Sedimentation

A 94-year-old man with a medical history of chronic kidney disease, hypertension, dementia, and blindness secondary to glaucoma presented to the ED for worsening left leg pain. Upon questioning it was discovered he also had a history of recurrent falls and had been bedridden for the past 3 months. He reported neck pain, right shoulder pain, and left leg pain. Incidentally, he was found to have a hemoglobin level of 8.3 g/dL, a drop of 3 g in 1 month's time. Other testing in the ED, including urinalysis, X-rays, and a CT of the abdomen and pelvis, was negative. The patient was hemodynamically stable. He was admitted for further evaluation of new normocytic anemia and leg pain. An erythrocyte sedimentation rate (ESR) was ordered.

One of the first descriptions of the ESR is detailed in a book by British surgeon and anatomist John Hunter (1728–1793), famous for purported experimental self-inoculation with gonorrhea (which led to his eventual fatal co-infection with syphilis), whose home is said to be the model for that of Dr. Jekyll and Mr. Hyde. In his book, “Treatise on the Blood, Inflammation, and Gun-Shot Wounds,” Dr. Hunter observed “…that the red globules subsided much faster in the inflammatory blood than in the other.” He then made the connection between this reaction in the blood to “inflammatory fevers” and “symptomatic fevers” (11. Madrenas J, Potter P, Cairns E. Giving credit where credit is due: John Hunter and the discovery of erythrocyte sedimentation rate. Lancet. 2005;366:2140-1. [PMID: 16360794]).

The first method for measuring the ESR was described by the Polish physician Edmund F. Biernacki (1866–1911). His explanation was based on the close relationship between the speed of sedimentation of red blood cells and the level of fibrinogen (22. Grzybowski A, Sak J. Edmund Biernacki (1866–1911): Discoverer of the erythrocyte sedimentation rate. On the 100th anniversary of his death. Clin Dermatol. 2011;29:697-703. [PMID: 23293796]). Dr. Biernacki described the diagnostic value of the ESR in 1897 in both German and Polish publications. For his experiments, he used glass cylinders of his own design and blood mixed with sodium oxalate to prevent coagulation. He later detailed the relationship between increased ESR and many disease states, including rheumatic diseases, febrile states, tuberculosis, nephritis, and hepatic disorders (33. Kucharz EJ. Edmund Biernacki and the erythrocyte sedimentation rate. Lancet. 1987;1:696. [PMID: 2882126]).

In 1917, Ludwik Hirszfeld, a Polish microbiologist, noted elevation of ESR in a group of patients with malaria. In 1918, a Swedish hematologist, Robert Fahraeus, observed increased ESR in pregnancy. Alf Westergren, a Swedish internist, followed this work by experimenting with sodium citrate as an anticoagulant and using the ESR to aid in prognosis in patients with tuberculosis (22. Grzybowski A, Sak J. Edmund Biernacki (1866–1911): Discoverer of the erythrocyte sedimentation rate. On the 100th anniversary of his death. Clin Dermatol. 2011;29:697-703. [PMID: 23293796]). The International Committee for Standardization in Haematology later adopted the Westergren method for determination of ESR (22. Grzybowski A, Sak J. Edmund Biernacki (1866–1911): Discoverer of the erythrocyte sedimentation rate. On the 100th anniversary of his death. Clin Dermatol. 2011;29:697-703. [PMID: 23293796], 44. Reference method for the erythrocyte sedimentation rate (ESR) test on human blood. J Clin Pathol. 1973;26:301-2. [PMID: 4701798]).

Our patient's ESR was found to be 104 mm/h. A diagnosis of polymyalgia rheumatica (PMR) was made. PMR is a disease of the elderly, mostly affecting those over the age of 50 (55. Salvarani C, Gabriel SE, O’Fallon WM, Hunder GG. Epidemiology of polymyalgia rheumatica in Olmsted County, Minnesota, 1970-1991. Arthritis Rheum. 1995;38:369-73. [PMID: 7880191]). Presenting symptoms include stiffness and aching, most commonly in the neck, shoulders, upper arms, and pelvic girdle. The joint pain and stiffness is most classically associated with an increase in systemic inflammation, as demonstrated by high levels of inflammatory markers, such as ESR (66. Salvarani C, Pipitone N, Versari A, Hunder GG. Clinical features of polymyalgia rheumatica and giant cell arteritis. Nat Rev Rheumatol. 2012;8:509-21. [PMID: 22825731] doi:10.1038/nrrheum.2012.97).

The patient was started on a prednisone taper. Amazing his family and our team, he was up out of bed the next day. His hemoglobin level began to rise as well. He was discharged on long-term taper with close follow-up.