• Erythrocyte Sedimentation Rate

    by
    Shashikiran
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    139 Comments Comments
    Erythrocyte sedimentation rate (ESR) is a non-specific test for inflammation. It is easy to perform, widely available and inexpensive making it a widely used screening test. It is also used a monitoring tool for response to treatment in conditions in which it is raised (tuberculosis, autoimmune diseases etc).
    Basics:

    The ESR test in performed in the laboratory by placing anticoagulated blood in an upright tube (Westegren's most often). At the end of an hour of this, the rate of the RBC sedimentation is measured.

    ESR

    Normal value:

    ESR values tend to rise with age and are generally higher in women. ESR is also elevated in the black population and those with anemia.

    A rule of thumb for calculating maximum normal ESR in a person is:

    Normal ESR Formula

    Mechanism:

    ESR is determined by the interaction between factors that promote (fibrinogen) and resist (negative charge of RBCs - that repel each other) sedimentation. Normal RBCs settle slowly as they do not form rouleaux or aggragate together. Instead, they gently repel each other due to the negative charge on their surfaces.

    Increased rouleaux formation contributes to high ESR. Rouleaux are stacks of many RBCs that become heavier and sediment faster. Plasma proteins, especially fibrinogen, adhere to the red cell membranes and neutralize the surface negative charges, promoting cell adherence and rouleaux formation.

    Rouleaux formation

    The aggregated RBCs in the rouleaux formation have a higher ratio of 'mass to surface area' as compared to single RBCs and hence sink faster in plasma.

    ESR of more than 100 mm/hr is strongly associated with serious underlying disorders like connective tissue disease, infections and malignancies.

    Some conditions with very high (>100 mm/hr) ESR:
    1. Multiple myeloma
    2. Connective tissue disorders - SLE, RA and other autoimmune diseases
    3. Tuberculosis
    4. Malignancies
    5. Severe anemia
    Some conditions with low ESR:
    1. Polycythemia
    2. Severe Leukocytosis
    3. Sickle cell disease (anemia)
    4. Hereditary spherocytosis
    5. Congestive cardiac failure
    6. Corticosteroid use
    7. Hypofibrinogenemia
    Note that sickle cell anemia and spherocytosis have low ESR unlike other anemias. This is due to reduced rouleaux formation owing to the abnormally shaped RBCs in this condition.

    IMPORTANT

    Erythrocyte sedimentation rate is a non-specific test and is not diagnostic of any particular disease. It has a high sensitivity but low specificity. Never base a diagnosis solely on an ESR value, either normal or high. Interpretation of the result should always be along with the patient's clinical history, examination findings and results of other tests done.

    If high ESR is encountered without any obvious reasons, patient should be reassured and the test repeated after a reasonable amount of time (a couple of months). There is no need to extensively search for an occult disease without repeating it again.


    This article was originally published in forum thread: Erythrocyte Sedimentation Rate started by Openman View original post
    Comments 139 Comments
    1. themommm's Avatar
      I have an ESR of 197 and a CRP of 1.7. I also have a vitamin D level of 14, low iron, and high uric acid. The doc was surprised to see a normal calcium level and B12. I have AS, but they are thinking there might be something else going on as well. What do you suggest getting checked?
    1. girl's Avatar
      Can IVIg cause an elevated ESR (117)? Or does the high ESR mean the IVIg isn't adequately controlling my RA and lupus? I feel okay, but don't know if there could be underlying disease activity.
    1. Shashikiran's Avatar
      @themommm: It is difficult to analyse without knowing your age, body profile, preexisting conditions and current symptoms. However, a very high ESR with normal CRP suggests that inflammation is not the cause for high ESR - so I would look for conditions with high or abnormal proteins. IF facility is available, one of the investigations would be protein electrophoresis.

      @girl: Yes, IVIG can cause a transient elevation of ESR. Usually ESR rises about 24 hours after the IVIG infusion and remains elevated for up to about 7 days and this does not indicate disease activity. For assessing disease activity of rheumatoid arthritis and lupus, C-reactive protein levels should be tested instead.
    1. girl's Avatar
      Thank you. I'm waiting for my regular doctor to review all my test results with me, and meanwhile, it's easy to worry about the worst possible scenario.
    1. darelias's Avatar
      I just got results back from an ESR that were 20. I am a 35 year old white female. Had the test run because of an abnormal Hi Sens C-reactive Protein test Value 6.2 Waiting on new Protein test, is the ESR normal?
    1. Shashikiran's Avatar
      @darelias: Your ESR (20) is normal. What problem did you have BTW?
    1. darelias's Avatar
      I had the test done after my mother passed away at 58 from Diabetes. It was a preventative screening. Second Protein came back last night 6.2 again. Low cholesterol/blood pressure. I am overweight (BMI 35.7) so I am not sure what is going on.
    1. gsrao's Avatar
      sir,
      iam 42 years old. male. my esr is 20 in 1st hour, 42 in 2nd hour. kee joints get little pain when climbing stairs. is ra in begining stage?
    1. Shashikiran's Avatar
      @darelias: Don't worry about the ESR or the protein then, focus on reducing your wieght to come as close to normal BMI as possible. Hope your blood glucose is normal.

      @gsrao: Your ESR is normal, and does not suggest RA. Symptoms are more important for suspecting RA. Duration, joints involved, hand stiffness in the morning etc. Any recent increase in weight?
    1. anuj's Avatar
      My wife's age is 42 and her esr is 60-please advice .
      Anuj
    1. Shashikiran's Avatar
      @anuj: It is high. As explained above, it is non-specific and difficult to advice further without knowing the symptoms.
    1. Jan's Avatar
      Hi there, I'm a healthy 23 female with a ESR of 22 and a slightly enlarged liver. My only complaint is an ear ache and bloating / fullness in my abdomen, maybe from constipation. I don't see my doctor to discuss the results until next week. Any thoughts? Do you think it's something serious?
    1. Lesley's Avatar
      HI I am 45 yr old white femal with ESR of 29. Have been diagnosed with tendonitis in my elbow/wrist and now have swelling in my fingers. I am hypothroid. RA test negative, and have had slightly low platelets for 2 years. Dr. keeps repeating blood count test every few months but it doesn't vary much, any ideas what could be going on?
    1. Reena's Avatar
      my esr was 50 and i was having pain the legs...all other aspects of cbc were normal...CRP was normal...uric acid was nil..even now i have muscular pain in the legs...is it because of muscle weakness...i am a 31 year old female with 2 children
    1. Sunits's Avatar
      i m 25 yr old,malaria infection detected,hb-10,esr-103........is thr any problm?
    1. Madhuri's Avatar
      Hi, My mom's age is 46 Years and she has continuous fever from 4 months from (99-100). Her ESR is 90. other than this there are no symptoms. All the tests are negative. What could be the problem.
    1. rivasarra's Avatar
      i am a 27 yr old, married, asian woman with ESR 17. is this normal?
    1. bobyjose08's Avatar
      i am 42 year old my esr rate is showing 28mm/hr.polymorphs is 61%... feeling pain in right hand..feeling cold all the day
    1. anjum's Avatar
      my esr is 80mm/hr.which situation it represents.
    1. Anand's Avatar
      I am 25 Yrs old and my ESR is 17mm/hr. I have been having cough for a couple of weeks now. Is my ESR very high? Should this be a cause of worry?
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