C-Reactive Protein: Clinical Applications
Dr. S.G. Deodhare
Versus ESR Measurement
Methods of Measuring CRP
Latex Agglutination Assay
or High-sensitivity (hs) CRP Assay
Factors that affect Results
Parameters indicating Infection
Clinical Applications of CRP
Bacterial infections in Newborn babies
Infections during Pregnancy
Bacterial and Protozoal Infections
Urinary Tract Infections
Bones and Joint Infections
Inflammatory bowel disease
as Predictor of Cardiovascular Events
CRP Levels in Overweight Adults
In Extensive Burns
protein (CRP) has been a measure of acute phase reactions to inflammation
for the last 15 years. Recently improved high sensitive and standardized
quantitative assays in serum and cerebrospinal fluid (CSF) have allowed a
re-evaluation of its potential as a diagnostic laboratory test. CRP is an
abnormal serum glycoprotein produced by the liver during acute
inflammation. Because it disappears rapidly when inflammation subsides,
its detection signifies the presence of a current inflammatory process.
Further, by serial measurements important information can be obtained on
the resolution or continuation of the inflammatory process.
protein was first described by Tillet and Francis in 1930. They concluded
that sera of patients suffering from acute infection precipitated with a
non-proteic pneumococcus extracts called C polysaccharide in the presence
of calcium ions. The protein that caused this reaction was therefore
called C-reactive protein (CRP). All acute inflammatory processes
(infectious and non-infectious), and certain malignant conditions, result
in rise in serum CRP as a non-specific phenomenon. CRP production is a
non-specific response to disease and it can never, on its own, be used as
a diagnostic test. However if the CRP result is interpreted in the light
of full clinical information on the patient, then it can provide
exceptionally useful information.
CRP was the first recognized acute phase reactant, it can bind to a number
of molecules, including phosphate esters, lipids, polyanions (DNA
polylysin), polycations (histones, protamine) and a variety of
polysaccharids. CRP is synthesized by the liver under regulatory control
of cytokines. Synthesis of CRP and other acute phase proteins by
hepatocytes is modulated by cytokines. Interleukins 1b and 6 and tumour
necrosis factor are the most important regulators of CRP synthesis. The
intact CRP molecule is a pentameric protein with identical subunits
arranged in a doughnut-shaped polymer.
function of CRP is felt to be related to its role in the innate immune
system (Du Clos, Terry V, 2000). Similar to immunoglobulin IgG, it
activates complement, binds to Fc receptors and acts as an opsonin
for various pathogens. Interaction of CRP with Fc receptors leads to the
generation of proinflammatory cytokines that enhance inflammatory
response. Unlike IgG, which specifically recognizes distinct antogenic
epitopes, CRP recognizes altered self and foreign molecules based on
pattern recognition. Thus CRP is thought to act as a surveillance molecule
for altered self and certain pathogens. This recognition provides an early
defence and leads to a proinflammatory signal and activation of the
humoral, adaptive immune system.
CRP binds to molecular groups found on a wide variety of bacteria and act
as an opsonin.
a number of functions have been ascribed to CRP, including initiation of
opsonization and phagocytosis and activation of complement (Fig.1),
neutrophils, and monocyte-macrophage. Collectively these properties imply
an important role for CRP in the recognition of microbial organisms and as
an immunomodulator in the host defence. CRP may also be important in the
recognition of necrotic tissues.
binds to apoptotic cells, protects the cells from assembly of the terminal
complement components, and sustains an anti-inflammatory innate immune
response (Gershov D et al 2000).
of CRP increase very rapidly in response to trauma, inflammation and
infection and decrease rapidly with the resolution of the condition
(Fig.2). Since an elevated CRP level is always associated with
pathological changes, determination of CRP is of great value in diagnosis,
treatment and monitoring of inflammatory conditions. CRP is a more
sensitive and reliable indicator of inflammatory processes than the ESR
and the leucocyte count. The serum CRP concentrations increase faster than
that of the ESR and when the condition subsides, CRP falls very quickly,
reaching normal levels several days before the ESR normalises (Fig.2).
Measurement of serum has thus emerged as a useful tool to help to answer
the following questions: Is the patient getting better? Is he or she
getting worse? Are there any complications? Or is there anything wrong
with the person? Rises in CRP are only one part of a number of intricate
changes in serum proteins and enzymes but it happens to be one that is
earliest to measure because it increases so dramatically.
CRP begins to rise in bacterial infections within 4-6 hours, peaks at
36-50 hours, closely parallels acute response with 4-7 hour half-life,
allowing to normal 3-7 days after the stimulus is withdrawn. The ESR shows
a slower rise and return to normal than C-reactive protein (CRP).
versus ESR measurement
sedimentation rate (ESR) is more commonly used as a non-specific marker of
disease activity. However, as more is learned about CRP, measuring this
parameter could be a better test than the ESR. The ESR, which is an
indirect parameter of acute phase protein changes, can be influenced by
concentrations of fibrinogen, monoclonal proteins and red cell morphology,
whereas CRP has no cross-interfaces. CRP is useful for its negative
predictive value as a negative CRP rules out the possibility of an
inflammatory or necrotic course. A positive reaction is certainly an
indication of a problem, but it is not specific for any single disease.
has several disadvantages that prevent it from being an ideal laboratory
test to monitor acute inflammation or tissue injury. However, the ESR
remains useful for the detection of paraproteinaemia, which do not
necessarily provoke an acute phase response. SLE and progressive systemic
sclerosis, even when active, usually cause only a trivial increase in CRP
(in the range 1-6 mg%), although the ESR may be very high .The reason for
the discrepancy between ESR and CRP is unknown, but indicates the two
tests are complementary. A comparison of ESR with CRP is shown in Table1.
1 Comparison of CRP with Erythrocyte Sedimentation Rate
METHODS OF MEASURING CRP
methods for measuring CRP include precipitation and agglutination assays.
The latex agglutination assay is a qualitative test with a detection limit
of approximately 10 mg/litre, the upper limit of normal. Because CRP
levels can increase so rapidly and dramatically, the latex agglutination
assay is subject to false-negative reactions due to a prozone-type
phenomenon in which all of the antibody combining sites on the latex
particles are bound to an excess of CRP so no cross-linking
(agglutination) can occur. Consequently the qualitative tests should be
performed on several dilutions of serum to avoid negative reactions. If
several dilutions are formed, the latex agglutination method can easily be
converted to a semi-quantitative assay so distinctions can be made between
levels of positivity (e.g. less than 50 mg/litre and more than 150 mg/litre).
Such semi-quantitative distinctions would be very useful to the clinician
trying to distinguish between bacterial (high CRP levels) and viral
infections (normal to slightly elevated CRP).
specific antibodies to CRP permit the development of rapid, specific, and
very sensitive assays for this protein. These newer immunoassays include
laser nephelometry (the most popular method), RIA, and enzyme immunoassays
and have created a renewed interest in CRP testing in a variety of
clinical settings. Measurement of CRP may be superior to the erythrocyte
sedimentation rate (ESR) and may someday replace it. Recently, instrument
manufacturers have developed assay systems that allow random access assays
for CRP to be performed virtually on demand with 10 to 20 minutes
or High-sensitivity (hs) CRP Assay
ultra-sensitive immunoturbidimetric assay has been developed for CRP. The
new assay measures the increased turbidity resulting from antibody-antigen
complexes formed when sample and antibody reagent is mixed. The assay has
sensitivity of 0.1 mg/litre. The ready-to-use liquid reagents can be
placed directly on a chemistry analyser and will yield precise results in
minutes (Cortlandt Manor, NY, USA).
that affect results
in all serological tests, haemolytic, lipemic or turbid sera may cause
incorrect results and should not be used. Drugs that may cause
false-positive results include oral contraceptives. Drugs that may cause
false-negative results due to suppression of inflammation include NSAIDS,
steroids and salicylates. The presence of intrauterine device may cause
inflammation, which produces a positive test. Overnight refrigeration of
the sample may produce a false-positive result. There is no need to
refrigerate samples if the assay is to be performed on the same day.
Demographic factors including age, sex and race should be used to adjust
the upper reference limit for CRP. Clinicians should be aware of these
factors before using CRP to assess inflammatory disease.
combinations such as CRP, IL-6 and procalcitonin have been found useful in
the diagnosis of pneumonia in children. Using the combination of IL-8
and/or CRP to restrict antibiotic therapy in truly infected infants
reduces unnecessary antibiotic therapy and is cost effective. Measurement
of CRP levels and white blood count has an additional diagnostic value in
the diagnosis of acute appendicitis.
Parameters indicating Infection
laboratory parameters indicating infections include white blood count,
immature-to-total neutrophil ratio, CRP, ESR and procalcitonin. The
immature-to-total neutrophil (IT) ratio is calculated as the sum of
immature granulocytes divided by the sum of all neutrophil granulocytes.
The IT ratio is considered to be elevated if it is more than 0.20 (Russel
GAB et al 1992).
recent years, several new markers of infection have been investigated,
such as tumour necrosis factor-alpha, soluble tumour necrosis factor
receptor, interleukin (IL-6), IL-1b,
IL-8, IL-1 receptor antagonist, soluble intracellular adhesion molecule,
granulocyte colony-stimulating factor, soluble IL-2 receptor and neopetrin,
markers of complement-activation, leucocyte-a1-proteinase
inhibitor, and most recently CD116 as a cell surface marker (Weirch E et
al 1998). None of these markers has yet made the progress from the
laboratory to clinical application.
APPLICATIONS OF CRP
reviews on CRP have been published prior to 1997 (Deodhar S, 1989), yet
some conclusions require modification in view of the many recent
investigations that used more advanced quantitative methods to study new
and more carefully defined clinical conditions in larger patient
populations. In addition several studies utilised serial CRP
determinations rather than a single value at time of initial assessment
(Jaye DL, Waits KB 1997).
Infections in newborn babies
newborns and premature babies, the symptoms of bacterial infections are
often highly uncharacteristic in the first few days of life. Infectious
diseases such as bacterial meningitis, sepsis and pneumonia can frequently
be severe in newborn babies. Neonates, especially born preterm, often fail
to induce elevations in temperature and white cell counts that are
hallmarks of infection in older children. Determination of serum CRP can
be used to help to confirm or rule out bacterial infections in the
neonatal period, for even premature babies have the capacity to synthesise
CRP in the liver if they contract an infection.
Silva, et al 1995 reviewing the use of CRP as a tool for diagnostic
neonatal sepsis, concluded that CRP is probably the best available
diagnostic test. Further, Yentis SM, Soni N, Sheldon JC, 1995 found daily
measurements of CRP to correlate with resolution of sepsis, specifically,
“A decrease in CRP by 25% or more from previous day’s level was a good
indicator of resolution of sepsis, with a sensitivity of 97%, specificity
of 95% and predictive value of 97%”.
elevation in neonates has been documented in non-infectious conditions
including meconium aspiration, respiratory strea syndrome, foetal hypoxia
and intraventricular haemorrhage. These disorders may mimic bacterial
CRP is not useful alone in the primary diagnosis of neonatal sepsis, but
may be helpful as a part of screening panel. Further helpful for
monitoring response to therapy.
is of particular interest in view of its potential severity and the
importance of rapid diagnosis and appropriate treatment.
studies using serum CRP have described almost perfect discrimination
between bacterial versus viral meningitis in children. Bacterial
meningitis is associated with much higher serum CRP levels at presentation
than cases of aseptic or proven viral meningitis. The latter frequently
have CRP concentrations within the normal range or which are only very
slightly raised, unless they develop secondary bacterial infective
complications. Patients with meningitis in whom CRP values are determined
at least 12 hours after the onset of fever are less than 2 mg/dL are far
less likely to have bacterial meningitis. False-negative cases among CRP
test results were found to be examined too early in bacterial
meningitis (Tatara R, Imen H, 2000). Patients with tuberculosis
meningitis seem to fall in between. Appropriate therapy for either
bacterial or tuberculous meningitis causes the CRP level to fall, and
especially in infants and children, this simple CRP test can be used to
monitor objectively the response to treatment with many advantages over
repeated lumbar puncture.
serum CRP levels monitoring in children with bacterial meningitis
represents useful and objective information about the clinical evaluation.
The procedure is inexpensive and suitable for use in endemic areas lacking
sophisticated laboratory facilities (Dias LR, Alves Ribeiro M, Farhat CK,
standardised quantitative assessments of CRP can be very useful in
distinguishing between bacterial and other forms of meningeal irritation
during the first few days of hospitalisation. Many studies have indicated
that by serial measurements important information on the resolution or
continuation of inflammatory processes can be obtained.
CRP concentrations are seven fold lower than those of serum. This
difference is explained by direct hepatic release of CRP into plasma,
which then undergoes ultra filtration to form CSF. Meningeal irritation
stimulates CRP production. Once CRP enters the CSF it binds to damaged
tissue. Minimal CSF inflammation may be apparent in patients undergoing
lumbar puncture very early in the course of the disease, especially in
neonates with rapidly developing meningitis in whom bacterial
multiplication can outpace the ability of liver to mount a CRP response
(Benjamin DR et al, 1984). These aspects of CRP metabolism in the central
nervous system, poorly defined normal ranges, the lack of evidence of de
novo synthesis in CSF and the impracticality of testing multiple
samples of CSF as often as serum for monitoring response to treatment
favour the use of serum CRP analysis instead of CSF. Still some authors
recommend CSF CRP as an important tool in differential diagnosis of
meningitis (Abrahamson JS, et al 1985). Yet others gave opposite opinions
perhaps because of their different test design (Donald PR, et al 1985).
of the CRP levels with WBC have an additional diagnostic value in the
diagnosis of acute appendicitis (Erkasap S, et al 2000).
Serum CRP cannot differentiate bacterial and
viral aetiology of community acquired pneumonia in children in primary
health settings (Heishanen-Kosma T, Korppi M, 2000). However, (Toikka P et
al, 2000) have found that in some patients with very high serum CRP,
Interlukin-6 and procalcitonin values, bacterial pneumonia is probable.
Infections during pregnancy
It is often difficult to diagnose abdominal
infections in pregnant women. The ESR is regularly above normal during
pregnancy, and therefore of limited diagnostic value in these situations.
Since CRP is usually at a normal level in pregnant women, increased CRP
concentrations strongly indicate infectious complications.
Bacterial and Protozoal Infections
Acute systemic Gram-positive and Gram-negative
bacterial infections are among the most potent stimuli for CRP production.
In chronic bacterial infections such as tuberculosis and leprosy they are
usually lower, though still markedly raised. Malaria, especially with P.
falciparum is associated with high CRP values.
The combination of IL-8 and/or CRP is a
reliable and early test for the diagnosis of nosocomial bacterial
infection in newborn infants. Using the combination of IL-8 and/or CRP to
restrict antibiotic therapy to truly infected infants reduces unnecessary
antibiotic therapy and is cost-effective (Franz AR et al 1999).
Urinary Tract Infections
Localization of infection within the urinary
tract influences decisions regarding the choice and route of antimicrobial
therapy, and what follow-up is needed. Clinical assessment alone cannot
reliably distinguish cystitis from pyelonephritis in every case,
particularly in very young children.
Urinary tract infection triggers the mucosal
cytokine response; hence ESR and CRP might be valuable in identifying
serious infections (Benson M et al. 1994). Some investigators, using
cut-off values of 25 to 50 mg/liter have suggested that raised CRP can be
of value in predicting whether a child has cystitis or pyelonephritis.
In general, clinical symptoms of urinary tract
infection associated with a high CRP level (usually above 50 mg/liter)
indicates pyelonephritis, while a normal to slightly elevated CRP level
indicates an uncomplicated lower urinary tract infection.
Bones and Joint Infections
Recently the use of CRP and fever for
distinguishing children with septic arthritis and for determining whether
arthrocentesis was required has been advocated. CRP rises rapidly and
decreases to normal ranges within 1 week of treatment in most cases of
haematogenous osteomyelitis without septic arthritis (Roine I et al 1995).
Serial measurements of CRP are a logical
option for routine use in conjunction with other clinical and laboratory
data in evaluating children with acute haematogenous osteomyelitis. A
secondary rise may be an important warning sign of recurrence of both
septic bone and joint infections.
CRP values correlate better than ESR with the
severity of clinical disease activity as well as radiological findings in
rheumatoid arthritis and are ideal for following active inflammation in
this condition as well as its resolution and responses to
anti-inflammatory treatment. In contrast, CRP may be only moderately
increased or even absent in seronegative arthropathies, scleroderma and
dermatomyositis, making it less useful for monitoring these conditions.
Correlation of CRP concentrations with disease
activity in SLE has been less promising than for rheumatoid arthritis.
Some persons with severe active disease have little or no elevation. In
SLE, measurement of CRP may be most useful for diagnosis of infectious
complications and monitoring response to antimicrobial therapy rather than
assessing disease activity (Barland P and Lipstein E, 1996).
Inflammatory Bowel Disease
CRP concentrations are significantly higher in
persons with inflammatory bowel disease than in unaffected controls. The
CRP may have some role in the differential diagnosis of ulcerative
colitis, where values tend to be higher than in Crohn’s disease
(Thompson D et al 1992).
CRP has been found useful in the diagnosis,
the presence and the extent of tissue necrosis.
Myocardial infarction is invariably associated
with a major CRP response. The
peak value of CRP occurs about 50 hours after the onset of pain in
myocardial infarction and correlates closely in magnitude, though clearly
not in timing, with the peak serum level of cardiac isoenzymes such as
creatinine kinase MB. In patients who recover uneventfully the CRP falls
rapidly towards normal in the usual exponential fashion (Danesh J et al
However, complications such as persistent
cardiac dysfunction, further infarction, aneurysm formation, intercurrent
infection, thromboembolism are associated with either persistently raised
CRP levels or secondary increase after the initial decrease.
Angina without infarction and invasive
investigation, such as coronary arteriography do not stimulate CRP
production, whereas some other causes of chest pain such as pulmonary
embolism, pleurisy or pericarditis are usually associated with raised CRP
levels. Routine assays of CRP after infarction or in patients with chest
pain may thus assist in diagnosis and the recognition and management of
Over the last three years, CRP assays have
been tested in a series of large-scale prospective clinical studies which
demonstrated the value of this marker in predicting risk of future heart
attack, stroke, and peripheral vascular disease in otherwise healthy men
and women. In 1997, it was already reported that levels of CRP were
elevated at baseline among apparently healthy individuals who subsequently
developed first-ever heart attacks compared to those who did not. The men
in the highest CRP quartile had three times the risk of myocardial
infarction, two times the risk of ischemic stroke and four times the risk
of developing severe peripheral artery disease compared to men in the
lowest quartile. Similar data were reported in 1998 concerning healthy
middle-aged women. Moreover, in both these studies, the clinical use of
CRP significantly added to the predictive value of total and HDL
It is interesting to note that most of the
beneficial effect of aspirin could be observed in subjects with the higher
CRP levels. This raises the likelihood that this is due to its general
anti-inflammatory effect rather than as an inhibitor of platelet
Recent studies suggested that elevated
concentration of CRP and cardiac Troponin I in patients with an acute
coronary syndrome are associated with a high risk of cardiac events. It
was demonstrated that in the patient group with unstable angina or NQMI
(non-Q wave myocardial infarction) abnormal CRP concentration on admission
and elevated concentration of Troponin I are important for predicting the
incidence of major cardiac complications within six months.
CRP as Predictor of Cardiovascular Events
reports indicate that inflammation may be associated with atherosclerosis,
and low levels of CRP may already be present as an indication of
atherosclerosis. Myocardial infarction is frequently at the end of a long
process of inflammation-mediated atherosclerosis. Thus the inflammation is
believed to have a role in pathogenesis of cardiovascular events,
measurement of markers of inflammation has been proposed as a method to
improve the prediction of these events.
may be used as a marker of subclinical atherosclerosis and cardiovascular
risk. Specifically CRP has been positively linked to future cardiovascular
events in healthy women, healthy men and elderly patients (Gracia-Moll X
et al 2000).
and cardiovascular disease is linked by complement: CRP induces adhesion
molecule expression in human endothelial cells in the presence of serum.
These findings support the hypothesis that CRP may play a direct role in
promoting the inflammatory component of atherosclerosis and present a
potential target for the treatment of atherosclerosis (Pasceri V et al
of all myocardial infarctions occur in persons in whom plasma lipids are
normal. The study by Ridker PM et al 2000 showed that the addition of
measurement of C-reactive protein (CRP) to the screening based on lipid
levels may provide an improved method of identifying women at risk of
cardiovascular events. Cardiovascular events were defined as death from
coronary heart disease, non-fatal myocardial infarction or stroke or the
need for coronary revascularisation procedures.
clinical studies validate the use of CRP assays in the prediction of future
cardiovascular disease. The study by (Kitpatric ES et al 2000) suggests
that some of the risk factors associated with coronary heart disease in
Type 1 diabetes patients are also independently predictive of high CRP
CRP Levels in Overweight Adults
and obese patients may be maintaining a state of low-grade systemic
inflammation, increasing their risk for cardiovascular disease. The clue
is their consistently above-normal blood concentrations of CRP, a
sensitive marker of systemic inflammation (Visser M et al 1999).
prevalence of elevated CRP levels increased with increasing BMI in both
men and women. Obese men were 2 times more likely and obese women 6 time
more likely to have elevated CRP levels than their counterparts of normal
weight. These findings remained clinically significant after adjusting for
age, race, waist-to-hip ratio, inflammatory disease and other factors
known to influence CRP concentrations (e.g. smoking status).
CRP levels closely reflect the severity and progress of acute pancreatitis
providing a better guide to intra-abdominal events than other markers such
as leucocyte counts, ESR and temperature. A CRP concentration greater than
100 mg/litre at the end of the first week of illness is associated with a
more prolonged subsequent course and a higher risk of the development of a
pancreatic collection. Serial CRP measurements therefore can serve as a
useful guide to the need of appropriate imaging techniques and finally to
confirm resolution before discharge from hospital.
CRP concentration always rises after significant trauma, surgery or burns,
peaking after 2 days and then falling towards normal with recovery and
healing. Infections or other tissue-damaging complications alter this
“normal” pattern of CRP response and the failure of CRP to continue
falling or the appearance of a second peak may precede clinical evidence
of intercurrent infection by 1-2 days.
usually increases more than 100 mg/litre by 48 to 72 hours. In the absence
of complications values decline thereafter and reach normal concentrations
3 to 7 days later. CRP elevation persists for a much longer time after
surgery when the postoperative course is complicated by infection
or other processes involving tissue necrosis, suggesting its value for
monitoring outcomes (Deodhar S, 1989).
increases significantly in patients with extensive burns versus those with
minor burns. A second later
peak of CRP develops if infection occurs as a later complication of the
burn suggesting the value of CRP to monitor the course of healing.
malignant tumours, especially when they are extensive and metastatic,
induce an acute phase response. This is particularly so with those
neoplasms which cause systemic symptoms such as fever and weight loss, for
example, Hodgkin’s disease and renal cell carcinoma. However, given the
non-specific nature of the acute phase response, a definite role of CRP
measurements in the management of cancer patients, other than in cases of intercurrent
infection has not yet been established.
40% of cancer patients with fever and neutropenia develop culture-proved
bacterial infection. Fever, however can also be caused by viral infections
or a number of other non-infectious causes. Because of significant
morbidity and mortality associated with infections in this patient group,
there is aggressive use of antibiotics. Fever may be the only sign of
serious infection in these patients in whom there is a minimal
inflammatory response to infection. Therefore additional tests are needed.
CRP is not affected by chemotherapy or transfusions, factors that may
influence the ESR. Pronounced elevations of CRP do not occur in
malignancies without other concomitant stimuli for synthesis such as
intercurrent infections (Santolaya M E et al 1994).
WBC did not always change in parallel with CRP in patients with malignant
lymphoma and rheumatoid arthritis in elderly patients.
is an independent survival determinant in advanced non-small-cell lung
cancer. Median survival time in patients with normal CRP (0.2 mg/dL) and
high positive (73 mg/dL) was 24.9 months and 3.7 months respectively.
is elevated during most rejection episodes in transplant recipients. The
CRP is a sensitive indicator of renal but not cardiac allograft rejection.
A raised CRP may not differentiate between infection and graft rejection
but has been able to differentiate between infection and graft versus host
disease. However, contradictory results were reported by some workers, so
a firm conclusion is difficult to draw regarding use of CRP in this
Studies by Eisenberg MS et al 2000 suggest
that elevated levels of CRP are associated with subsequent graft failure
in cardiac transplant recipients.
body of literature concerning studies of the application of CRP
measurements in the paediatric and adult populations continues to grow.
Based on current data, serial CRP measurements appear to be most useful
for monitoring patient response to therapy after the primary diagnosis of
invasive infections or inflammatory diseases, for monitoring patients
after major surgical procedures and those with serious burns. Monitoring
CRP over time may be used to assess for recurrent disease, a secondary
process or ineffective therapy. In addition, CRP appears to be suited to
most applications for which the ESR is used but offers many advantages.
applications of measurement of serum CRP concentration fall into four main
for organic disease
of extent and activity of disease
of cardiovascular events
· Detection and management of intercurrent infection.
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