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Lab Test: Erythrocyte Sedimentation Rate, ESR Level

    Lab Test
    • Erythrocyte sedimentation rate (ESR)
    • Measurement of the distance in millimeters that erythrocytes fall from the top of a vertical tube during one hour for the evaluation and management of inflammatory states; serves as a marker of red cell aggregation. 
    • Used to detect illnesses associated with acute and chronic infection advanced neoplasm, and tissue necrosis or infarction.
    Reference Range

    • Adult males:  0-17 mm/hour
    • Adult females:  1-25 mm/hour
    • Children:  0-10 mm/hour * (PDR)
    • Westergreen method
      • Male:  up to 15 mm/hour
      • Female:  up to 20 mm/hour
      • Child:  up to 10 mm/hour
      • Newborn:  0-2 mm/hour

    Indications & Uses
    • Suspected and known Kawasaki disease - ESR is generally > 20 mm/hr in acugte disease, subsiding to normal 6 to 10 weeks after fever onset. An elevated ESR > 40 mm/hr in so-called incomplete Kawasaki disease is a strong indication to proceed with further laboratory testing and an echocardiogram. A marked elevation of 100 mm/hr or greater, or a persistent elevation, is consistent with active angitis and is predictive of coronary artery involvement. 
    • Suspected bursitis - ESR is usually elevated, but the ESR does not distinguish between infection and other causes of inflammation.
    • Suspected giant cell (temporal) arteritis - marked elevation of ESR (e.g., > 50 mm/hr) is a hallmark finding in this arteritis. A normal ESR level combined with low clinical suspicion reduces the probability of disease to less than 1%.  Normal ESR has been noted in up to 24% of biopsy-proven giant cell arteritis patients before steroid therapy.
    • Suspected gout - ESR often is mildly increased during gout attacks but may be as high as 2 times normal, indicating inflammation.
    • Suspected Lyme disease - ESR >30 mm/hr may be seen in 25% to 50% of patients. ESR in patients with chronic arthritis ranges from 4 to 54 mm/hr (median, 24 mm/hr). In patients with cardiac involvement, the ESR ranges from 3 to 74 mm/hr (median, 47 mm/hr) ESRs ranging from 2 to 46 mm/hr (median, 22 mm/hr)
    • Suspected multiple myeloma - elevated ESR may raise suspicion for multiple myeloma, but it is not diagnostic for the disease. 
    • Suspected pelvic inflammatory disease - elevated ESR supports the diagnosis of PID in patients with pelvic tenderness and signs of lower genital trace inflammation, in whom no other cause(s) for the illness can be identified.  Patients with chlamydial PID tend to present with more highly elevated ESR (over 30 mm/hr) than those with gonococcal PID.
    • Suspected rheumatoid arthritis - ESR should be included as part of the baseline laboratory evaluation.  An elevated ESR suggests poor prognosis.
    • Suspected septic arthritis - In a series of children with septic arthritis of the hip, the average ESR was 94 mm/hr.  The combination of ESR >40 mm/hr, nonweight-bearing status, and serum WBC count >12,000/mm3 helps differentiate septic arthritis from transient synovitis of the hip in children.  The ESR is usually >60 mm/hr in patients over 60 years of age with septic arthritis. 
    • Suspected subacute thyroiditis - ESR is usually markedly elevated in subacute granulomatous thyroiditis and normal in subactue lymphocytic thyroiditis. 
      • The ESR may be elevated >100 mm/hr in painful thyroiditis.
      • A normal ESR excludes the diagnosis of active subacute granulomatous thyroiditis.
      • In silent thyroiditis (painless) the ESR may be normal or only slightly elevated.
      • In patients with recurrent subacute thyroiditis the ESR may be <40 mm/hr in up to one-third of the patients.
    Clinical Application
    • ESR is a measurement of the rate at which the RBCs settle in saline solution or plasma over a specified time period.  It is nonspecific and should not diagnostic for any particular organ disease or injury and thus is not useful as a screening test. 
    • ESR provides the same information as an acute-phase reactant protein. The ESR is a fairly reliable indicator of the course of disease and therefore can be used to monitor disease therapy, especially for inflammatory autoimmune diseases (e.g., temporal arteritis, polymyalgia rheumatic). 
    • Increased levels may indicate:
      • Chronic renal failure (e.g., nephritis, nephrosis), malignant diseases (e.g., multiple myeloma, Hodgkin disease, advanced carcinomas), bacterial infections (e.g., abdominal infections, acute pelvic inflammatory disease, syphilis, pneumonia), inflammatory diseases (e.g. temporal arteritis, polymyalgia rheumatic, rheumatoid arthritis, rheumatic fever, systemic lupus erythematosus [SLE]), necrotic diseases (e.g., acute myocardial infarction, necrotic tumor, gangrene of an extremity), diseases associated with increased proteins (e.g., hyperfibrinogenemia, macroglobulinemia), and severe anemias (e.g., iron deficiency or B12 deficiency). 
    • Falsely decreased levels may indicate:
      • Sickle cell anemia, spherocytosis, hypofibrinogenemia, or polycythemia vera.
    Related Tests
    • Complement assay
    • Fibrinogen - this is an important protein involved in the hemostatic mechanism. 
    • C-reactive protein
    Drug-Lab Interactions
    • Artificially low results can occur when the collected specimen is allowed to stand longer than 3 hours before the test. 
    • Pregnancy (second and third trimester) can cause elevated levels.
    • Menstruation can cause elevated levels.
    • The sedimentation tube must be perfectly vertical.  Any tilt can distort results.
    • Some anemias can falsely increase the ESR.  There are correction nomograms available for variations in RBC count. 
    • Polycythemia is associated with decreased ESR.
    • Diseases associated with increased proteins (e.g., macroglobulinemia) can falsely increase the ESR. 
    • Increasing age may cause increased results (steadily rises by 0.85 mm/hr for each 5-year increase in age).
    • Drugs that may cause increased ESR levels include:  dextran, methyldopa (Aldomet), oral contraceptives, penicillamine procainamide, theophylline, and vitamin A.
    • Drugs that may cause decreased levels include:  aspirin, cortisone, and quinine.
    Test Tube Needed
    • EDTA (lavender top) or citrate (blue top) tube* (PDR)
    • Yellow top tube
    • Collect whole blood or capillary blood (suitable in pediatric patients).
    • Transfer the specimen immediately to the laboratory. 
    • Apply pressure or a pressure dressing to the venipuncture site and assess the site for bleeding. 
    • In the laboratory, the blood is aspirated into a calibrated sedimentation tube and allowed to settle, usually for 60 minutes.  The remaining clear area (plasma) is measured as the sedimentation rate. 
    • An alternate method is performed by measuring the distance (in millimeters) that RBCs descent (or settle) in normal saline solution in 1 hour.  These processes are now automated.
    Storage and Handling
    • May store specimen for 2 hours at 25°C or for 12 hours at 4°C.
    What To Tell Patient Before & After
    • Explain the procedure to the patient.
    • Hold medications that may affect test results, if indicated.
    • LaGow B et al., eds. PDR Lab Advisor. A Comprehensive Point-of-Care Guide for Over 600 Lab Tests.  First ed. Montvale, NJ: Thomson PDR; 2007.
    • Pagana K, Pagana TJ eds. Mosby's Manual of Diagnostic and Laboratory Tests. 5th Ed.  St. Louis, Missouri. 2014.

MESH Terms & Keywords

  • Erythrocyte, Sedimentation, Rate, ESR