ESR Cheat sheet - Exam Favorite Causes

Exam favorite questions about ESR

1. ESR >100 mm/hr

Giant Cell Arteritis (Temporal Arteritis)

• Age >50, new onset headache, scalp tenderness

• Jaw claudication, visual symptoms

• ESR usually >100

• Start prednisolone 40–60 mg immediately to prevent blindness

• Closely linked with PMR

Polymyalgia Rheumatica (PMR)

 • Age >50, morning stiffness in shoulders/hips

 • ↑ ESR, normal CK

 • Dramatic response to low-dose steroids

Tuberculosis

 • Chronic cough, fever, weight loss, night sweats

 • Markedly ↑ ESR — especially in extrapulmonary TB

Multiple Myeloma

 • Elderly, bone pain (back/ribs), anemia, renal impairment

 • Very high ESR due to rouleaux formation from monoclonal proteins

Advanced / Metastatic Malignancy

 • ESR correlates with systemic inflammation and tumor burden

 

Normal or Low ESR → “False Negatives”

Inflammation present but ESR misleadingly low.

 • Polycythemia Vera → high RBC mass → slow sedimentation

 • Sickle Cell Disease → abnormal RBC shape → no rouleaux

 • Leukocytosis → WBCs interfere with RBC falling

 • Hypofibrinogenemia / low acute-phase proteins

Exam clue: High inflammatory symptoms but normal ESR → think these conditions.

ESR in Chronic Disease Monitoring

Rheumatoid Arthritis

 • Tracks disease activity

 • Part of DAS-28 score

SLE

 • ESR ↑ but CRP usually normal

 • CRP rises only with infections or serositis

Inflammatory Bowel Disease (Crohn’s/UC)

 • ESR helpful for flare assessment and long-term monitoring

Infective Endocarditis

 • ESR ↑ (minor Duke criterion)

Osteomyelitis

 • ESR + CRP ↑

 • ESR stays high longer → useful for long-term monitoring

Falsely high ESR

 • Pregnancy

 • Anemia

 • Elderly

 • Obesity

 • Post-MI or post-surgery (stays high for weeks)

Falsely low ESR

 • NSAIDs / steroids

 • Polycythemia vera

 • Sickle cell disease

 • Leukocytosis

ESR in Pediatrics

• Kawasaki Disease: ↑ ESR + ↑ CRP + fever >5 days

• Juvenile Idiopathic Arthritis (JIA): persistent ↑ ESR helpful for diagnosis and monitoring

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ESR Masterclass: Interpretation, Causes & Clinical Significance (Complete Guide)

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The Erythrocyte Sedimentation Rate (ESR) is one of the most frequently ordered inflammatory markers in clinical practice. Despite being an old test, ESR still plays a major role in diagnosing autoimmune diseases, infections, malignancies, and chronic inflammatory conditions. Understanding causes of high ESR, causes of low ESR, and when ESR >100 mm/hr becomes clinically significant is crucial for students, residents, and practicing clinicians.

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⭐ What Is ESR? (Definition & Physiology)

ESR measures the rate at which red blood cells fall in a vertical tube over one hour.

It reflects plasma protein composition, especially:

Fibrinogen

Immunoglobulins

Acute-phase reactants

High levels of these proteins promote rouleaux formation, increasing ESR.

🔍 High-search keyword examples:

ESR test, ESR normal range, high ESR causes, ESR vs CRP, ESR in autoimmune diseases

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🔥 ESR >100 mm/hr: The Exam-Favorite Causes

An ESR more than 100 mm/hr almost always indicates a serious underlying condition.

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1. Giant Cell Arteritis (Temporal Arteritis)

Age >50

New-onset headache, scalp tenderness

Jaw claudication

Visual disturbances → risk of permanent blindness

ESR usually >100 mm/hr

Immediate treatment: Prednisolone 40–60 mg daily

Linked strongly with Polymyalgia Rheumatica (PMR).

Keywords: high ESR elderly, GCA symptoms, temporal arteritis diagnosis

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2. Polymyalgia Rheumatica (PMR)

Age >50

Morning stiffness in shoulders/hips

Very high ESR

Normal CK (clue!)

Dramatic response to low-dose steroids

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3. Tuberculosis (Pulmonary & Extrapulmonary)

Chronic cough

Fever, night sweats

Weight loss

One of the highest ESR elevations, esp. in TB lymphadenitis & TB spine

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4. Multiple Myeloma

Elderly patients

Bone pain (spine, ribs)

Anemia

Renal impairment

Extreme ESR rise due to monoclonal proteins → rouleaux formation

Keywords: myeloma ESR, very high ESR cancer, rouleaux formation

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5. Advanced or Metastatic Malignancy

ESR correlates with tumor burden, chronic inflammation, and necrosis.

Seen in: lung cancer, breast cancer, prostate cancer, lymphoma.

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⚠️ Normal or Low ESR Doesn’t Always Mean “No Inflammation”

These are false negatives—important exam clues.

Conditions where ESR remains normal despite inflammation:

Polycythemia vera → too many RBCs, slower fall

Sickle cell disease → abnormal shapes prevent rouleaux

Leukocytosis → WBCs hinder sedimentation

Hypofibrinogenemia → fewer acute-phase proteins

Exam tip:

➡ High fever + severe inflammation + normal ESR → suspect these conditions.

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📊 ESR in Chronic Disease Monitoring

1. Rheumatoid Arthritis (RA)

ESR used to track disease activity

Part of DAS-28 score

2. Systemic Lupus Erythematosus (SLE)

ESR ↑ but

CRP normal (unless infection/serositis)

This is a classic exam differentiator.

3. Inflammatory Bowel Disease (Crohn’s & Ulcerative Colitis)

Helps monitor flares

Used with fecal calprotectin & CRP

4. Infective Endocarditis

ESR ↑

Considered a minor Duke criterion

5. Osteomyelitis

ESR and CRP both high

ESR stays elevated for weeks → great for long-term follow-up

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📈 Falsely High ESR (No Real Inflammation)

These raise ESR independently of disease.

Pregnancy

Anemia

Elderly age

Obesity

Post-MI

Post-surgery (remains high for weeks)

High-search keywords: pregnancy ESR, elderly high ESR, anemia ESR

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📉 Falsely Low ESR

NSAIDs

Steroids

Polycythemia vera

Sickle cell disease

Leukocytosis

Keyword: low ESR despite inflammation

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🧒 ESR in Pediatrics

1. Kawasaki Disease

↑ ESR + ↑ CRP

Fever >5 days

Mucocutaneous changes

2. Juvenile Idiopathic Arthritis (JIA)

Persistent high ESR

Helps in monitoring flares and remission

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🆚 ESR vs CRP: Which Is Better?

CRP: rises fast, specific for inflammation

ESR: slower, influenced by RBC shape/number

Best approach:

Use both together for maximum diagnostic accuracy.

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🔍 When to Order ESR? (Practical Clinical Use Cases)

Suspected vasculitis

Workup of fever of unknown origin (FUO)

Monitoring chronic inflammatory diseases

Suspected osteomyelitis or endocarditis

Screening in unexplained anemia or weight loss (possible myeloma)

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🧪 Normal ESR Values (By Age & Sex)

Men <50 years: <15 mm/hr

Women <50 years: <20 mm/hr

Men >50 years: <20 mm/hr

Women >50 years: <30 mm/hr

Rule of thumb:

Older adults naturally have slightly higher ESR.

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📝 Conclusion: Why ESR Still Matters

Despite being a simple test, ESR remains one of the most powerful and cost-effective inflammatory markers. Mastering its interpretation helps diagnose:

Autoimmune disorders

Serious infections

Malignancies

Chronic inflammatory diseases

Vasculitis syndromes

Understanding false highs and false lows is essential for correct clinical judgment—especially in exams and real-world practice.