الفهرس 
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Abstract
Pleural effusion is the accumulation of liquid in the pleural cavity and, in most cases, is considered a result of a systemic or intrathoracic process. This pathological entity is a frequent problem in pulmonology and, though its incidence varies with clinical background, 90% of all pleural effusions are attributed to congestive heart failure, malignant processes, and pneumonia. The main issues regarding pleural effusions are the differentiation of exudates and transudates and the accurate determination of effusion etiology (i.e. whether the pleural effusion is malignant or non-malignant). The differentiation of exudates and transudates requires the evaluation of various biochemical parameters and their comparison in pleural fluid and serum. When differentiating transudates from exudates using classical Light’s criteria, it is helpful to recognize the pathogenic mechanism resulting in the pleural effusion. Recognizing the correct pathogenic mechanism is also useful for the purpose of differential diagnosis. CA-125 is a 200 KD glycoprotein, which exists on the surface of ovarian, and some inflammatory and non-inflammatory cells. Proliferation of these cells causes this antigen to be released in serum. CA125 was first known as a specific tumor marker of the ovary but gradually it was found that inflammation even without polymorphism (the early stage of pregnancy, menstrual cycle, PID, and endometriosis) causes this tumor marker to increase. Later it was revealed that tuberculosis in various sites of body cause increase in serum antigen level. The aim of this study was to evaluate the diagnostic value of CA-125 and to determine the cut-off value, distinguishing tuberculous from malignant pleural effusion. This work was carried out in Chest Department, Tanta University Hospitals and Tanta Chest Hospital on 90 patients with pleural effusion. The duration of study was 18 months, started from April 2019 till September 2020. Subjects of the study were classified into 3 groups: group I ”Tuberculous”: Included 30 patients with a confirmed diagnosis of tuberculous pleural effusion. group II ”Malignant”: Included 30 patients with a confirmed diagnosis of malignant pleural effusion. group III ” Control - Parapneumonic”: Included 30 patients with a confirmed diagnosis of parapneumonic effusion. Inclusion criteria: • Patients above 18 years old. • Patients with a confirmed diagnosis of parapneumonic, tuberculous and malignant pleural effusion. Exclusion criteria: • Patients with hepatic cirrhosis, heart failure, or any other non-infectious diseases. • Female patients with endometriosis and pregnancy. The following parameters were done: Consent taking from patient, History taking and complete physical examination, Chest X-ray ”PA and lateral view”, CT Chest, ECG and Echocardiography to exclude cardiac patient from the study, Sputum for acid fast bacilli 3 times, Tuberclin test, laboratory investigations: CBC, ESR, CRP, Renal and liver function tests. Specific laboratory investigations: Thoracocentesis: the pleural fluid was examined for: Gross appearance, Chemical analysis; differentiating exudative from transudative effusion, Cytological analysis; for total and differential cell count, and for malignant cells, Bacteriological analysis; for acid fast bacilli smear staining, and/ or culture and sensitivity, Adenosine deaminase levels ”ADA” and Cancer antigen-125 ”CA-125” measured in both serum and pleural fluid using ELISA kit. Pleural biopsy was not needed in diagnosis of our cases. Preparation of pleural fluid sample: • Pleural fluid samples were collected in a siliconized container. • The fluid was filtered and centrifuged at 3000 rpm at 4° C for 30 minutes to isolate the floating aliquots. • The pleural fluid samples were numbered and stored at -20° C. Serum sample preparation: After collection of the blood sample, it was allowed to clot by leaving it undisturbed at room temperature for 10-20 minutes. Then, the sample was centrifuged at 2,000-3,000 rpm for 20 minutes and the serum was separated in eppendorf tube and stored at -20 C. Results: The current study found that age (mean ± SD) was significantly higher in group II (60.80 ± 15.84) when compared to group III (51.31 ± 11.17) (P3=0.009) with no statistically significant difference between groups I and II (P1=0.092) or Groups I and III (P2=0.343). Total leucocytic count was significantly higher in group III when compared to Groups I and II (P2=0.024) and (P3=0.011) respectively, with no statistically significant difference between Groups I and II (P1=0.763). ESR was significantly higher in group I when compared to group II and III (P1=0.001) and (P2=0.001) respectively, with no statistically significant difference between Groups II and III (P3=0.372). CRP was significantly higher in group III when compared to Groups I and II (P2 = 0.001) and (P3 = 0.001) respectively, with no statistically significant difference between Groups I and II (P1 = 0.738). The numbers of tuberclin positive cases were: 18 (60.0%), 10 (33.3%) and 8 (26.7%) in group I, II and III respectively. As regard gross appearance of pleural effusion: the numbers of cases with cloudy pleural fluid were: 0 (0%), 0 (0%) and 6 (20.0%) in group I, II and III respectively. While the numbers of cases with turbid yellow pleural fluid were: 22 (73.3%), 8 (26.7%) and 18 (60.0%) in group I, II and III respectively. And the numbers of cases with bloody turbid pleural fluid were: 8 (26.7%), 22 (73.3%) and 6 (20.0%) in group I, II and III respectively As regard specific gravity, there was no statistically significant difference between the three studied groups. PH was significantly lower in group I when compared to group II (P1=0.001), and in group III when compared to Groups I and II (P2=0.001) and (P3=0.001) respectively. Pleural fluid protein was significantly higher in Groups II and III when compared to group I (P1 = 0.022) and (P2 = 0.009) respectively, with no statistically significant difference between Groups II and III (P3 = 0.753). Glucose was significantly higher in Groups I and II when compared to group III (P2 = 0.001) and (P3 = 0.001) respectively, with no statistically significant difference between Groups I and II (P1 = 0.129). LDH was significantly higher in Groups II and III when compared to group I (P1 = 0.001) and (P2 = 0.001) respectively, with no statistically significant difference between group II and III (P3 = 0.080). Pleural fluid Protein / Serum Protein was no statistically significant difference between the three studied groups. Pleural fluid LDH / Serum LDH was significantly higher in group II when compared to Groups I and III (P1=0.001) and (P3 = 0.009) respectively, and in group III when compared to group I (P2=0.001). ADA was significantly higher in group I when compared to Groups II and III (P1 = 0.001) and (P2 = 0.001) respectively, with no statistically significant difference between group II and III (P3 = 0.1543). According to the results of the thoracentesis, all cases included in the 3 studied groups, had exudative pleural effusion. Serum level of CA-125 was significantly higher in group II when compared to group I and III (P1=0.001) and (P3 = 0.001) respectively, and in group I when compared to group III (P2=0.017). Pleural fluid levels CA-125 was significantly higher in group II when compared to group I and III (P1=0.001) and (P3 = 0.001) respectively, and in group I when compared to group III (P2=0.034). Our data showed that correlations between CA125 in serum and pleural fluid levels was highly positive significant P=0.001 in malignant effusion group (group II) and in tuberculous effusion group (group I). The present study concluded that, Serum and pleural fluid CA-125 levels may be used for differentiation between TB and malignancy-induced effusions. Also, CA-125 may be added to the diagnostic workup of pleural fluid for accurate diagnosis of malignant pleural effusion.