Study of Serum Adenosine Deaminase (ADA) and Ascorbic Acid Levels in Recurrent Tonsillitis RENU NAGPAL, Y. N. RAO, P. L. DHINGRA & S.K. VERMA

A b i o c h e m i c a l s t u d y c o n s i s t i n g o f e s t i m a t i o n o f s e r u m a d e n o s i n e d e a m l n a s e a n d a s c o r b i c a c i d w a s c a r r i e d o u t i n 20 p a t i e n t s o f r e c u r r e n t t o n s i l l i t i s (i) d u r i n g t h e a c u t e a t t a c k , (ii) a f t e r m e d i c a l t r e a t m e n t a n d (Hi) a f t e r t o n s i l l e c t o m y . T h e s e p a r a m e t e r s w e r e c o m p a r e d w i t h a c o n t r o l g r o u p o f 20 h e a l t h y i n d i v i d u a l s . T h e s t u d y r e v e a l e d s i g n i f i c a n t d e c r e a s e o f A D A a n d a s c o r b i c a c i d l e v e l s d u r i n g a c u t e s t a g e o f r e c u r r e n t t o n s i l l i t i s , a n d s u b s e q u e n t r e c o v e r y a f t e r m e d i c a l t r e a t m e n t a n d t o n s i l l e c t o m y . L e v e l s o f a s c o r b l c a c i d w e r e s i m i l a r l y r e f l e c t e d . I n t h e a c u t e s t a g e o f r e c u r r e n t t o n s i l l i t i s , t o n s i l s , i n s t e a d o f a c t i n g a s p r o t e c t i v e h a r r i e r s , a p p e a r t o b e c o m e a s o u r c e f o r t h e b r e a k d o w n o f i m m u n o l o g i c a l m e c h a n i s m .

Adensione deaminase (ADA) is an enzyme of pur ine metabolism. I t catalizes the conversion of adenosine to inosine which is finally converted to uric acid. ADA is widely distribu- ted in h u m a n tissues but part icular ly high levels are present in lymphoid tissue (Hirschhorn et al., 1979). Relationship between T- lymphocyte ADA activity and im m une response of the body has been reported by several workers (James et al., 1986 and K u m a r et al. 1986). High levels of serum A D A are seen in diseases where cellular immuni ty is st imula- ted e.g. typhoid fever, infectious mononucleosis, and brucellosis (Ocana et al., 1972). About one third to one ha l f of the cases of severe combined immune-deficiency are deficient in this enzyme.

High concentrat ion of ascorbic acid (Vit.C) in leucocytes and its rapid ntilisation durirLg infection and .phagocytosis suggests its role in i m m u n e process. This protective role of ascorbic acid in recurrent infections is a t t r ibuted to its stimula- ting effect on the interferon synthesis and lymphocyte function leading to an augmented i m m u n e response (Wa ldman et al., 1975; and Wilson and Loh. 1973).

These two parameters of serum ADA activity and ascorbic acid were

Renu Nagpal, Senior Resident & Y. N. R.ao, Associate Professor, Biochemistry Department. P. L. Dhingra, Professor of E.N.T. & S. K. Verma, Department of E.N.T., Maulana Azad Medical College, New Delhi.

Address for reprint : Y.N. Rao, Associate Prof. and Head, Deptt. of Biochemistry, Maulana Azad Medical College New Delhi-1 i0 002.

studied to evaluate their role in the aetio-pathogensis of recurrent tonsillitis.

M a t e r i a l a n d M e t h o d

In all forty subjects were studied.

Control Group This consisted of 20 normal

subjects with no history of renal, hepatic, cardiac or E N T disease. There were 11 males and 9 females in the age group of 18-35 years.

Experimental Group

This consisted of 20 patients (6 females and 14 males) of recurrent tonsillitis, presenting in acute phase of disease. Diagnosis of recurrent tonsillitis was made on history of repeated attacks of sore throat often accompanied by fever, headache, malaise and sometimes chills and the objective findings of enlarged or embedded tonsils, congestion of pillars arid soft palate, sometime with pus follicles on the surface of tonsils.

Each subject of exper imenta l group had blood samples tested for levels of ADA and ascorbic acid three times during the study:

1. During acute phase of tonsillitis. 2. Two to three weeks following

successful medical t rea tment . 3. After tonsillectomy.

Estimation of serum adenosine deaminase (ADA) was done by the method of Galant i and Giusti (1966); serum ascorbic acid by method of Roe and K u e t h a r (1943) and Roe (1961). Ascorbic acid was not administered to the pat ients taken up for study. Statistical ana- lysis of the results was carried out by applying student ' t ' test to compare

the results of each investigation in the experimental group with those in the control group and paired ' t ' test for comparing the results within the experimental groups.

O b s e r v a t i o n °

Serum levels of different para- meters studied and their statistical analysis are given in table 1 and I I .

Adenosine Deaminase

The serum A D A levels in tlle control group were in the range of 3.1-12 U/L with a m e a n of 6.3 U/L. ADA levels in tonsillitis patients in acute a t tack were 3.1-7.1 U /L with a mean value of 4.43 U/L. Thus, ADA levels dropped in acute stage of infection and this was found statis- tically to be highly significant, the 'p ' value being <.02.

Mean level of A D A after medical t rea tment was 5.02 U/L with a range of 3.1-10 U /L , an increase in the mean ADA level over the one in acute stage. This increase in A D A level after medical t rea tment was found statistically to be highly signi- ficant (P <.001).

The mean enzyme activity after tensillectomy was 5.34 U/L as compared to p re - t rea tment level (4.43 U/L) . Thus, it was seen that serum adenosine deaminase levels in cases of acute tonsillitis were decreased but rose to near normal levels following medical and surgical t reatment .

Ascorbic Acid

The mean ascorbic acid level in control group was 4.15 mg/L while

Indian Journal of Otolaryngology, Volume 42, No. 1, March, 1990

Study of Serum Adenoshze Deaminase (ADA) and Ascorbic Acid Levels in Recurrent Tonsillitis--Wagpal et al.

TABLE I

M e a n S e r u m ADA, a nd A s c o r b i c Ac id L e v e l s in C o n t r o l G r o u p a n d T o n s i l l i t i s Pat i ent s

Group Ascorbic

ADA acid Uni t /L Mg/L

Control Group

Patients of recurrent tonsillitis (acute stage)

Same patient~ after medical t reatment

Same patient~ after Tonsillectonly

6.30 4.15

4.43 3.40

5.02 4.75

5.34 4.30

and uric acid is blocked, leading to accumula t ion of adenosine, deoxya- denosine and their nucleotides which are toxic to the lymphoid tissue, par t icular ly T-cells. (Parkmen, et al., 1975, Hirschhorn, et al., 1979). S immond et al. (1978) and Muller c t a l . (I983) postulated that ADA deficiency impairs synthesis of D N A in rapidly dividing lymphoid tissue cells which is vital in the develop- ment of i m m u n e responsc. Tonsils by nature of their position and cellular composit ion are believed to per form protective function against bacterial infections but it appears tha t in chronic recurrent tonsillitis they are contributing to depression of immune response.

TABLE II

Compara t ive Groups ADA

' t ' value 'p ' value Significance

Ascorbic Acid

"t' Value 'p ' Value Significance

Control and acute tonsilliltis

Control and medically treated

Control and Surgically treated

Acute tonsillitis & medically treated

Acute tonsillitis & surgically treated

2.65 < 0.02 S

1.71 > 0.05 NS

1.23 > 0.05 NS

6.152 < .001 HS

4.50 < .001 HS

1.99 > .05 N.S.

1.39 > .05 N.S.

3.80 > .05 N.S.

6.459 > .001 H.S.

5.83 > .001 H.S.

it was 3.4 mg/L in acute phase of tonsillitis and 4.75 mg/L after me- dical t rea tment and 4.30 mg/L after tonsillectomy. There was a signifi- cant increase in ascorbic acid level after medical t rea tment of a,~ute phase of tonsillitis ( 'p ' value < .001). Similar increase was seen in tonsillec- tomised patients, compared to their level of ascorbie acid in acute stage. But levels of serum ascorbic acid after tonsillectomy were decreased compared to those after medical t reatment .

D i s c u s s i o n

Adequate ADA levels are neces- sary for normal functioning of im-

S = Significant NS = Not Significant HS = Highly Significant

mune system. Low or absent ADA levels have been associated with a variety of immune deficiency disor- ders. In our study ADA levels were found to be low during the acute stage of tonsillitis and rose significan- tly following medical and surgical t reatment . This indicates suppres- sion of immune response during acute stage of tonsillitis and their recovery following t reatment of infection or removal of infected tonsils. T h e exact mechanism h o w A.DA deficiency causes the immune deficiency is not yet clear. I t is postulated that in the absence of this enzyme the catabolic pa thway of conversion of adenosine to inosine and then to hypoxanthine, xanthine

Serum ascorbic acid levels, in our ~tudy were low in acute stage of tonsillitis and they rose after medical t reatment . This migh t be due to increased utilisation of ascorbic acid during acute infection. As the in- fection was controlled, body tissue consumption decreased with conse- quent rise of ascorbic acid level. Several workers. (Hume and Wayers, 1973; Wilson and Loh, 1973 and Greene and Wilson, 1975) have also shown tha t levels of serum ascorbic acid fall rapidly during acute infections and re turn to nor- mal after recovery. After tonsillec- tomy serum ascorbic acid levels were more than p re t rea tment values but were less as compared to values after

2 Indian Journal of Otolaryngology, Volume 42, No. 1, March, 1990

Stud), o f Serum Adenosine Deaminase (ADA) and Ascorbic Acid Levels in Recurrent Tonsillitis--Nagpal el al.

m e d i c a l t r e a t m e n t . T h i s c o u l d b e d u e to i n c r e a s e d d e m a n d fo r a s c o r b i c a c i d d u r i n g a n d a f t e r s u r g e r y .

T h e p r e s e n t s t u d y t h u s s h o w s a n

a s s o c i a t i o n b e t w e e n d e c r e a s e d leve l s o f s e r u m a d e n o s i n e d e a m i n a s e a n d a s c o r b i c a c i d w i t h t h e a c u t e p h a s e o f r e c u r r e n t t ons i l l i t i s . I t is n o t c l e a r w h e t h e r t h e d e c r e a s e d l eve l s o f t h e

t w o p a r a m e t e r s i m p a i r t h e i m m u n e m e c h a n i s m s a n d c a u s e a c u t e a t t a c k s o f t ons i l l i t i s o r i t is t h e a c u t e t o n s i l - l i t is w h i c h l o w e r s t h e i r levels .

References

1. Galanti , B. and Giusti, G. (1966): Methods of Enzymatic analysis, 2nd edition, Vol-2, edited by Hans Ulrich Bergmeyer, New York Academic Press: 1092-1099.

2. Greene, M. and "~Vilson, C.W.M. (1975) : Effects of aspirin on ascorbic acid metabolism during colds. British Journal of Clinical Pharmacology. Vo1.2 : 369.

3. Hirschhorn, R. and Mart in, D. ~,V. (1979) : Enzyme Defects in Immunode- ficiency Diseases. Immune Deficiency edited by M.D. Cooper, A.R. Lawton, P.A. Miecher, H. J . Mueller-Eberhard, Springer-Verlag Berlin Heidelberg New York 65--87.

4. Hume, R. Wayers, E. (1973) ; Changes in leucocyte ascorbic acid during the common cold. Scotland Medical Journal, 1 8 : 3 .

5. James, L. M., R o m a n P. S., Duniel, B. and Even M . H . (1986): Decreased Adenosine Deaminase and 5 x Nucleo- tidase activity in peripheral blood T cells in Hodgkin disease, American Journal of Hematology. 21 -'57--66.

6. Kumar, S. D., Helenc, Z. H., Amita, D. and Sara S. (1986): Evaluation of adenosine deaminase activity in patients with head and neck cancer. Journal of Surgical Research. 40 • 368--733.

Muller, M. h~[., Krupp, M. and Chiba P. (1983): Eazymological aspects of disorders in purine metabolism. ClbEcal Biochemistry Feb 16 (i) : 31--36.

8. Ocana, I. and Vasquez, J . M . M . (1983) : Adenosine deaminase in pleural fluids. Chest. 84. 51--53.

9. Parkman, R.. Gelfand, E.W. and Rosen, F.S. (1975) : Severe combined immuno- deficiency disease and Adenosine deami- nase deficiency. New England Journal of Medicine. 292 ; 714-719.

10. Roe, J .H. (1961): Practical Clinical Biochemistry. 5th edition, Vol .--? , edited by Harold Varley, Alan H. Gowen Lock, and Maurice Bell, William Heinemann Medical Books Ltd., London : 254-257.

I1. Roe, J .H. and Kuether, C.A. (1943) : Practical Clinical Biochemistry. 5th edition Vol. 2, edited by Harold Varley, Alan H. Gowen Lock and Maurice Bell, William Heinemann Medical Books Ltd. London : 254-257.

12. Simmonds, H.A., Corrigall, V. and Panayi, G.S. (1978) : A role of purine metabolism in the immune response, Adenosine deamlnase activity and deo- xyadenosine catabolism, Lancet. 1, No. 8054 : 60-63.

13. ~Valdman, R.H., Ganguly, R., Gal- laghar, E. and Durieux, M.F. (1975) : Effects of orange juice on viral infections. Americal Journal of Epidimiology 102 : 466.

14. "Wilson, Q.W.It. and Loh, H.S. (1973) : Common cold and Vit. C. Lancet-- No. 71101 • 638-641.

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