HNY Policy and Pathway Repository - North Yorkshire

A raised plasma viscosity (PV) or erythrocyte sedimentation rate (ESR) is a non specific marker of underlying infection, inflammation, trauma or malignancy. High values can also be seen in multiple myeloma due to the serum paraprotein.

Note that the ESR, and less so the PV, are both affected by patient age and pregnancy. The ESR is also affected by the age of the sample (should be received within 4 hours) and by the haemoglobin value (can be falsely high if anaemia).

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Differential diagnosis:

• Acute or chronic infection, including tuberculosis or HIV.
• Other inflammatory disorders, e.g. inflammatory bowel disease, sarcoidosis.
• Malignancy- solid organ or haematological (esp. multiple myeloma).
• Collagen disorders, e.g. rheumatoid arthritis, SLE, temporal arteritis, vasculitis.

Baseline investigations:

• Full history and examination to look for potential cause.
• If no obvious explanation then screen for multiple myeloma: FBC, U+E, serum calcium, serum immunoglobulins & serum free light chains. Plain x-ray if bone pain.
  Note that polyclonal raised immunoglobulins can be seen with an underlying inflammatory condition, but do not suggest multiple myeloma (see separate protocol for polyclonal hypergammaglobulinaemia).
• Consider occult infection, inflammation or malignancy. 'Routine investigations' such as CXR, autoimmune screen and urinalysis are often performed however investigations should be led by the clinical history.

Referral

Haematology referral if:

• Features suggesting haematological malignancy / multiple myeloma (laboratory results, signs or symptoms).
• Serum paraprotein or significantly abnormal SFLC ratio. See paraprotein investigation. Urgent referral if hyperviscosity symptoms e.g. headaches, lethargy, visual disturbance / retinal haemorrhages, breathlessness (often only seen if PV >4 cp).

An unexplained persistent raised PV without the above features may warrant referral to General Medicine if there is clinical concern.

Haematology Handbook - South Tees Hospitals NHS Foundation Trust

• South Tees Hospitals