What is the significance of a normal white blood cell (WBC) count with elevated C-reactive protein (CRP) in a patient with cholangitis?

From the Guidelines

In patients with suspected cholangitis, a normal white blood cell count but high CRP levels should not delay treatment, as CRP is a more sensitive marker of acute inflammation. The diagnosis of cholangitis can be challenging, and the presence of elevated CRP levels, even with a normal white blood cell count, should prompt further investigation and treatment. According to the EASL clinical practice guidelines on sclerosing cholangitis 1, the diagnosis of acute bacterial cholangitis requires either a single criterion (suppurative cholangitis on ERCP), or at least 1 major criterion (body temperature >38°C, leukocyte count >12/nl or C-reactive protein >75 mg/L), and at least 2 minor criteria (positive bile culture, increase in ALP or total bilirubin above 2x ULN, no other focus of infection). Some key points to consider in the management of cholangitis include:

• The use of broad-spectrum antibiotics, such as piperacillin-tazobactam or a combination of ceftriaxone and metronidazole, for 4-7 days 1
• Urgent biliary decompression through ERCP within 24-48 hours, as recommended by the European Society of Gastrointestinal Endoscopy (ESGE) and the European Association for the Study of the Liver (EASL) clinical guideline 1
• The importance of considering the clinical context and other signs of infection, such as fever, right upper quadrant pain, and jaundice, in addition to laboratory results
• The role of CRP as a sensitive marker of acute inflammation, which can rise more rapidly than white blood cell counts in response to infection 1.

From the Research

Normal White Cell Count but High CRP in Cholangitis

• A normal white cell count with high CRP (C-reactive protein) in cholangitis may indicate a complex clinical scenario, as CRP is a marker of inflammation and infection 2.
• The Tokyo Guidelines 2018 provide recommendations for antimicrobial therapy in acute cholangitis and cholecystitis, emphasizing the importance of monitoring and updating local antibiograms to address emerging antimicrobial resistance 3.
• Studies have shown that antibiotic therapy, such as ceftriaxone, can be effective in managing acute cholangitis, with clinical efficacy evaluated by body temperature, white blood cell count, and serum levels of CRP 4, 2.
• The duration of antibiotic therapy for acute cholangitis is an important consideration, with some studies suggesting that fever-based antibiotic therapy can be safe and effective when resolution of fever is achieved following endoscopic biliary drainage 5.
• The role of CRP in monitoring the clinical course of cholangitis is not fully understood, but it may be a useful marker of inflammation and infection, particularly in patients with a normal white cell count 2.

Diagnostic and Therapeutic Considerations

• Endoscopic retrograde cholangiography, magnetic resonance cholangiopancreatography, and endoscopic ultrasonography are commonly used diagnostic and therapeutic tools in the management of cholangitis 6.
• Biliary drainage procedures are necessary for controlling the progression of cholangitis, and antibiotic therapy plays a crucial role in managing the infection 4, 5, 2.
• The choice of antibiotic therapy should be guided by local antibiograms and the severity of the infection, with consideration of the potential for antimicrobial resistance 3.