Erythrocyte sedimentation rate

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Synonyms and keywords: Biernacki Reaction; Sedimentation rate; Westergren ESR


The erythrocyte sedimentation rate (ESR), also called sedimentation rate, sed rate, or Biernacki Reaction, is a non-specific, indirect measurement of the acute phase reactant concentration which is altered in conditions of inflammation. It is commonly used as a medical screening test. To perform the test, anticoagulated blood is placed in an upright tube, known as a Westergren tube and the rate at which the red blood cells fall is measured and reported in mm/h. When an inflammatory process is present, the high proportion of fibrinogen in the blood causes red blood cells to stick to each other. The red cells form stacks called 'rouleaux' which settle faster. Rouleaux formation can also occur in association with some lymphoproliferative disorders in which one or more immunoglobulins are secreted in high amounts. Rouleaux formation is, however, a physiological finding in some equidae and can be as such in felidae and suidae species, namely the horse, cat and pig respectively. The basal ESR is slightly higher in females than males and increases with age. It is also affected by the size, shape, and number of red cells, as well as by other constituents in the blood such as immunoglobulins. The ESR is increased in pregnancy, anemia, or any cause or focus of inflammation and decreased in sickle cell anemia, polycythemia, and congestive heart failure.


This test was invented in 1897 by the Polish doctor Edmund Biernacki.[1] In 1918 the Swedish pathologist Robert Sanno Fåhræus declared the same and along with Alf Vilhelm Albertsson Westergren are eponymously remembered for the Fåhræus-Westergren test (in the UK, usually termed Westergren test),[2] which uses sodium citrate-anticoagulated specimens.[3]


Although it is frequently ordered, the erythrocyte sedimentation rate (ESR) is not a useful screening test. It is only useful for diagnosing three diseases: myeloma, temporal arteritis and polymyalgia rheumatica (in which it may exceed 100 mm/hour).

It is commonly used for a differential diagnosis for Kawasaki's Disease and it may be increased in some chronic infective conditions like tuberculosis and infective endocarditis. It is a component of the PDCAI, an index for assessment of severity of inflammatory bowel disease in children.

The clinical usefulness of erythrocyte sedimentation rate (ESR) is limited to monitoring the response to therapy in certain inflammatory diseases such as temporal arteritis, polymyalgia rheumatica and rheumatoid arthritis. It can also be used as a crude measure of response in Hodgkin's lymphoma. Additionally, ESR levels are used to define one of the several possible "adverse prognostic factors" in the staging of Hodgkin's lymphoma.

The use of the ESR as a screening test in asymptomatic persons is limited by its low sensitivity and specificity. When there is a moderate suspicion of disease, the ESR may have some value as a "sickness index."

An elevated ESR in the absence of other findings should NOT trigger an extensive laboratory or radiographic evaluation.

Normal Values

Note: mm/hr. = millimeters per hour.

Values are increased in states of anemia,[4] and in black populations.[5]


ESR reference ranges from a large study:[6]

(ESR 95% limits) Age (years)
20 55 90
Men 12 14 19
Women 18 21 23

As an alternative the following formula may be used to give predicted values for ESR based on age and gender:[7]


  • Newborn: 0 to 2 mm/hr.
  • Neonatal to puberty: 3 to 13 mm/hr.
  1. Newborn: 0-5 mm/hr.
  2. Neonatal to puberty: 0-15 mm/hr.

Causes of increased erythrocyte sedimentation rate

Common Causes

Causes by Organ System

Cardiovascular Arteritic anterior ischemic optic neuropathy, Atrial myxoma, Churg-Strauss syndrome, Dressler's syndrome, Kawasaki disease, Myocardial infarction, Myocarditis, Polyarteritis nodosa, Raynaud's phenomenon, Takayasu's arteritis, Vasculitis, Wegener granulomatosis
Chemical/Poisoning Eosinophilic pneumonia
Dental No underlying causes
Dermatologic Alopecia, Dermatomyositis, Erythema nodosum, Henoch-Schonlein purpura, Scleroderma
Drug Side Effect Eosinophilic pneumonia
Ear Nose Throat No underlying causes
Endocrine Diabetic myonecrosis, Hypothyroidism, Thyroiditis
Environmental No underlying causes
Gastroenterologic Acute liver failure, Acute pancreatitis, Cholecystitis, Crohn's disease, Colitis, Familial mediterranean fever, Hepatitis, Inflammatory bowel disease, Lupoid hepatitis, Non-alcoholic fatty liver disease, Peritonitis
Genetic Chronic granulomatous disease, Erythromelalgia, Familial mediterranean fever, Hyperimmunoglobulinemia D with recurrent fever, Infantile cortical hyperostosis, Majeed syndrome
Hematologic Acanthocytosis, Anemia, Cryoglobulinemia, Erdheim-Chester disease, Hemolytic anemia, Hemolytic-uremic syndrome, Hodgkin's lymphoma, Hyperfibrinogenemia, Iron deficiency anemia, Leukemia, Macroglobulinemia, Multiple myeloma, Myeloma, Non-Hodgkin lymphoma, Sinus histiocytosis, Thrombocytosis, Waldenström macroglobulinaemia
Iatrogenic No underlying causes
Infectious Disease Bacterial infection, Cat scratch disease, Entamoeba histolytica, Eosinophilic pneumonia, Fungal infection, Infection, Leptospirosis, Lung abscess, Mycobacterium tuberculosis, Osteomyelitis, Pneumonia, Pott's disease, Q fever, Rheumatic fever, Septic arthritis, Syphilis, Tuberculosis, Viral infection
Musculoskeletal/Orthopedic Dermatomyositis, Diabetic myonecrosis, Familial mediterranean fever, Osteomyelitis, Pott's disease, Reiter's syndrome, Septic arthritis, Transient synovitis
Neurologic Arteritic anterior ischemic optic neuropathy, Multi-infarct dementia
Nutritional/Metabolic Vitamin B12 Deficiency anemia
Obstetric/Gynecologic Pregnancy
Oncologic Atrial myxoma, Leukemia, Macroglobulinemia, Malignancy, Metastases, Multiple myeloma, Myeloma, Non-Hodgkin lymphoma, Paraneoplastic syndrome, Waldenström macroglobulinemia
Ophthalmologic Arteritic anterior ischemic optic neuropathy, Ocular ischemic syndrome
Overdose/Toxicity No underlying causes
Psychiatric No underlying causes
Pulmonary Bronchiectasis, Eosinophilic pneumonia, Idiopathic pulmonary fibrosis, Lung abscess, Pneumonia, Pulmonary embolism
Renal/Electrolyte Acute glomerulonephritis, Hemolytic uremic syndrome, IgA nephropathy, Pyelonephritis, Renal disease
Rheumatology/Immunology/Allergy Ankylosing spondylitis, Arteritic anterior ischemic optic neuropathy, Churg-Strauss syndrome, Crohn's disease, Dermatomyositis, Dressler's syndrome, Gout, Hemolytic-uremic syndrome, Henoch-Schonlein purpura, IgA nephropathy, Inflammation, Inflammatory bowel disease, Kawasaki disease, Lupoid hepatitis, Polyarteritis nodosa, Polymyalgia rheumatica, Raynaud's phenomenon, Reiter's syndrome, Rheumatic fever, Rheumatoid arthritis, Scleroderma, Still's disease, Systemic lupus erythematosus, Takayasu's arteritis, Temporal arteritis, Ulcerative colitis, Wegener granulomatosis, Wissler-Fanconi syndrome
Sexual No underlying causes
Trauma No underlying causes
Urologic No underlying causes
Miscellaneous Burn injury, Retroperitoneal fibrosis, Sarcoidosis

Causes in Alphabetical Order[8][9]

Causes of decreased erythrocyte sedimentation rate

Common Causes

Causes by Organ System

Cardiovascular Congestive heart failure
Chemical/Poisoning No underlying causes
Dental No underlying causes
Dermatologic No underlying causes
Drug Side Effect No underlying causes
Ear Nose Throat No underlying causes
Endocrine No underlying causes
Environmental No underlying causes
Gastroenterologic No underlying causes

Abetalipoproteinemia, Bruton's agammaglobulinemia, Chorea acanthocytosis, Congenital afibrinogenemia, Polycythemia, Sickle cell disease,Hereditary spherocytosis


Abetalipoproteinemia, Acanthocytosis, Anisoctyosis, Bruton's agammaglobulinemia, Chorea acanthocytosis, Congenital afibrinogenemia,Dysproteinemia, Hereditary spherocytosis, Hyperviscosity state, Hypofibrinogenemia, Hypogammaglobulinemia, Leukocytosis, Macrophage-activation syndrome, Microcytosis, Polycythemia, Sickle cell disease, Spherocytosis

Iatrogenic No underlying causes
Infectious Disease Leukocytosis
Musculoskeletal/Orthopedic No underlying causes
Neurologic Chorea acanthocytosis
Nutritional/Metabolic Abetalipoproteinemia
Obstetric/Gynecologic No underlying causes
Oncologic Dysproteinemia, Macrophage-activation syndrome
Ophthalmologic No underlying causes
Overdose/Toxicity No underlying causes
Psychiatric No underlying causes
Pulmonary No underlying causes
Renal/Electrolyte Dysproteinemia
Rheumatology/Immunology/Allergy Bruton's agammaglobulinemia, Dysproteinemia, Hypogammaglobulinemia, Macrophage-activation syndrome
Sexual No underlying causes
Trauma No underlying causes
Urologic No underlying causes
Miscellaneous Technical factors (dilutional problem, inadequate mixing, clotting of blood sample, short ESR tube, vibration during testing)

Causes in Alphabetical Order


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  3. "ICSH recommendations for measurement of erythrocyte sedimentation rate. International Council for Standardization in Haematology (Expert Panel on Blood Rheology)" (Scanned & PDF). J. Clin. Pathol. 46 (3): 198–203. 1993. PMID 8463411.
  4. Kanfer EJ, Nicol BA (1997). "Haemoglobin concentration and erythrocyte sedimentation rate in primary care patients" (Scanned & PDF). Journal of the Royal Society of Medicine. 90 (1): 16–8. PMID 9059375.
  5. Gillum RF (1993). "A racial difference in erythrocyte sedimentation". Journal of the National Medical Association. 85 (1): 47–50. PMID 8426384.
  6. Wetteland P, Røger M, Solberg HE, Iversen OH (1996). "Population-based erythrocyte sedimentation rates in 3910 subjectively healthy Norwegian adults. A statistical study based on men and women from the Oslo area". J. Intern. Med. 240 (3): 125–31. PMID 8862121. - listing upper reference levels expected to be exceeded only by chance in 5% of subjects
  7. Template:GPnotebook
  8. Sailer, Christian, Wasner, Susanne. Differential Diagnosis Pocket. Hermosa Beach, CA: Borm Bruckmeir Publishing LLC, 2002:77 ISBN 1591032016
  9. Kahan, Scott, Smith, Ellen G. In A Page: Signs and Symptoms. Malden, Massachusetts: Blackwell Publishing, 2004:68 ISBN 140510368X
  10. 10.0 10.1 Brigden, ML. (1999). "Clinical utility of the erythrocyte sedimentation rate". Am Fam Physician. 60 (5): 1443–50. PMID 10524488. Unknown parameter |month= ignored (help)

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