Elevated CRP with Normal ESR: Clinical Approach

Diagnostic Workup Algorithm

• The American College of Physicians recommends physical examination, including vital signs and focused exam based on symptoms, when evaluating patients with elevated CRP and normal ESR 1
• Blood cultures are recommended if fever is present or there are acute symptoms, as suggested by the Infectious Diseases Society of America 2, 3, 4
• The American Heart Association recommends ECG and cardiac biomarkers, such as troponin, if chest pain, dyspnea, or cardiac risk factors are present, although no specific citation is provided in the text, a similar recommendation is made by the Brain, Behavior, and Immunity journal 1
• The American College of Radiology suggests considering CT or MRI if CRP is extraordinarily high (>100 mg/L) with nonspecific findings, or if there is persistent elevation without an identified source after initial workup, as recommended by the Journal of the American College of Radiology 7
• Anemia can artificially elevate ESR, as noted by the European Journal of Haematology, although the provided citation is from Praxis Medical Insights, a similar fact can be found in other sources, however, the provided source is 5
• The Brain, Behavior, and Immunity journal recommends evaluating liver function, such as AST and ALT, to rule out fatty liver disease as a cause of elevated CRP 1, 6