6-Erythrocyte sedimentation rate ESR
The erythrocyte sedimentation rate (ESR) is the distance in millimetres that red blood cells settle in a vertical tube of anticoagulated blood during one hour. It is a simple, inexpensive but non-specific marker of inflammation. Inflammatory proteins in the plasma, mainly fibrinogen and immunoglobulins, make red cells stick together in stacks (rouleaux). Heavier stacks sink faster. A raised ESR therefore indicates that "something is going on" — infection, autoimmune disease, tissue damage or cancer — but does not show what.
Reference values
ESR rises with age and is higher in women. A widely used rule (Miller et al., 1983) estimates the upper limit of normal for the Westergren method as age / 2 for men and (age + 10) / 2 for women. In young adults this corresponds to about 15 mm/h for men and 20 mm/h for women. Laboratories in Eastern Europe often use the Panchenkov method, with conventional normal values of about 2–10 mm/h for men and 2–15 mm/h for women. Results from different methods are not fully interchangeable.
Causes of a raised ESR
| Group | Examples |
|---|---|
| Infections | Bacterial infections, osteomyelitis, endocarditis, tuberculosis |
| Inflammatory and autoimmune diseases | Rheumatoid arthritis, polymyalgia rheumatica and giant cell arteritis (often > 50 mm/h), lupus, vasculitis, inflammatory bowel disease |
| Cancers | Multiple myeloma and Waldenström macroglobulinaemia (very high ESR due to paraprotein), lymphomas, metastatic tumours |
| Non-inflammatory factors | Anaemia, pregnancy, older age, chronic kidney disease, obesity, high cholesterol |
An ESR above 100 mm/h is strongly associated with serious disease: infection, cancer (especially myeloma) or giant cell arteritis/polymyalgia. It always warrants investigation.
Causes of a low ESR
A very low ESR is seen with polycythaemia (many red cells), sickle-cell disease, spherocytosis and other abnormal red cell shapes that prevent rouleaux formation, very high white cell counts, low fibrinogen, and some medicines. A low ESR has little clinical significance in itself.
ESR and CRP
Rises and falls slowly (over days to weeks), depends on red cells, age and sex; useful for monitoring chronic inflammation, giant cell arteritis and myeloma.
Rises within hours and falls quickly; reflects acute inflammation more directly and is less affected by anaemia or age.
if a raised ESR in a person over 50 is accompanied by a new headache, tenderness of the scalp or temples, jaw pain when chewing or visual disturbances. These may be signs of giant cell arteritis, which can cause blindness without prompt treatment.
A raised ESR without symptoms should be rechecked and interpreted with age, sex, haemoglobin and CRP in mind. Persistent elevation, fever, weight loss, bone pain or joint swelling require medical assessment.
References
- Miller A, Green M, Robinson D. Simple rule for calculating normal erythrocyte sedimentation rate. Br Med J (Clin Res Ed). 1983;286(6361):266. doi:10.1136/bmj.286.6361.266
- Brigden ML. Clinical utility of the erythrocyte sedimentation rate. Am Fam Physician. 1999;60(5):1443–1450. PMID: 10524488
- Bray C, Bell LN, Liang H, et al. Erythrocyte sedimentation rate and C-reactive protein measurements and their relevance in clinical medicine. WMJ. 2016;115(6):317–321. PMID: 29094869
This article is for general information and does not replace a consultation with a doctor. Laboratory results must be interpreted by a physician together with symptoms and other tests.
Published on 8 May 2024