LETTER
Erythrocyte Sedimentation Rate and C-Reactive Protein in the Diagnosis of Polymyalgia Rheumatica
Fabrizio Cantini, MD;
Carlo Salvarani, MD; and
Ignazio Olivieri, MD
15 May 1998 | Volume 128 Issue 10 | Pages 873-874
TO THE EDITOR:
An erythrocyte sedimentation rate (ESR) of at least 40 mm/h has been included in the diagnostic criteria of polymyalgia rheumatica [1]. However, some studies have reported a percentage of patients with polymyalgia rheumatica who have an ESR at diagnosis that oscillates between 10% to 20% of normal [2-4]. C-reactive protein, a direct measure of acute phase response, could be a more sensitive marker of disease activity than ESR in patients with polymyalgia rheumatica. As a result, it could be useful for diagnosis and evaluation of relapse and recurrence.
We determined ESR (by the Westergren method) and C-reactive protein levels (by nephelometry; normal value < 0.5 mg/dL) in 177 consecutive patients with polymyalgia rheumatica who were clinically assessed at diagnosis, monthly for the first 6 months, and then every 3 months during the follow-up period. The median duration of follow-up was 37 months (range, 5 to 70 months). At diagnosis and during follow-up, all patients were also evaluated for the 1987 modified American Rheumatism Association criteria for rheumatoid arthritis [5].
Ten of 177 patients (5.6%) had normal (
30 mm/h) ESRs at diagnosis (median, 22 mm/h [range, 14 to 30 mm/h]). Fifteen of 177 patients (8.5%) had ESRs less than 40 mm/h at diagnosis (median, 27 mm/h [range, 14 to 39 mm/h]). Only 2 of 177 patients (1.1%) had normal C-reactive protein values at diagnosis (0.5 and 0.3 mg/dL, respectively). One of these patients also had a normal ESR (18 mm/h), and the other had an elevated ESR (49 mm/h).
Compared with patients who had high ESRs, patients who had normal ESRs were more frequently male (32% compared with 70%; P = 0.03) and had systemic signs and symptoms less frequently (62% compared with 70%; P = 0.002). C-reactive protein levels were lower in patients with normal ESRs (1.9 ± 1.4 mg/dL compared with 6.8 ± 5.2 mg/dL; P = 0.005). However, 9 of 10 patients with a normal ESR at diagnosis had increased C-reactive protein levels (median, 1.4 mg/dL [range, 0.7 to 4.7 mg/dL]).
Our prospective follow-up study suggests that the frequency of polymyalgia rheumatica with normal ESR at diagnosis is lower than that reported in previous retrospective studies [2-4]. The C-reactive protein level is more sensitive than ESR in the assessment of disease activity at diagnosis of polymyalgia rheumatica and could substitute for ESR in the diagnostic criteria for the condition.
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Author and Article Information
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Ospedale di Prato; Prato, Italy
Aziendo Ospedaliera Arcispedale S. Maria Nuovo; Reggio Emilia, Italy
Ospedale S. Orsola-Malpighi; Bologna, Italy
1. Salvarani C, Macchioni PL, Boiardi L. Polymyalgia rheumatica. Lancet. 1997; 350:43-7.
2. Ellis ME, Ralsto S. The ESR in the diagnosis and management of the polymyalgia rheumatica/giant cell arteritis syndrome. Ann Rheum Dis. 1983; 42:168-70.
3. Helfgott SM, Kieval RI. Polymyalgia rheumatica in patients with a normal erythrocyte sedimentation rate. Arthritis Rheum. 1996; 39:304-7.
4. Gonzalez Gay MA, Rodriguez-Valverde V, Blanco R, Fernandez-Sueiro JL, Armona J, Figueroa M, et al. Polymyalgia rheumatica without significantly increased erythrocyte sedimentation rate. Arch Intern Med. 1997; 157:317-20.[Abstract]
5. Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum. 1988; 31:315-24.
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