Erythrocyte Sedimentation Rate (ESR)


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Subject: Erythrocyte Sedimentation Rate (ESR)

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  • ESR is the distance in millimeters that erythrocytes fall during 1 hour in a sample of venous blood (Westergren principle). Newer techniques allow the test to be performed in 30 minutes, resulting in improved turnaround time.

  • Normal range: 0–15 mm/hour in men and 0–20 mm/hour in women.


  • ESR is not a good screening test because of its low sensitivity. CRP is superior to ESR because it is more sensitive and reflects a more rapid change in the patient's condition. ESR may be used as a screening test to detect the presence of a systemic disease; however, a normal test does not exclude malignancy or other serious disease, although it does rule out temporal arteritis or polymyalgia rheumatica.

  • Finding a much accelerated ESR (>100 mm/hour) in patients with ill-defined symptoms directs the physician to search for a severe systemic disease, especially paraproteinemias, disseminated malignancies, connective tissue diseases, and severe infections such as bacterial endocarditis.

  • Finding a normal ESR in patients with paraproteinemia suggests the development of hyperviscosity syndrome.

  • ESR is also used to monitor the course or response to therapy of diseases if greatly accelerated initially.


Increased In

  • Infections

  • Vasculitis, including temporal arteritis

  • Inflammatory arthritis

  • Renal disease

  • Anemia

  • Malignancies and plasma cell dyscrasias

  • Acute allergy

  • Tissue injury, including myocardial infarction

  • Pregnancy (but not first trimester)

  • Estrogen administration

  • Aging

Decreased In

  • Polycythemia vera

  • Sickle cell anemia

  • CHF

  • Typhoid and undulant fever, malarial paroxysm, trichinosis, pertussis, infectious mononucleosis, uncomplicated viral diseases

  • Peptic ulcer

  • Acute allergy


Causes of a Falsely Increased ESR

  • Increased fibrinogen; increased gamma- and betaglobulins

  • Drugs (dextran, penicillamine, theophylline, vitamin A, methyldopa, methysergide)

  • Technical factors (e.g., hemolyzed sample, high temperature in the laboratory)

  • Hypercholesterolemia

Causes of a Falsely Decreased ESR

  • Abnormally shaped RBCs (sickle cells, spherocytes, acanthocytes)

  • Microcytosis

  • HbC disease

  • Hypofibrinogenemia

  • Technical factors (low temperature in the laboratory, clotted blood)

  • Extreme leukocytosis

  • Drugs (quinine, salicylates, high steroid levels, drugs that cause high glucose levels)