Elsevier

Ophthalmology

Volume 113, Issue 10, October 2006, Pages 1842-1845
Ophthalmology

Original Article
Prevalence of a Normal C-Reactive Protein with an Elevated Erythrocyte Sedimentation Rate in Biopsy-Proven Giant Cell Arteritis

https://doi.org/10.1016/j.ophtha.2006.05.020Get rights and content

Objective

The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are laboratory tests that have been said to have a strong correlation with a positive temporal artery biopsy in patients with suspected giant cell arteritis (GCA). Published reports suggest that the CRP is a more sensitive diagnostic indicator of GCA and can be elevated when the ESR is normal. It is also clear that the CRP and ESR can both be normal or both be elevated in patients with biopsy-proven GCA and that the CRP can be elevated when the ESR is normal. The purpose of this study was to ascertain if the CRP can be normal when the ESR is elevated in biopsy-proven GCA.

Design

Retrospective, longitudinal, comparative study.

Participants

One hundred nineteen patients from 6 major tertiary-care university-affiliated medical centers.

Methods

The charts from 119 patients with temporal artery biopsies positive for GCA were reviewed for age, gender, pretreatment ESR, and pretreatment CRP.

Main Outcome Measures

The ESR in millimeters per hour Westergren was graded as normal or abnormal based on 2 validated formulas. The CRP was graded as normal or abnormal based on established criteria set forth in the literature as well as at The Johns Hopkins Hematology laboratory.

Results

In this study, the ESR had a sensitivity of 76% to 86%, depending on which of 2 formulas were used, whereas an elevated CRP had a sensitivity of 97.5%. The sensitivity of the ESR and CRP together was 99%. Only 1 of the 119 patients (0.8%) presented with a normal ESR and normal CRP (double false negative); 2 patients (1.7%) had a normal CRP despite an elevated ESR according to both formulas.

Conclusion

Although most patients with GCA have both an elevated ESR and CRP, there can be nonconcordance of the 2 blood tests. Although such nonconcordance is most often a normal ESR but an elevated CRP, the finding of an elevated ESR and a normal CRP also is consistent with GCA. The use of both tests provides a slightly greater sensitivity for the diagnosis of GCA than the use of either test alone.

Section snippets

Materials and Methods

A retrospective, longitudinal, comparative study was performed. Chart review and data collection were conducted in the ophthalmology departments of 6 major tertiary-care university-affiliated medical centers from August 2004 through June 2005. Deidentified data were then sent to the coordinating center at The Johns Hopkins Hospital for final analysis. The study sample consisted of 119 patients with biopsy-proven GCA who had pretreatment ESR and CRP assays drawn between 1994 and 2005, a time

Demographic Characteristics

Of the 119 patients in this study, 87 (73.1%) were female. The mean age at presentation was 75.8, with a range of 52 to 97 years.

Erythrocyte Sedimentation Rate and C-Reactive Protein Levels

In this study, 99 of the 119 patients (83.2%) presented with both an elevated pretreatment ESR and CRP. As shown in Table 1, the ESR was elevated in 88 of these patients using both formulas. The other 11 patients had an elevated ESR by the Hayreh et al formula but not the Miller et al formula. Seventeen patients (14.3% of the original 119 patients) had a normal

Discussion

Visual loss is the most common devastating and irreversible complication of GCA and can be prevented with treatment. The first step in management, therefore, is early and accurate diagnosis. It is clear from previous studies that both the ESR and the CRP are highly sensitive tests for the diagnosis of GCA and that their combination increases the sensitivity further.5, 9, 11, 12, 13 Because the CRP is an acute-phase plasma protein that rises before ESR in most disease states, we hypothesized

Acknowledgments

The authors are indebted to Dr Susan Vitale, Johns Hopkins Hospital, for her assistance with the statistical analysis for the manuscript.

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  • Cited by (0)

    Manuscript no. 2005-1178.

    The authors have no commercial or proprietary interest in the products or companies mentioned in the article.

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