Erythrocyte Sedimentation Rate

Aka: Erythrocyte Sedimentation Rate, ESR

1. Mechanism
   1. Acute phase reactants in blood
      1. Nonspecifically bind to Red Blood Cells
      2. Increases sedimentation rate
   2. Measures settling rate of anticoagulated erythrocytes
      1. Height of RBCs that settle in tube within 1 hour
   3. Marker of tissue inflammation
      1. High Sensitivity
      2. Low Specificity
   4. Factors affecting ESR
      1. Older age
      2. Female gender
      3. Pregnancy
2. Dynamics of sedimentation rate
   1. Rises >24 hours after inflammation onset and symptoms
   2. Gradually returns to normal 4 weeks after resolution
3. Normal
   1. Newborn: 0-2 mm/hour
   2. Children: 3-13 mm/hour
   3. Women
      1. Range for ages 18 to 50 years: 1-20 mm/hour
      2. Range for age over 50 years: 1-30 mm/hour
      3. Normal Maximum: (Age in years + 10) / 2
   4. Men
      1. Range for ages 18 to 50 years: 1-15 mm/hour
      2. Range for age over 50 years: 1-20 mm/hour
      3. Normal Maximum: (Age in years) / 2
4. Indications
   1. Grades acute illness severity in Emergency Setting
      1. 299 Peds patients with Limp, Abdominal Pain, Fever
         1. ESR >50 (n=101): 56% had significant illness
         2. ESR 20-50 (n=109): 27% had significant illness
         3. ESR <20 (n=89): 8% had significant illness
      2. Where significant illness
         1. Rheumatoid Arthritis
         2. Osteomyelitis
         3. Pneumonia
         4. Pyelonephritis
      3. Reference
         1. Huttenlocher (1997) Clin Pediatr 339-44
   2. Diagnosis of Rheumatic Conditions
      1. Polymyalgia Rheumatica (sensitivity: 80%)
      2. Temporal Arteritis (sensitivity: 95%)
   3. Staging of condition
      1. Rheumatic conditions with waxing and waning course
      2. Rheumatoid Arthritis
5. Falsely decreased ESR (interfere with rouleaux formation)
   1. Severe Leukocytosis
   2. Polycythemia
   3. Red Blood Cell abnormalities
      1. Acanthocytosis
      2. Poikilocytosis
      3. Anisocytosis
      4. Spheocytosis
      5. Sickle cell disease
      6. Microcytosis (e.g. Iron Deficiency Anemia)
   4. Protein abnormalities
      1. Hypofibrinogenemia
      2. Hypogammaglobulinemia
      3. Macroglobulinemia (e.g. Hyperviscosity Syndrome)
6. Increased ESR in Infectious Disease
   1. Bacterial Infections
   2. Infectious hepatitis
   3. Cat Scratch Disease
   4. Post-perfusion syndrome
   5. Primary Atypical Pneumonia
   6. Tuberculosis
   7. Secondary Syphilis
   8. Leptospirosis
   9. Systemic Fungal Infection
7. Increased ESR in Hematologic and Neoplastic Disease
   1. Severe Anemia or macrocytosis
   2. Leukemia
   3. Lymphoma
   4. Metastatic tumor
   5. Chronic granulomatous disease
8. Increased ESR in Gastrointestinal Disease
   1. Inflammatory Bowel Disease
   2. Acute Pancreatitis
   3. Lupoid hepatitis
   4. Cholecystitis
   5. Peritonitis
9. Increased ESR in Collagen Vascular Disease
   1. Rheumatic Fever
   2. Rheumatoid Arthritis
   3. Systemic Lupus Erythematosus
   4. Dermatomyositis
   5. Scleroderma
   6. Systemic Vasculitis
   7. Henoch-Schonlein Purpura
   8. Mediterranean fever
10. Increased ESR in Renal disease
    1. Acute Glomerulonephritis
    2. Chronic Glomerulonephritis with Renal Failure
    3. Nephrosis
    4. Pyelonephritis
    5. Hemolytic Uremic Syndrome (HUS)
11. Increased ESR in Miscellaneous disorders
    1. Hypothyroidism
    2. Thyroiditis
    3. Sarcoidosis
    4. Infantile cortical hyperostosis
    5. Trauma from surgery or Burn Injury
    6. Drug Hypersensitivity Reaction
12. References
    1. Brigden (1999) Am Fam Physician 60:1443-50
    2. Lascari (1972) Pediatr Clin North Am 19:1113-21