients of 12; 75%). Among HIV-in-
Correspondence: Dr. Esteban Martinez, Department of Internal Medicine. Hospital de la Santa Creu i Sant Pau, Avda. Sant Antoni Maria Claret, 167,08025, Barcelona, Spain.
References I. Westh H, Skibsted L, Korner B. Streptococcus pneumoniae infections of the female genital tract and in the newborn child. Rev Infect Dis 1990;12:416-22. 2. Christopher GW, Hucker lA, White DW, Carter BL. Pneumococcal infections of the female genital tract. Rev Infect Dis 1990; 12:1203-4. 3. Bukovsky I, Neuman M, Ron-EI R, Langer R, Caspi E. Pneumococcal peritonitis in the presence of intra-uterine device-conservative treatment; a case report. Eur J Obstet Gynecol Reprod Bioi 1989;33:7982. 4. Goldman lA, Yeshaya A, Peleg D, Dekel A, Dicker D. Severe pneumococcal peritonitis complicating IUD: case report and review of the literature. Obstet Gynecol Surv 1986;41:672-4. 5. Muray JM, GalIi-Douani D, Ciraru-Vigneron N, BarrierJ. Pneumococcal peritonitis. An unusual diagnosis in gynecology. J Gynecol Obstet Bioi Reprod (Paris) 1982;11:829-32. 6. Browne MK, Cassie R. Spontaneous bacterial peritonitis during pregnancy. Case report. Br J Obstet Gynaecol 1981 ;88: I 158-60. 7. Fenoll A, Martin Bourgon C, Munoz R, Vicioso D, Casal J. Serotype distribution and antimicrobial resistance of Streptococcus pneumoniae isolates causing systemic infection in Spain, 1979-1989. Rev Infect Dis 1991;13:56-60.
fected patients, CSF ADA values were not significantly different between the group with tuberculous meningitis and the one with cryptococcal meningitis. CSF biochemical and cytological data from HIV-infected patients with cryptococcal meningitis are shown in table 1. The values for CSF ADA showed a close direct correlation with the number oflymphocytes in CSF (r = .689, P = .04). As far as we know, the association between cryptococcal meningitis and raised levels of CSF ADA has not been previously reported. There are at least two reasons. On the one hand, the incidence of cryptococcal meningitis is low, even among patients infected by HIV (4.5%; 12 of 269 patients with HIV infection diagnosed at our hospital), because it seems that severe immunosuppression is required (the mean CD4 lymphocyte count for our patients was 21 ± 13/mm 3, ranging from 3 to 47). Moreover, many laboratories do not routinely measure ADA levels in CSF. Although HIV-infected patients show a higher incidence of tuberculous meningitis than do non-HlV-infected patients [5], the former are also at risk for developing meningitis due to C. neoformans. Therefore, the previously described high specificity ofthe measurement ofADA in CSF for the diagnosis oftubercuTable 1. CSF biochemical and cytological data for nine infected patients with cryptococcal meningitis. Parameter Protein (g/L) Ratio ofCSF/blood glucose Leukocytes/mnr' * Adenosine deaminase (U/L)
Mean ± SD .64 ± .39 .44 ± .17 158 ± 167 14.7 ± 5.7 t
Range .08-1.5 .16-.73 20-426 8.2-25.2 t
* All the patients had a pleocytosis of lymphocytic predominance. t
The normal valve at our hospital is
