From the Guidelines
An elevated erythrocyte sedimentation rate (ESR) requires a systematic workup focused on identifying the underlying cause, starting with a thorough history and physical examination, and ordering additional laboratory tests including complete blood count, comprehensive metabolic panel, C-reactive protein, urinalysis, and age-appropriate cancer screenings, as recommended by the 2015 European League Against Rheumatism/American College of Rheumatology collaborative initiative 1.
Initial Evaluation
The initial evaluation of an elevated ESR should include:
- A thorough history and physical examination to look for symptoms of infection, autoimmune disease, malignancy, or other inflammatory conditions
- Additional laboratory tests, such as:
- Complete blood count
- Comprehensive metabolic panel
- C-reactive protein
- Urinalysis
- Age-appropriate cancer screenings
- Specific tests based on clinical suspicion, such as:
- Rheumatoid factor
- Antinuclear antibody
- Serum protein electrophoresis
- Blood cultures
Imaging Studies
Imaging studies, such as chest X-ray or CT scans, may be indicated depending on symptoms, as suggested by the 2020 update of the EULAR recommendations for the management of large vessel vasculitis 1.
Referral to Specialist
If the initial workup is negative but ESR remains significantly elevated, consider referral to a specialist (rheumatologist, hematologist, or infectious disease) for further evaluation, as recommended by the 2020 systematic review and meta-analysis on the diagnostic accuracy of symptoms, physical signs, and laboratory tests for giant cell arteritis 1.
Periodic Monitoring
In cases where no cause is found despite thorough investigation, periodic monitoring every 3-6 months with repeat ESR and focused clinical assessment is reasonable, taking into account the patient's age and the fact that ESR is a nonspecific inflammatory marker that increases with age, and mild elevations (up to 40-50 mm/hr) can occur in elderly patients without pathology 1.
From the Research
Elevated ESR Workup
Elevated Erythrocyte Sedimentation Rate (ESR) is a common laboratory finding that can indicate the presence of an underlying disease or condition. The following are some key points to consider when evaluating an elevated ESR:
- ESR is a non-specific test that can be elevated in a variety of conditions, including infections, inflammatory diseases, and malignancies 2, 3.
- An ESR value exceeding 100 mm/hr has a 90% predictive value for serious underlying disease, most often infection, collagen vascular disease, or metastatic tumor 2, 3.
- The causes of extremely elevated ESR (≥ 100 mm/1 h) include infectious diseases, hematological system diseases, autoimmune diseases, and renal failure 4.
- In the elderly population, elevated ESRs have a similar pathological significance to those in younger individuals, but may be more prevalent and require careful investigation even in asymptomatic patients 5.
Diagnostic Approach
When evaluating an elevated ESR, the following steps can be taken:
- Repeat the test in several months to confirm the elevation and rule out laboratory error 2.
- Conduct a thorough medical history and physical examination to identify potential underlying causes 2, 5.
- Order additional laboratory tests, such as complete blood count (CBC), liver function tests, and renal function tests, to help identify the cause of the elevated ESR 4.
- Consider imaging studies, such as chest X-ray or ultrasound, to evaluate for potential underlying conditions 4.
Specific Conditions
Certain conditions are more commonly associated with elevated ESR, including:
- Infections, such as pulmonary infections 4.
- Hematological system diseases, such as hematopoietic stem cell diseases and lymphocyte and plasma cell diseases 4.
- Autoimmune diseases, such as diffuse connective tissue diseases 4.
- Malignancies, such as cancer 2, 3, 5.
- Renal failure 4.
Laboratory Correlations
ESR has been correlated with other laboratory tests, including: