MARKER OF

INFLAMMATION

Ida Parwati

Department of Clinical Pathology

Faculty of Medicine Universitas Padjadjaran
 INFLAMMATION

Host reaction to injury

Considered as innate immune response
Inflammatory reactions:
inactivate/eliminate injuries
substances/limit their spread
Acute and chronic
Measurement of Inflammatory markers:

Two main functions:

1. To detect acute nflammation that might
indicate specific disease
2. To give a marker of treatment response

Diseases with prominent activation of

inflamatory response:
1. Infections
2. Autoimmune diseases
3. Some haematological malignancies
 Stimulation and synthesis of
Acute inflammation
positive acute-phase reactants
Process
during inflammation.
Inflammation caused by infection
or tissue damage stimulates the
circulating inflammation-
associated cytokines, including
IL-1, IL-6, TNF. These cytokines
stimulate hepatocytes to
increase the synthesis and
release of positive acute-phase
proteins, including CRP.
IL-6 is the major cytokine
stimulus for CRP production.
 INNATE IMMUNITY
Inflammatory cells:
neutrophils
eosinophils
basophils
platelets
monocyte
Acute phase responses
Erythrocyte sedimentation rate (ESR)
C-reactive protein
Serum amyloid A
Complement protein
 Complete Blood Count (CBC)

Provides important information about the kinds

and numbers of RBC, WBC and platelets.
Part of routine physical examination
 WBC count

expressed as concentration cells per unit

volume of blood (mm3).
No distinction is made among the six normal cell
types (band neutrophils,segmented neutrophils,
lymphocytes, monocytes, eosinophils,
basophils).
Increase WBC count leucocytosis
Decrease WBC count leucopenia
 WBC Differential
5 major kinds of WBC
Immature neutrophil, band neutrophil include
to the test.
Each type of cell plays a different role in
protecting the body.
Number of each type give important
information about the immune system.
Expressed as a percentage of each type
 Increase/decrease number of each type
help to identify :
infection (neutrophilia, lymphocytosis)
Allergic or toxic reaction to certain medication
(eosinophilia)
Malignancy (leukemia)
 THE ACUTE PHASE RESPONSE

Part of the innate immunity responses to

infection/inflammation
Non specific defense reaction
Very useful in clinical practice as a general
indicator of illness, assessing severity and
prognosis in chronic disease.
 ACUTE PHASE protein

Protein produce by the liver

Mediated by the cytokines
Inflammation/infection 1000 fold the
normal level
 Erythrocyte Sedimentation Rate
(ESR)

Non specific for particular disease but is

used as an indicator of inflammation
To evaluate the treatment (non specific)
To follow the course of certain
inflammatory process
 Erythrocyte Sedimentation Rate
Principle: sedimentation
Measures the settling of erythrocytes in diluted plasma
over a specified time period (1 hour)

In a sample of anticoagulated blood that is left

undisturbed, the erythrocytes will gradually separate
from the plasma and settle to the bottom of the tube
 Factors affect ESR
Properties of the plasma
plasma protein (fibrinogen, globulin)
rouleaux formation
Properties of the erythrocytes
(size, shape, number)
Technical factors
 Condition in which the ESR may be
increased/decreased

Increased: Decreased:
Pregnancy Sickle cell anemia
Anemia Polycythemia
Macrocytosis Spherocytosis
Inflammatory disease Increased plasma viscosity
Cancer Microcytosis
Acute and chronic infection
Multiple myeloma
Increased plasma fibrinogen
 Erythrocyte Sedimentation Rate
Specimen:
Citrate /EDTA anticoagulated blood
Method:
Manual :
Westergreen Method
Wintrobe Method
Automatic
 Normal values :
Adult men 0-15 mm/h
Adult women 0-20 mm/h
 C-Reactive Protein
C-RP is a serum constituent originally define by
its ability to precipitate Pneumococcus C
polysaccharide

C-RP is an acute phase reactant:

A protein synthesized by the liver as a non-specific
response to the inflammation
 CRP
Key functions of CRP within the innate immune system
include the ability to:
(1) recognize & bind to phosphocholine exposed in damaged
cell walls and found in many bacteria, fungi, parasites;
(2) act like an opsonin, marking bacteria, damaged cell walls,
and nuclear debris for phagocytosis;
(3) bind to Cl, the first component of the classical pathway of
the complement system that triggers phagocytic activity;
and
(4) bind to PMNs and monocytes, which stimulate the
production of inflammatory cytokines.
 C-Reactive Protein

C-RP concentration increased in the serum of

individu as a response to varies inflammatory
condition and tissue necrosis and decreased as
the causative condition subside
 C-Reactive Protein
Specimen: serum
Reference range:
Normal < 6 mg/L
BONE MARKERS
 BONE PHYSIOLOGY:

Bone consists
Organic (30%) 95% collagen
5% non-collagen protein
cells
inorganic matrix (70%) hydroxyapatite
 Bone Bone
formation resorption

Osteoblasts Osteoclasts

Bone matrix
(95% Type I Collagen)
BONE FORMATION AND RESORPTION

Bone turnover is characterized by two

metabolic processes:
Formation of new bone by osteoblast
Degradation/resorption of old bone by osteoclast

Bone mass depends on the balanced between

bone formation and resorption
BONE TURN-OVER

Bone mass reaches its peak

In the third decade

- +
Bone mass decreased :
1 % per year 2 - 4 % per year

Bone mass decreased after menopause:

Spine - up to 6 % / year
Trabecular bone - up to 5 - 10 % /year
THE RELATIONSHIP BETWEEN THE BONE MASS and AGE

modelling remodelling
50

40

30 peak bone
mass
menopause
20

10 men old age

women
puberty
0

0 10 20 30 40 50 60 70 80
Age
BONE DISEASES:

BMD
BMD

Bone Resorption Bone Formation

Imbalanced between bone formation and bone resorption

 Bone formation can be assessed by
determination of: Total /Bone specific alkaline
phosphatase, osteocalcin and type 1 collagen

Bone resorption can be assessed by

determination of pyridinoline, cross linked N
telopeptide and C terminal telopeptide (-
crosslaps)
 OSTEOCALCIN
The most important non-collagen protein (Bone
specific peptide)

Synthesize by osteoblast (marker bone turnover)

Bone specific Calcium binding depends on Vit K

and Vit D3

After release from osteoblast, assimilated into

bone matrix and also secreted to the bloodstream
 OSTEOCALCIN
Specimen: serum or plasma
Reference range:
Male
18 - < 30 years: 24 70 ng/mL
30 - 50 years: 14 42 ng/mL
>50 - 70 years: 14 46 ng/mL
Female
Premenopause> 20 years: 11 43 ng/mL
Postmenopause : 15 46 ng/mL
 ALKALINE PHOSPHATASE
An enzyme located in osteoblast, liver ,
intestine, kidney and placenta
Function: activate the chemical reaction in in
cells which the enzyme located
High concentration of ALP specific organ has
increased the production or release this enzyme
( bone or liver)
The causes of elevated ALP from bone disease
no elevation of ALT or AST
 ALKALINE PHOSPHATASE

Specimen: serum
Reference range: 370C
Male < 129 U/L
Female < 104 U/L
Children higher (depends on age)
 -CROSSLAPS

The specific degraded product of type 1

collagen (the C terminal telopeptides)

Increased bone resorption will cause the

elevation of -crosslaps in serum
 -CROSSLAPS
Specimen: serum
Reference range:
Male
30 - 70 years: 0.016 0.584 ng/mL
> 70years: 0.104 0.854 ng/mL
Female
Premenopause : 0.025 0.573 ng/mL
Postmenopause : 0.104 1. 008 ng/mL
 DISEASE OF BONE METABOLISM:
Osteoporosis

Primary osteoporosis
post-menopausal osteoporosis
male osteoporosis

Secondary osteoporosis
endocrine abnormalities
malignancy Fractures caused by spine Osteoporosis
inflammation
 WHO Diagnostic Guidelines
Definition and Osteoporosis clinical status

Stage BMD Fractures

Osteopenia Osteoporosis
I Osteopenia 1.0 - 2.5 no

II Osteoporosis > 2.5 no

III Severe Osteoporosis > 2.5 yes

- 1.0 to - 2.5 SD > 2.5 SD

BMD : Bone Mass Density

Bone tissue in Osteoporosis
The consequensies of Osteoporosis

Fractures of femoral neck

Fractures of proximal tibia

Fractures of vertebral bodies acute surgical intervention

30 % invalidity
loss of body size
20 % mortality
widow back
pain
(chronic or acute)

Fractures of radius and humerus

conservative therapy possible
less critical than
leg or hip fractures
Osteoporosis
Fracture of Proximal Femur
Bone markers:

Bone Formation Bone Resorption

Bone specific alkaline Free crosslinks
phosphatase (BALP) (PYR, DPD)

C-terminal collagen I
degradation products 2)
Osteocalcin 1)
N-terminal collagen I
degradation products 4)

Collagen propetides Type I C-terminal peptide

(PNIP, PCIP) (ICTP)
Osteoblasts Osteoclasts

others: Calcium
Vitamine D3
PTH 3)
Calcitonin