Correlation between C-Reactive Protein Concentrations and

Erythrocyte Sedimentation Rate in Patients with Positive Widal Test

Citra Yolanda Sari

, Budi Santosa

and M. Evy Prastiyanto

Forensic Science, Postgraduate School, Universitas Airlangga, Jl. Airlangga No. 4-6, Surabaya, East Java, Indonesia

Laboratory of Clinical Pathology, Faculty of Nursing and Health Sciences, Muhammadiyah Semarang University,

Semarang, Central Java, Indonesia 50272

Laboratory of Microbiology, Faculty of Nursing and Health Sciences, Muhammadiyah Semarang University, Semarang,

Central Java, Indonesia 50272

Keywords: CRP, ESR, Patient with positive Widal,

Abstract: Clinical symptomps of typhoid and paratyphoid fever greatly vary, while the gold standard of its laboratory

examination is bacterial culture which commonly takes 3 days for the results. Further tests should be

performed to support diagnosis of this disease. The tests possibly performed to patients with suspected

typhoid are C-Reactive Protein (CRP) and Erythrocyte Sedimentation Rate (ESR). CRP is an acute-phase

protein that is tested to nonspecifically monitor the occurrence of an infection, while ESR is a nonspecific

test for inflammation which is clinically functional for screening inflammatory diseases. The aim of this

study is to determine the correlation between CRP and ESR in patients with positive Widal test. This study

uses correlation analysis to 30 samples which fit inclusion criteria in RS Roemani Muhammadiyah

Semarang and are obtained by purposive sampling. The samples were tested the CRP concentration by

semi-quantitative latex immunoagglutination method and were tested the ESR by westergren method. The

results shows average concentration of CRP was 18.40 mg/L, and average number of ESR was 15.20 mm/h.

Statistical analysis uses in this study is pearson correlation test. A strong and significant correlation between

CRP and ESR in patients with positive Widal with p-value = 0.000 (p < 0.05) and r = 0.886 is obtained.

1 INTRODUCTION

Typhoid and paratyphoid fever are two acute

systemic diseases of digestive tract that remain

global health problems for the world’s populations.

Approximately 21 million cases and 220,000 deaths

were reported per year (WHO, 2014). Typhoid and

paratyphoid fever were found to be endemic in

Indonesia with the incidence rate of 350-810 per

l00,000 population and mortality rate of 0,6-5%

(Kepmenkes, 2006). The cases number of the

diseases varied in different regions, in Semarang for

example, in 2015 there were 9,748 cases reported

(Dinkes, 2015). The data above suggested that

incidence rate of typhoid and paratyphoid fever are

still considered high and an appropriate laboratory

test is required.

The laboratory examination commonly

performed to diagnose the disease is Widal test.

Positive result of Widal test indicates the existence

of specific antibody against component of

Salmonella in human blood. It is quickly performed

but the specificity is less than 50 %. Gold standard

for typhoid and paratyphoid fever is bacterial culture

of Salmonella. However, a three days examination

and facility of clinical microbiology laboratory has

caused the delay of diagnosis (Kepmenkes, 2006),

therefore, certain laboratory tests are considered

necessary to confirm typhoid and paratyphoid fever

in addition to its gold standard as diagnostic

examination.

The other laboratory tests possibly performed in

suspected infections are C-Reactive Protein and

Erythrocyte Sedimentation Rate tests. CRP is acute-

phase protein synthesized by liver as an immune

response to infection, while ESR is a nonspecific

laboratory examination for inflammatory diseases by

determining the rate of fall of erythrocytes to form

sediment in a certain period (Baratawidjaja, 2006;

Bastiansyah, 2008). ESR is much often performed

compared to CRP, because ESR is one of the routine

laboratory examinations for infections, however,

436

Sari, C., Santosa, B. and Prastiyanto, M.

Correlation between C-Reactive Protein Concentrations and Erythrocyte Sedimentation Rate in Patients with Positive Widal Test.

DOI: 10.5220/0007544504360439

In Proceedings of the 2nd International Conference Postgraduate School (ICPS 2018), pages 436-439

ISBN: 978-989-758-348-3

there have been some studies proving a correlation

between the two examinations, one of which was

study by Malinda in 2017 showing a strong

correlation between ESR values and CRP

concentrations in patients with suspected lung

tuberculosis with correlation coefficient 0.81

(Rukmana, 2017).

There is an increase of average CRP

concentrations of 43 mg/L in children with positive

result of Salmonella typhi culture, Widal, and

typhidot tests (Choo et al, 2001). There is an

increase of CRP concentrations and ESR values of

53 mg/L and 30 mm/h in typhoid fever patients,

respectively (Idhayu, 2016). There is no report on

correlation between CRP concentrations and ESR

values in patients with positive Widal test referring

to a diagnosis of typhoid or paratyphoid fever.

2 MATERIALS AND METHODS

Materials:

CRP-Latex kit by Glory Diagnostic, Sevilla,

Spain, NaCl 0.9 %, Pipette, Micropipette 50 µl, 200

µl, 1000 µl, Westergren pipette, Westergren stand.

Sample Collections:

Venous blood specimens were collected from

median cubital vein using syringe, blood was

divided into two tubes prior to CRP and ESR

examination. Serum was used for CRP test, while

plasma was used for ESR test. Samples collections

were done in RS. Roemani Muhammadiyah

Semarang starting from July until August 2017,

totaling 30.

2.1 CRP Test by Semi-quantitative

Latex Immunoagglutination

CRP concentrations were measured through several

steps including CRP qualitative test and quantitative

test using CRP latex kit. Fifty microllitres of positive

control, negative control, and patient’s blood were

added into the well of CRP test-slide. One drop of

CRP-latex reagent was added into the slide and then

homogenized. Agglutination was examined within 2

minutes. If there is visible agglutination that shows

positive result, when the result was positive, further

measurement should be done using semi-quantitative

test. A five serial dilutions of 50 µl of NaCl 0.9 %

and 50 µl of patient’s serum were done in each well

of CRP test-slide until the six circles on slide. One

drop of CRP-latex reagent was added, the slide was

homogenized, and visible agglutination was

examined within 2 minutes. Dilution factor used was

6 mg/L.

2.2 ESR Test by Westergren method

ESR test used westergren pipette, westergren stand,

and NaCl 0.9 % solution. EDTA blood samples were

diluted using NaCl 0.9 % solution with ratio of 1:4.

The diluted samples were homogenized in a tube

and incubated for one hour at room temperature. The

result was recorded within one hour. After 1 hour,

the result was noted.

The mean and standard deviation of CRP and

ESR values were statistically analyzed. Correlation

between CRP concentrations and ESR in patients

with positive Widal test was done by Pearson test

analysis.

3 RESULTS AND DISCUSSION

The average of CRP concentration in 30 patients

with positive Widal test was 18.40 mg/l. The lowest

CRP concentration was 6 mg/l, and the highest was

48 mg/l. The average of ESR value in 30 patients

with positif Widal result was 15.20 mm/h. The

lowest ESR value was 3 mm/h, while the highest

was 30 mm/h (Table 1).

Table 1: Frequency Distribution of CRP Concentrations

and ESR Values in Patients with Positive Widal.

Variable

Sample

Average

Min-Max

CRP

18.40

11.245

6-48

LED

15.20

6.289

3-30

SD : Standard Deviation

The comparison between CRP concentrations

and ESR values in patients with positive Widal test

showed a tendency of ESR values to increase

following the increasing of CRP concentration levels

(Figure 1).

Correlation between C-Reactive Protein Concentrations and Erythrocyte Sedimentation Rate in Patients with Positive Widal Test

437

Figure 1: Comparison between CRP Concentrations and

ESR Values of Patients with Positive Widal Results.

Relationship between CRP concentrations and

ESR values of patients with positive Widal test was

shown in a scatter diagram below.

Figure 2: Results of Relationship between CRP

Concentrations and ESR Values in Patients with Positive

Widal.

Results of Pearson correlation analysis showed

that correlation coefficient or r = 0.886 suggesting a

strong correlation between CRP concentrations and

ESR values, whereas value of p= 0.000 (p≤0.005)

showed significant correlation between CRP

concentrations and ESR values, suggesting a

significant and strong correlation between CRP

concentrations and ESR values in patients with

positive Widal test. The scatter diagram showed

gradient of a straight line going upword, indicated

that there was tendency of increasing ESR values

following an increase of CRP concentrations.

Pearson correlation analysis showed that

correlation value of 0.886 with p value 0.000 was

obtained, suggesting a strong and significant

correlation between CRP concentrations and ESR

values in patients with positive Widal test. The result

suggested that a tendency of ESR values to increase

following the increasing of CRP concentrations.

The results of this study were relevant with

Malinda (2017) on correlation between ESR values

and CRP concentrations in patients suspected with

lung Tuberculosis, proved a strong correlation

between ESR values and CRP concentrations in

patients with suspected lung tuberculosis, with r =

0.81 (Rukmana, 2017). In addition, this study is also

relevant with research by Widarti in 2014 showed a

meaningful correlation between ESR values and

CRP concentrations in patients suspected with lung

tuberculosiswith r = 0.889 (Widarti, 2014).

During infection, bacterial products such as

Lipopolysaccharide (LPS) activated macrophage and

other cells to release various cytokines such as

Interleukin 1, Interleukin 6, Interleukin 8, And TNF

as non-spesific immune response to bacterial

antigens. These cytokines stimulated liver to

synthesize and release some plasma protein called

acute-phase protein, such as C-Reactive Protein,

Mannan Binding Lectin (MBL), seruloplastin, and

fibrinogen (Longo and Fauci, 2013; Baratawidjaja,

2006).

Study by Amal et al in 2012 about effect of

typhoid fever to cytokines (Interleukin 6 and 8) and

C-Reactive Protein showed a significant increase of

the average Il-6, Il-8, and CRP as much as 153

pg/ml, 131 pg/ml, and 37.2 mg/l, respectively (Ali,et

al 2012).

The increasing CRP concentrations in blood

caused the increase of plasma viscosity. It led to a

decrease of potential zeta, a repulsive force among

erythrocytes, allowing the formation of rouleaux and

faster sedimentation of erythrocytes. The increase of

ESR values are not only influenced by the increase

of CRP concentrations, but also possibly influenced

by erythrocyte factors and other acute-phase proteins

like fibrinogen. During infection, the other acute-

phase proteins are also increased although it does

not occur prior to the increase of CRP

concentrations. However, the other acute-phase

proteins also caused plasma viscosity and increased

the ESR values (Kiswari, 2014).

4 CONCLUSIONS

The conclusion of this study obtains the average

CRP concentration from 30 patients with positive

Widal test is 18.40 mg/l. The lowest CRP

concentration is 6 mg/l, and the highest is 48 mg/l.

The average ESR value from 30 patients with

positive Widal result is 15.20 mm/h. The lowest

ESR value is 3 mm/h, while the highest is 30 mm/h.

A strong and significant correlation between CRP

ICPS 2018 - 2nd International Conference Postgraduate School

438

and ESR in patients with positive Widal with p-

value p < 0.05 and r = 0.886 is obtained.

ACKNOWLEDGEMENTS

Researchers would like to show gratitude to family,

especially to parents for their endless support.

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