The purpose of this study was to show the significance of a positive Propionibacterium acnes sample around a joint replacement. Records from the microbiology laboratory data over a 3-year period were reviewed to identify patients with prosthetic joints from whom Propionibacterium acnes was isolated at least once. The medical records of all those patients were retrieved and the demographic, clinical, microbiological and haematological data were collected and examined. The preoperative values of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were recorded. Fifty patients underwent a routine revision of a joint arthroplasty; six patients had a joint aspiration. Only one patient had further revision surgery for infection. The preoperative values of ESR and CRP were very variable. The presence of a positive sample around a joint arthroplasty is of uncertain significance. Further studies are needed in order to establish uniform criteria for the diagnosis of infection caused by Propionibacterium acnes.
C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) play helpful roles in determining the presence of infection after TKA. To provide baseline values, we documented normative temporal values of CRP and ESR in unilateral and staged bilateral TKAs for osteoarthritis. Levels of CRP and ESR were evaluated before surgery and on the first, second, fifth, seventh, fourteenth, forty-second, and ninetieth postoperative days in 320 uncomplicated primary TKAs. C-reactive protein and ESR levels were compared in three groups: unilateral (108 knees), first knee bilateral (106 knees), and second knee bilateral (106 knees) groups. All three groups exhibited similar temporal patterns. Mean CRP levels increased rapidly, reaching a peak on the second day and decreased to less than the normal reference level on the forty-second day. They returned to preoperative levels on the ninetieth day. Mean ESR levels peaked on the fifth day and returned close to the preoperative levels only on the ninetieth day. Wide variations were observed and many cases (43%) did not follow the typical patterns. C-reactive protein had greater fold changes, less frequent atypical temporal patterns, and lower correlation between preoperative and postoperative levels than ESR. Our findings should help surgeons interpret CRP and ESR to determine the presence of infection after TKA.
Level of Evidence: Level I, diagnostic study. See the Guidelines for Authors for a complete description of levels of evidence.
Inflammatory sacroiliitis associated with spinal cord injury (SCI) as an unusual cause of elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level has not been reported previously to our knowledge.
To represent a case of SCI associated with bilateral sacroiliitis causing ESR and CRP level elevation.
Case report of a man with T9 paraplegia.
ESR and CRP levels were high. Pelvic radiography was nearly normal, except for mildly blurred sacroiliac joints with normal margins. A 3-phase bone scan revealed bilateral sacroiliitis and heterotopic ossification at medial side of the left knee. Past history was significant for a recent urinary tract infection. Indomethacin and etidronate were prescribed. Significant decreases in ESR and CRP level were seen 1 month later.
Sacroiliitis might be an unusual cause of elevated ESR and CRP levels in patients with SCI. Sensory and motor deficits may obscure the typical clinical presentation; therefore, imaging studies are essential for the diagnosis.
Sacroiliitis, Reactive arthritis; Paraplegia, Heterotopic ossification, Spinal cord injuries
Two-stage exchange arthroplasty is the gold standard for treatment of infected TKA. The erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and synovial fluid white blood cell (WBC) count with differential are often used to determine treatment response; however, it is unclear whether these tests can answer the critical question of whether joint sepsis has been controlled between stages and if reimplantation is indicated.
We therefore asked if (1) these serologies respond between stage one explantation and stage two reimplantation during two-stage knee reconstruction for infection; and (2) changes in the values of these serologies are predictive of resolution of joint infection.
We retrospectively reviewed the serologies of 76 infected patients treated with a two-stage exchange protocol. The ESR, CRP, and aspiration were repeated a minimum of 2 weeks following antibiotic cessation and prior to second stage reoperation. Comparisons were made to identify trends in these serologies between the first and second stage procedures.
Eight knees (12%) were persistently infected at the time of second stage reoperation. The ESR remained persistently elevated in 37 knees (54%), and the CRP remained elevated in 14 knees (21%) where infection had been controlled. We were unable to identify an optimum cutoff value for the ESR, CRP, or the two combined. The best test for confirmation of infection control was the synovial fluid WBC count.
Although the ESR, CRP, and synovial fluid WBC counts decreased in cases of infection control, these values frequently remained elevated. We were unable to identify any patterns in these tests indicative of persistent infection.
Level of Evidence
Level II, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.
It is believed that some cases of aseptic failure of THA may be attributable to occult infections. However, it is unclear whether preoperative erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are more likely elevated in these patients than those without overt infection.
We asked whether some patients with aseptic THA failures have abnormal serologic indicators of periprosthetic joint infection (PJI) at the time of revision, namely ESR and/or CRP.
Three hundred twenty-three revision THAs for aseptic loosening from 2004 to 2007 were retrospectively evaluated. We categorized all cases into two groups: (1) those with overt PJI (n = 14) plus patients who had a positive intraoperative culture during the index revision (n = 13) and (2) those who did not require rerevision (n = 276) or required surgery for noninfected causes (n = 20). Mean and frequency of abnormal ESR and CRP were compared between the two groups. The minimum followup was 11 months (average, 35 months; range, 11-54 months).
The mean and frequency of abnormal CRP in first group (n = 27) at 2.1 mg/dL and 48% respectively, were greater than those of the uninfected (n = 296) at 1.2 mg/dL and 27%, respectively. However, there were no differences between two groups regarding mean or frequency of abnormal ESR.
Some patients with presumed aseptic loosening may have abnormal serologic indicators of PJI that either have escaped diagnosis or were not adequately investigated. All patients undergoing revision THA should have ESR and CRP measured preoperatively and those with abnormal CRP should have additional evaluations to rule out or confirm PJI.
Level of Evidence
Level III, retrospective comparative study. See the Guidelines for Authors for a complete description of levels of evidence.
The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are employed in the evaluation of patients with suspected septic arthritis, osteomyelitis, and acute rheumatic fever. The purpose of this study is to determine if one test has greater sensitivity (rises earlier) than the other. Laboratory data were retrieved for pediatric patients hospitalized with one of the above three conditions, who had both ESR and CRP tests done on or shortly prior to admission. Sensitivity calculations were performed for mild, moderate, and severe degrees of ESR and CRP elevation. Microcytic erythrocytes, as defined by mean corpuscular volume (MCV) <80 µL, were identified to see if this affects the ESR. ESR or CRP sensitivities depend on the cutoff value (threshold) chosen as a positive test. The sensitivities were similar for similar degrees of elevation. ESR and CRP discordance was not significantly related to MCV. We concluded that the CRP does not rise earlier than the ESR (their sensitivities are similar). Previously published conclusions are dependent on arbitrary thresholds. We could not find any evidence that MCV affects the ESR.
erythrocyte sedimentation rate; C-reactive protein; osteomyelitis; septic arthritis; acute rheumatic fever.
Knee osteoarthritis is a common cause of severe pain and functional limitation. Total knee arthroplasty is an effective procedure to relieve pain, restore knee function, and improve quality of life for patients with end stage knee arthritis. The aim of this study was to investigate the inflammatory process in patients with primary knee osteoarthritis before surgery and in subsequent periods following total knee arthroplasty. A prospective study of 49 patients undergoing primary total knee replacements was conducted. The patients were evaluated by monitoring serum interleukin-6 (IL-6), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), knee skin temperature, and clinical status. Measurements were carried out preoperatively and postoperatively on day one and at two, six, 14, and 26 weeks during follow-up review in the knee clinic. The serum IL-6 and CRP were elevated on the first postoperative day but fell to preoperative values at two weeks postoperatively. Both returned to within the normal range by six weeks postoperatively. In addition, the postoperative ESR showed a slow rise with a peak two weeks after surgery and returned to the preoperative level at 26 weeks postoperatively. The difference in skin temperature between operated and contralateral knees had a mean value of +4.5°C at two weeks. The mean value decreased to +3.5°C at six weeks, +2.5°C at 14 weeks, and +1.0°C at 26 weeks. The difference in skin temperature decreased gradually and eventually there was no statistically significant difference at 26 weeks after surgery. A sustained elevation in serum IL-6, CRP, ESR, and skin temperature must raise the concern of early complication and may suggest the development of postoperative complication such as haematoma and/or infection.
1) To evaluate the utility of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) for the diagnosis of giant cell arteritis (GCA) 2) to determine the frequency of normal ESR and CRP at diagnosis of GCA.
All patients undergoing temporal artery biopsy (TAB) between 2000 and 2008 were identified. Only subjects with both ESR and CRP at the time of TAB were included. The medical records of all patients were reviewed.
We included 764 patients (65% women), mean age 72.7 (±9.27) years, who underwent TAB. Biopsy was consistent with GCA in 177 patients (23%). Elevated CRP and elevated ESR provided a sensitivity of 86.9% and 84.1% respectively, for a positive TAB. The odds ratio (OR) of a concordantly elevated ESR and CRP for positive TAB was 3.06 (95% CI 2.03, 4.62) while the OR for concordantly normal ESR and CRP was 0.49 (95% CI 0.29, 0.83).
Seven patients (4%) with a positive TAB for GCA had a normal ESR and CRP at diagnosis. Compared to GCA patients with elevated markers of inflammation, a greater proportion of these patients had polymyalgia rheumatica symptoms (p=0.008) while constitutional symptoms, anemia and thrombocytosis were observed less often (p<0.05).
CRP is a more sensitive marker than ESR for a positive TAB that is diagnostic of GCA. There may be clinical utility in obtaining both tests in the evaluation of patients with suspected GCA. A small proportion of patients with GCA may have normal inflammatory markers at diagnosis.
In addition to the examination of clinical signs, several laboratory markers have been measured for diagnostics and monitoring of pediatric septic bone and joint infections. Traditionally erythrocyte sedimentation rate (ESR) and leukocyte cell count have been used, whereas C-reactive protein (CRP) has gained in popularity. We monitored 265 children at ages 3 months to 15 years with culture-positive osteoarticular infections with a predetermined series of ESR, CRP, and leukocyte count measurements. On admission, ESR exceeded 20 mm/hour in 94% and CRP exceeded 20 mg/L in 95% of the cases, the mean (± standard error of the mean) being 51 ± 2 mm/hour and 87 ± 4 mg/L, respectively. ESR normalized in 24 days and CRP in 10 days. Elevated CRP gave a slightly better sensitivity in diagnostics than ESR, but best sensitivity was gained with the combined use of ESR and CRP (98%). Elevated ESR or CRP was seen in all cases during the first 3 days. Measuring ESR and CRP on admission can help the clinician rule out an acute osteoarticular infection. CRP normalizes faster than ESR, providing a clear advantage in monitoring recovery.
Level of Evidence: Level II, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.
Infection is one of the most serious complications after total knee arthroplasty (TKA). The current incidence of prosthetic knee infection is 1-3%, depending on the series. For treatment and control to be more cost effective, multidisciplinary groups made up of professionals from different specialities who can work together to eradicate these kinds of infections need to be assembled. About the microbiology, Staphylococcus aureus and coagulase-negative staphylococcus were among the most frequent microorganisms involved (74%).
Anamnesis and clinical examination are of primary importance in order to determine whether the problem may point to a possible acute septic complication. The first diagnosis may then be supported by increased CRP and ESR levels. The surgical treatment for a chronic prosthetic knee infection has been perfectly defined and standardized, and consists in a two-stage implant revision process. In contrast, the treatment for acute prosthetic knee infection is currently under debate. Considering the different surgical techniques that already exist, surgical debridement with conservation of the prosthesis and polythene revision appears to be an attractive option for both surgeon and patient, as it is less aggressive than the two-stage revision process and has lower initial costs.
The different results obtained from this technique, along with prognosis factors and conclusions to keep in mind when it is indicated for an acute prosthetic infection, whether post-operative or haematogenous, will be analysed by the authors.
Acute haematogenous infections; Acute post-operative infections; Biofilm; Implant retention; Open debridement; Total knee arthroplasty.
Periprosthetic infections following total knee arthroplasty (TKA) are diagnostically challenging. We evaluated the sensitivity and specificity of ESR and CRP, false negative rates, whether false negative rates differed between early post-operative and late infections, and the predictive ability of ESR and CRP to differentiate infected patients. Between 2000 and 2007, a prospectively collected database was reviewed to identify patients with suspected periprosthetic infections, and who had ESR and CRP laboratory values. One hundred and thirteen patients were identified. False negative rates were calculated. Finally, receiver operating characteristic curves were used to determine the predictive ability of ESR and CRP to differentiate infected from non-infected patients. CRP had a sensitivity of 95% and specificity of 20%. ESR had a sensitivity of 91% and a specificity of 33%. The false negative rate was 9.2% for ESR, 5.3% for CRP, and 11.1% for combined ESR and CRP. False negative rates were higher for early post-operative infections. Although ESR and CRP can be excellent adjunctive diagnostic tools, we emphasise that because some patients may not mount a sufficient immune response, the entire clinical picture must be evaluated, and periprosthetic infection should not be ruled out on the basis of ESR and CRP results alone.
The present study sought to 1) investigate the degrees of correlations between different disease activity scores (DASs) and health-related quality of life (HRQoL), and 2) determine if DASs correlate with either physical or mental HRQoL.
Eighty patients with rheumatoid arthritis (RA) were assessed for different DASs, measured with erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP), namely DAS4-ESR, DAS-3 ESR, DAS4-CRP, DAS3-CRP, DAS4-28 ESR, DAS3-28 ESR, DAS4-28 CRP, and DAS3-28 CRP, and Simplified Disease Activity Indexes namely SDAI-ESR, and SDAI-CRP. Physical and mental HRQoL were measured using the SF-36. The Pearson correlation test was employed to examine the correlations between HRQoL and different DAS indices. PASS 2000 (Power Analysis and Sample Size) software was utilized to find significant differences between the correlations.
SF-36 total score showed a significant inverse correlation with the DAS4-ESR, DAS-3 ESR, DAS4-CRP, DAS3-CRP, DAS4-28 ESR, DAS3-28 ESR, DAS4-28 CRP, and DAS3-28 CRP, with correlation coefficients of -0.320, -0.314, -0.330, -0.323, -0.327, -0.318, -0.360 and -0.348, respectively (P < 0.01 for all). The correlation coefficients between different DAS indices and the HRQoL score were not significantly different. In addition, all DASs showed significant correlations with physical HRQoL, but not with mental HRQoL.
Among patients with RA, disease severity indices are associated with physical, but not mental HRQoL. However this study failed to show any differences between various DASs in their clinical use.
Health-Related Quality of Life; Rheumatoid Arthritis; Disease Activity Score
We investigated and compared the capacity of mean platelet volume (MPV) and other inflammatory markers in detecting Crohn’s disease (CD) activity and differentiating CD patients from healthy controls.
MPV, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and white blood cells were measured in 61 CD patients and 50 healthy subjects. Disease activity was assessed by the Crohn’s Disease Activity Index.
A significant decrease in MPV was noted in patients with CD compared with healthy controls (P <0.0001), but statistical difference was not found between active and inactive CD groups. In CD, no significant correlation was found between MPV and other inflammatory markers. The overall accuracy of MPV (cutoff: 10.35 fl), CRP (cutoff: 4.85 mg/dl) and ESR (cutoff: 8.5 mm/hour) in differentiating CD patients from healthy controls was 76.6%, 65.8% and 72.1% respectively. The overall accuracy of CRP (cutoff: 4.95 mg/dl) and ESR (cutoff: 16.5 mm/hour) in determination of active CD was 80.3% and 73.8%.
MPV declined in CD patients compared with healthy subjects. MPV had the best accuracy in determination of CD patients and healthy controls. MPV did not show a discriminative value in disease activity.
Crohn’s disease; Mean platelet volume; C-reactive protein; Erythrocyte sedimentation rate; Inflammatory bowel disease
The erythrocyte sedimentation rate (ESR) and C reactive protein (CRP) were measured in 74 patients with polymyalgia rheumatica (PMR)/giant cell arteritis (GCA) on presentation, in the first month of treatment, and at long term follow up (up to 177 weeks). Before treatment the ESR was raised (greater than 30 mm/h) in all cases and the CRP was raised (greater than 6 mg/l) in 49/55 cases. The ESR was a better indicator of clinical disease activity except in patients who felt completely well at week 1. 'False positive' increases of ESR or CRP were rare. During relapses ESR was normal in 37/77 (48%) of cases and CRP in 41/73 (56%). It is suggested that ESR is the most useful laboratory parameter in assessing PMR/GCA.
OBJECTIVE—To determine the value of HLA DR β1 disease associated epitope (DAE) and erythrocyte sedimentation (ESR) in predicting the need for major joint replacement in rheumatoid arthritis (RA).
METHODS—Sixty five RA patients who had undergone hip, knee or shoulder arthroplasty within 15 years of disease onset and 65 who had not. HLA DR β1 genotype was determined by polymerase chain reaction. ESR at first hospital visit was noted.
RESULTS—Significantly more patients with two DAE required surgery, (32% v 9%), χ2 = 13.9, p=0.001, odds ratio=5.4 (95% CI: 1.8, 16). Sensitivity was poor, 32%, specificity high, 91%. Presentation ESR was higher in surgery patients compared with non-surgery patients, 52 mm 1st h v 25 mm 1st h, p< 0.001, but was independent of DAE status. Sensitivity of an ESR of 30 mm 1st h was 75%, specificity 53%.
CONCLUSION—The presence of two DAE is a risk factor for major joint surgery in RA and is independent of ESR, whereas in those with one or no DAE, a high ESR is an important predictor.
Keywords: HLA DR β1; erythrocyte sedimentation rate; rheumatoid arthritis
Chronic low back pain can be a manifestation of lumbar degenerative disease, herniation of intervertebral discs, arthritis, or lumbar stenosis. When nerve roots are compromised, low back pain, with or without lower extremity involvement, may occur. Local inflammatory processes play an important role in patients with acute lumbosciatic pain. The purpose of this study was to assess the value of erythrocyte sedimentation rate (ESR) and high sensitivity C-reactive protein (hsCRP) measurements in patients with chronic low back pain or radiculopathy.
ESR and hsCRP were measured in 273 blood samples from male and female subjects with low back pain and/or radiculopathy due to herniated lumbar disc, spinal stenosis, facet syndrome, and other diseases. The hsCRP and ESR were measured prior to lumbar epidural steroid injection.
The mean ESR was 18.8 mm/h and mean hsCRP was 1.1 mg/L. ESR had a correlation with age.
A significant systemic inflammatory reaction did not appear to arise in patients with chronic low back pain.
ESR; hsCRP; low back pain
To estimate the disease activity score (DAS)28‐C‐reactive protein (CRP) threshold values that correspond to DAS28‐erythrocyte sedimentation rate (ESR) values for remission, low disease activity and high disease activity in patients with rheumatoid arthritis.
DAS28 data were analysed using a large observational study (Institute of Rheumatology Rheumatoid Arthritis) database of 6729 patients with rheumatoid arthritis. Firstly, the relationship between the DAS28‐ESR and the DAS28‐CRP values was analysed. Secondly, the best DAS28‐CRP trade‐off values for each threshold were calculated using receiver operating characteristic (ROC) curves.
The correlation coefficient of ESR versus CRP was 0.686, whereas that of DAS28‐ESR versus DAS28‐CRP was 0.946, showing the strong linear relationship between DAS28‐ESR and DAS28‐CRP values. DAS28‐CRP threshold values corresponding to remission, low disease activity and high disease activity were 2.3, 2.7 and 4.1, respectively. The sensitivity and specificity from the ROC curves were gradually reduced as DAS28 values became lower.
This study showed that DAS28‐CRP and DAS28‐ESR were well correlated, but the threshold values should be reconsidered. As the results were derived from only Japanese patients, it is essential to compare DAS28‐CRP threshold values in people of other ethnic groups.
Serum C reactive protein (CRP) levels and erythrocyte sedimentation rates (ESR) were measured in 56 patients with rheumatoid arthritis. Radiographical damage, based on a count of erosions, was significantly more likely to occur when serum CRP and ESR were persistently raised, irrespective of the presence or absence of rheumatoid factor. Measurements of both CRP and ESR were more helpful than either alone, but CRP was probably the more informative. Serial measurements of CRP and ESR provide a reliable means of discriminating between drugs that provide symptomatic relief only and those with a more profound effect in rheumatoid arthritis.
C-reactive protein (CRP), which is a marker of inflammation, has not been widely studied in inflammatory thyroid disorders particularly in sub-acute thyroiditis (SAT).
This study was aimed to find the significance of CRP level rise in patients with SAT and compare that to the rise in erythrocyte sedimentation rate (ESR), a gold standard laboratory parameter in establishing the diagnosis of SAT.
Materials and Methods:
Serum CRP levels were measured at initial presentation in 28 subjects with SAT(12 male, 16 female, age (Mean +SD) 37.96 ±8.5 years),and 19 patients with Graves’ disease (2 male, 17 female, age [Mean +SD] 36.8 ±16.5 years) as controls. Erythrocyte sedimentation rate (ESR) was measured in all 28 patients with SAT by Westergrens’ method. Either Tc99 nucleotide thyroid scan or high resolution ultrasonography (HR-USG) was performed to differentiate SAT from Graves’ disease.Fine needle aspiration cytology (FNAC) of thyroid was performed selected patients.
Serum CRP level was high in 61% of SAT patients but in none of the Graves′patients. Mean (SEM) (90%CI) serum CRP level (mg/L) was also significantly higher (P <0.0004) in the SAT group [27.55 (5.76) (15.72-39.38)], than in the Graves’ group [4.09 (0.12) (3.81-4.36)]. The sensitivity of serum CRP was 73.33%, specificity 53.85%, positive predictive value (PPV) 64.71%, and negative predictive value (NPV) 63.64% as compared to the sensitivity (53.57%), specificity (15.38%), PPV (57.69 %), and NPV (13.33%) of ESR.
There is significantly higher rise in serum CRP level in patients with SAT is compared to patients with Graves’ disease. It correlates well with the rise in ESR. Such findings of this pilot study highlight the scope of using serum CRP as a diagnostic marker of SAT specially in situations when it may be confused with Graves’ disease, another common cause of thyrotoxicosis. It is logical to carry out studies to find a particular cut-off for serum CRP which can serve as an objective parameter for grading the inflammation in patients with SAT.
C-reactive protein; Graves’; sub-acute thyroiditis; thyroiditis
Thirty one patients with giant cell arteritis (GCA) receiving standardised prednisolone treatment were followed up for one year with analyses of plasma viscosity, erythrocyte sedimentation rate (ESR), C reactive protein (CRP), and fibrinogen concentration. On the day of diagnosis all patients had an increased plasma viscosity and ESR, whereas the concentration of CRP was normal in three patients and fibrinogen concentration and haptoglobin values were normal in one patient. IgG levels were increased in two patients. Plasma viscosity correlated significantly with the ESR, IgG level, and fibrinogen concentration. Laboratory variables in subgroups of patients with GCA proved by biopsy were not different from the whole group of patients with GCA. The follow up showed that CRP normalised faster than the ESR, plasma viscosity, and fibrinogen concentration. Plasma viscosity and the ESR paralleled clinical findings more closely and predicted flare ups better than the other variables. Plasma viscosity had advantages over the ESR for predicting flare ups and in the clinical monitoring of treatment with glucocorticoids.
We recently described a sonication technique for the diagnosis of prosthetic knee and hip infections. We compared periprosthetic tissue culture to implant sonication followed by sonicate fluid culture for the diagnosis of prosthetic shoulder infection. One hundred thirty-six patients undergoing arthroplasty revision or resection were studied; 33 had definite prosthetic shoulder infections and 2 had probable prosthetic shoulder infections. Sonicate fluid culture was more sensitive than periprosthetic tissue culture for the detection of definite prosthetic shoulder infection (66.7 and 54.5%, respectively; P = 0.046). The specificities were similar (98.0% and 95.1%, respectively; P = 0.26). Propionibacterium acnes was the commonest species detected among culture-positive definite prosthetic shoulder infection cases by periprosthetic tissue culture (38.9%) and sonicate fluid culture (40.9%). All subjects from whom P. acnes was isolated from sonicate fluid were male. We conclude that sonicate fluid culture is useful for the diagnosis of prosthetic shoulder infection.
Erythrocyte sedimentation rate and C-reactive protein are common preoperative diagnostic markers for prosthetic joint infection but their prognostic role before reimplantation has yet to be defined. We therefore determined the prognostic value of erythrocyte sedimentation rate and C-reactive protein performed before second-stage reimplantation for the treatment of infected total knee arthroplasty (TKA). We studied 109 patients who had undergone two-stage revision TKA for sepsis from 1999 to 2006. Receiver operating characteristic curves were constructed to determine the discriminatory value of erythrocyte sedimentation rate and C-reactive protein before reimplantation in predicting persistent infection. Twenty-three of the 109 patients (21%) required revision surgery for recurrence of prosthetic joint infection. The receiver operating characteristic areas under the curve suggested erythrocyte sedimentation rate and C-reactive protein poorly predicted persistent infection after TKA reimplantation. Cutoff values could not be obtained because of the high variance. We reached similar conclusions regarding the change in erythrocyte sedimentation rate and C-reactive protein levels from time of resection. More accurate diagnostic tools are needed to support clinical judgment in monitoring infection progress and thus deciding whether to proceed with TKA reimplantation.
Level of Evidence: Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Background: High C-reactive protein (CRP) values are frequently found in patients with bacterial respiratory infection, and CRP testing has been shown to be useful in differentiating pneumonia from other respiratory infections. Raised CRP values may also be found in viral respiratory infection, and as a result there is a risk that antibiotics may be wrongly prescribed.
Aims: To describe the course of the CRP response during untreated upper respiratory tract infections and associations between the development of CRP values, erythrocyte sedimentation rate (ESR) and respiratory symptoms.
Design of study: Prospective study.
Setting: Seven general practices in northern Norway.
Method: Patients with upper respiratory tract infection aged 16 years or over, who were not treated with antibiotics and who had been ill for no more than 3 days, were recruited. Microbiological examinations were undertaken, together with measurements of CRP, ESR and recording of symptoms daily during the first week of illness and on days 10, 14 and 21.
Results: An aetiological agent was established in 23 of the 41 included subjects. These were: influenza A, influenza B, rhinovirus, and other agents. Among the 15 patients examined on both the second and the third day of illness, the median CRP value increased from 7–10 mg/l, and the mean value was from 19–24 mg/l between day 2 and day 3. Peak CRP values were reached on days 2 to 4. Higher CRP values were found in those infected with influenza A and B than in the other subjects (P<0.001). A CRP value >10 mg/l was found in 26 subjects during the first 7 days, compared to five subjects after 1 week. Evidence of a secondary infection with group A streptococci was found in two of these five subjects. The development of the symptoms of sore throat, fatigue, clamminess, and pain from muscles and joints followed a similar course as the CRP response, while stuffy nose, cough, sputum production, and dyspnoea tended to persist after the CRP values had approached the normal range.
Conclusion: A moderately elevated CRP value (10–60 mg/l) is a common finding in viral upper respiratory tract infection, with a peak during days 2–4 of illness. Moderately elevated CRP values cannot support a diagnosis of bacterial infection when the illness has lasted less than 7 days, but may indicate a complication of viral infection after a week.
antibiotics; common cold; cough; C-reactive protein; erythrocyte sedimentation rate; influenza; upper respiratory infections
The objective of this study was to determine the prevalence and risk factors of low bone mineral density (BMD) in patients with spondylarthropathies (SpA) at an early stage of disease. In this cross-sectional study, the BMD of lumbar spine and hips was measured in 130 consecutive early SpA patients. The outcome measure BMD was defined as (1) osteoporosis, (2) osteopenia, and (3) normal bone density. Logistic regression analyses were used to investigate relations between the following variables: age, gender, disease duration, diagnosis, HLA-B27, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), extra-spinal manifestations and medication, with outcome measure low BMD (osteopenia and/or osteoporosis). The SpA population had a median time since diagnosis of 6.6 months and a disease duration of 6.3 years. In total, 9% of the early SpA patients had osteoporosis, 38% osteopenia, and 53% normal BMD. On univariate analyses, male gender, diagnosis of ankylosing spondylitis, increased CRP, high BASFI, and high BASMI were significantly associated with low BMD. Factors showing a relation with low BMD in the multivariate model were male gender (OR 4.18, 95% confidence interval (CI) 1.73–10.09), high BASMI (OR 1.54, 95% CI 1.14–2.07), and high BASFI (OR 1.18, 95% CI 1.00–1.39). In early SpA patients, a high frequency (47%) of low BMD in femur as well as in lumbar spine was found. Low BMD was associated with male gender and decreased functional capacity. These findings emphasize the need for more alertness for osteoporosis and osteopenia in spondylarthropathy patients at an early stage of the disease.
Ankylosing spondylitis; Bone mineral density; Osteoporosis; Spondylarthropathies
Sequential measurements of serum C-reactive protein (CRP), serum haptoglobin (Hp), and erythrocyte sedimentation rate (ESR) were made in 209 patients with rheumatoid arthritis (RA); 78 of them were treated with gold, 71 with dapsone, and 60 with prednisone. The results were expressed as proportional changes in the measurements at 28-day intervals after treatment began. The period of study was 140 days. During treatment with gold and dapsone there were statistically significant gradual and progressive falls of similar magnitude in serum CRP and ESR. During treatment with prednisone serum CRP and ESR fell abruptly by 28 days and thereafter altered little. At 140 days prednisone had had the largest proportional effect on both measurements. During gold treatment the fall in serum Hp was similar to that of the ESR. In contrast, prednisone had little effect on Hp levels despite large falls in serum CRP and the ESR. Either prednisone stimulates Hp synthesis or the divergence is an expression of the difference in type of effect between gold and prednisone on RA. The effect of dapsone on serum Hp was large and progressive; it partly reflects haemolysis and, since the haemolysis was not progressive, partly improvement in the RA. The results show the relative efficacy of the drugs and suggest that dapsone may be a useful alternative treatment for RA.