Intended for healthcare professionals

Rapid response to:

Practice Rational Testing

Raised inflammatory markers

BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e454 (Published 03 February 2012) Cite this as: BMJ 2012;344:e454

Rapid Response:

Re: Raised inflammatory markers

In response to your article on inflammatory markers we feel there is a potential danger in suggesting that normal inflammatory markers can be used as a rule-out tool in illnesses such as Giant Cell Arteritis (GCA) and Polymyalgia Rheumatica (PMR). Whilst it may be argued that patients with PMR will come to no serious long-term harm from undiagnosed illness, the same cannot be said about GCA where a delayed or missed diagnosis could have potentially serious implications including permanent loss of vision. The rates of normal ESR in PMR/GCA vary. However a normal ESR has been shown to occur in up to 22.5% of patients [1]. Patients with a delayed diagnosis of GCA are often the patients that present with atypical features [2] and a case review of 80 patients by Ellis showed that 3 patients with GCA- associated blindness had a normal ESR [1]. Whilst normal inflammatory markers make the diagnosis more unlikely, if there is a clinical suspicion, early referral should be sought, especially in suspected GCA [3,4].

(1) Ellis ME, Ralston S. The ESR in the diagnosis and management of the polymyalgia rheumatica/giant cell arteritis syndrome. Ann Rheum Dis 1983 Apr;42(2):168-170.
(2) Ezeonyeji AN, Borg FA, Dasgupta B. Delays in recognition and management of giant cell arteritis: results from a retrospective audit. Clin Rheumatol 2011 Feb;30(2):259-262.
(3) Dasgupta B, Borg FA, Hassan N, Alexander L, Barraclough K, Bourke B, et al. BSR and BHPR guidelines for the management of giant cell arteritis. Rheumatology (Oxford) 2010 Aug;49(8):1594-1597.
(4) Dasgupta B, Borg FA, Hassan N, Barraclough K, Bourke B, Fulcher J, et al. BSR and BHPR guidelines for the management of polymyalgia rheumatica. Rheumatology (Oxford) 2010 Jan;49(1):186-190.

Competing interests: No competing interests

14 February 2012
Toby Helliwell
GP
Dr Sara Muller, Dr Samantha L Hider
Arthritis Research Uk Primary Care and Health Sciences Centre, Keele, University
Arthritis Research UK Primary Care Centre, Keele University, Keele, Staffordshire, ST5 5BG