{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T13:18:15Z","timestamp":1787663895380,"version":"build-2736575974"},"reference-count":19,"publisher":"PAGEPress Publications","license":[{"start":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T00:00:00Z","timestamp":1787616000000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Monaldi Arch Chest Dis"],"abstract":"<jats:p>Undiagnosed exudative pleural effusion remains a frequent clinical challenge, particularly in high-burden settings where tuberculosis and malignancy predominate. Pleural fluid adenosine deaminase (ADA) is useful for suggesting tuberculous pleural effusion (TPE), but a substantial \u201cgray zone\u201d overlaps with malignant pleural effusion (MPE). This study evaluated the diagnostic yield of medical thoracoscopy with comparative analysis of pleural fluid ADA levels. This prospective, single-center, exploratory observational study was conducted over 1.5 years in a tertiary care hospital of north India. Consecutive adults (&gt;18 years) with undiagnosed exudative pleural effusion (Light\u2019s criteria) were enrolled after pleural fluid CBNAAT\/GeneXpert was negative for Mycobacterium tuberculosis and pleural fluid cytology negative for malignancy on at least two samples, taken \u226524 hours apart. A total of 150 patients were included (92 males, 58 females). All patients underwent single-port medical thoracoscopy under conscious sedation, systematic pleural inspection, and targeted biopsy (3-6 samples). Biopsies were sent for histopathology and CBNAAT. Thoracoscopic pleural biopsy established malignancy in 104\/150 (69.3%) and tuberculosis in 40\/150 (26.7%) patients, resulting in an overall diagnostic yield of 96%. Non-specific inflammation was observed in four patients, pyogenic inflammation in one, and one biopsy was inconclusive. Metastatic adenocarcinoma was the commonest malignancy (88\/104). In biopsy-proven TPE, tissue CBNAAT positivity was low (9\/40, 22.5%). ADA was significantly higher in tubercular effusions than MPE (40.17 vs. 20.11 IU\/L; p&lt;0.001). Major complications were infrequent with no procedure-related mortality.<\/jats:p>","DOI":"10.4081\/monaldi.2026.3910","type":"journal-article","created":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T12:18:40Z","timestamp":1787660320000},"source":"Crossref","is-referenced-by-count":0,"title":["Diagnostic yield of thoracoscopic pleural biopsy in undiagnosed exudative pleural effusion and comparative analysis of pleural fluid adenosine deaminase levels"],"prefix":"10.4081","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7729-5770","authenticated-orcid":false,"given":"Deepak","family":"Sharma","sequence":"first","affiliation":[{"name":"Department of Pulmonary and Critical Care Medicine, King George's Medical University, Lucknow"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1119-7094","authenticated-orcid":false,"given":"Sachin","family":"Kumar","sequence":"additional","affiliation":[{"name":"Department of Pulmonary and Critical Care Medicine, King George's Medical University, Lucknow"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ved","family":"Prakash","sequence":"additional","affiliation":[{"name":"Department of Pulmonary and Critical Care Medicine, King George's Medical University, Lucknow"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8447-6676","authenticated-orcid":false,"given":"Mohammad","family":"Arif","sequence":"additional","affiliation":[{"name":"Department of Pulmonary and Critical Care Medicine, King George's Medical University, Lucknow"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5299-7584","authenticated-orcid":false,"given":"Anurag","family":"Tripathi","sequence":"additional","affiliation":[{"name":"Department of Pulmonary and Critical Care Medicine, King George's Medical University, Lucknow"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0001-4963-3955","authenticated-orcid":false,"given":"Shubhra","family":"Srivastava","sequence":"additional","affiliation":[{"name":"Department of Pulmonary and Critical Care Medicine, King George's Medical University, Lucknow"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7525-1435","authenticated-orcid":false,"given":"Hemant","family":"Kumar","sequence":"additional","affiliation":[{"name":"Department of Respiratory Medicine, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5216-1645","authenticated-orcid":false,"given":"Mrityunjaya","family":"Singh","sequence":"additional","affiliation":[{"name":"Department of Respiratory Medicine, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Harshita","family":"Mishra","sequence":"additional","affiliation":[{"name":"Department of Pulmonary and Critical Care Medicine, King George's Medical University, Lucknow"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"2549","published-online":{"date-parts":[[2026,8,25]]},"reference":[{"key":"85645","doi-asserted-by":"crossref","unstructured":"Jany B, Welte T. Pleural effusion in adults-etiology, diagnosis, and treatment. Dtsch Arztebl Int 2019;116:377-86.","DOI":"10.3238\/arztebl.2019.0377"},{"key":"85646","doi-asserted-by":"crossref","unstructured":"Abdulelah M, Abu Hishmeh M. Infective pleural effusions-a comprehensive narrative review article. Clin Pract 2024;14:870-81.","DOI":"10.3390\/clinpract14030068"},{"key":"85647","doi-asserted-by":"crossref","unstructured":"Kumar Bar P, Mandal S, Banik T, e al. A clinicopathological study of pleural effusion with special reference to malignant aetiology in a tertiary care hospital in West Bengal. Int J Med Res Rev 2019;7:266-72.","DOI":"10.17511\/ijmrr.2019.i04.03"},{"key":"85648","doi-asserted-by":"crossref","unstructured":"Chauhan A, Parmar M, Dash GC, et al. The prevalence of tuberculosis infection in India: a systematic review and meta-analysis. Indian J Med Res 2023;157:135-51.","DOI":"10.4103\/ijmr.ijmr_382_23"},{"key":"85649","doi-asserted-by":"crossref","unstructured":"Arif M, Bhargava R, Shameem M, et al. Diagnostic yield of medical thoracoscopy in undiagnosed exudative pleural effusion - a tertiary centre experience from Aligarh Muslim University, Uttar Pradesh, India. J Clin Diagn Res 2020;14.","DOI":"10.7860\/JCDR\/2020\/44095.13990"},{"key":"85650","doi-asserted-by":"crossref","unstructured":"Al-Shimemeri AA, Al-Ghadeer HM, Giridhar HR. Diagnostic yield of closed pleural biopsy in exudative pleural effusion. Saudi Med J 2003;24:282-6.","DOI":"10.15537\/1658-3175.1993"},{"key":"85651","doi-asserted-by":"crossref","unstructured":"Chumpangern W, So-Ngern A, Toomsongkram P, et al. A comparative diagnostic yield among cytologic examination, cell block and closed pleural biopsy in exudative pleural effusion. J Thorac Dis 2024;16:6770-7.","DOI":"10.21037\/jtd-24-1006"},{"key":"85652","doi-asserted-by":"crossref","unstructured":"Kim HW, Kim KH, Shin AY, et al. Investigating the appropriate adenosine deaminase cutoff value for the diagnosis of tuberculous pleural effusion in a country with decreasing TB burden. Sci Rep 2022;12:7586.","DOI":"10.1038\/s41598-022-11460-w"},{"key":"85653","doi-asserted-by":"crossref","unstructured":"Kassirian S, Hinton SN, Cuninghame S, et al. Diagnostic sensitivity of pleural fluid cytology in malignant pleural effusions: systematic review and meta-analysis. Thorax 2023;78:32-40.","DOI":"10.1136\/thoraxjnl-2021-217959"},{"key":"85654","doi-asserted-by":"crossref","unstructured":"Parikh P, Odhwani J, Ganagajalia C. Study of 100 cases of pleural effusion with reference to diagnostic approach. Int J Adv Med 2016;3:328-1.","DOI":"10.18203\/2349-3933.ijam20161085"},{"key":"85655","doi-asserted-by":"crossref","unstructured":"Reddy SL, Varaprasad K, Narahari N, et al. Clinical and etiological profile of an exudative pleural effusion in a tertiary care center. Indian J Respir Care 2019;8:22-6.","DOI":"10.4103\/ijrc.ijrc_8_18"},{"key":"85656","doi-asserted-by":"crossref","unstructured":"Jindal S, Garg P, Dedun AR, et al. A study of pleural effusion with reference to different diagnostic modalaties. Int J Adv Med 2015;2:359-64.","DOI":"10.18203\/2349-3933.ijam20151009"},{"key":"85657","doi-asserted-by":"crossref","unstructured":"Helala LA, El-Assal GM, Farghally AA, Abd El Rady MM. Diagnostic yield of medical thoracoscopy in cases of undiagnosed pleural effusion in Kobri El Kobba Military Hospital. Egyptian J Chest Dis Tuberc 2014;63:629-34.","DOI":"10.1016\/j.ejcdt.2014.04.002"},{"key":"85658","unstructured":"Mittal N, Das B. Role of adenosine deaminase (ADA) in etiological classification of exudative pleural effusion. Int J Res Rev 2020;7:401-6."},{"key":"85659","doi-asserted-by":"crossref","unstructured":"Kumar H, Prakash V, Shukla S, et al. Role of thoracoscopy in diagnosis of tubercular pleural effusion in low ADA setting- a prospective, observational study. Indian J Tuberc 2024;71:389-94.","DOI":"10.1016\/j.ijtb.2023.06.013"},{"key":"85660","doi-asserted-by":"crossref","unstructured":"Yang C, Shi X, Zhang S, et al. Diagnostic performance of adenosine deaminase activity in pleural fluid in tuberculous pleural effusion and relevant factors: a single-center experience with 1,491 consecutive patients. BMC Pulm Med 2025;25:492.","DOI":"10.1186\/s12890-025-03947-9"},{"key":"85661","doi-asserted-by":"crossref","unstructured":"Indhu S, Mohanraj S, Chaitanya V, Patrudu BM. Role of pleural fluid lactate dehydrogenase to adenosine deaminase ratio in the etiological differentiation of exudative pleural effusion. J Assoc Pulmonologist Tamil Nadu 2024;7:48-53.","DOI":"10.4103\/japt.japt_8_24"},{"key":"85662","doi-asserted-by":"crossref","unstructured":"Hussein M, Thomas M, Al-Tikrity M, ey al. Etiology of exudative pleural effusion among adults: differentiating between tuberculous and other causes, a multicenter prospective cohort study. IJID Reg 2024;12:100425. Erratum in: IJID Reg 2025;17:100776.","DOI":"10.1016\/j.ijregi.2025.100776"},{"key":"85663","doi-asserted-by":"crossref","unstructured":"Lee J, Park J, Lim JK, et al. Tuberculous and malignant pleural effusions with adenosine deaminase levels of 40\u201370 IU\/L: trends in new cases over time and differentiation between groups. J Korean Med Sci 2024;40:e35.","DOI":"10.3346\/jkms.2025.40.e35"}],"container-title":["Monaldi Archives for Chest Disease"],"original-title":[],"link":[{"URL":"https:\/\/www.monaldi-archives.org\/macd\/article\/download\/3910\/2260","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.monaldi-archives.org\/macd\/article\/download\/3910\/2260","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T12:18:47Z","timestamp":1787660327000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.monaldi-archives.org\/macd\/article\/view\/3910"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,25]]},"references-count":19,"URL":"https:\/\/doi.org\/10.4081\/monaldi.2026.3910","relation":{},"ISSN":["2532-5264","1122-0643"],"issn-type":[{"value":"2532-5264","type":"electronic"},{"value":"1122-0643","type":"print"}],"subject":[],"published":{"date-parts":[[2026,8,25]]}}}