ROLE OF CRP FOR SCREENING

RESPIRATORY TRACT INFECTION

Prof. Dr. Aryati, dr., MS, SpPK(K)

Ketua Umum Pengurus Pusat Rabu, 20 Mei 2020
Perhimpunan Dokter Spesialis Patologi Klinik (PDS PatKLIn)
 RESPIRATORY TRACT INFECTION

Respiratory tract infection (RTI) is defined as any

infectious disease of the upper or lower
respiratory tract.
ü Upper respiratory tract infections (URTIs)
include the common cold, laryngitis,
pharyngitis/tonsilitis, acute rhinitis, acute
rhinosinusitis and acute otitis media.
ü Lower respiratory tract infections (LRTIs) include
acute bronchitis, bronchiolitis, pneumonia and
tracheitis.

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 COMMON AGENTS OF RESPIRATORY TRACT INFECTIONS ( Dasaraju & Liu, 1996)
CLINICAL ILLNESS BACTERIA VIRUSES FUNGI
Common cold Rare Rhinoviruses Adenoviruses Rare
(rhinitis, coryza) Coronaviruses RSV
Parainfluenza Viruses Influenza
Pharyngitis and Group A β hemolytic Mycoplasma pneumoniae Adenovirus Parainfluenza Viruses Candida albicans
tonsilitis streptococcus Mycoplasma hominis (type Coxsackievirus A Eipstein Barr Virus;
Corynebacterium 1) Influenza virus cytomegalovirus
diphteriae Mixed anaerobes Rhinoviruses Herpes simplex virus
Neisseria gonorrhoea Coronaviruses
Epiglottitis and Haemophilus influenzae type B RSV Rare
laryngotracheitis Corynebacterium diphteriae Parainfluenza Viruses
(croup);
Bronchitis and Haemophilus influenzae RSV Rare
bronchiolitis Streptococcus pneumoniae Parainfluenza Viruses
Mycoplasma pneumoniae Adenovirus
Herpes simplex virus
Pneumonia Streptococcus pneumoniae Legionella spp Adenovirus Cytomegalovirus Histoplasma capsulatum
Staphylococcus aureus Anaerobic bacteria Parainfluenza Viruses Herpes simplex virus Blastomyces dermatitidis
Streptococcus pyogenes Mycobacterium RSV Hantavirus Paracoccidioides
Haemophilus influenzae tuberculosis Influenza virus Coccidioides immitis
Klebsiella pneumoniae Coxiella burnetti Varicella-zoster virus Candida albicans
Escherichia coli Chlamidya psittaci Measles virus Filobasidiella
Pseudomonas aeruginosa Chlamidya trachomatis Cryptococcus neoformans
Mycoplasma pneumoniae Chlamidya pneumoniae Aspergillus
Pneumocystis carinii 3
 Respiratory
tract infection

Rhodes et al, 2011. DOI: 10.1038/nrrheum.2011.37 4

PATOGENESIS

Gambar 1. Respon terhadap inflamasi (Reinhart et al. Clinical Microbiology Review. 2012; 25 : 609-634) 5
COMPLETE BLOOD COUNT (CBC)

DR_ARYATI@YAHOO.COM
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BLOOD SMEAR EVALUATION (BSE)

Toxic granule Vacuolization

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BIOMARKER OF INFLAMMATION

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 ACUTE PHASE PROTEIN (APP)

alpha 1 antitrypsin

CRP (C-reactive Protein)

They are produced from the liver
Fibronectin as apart of immediate response to
infection or tissue injury.
Haptoglobin

Lactoferrin

Procalcitonin (PCT)

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INFLAMMATORY MARKERS

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C-REACTIVE PROTEIN

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 STRUKTUR CRP
ü Produced as homopentameric protein, termed
as native CRP (nCRP)
ü Will irreversibly dissociate at sites of
inflammation/ infection into five separate
monomers, termed monomeric CRP (mCRP)
ü Synthesized (primarily) in liver hepatocytes,
but alse by:
• Smooth muscle cells
• Macrophages
• Endothelial cells
• Lymphocytes
• Adipocytes

Sproston & Ashworth, 2018. doi: 10.3389/fimmu.2018.00754

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 C-REACTIVE PROTEIN

• Synthesized within 6-8 hours of exposure to an infective process or tissue

damage
• Half life 19hrs and may reach to 1000 fold during an acute phase
response
• Peaks at 36–50 hours. It decreased when there was no stimuli

• It has higher sensitivity and specificity than total neutrophils and I/T
ratio (immature granulocyte to total).

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CRP mempunyai kelebihan dibandingkan LED, kenaikan suhu
tubuh atau protein fase akut yang lain (a1-anti-trypsin, a1-
acid glukoprotein, haptoglobin)

CRP meningkat dalam waktu 6-8 jam setelah adanya stimulus,

mencapai puncak setelah 36-50 jam, dipertahankan selama masih
ada proses radang, inflamasi atau nekrosis jaringan dan menurun
dengan curam segera setelah proses radang, inflamasi atau nekrosis
menghilang.

Keuntungan penentuan CRP, tidak dipengaruhi oleh obat-obatan

kortikosteroid atau obat anti radang lain.
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HOW TO EVALUATE THE CRP RESULT
< 10 mg/L • Normal concentration
10 - 25 mg/L • Increased but diagnostically of less
importance
• During antibiotic treatment CRP should be reduced below this level
• Does not exclude bacterial infection if the disease has lasted short
• Take a new sample some hours later
25 - 50 mg/L • There is “something”. Bacterial or viral?
50 - 100 mg/L • Common in bacterial infections
• Seldom seen with viral infections

> 100 mg/L • Fairly common in bacterial infections

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CRP PADA RESPIRATORY INFECTION

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Ruiz-Gonzales, 2016. http://dx.doi.org/10.1155/2016/2198745 17
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CRP: a cutoff of 86,5 mg/L best differentiated concomitant⁄
secondary bacterial pneumonia from primary influenza
pneumonia (sensitivity 81,8% and specificity 59,3%)
Song et al, 2011. DOI:10.1111/j.1750-2659.2011.00269.x 20
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CRP PADA COVID-19

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 Stage 1 : Initial stage
Stage 2 : Progression stage
Stage 3 : Peak stage
Stage 4 : Recovery stage

“CRP increased significantly at the initial stage in

severe COVID-19 patients; while still no significant
difference in the CT scores were found between the
severe and mild groups” Tan et al, 2020. DOI: 10.1002/jmv.25871
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 CRP meningkat
>10mg/L pada seluruh
pasien dengan rata-
rata CRP 23,5 mg/L
pada kelompok pasien
COVID-19 kritis

Liu et al, 2020

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• Both CRP levels and diameter of the largest
lung lesion increased with disease
progression.
• CRP levels were positively correlated with
lung lesions and severe presentation
(correlation coefficient = 0.873,
0.734, P ˂ 0.001).

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METODE PEMERIKSAAN CRP

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 METODE PEMERIKSAAN CRP

• Kualitatif
• Semi Latex agglutination
kuantitatif

• Enzyme immunoassay
• Immunoturbidimetry (PETIA)
Kuantitatif • Nephelometry
• Reflectometry Immunoassay

Aryati, 2018
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 Latex agglutination

• Prinsip : reaksi aglutinasi antara antibodi anti

human CRP dan CRP pada sampel

Sampel + goat IgG antihuman CRP berlapis

partikel latex à komplek antigen-antibodi à
aglutinasi

Semikuantitatif : titrasi sampel dengan two fold

dilution

Aryati, 2018
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 Enzyme Immunoassay

• Prinsip : solid phase enzyme-linked

immunosorbent assay
Sampel + mouse monoclonal anti CRP antibody
(solid phase)
Inkubasi, washing

+ goat anti-CRP antibody berlabel HRP

Substrat TMB

Perubahan warna (biru) à ELISA reader

Aryati, 2018
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 Immunoturbidimetry (PETIA)

• Prinsip : reaksi antara antibodi spesifik

menghasilkan komplek imun tidak terlarut

Sampel + antibodi monoklonal anti-CRP

àkomplek antigen-antibodià kekeruhan

Spectrophotometer

Konsentrasi dalam sampel

PETIA = Particle Enhanced Turbidimetric Immunoassay
Aryati, 2018
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 Nephelometry

• Prinsip : reaksi antara analit terlarut dan

antibodi anti CRP yang terikat dengan partikel
polystyrene

Sampel + partikel latex berlapis antibodi

monoklonal anti-CRP àkomplek antigen-antibodi
dengan partikel latex

Light scaterring (nephelometric)

Konsentrasi dalam sampel

Aryati, 2018
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 REFLECTOMETRY IMMUNOASSAY
Brand NycoCard™ Reader II Afinion 2TM

Made in Norway Norway

Whole blood Whole blood
Sample type
Serum, Plasma Serum, Plasma
Principle Immunometric assay – measurement reflecto meter Immunomatric assay – measurement reflecto meter

Time to results 3 minutes (all process) 3 minutes (all process)

Sample Volume 5µL 2.5µL

Touch Screen No Yes
Automatic Process Semi automatic Yes
Serum/Plasma: 5-160 mg/L Serum/Plasma: 5-160 mg/L
Measuring Range
Whole blood : 5-200 mg/L Whole blood : 5-200 mg/L
Steps 5 3
2-8oC until expiry (12 months), 15-25oC 28 days
Storage 2-8oC until expiry, 15-25oC 6 weeks unopened
unopened
Setting No. need set up instrument No. need set up instrument
Code number No Yes so the result will not false positive
Time to Room Temperature At least 10 minutes to reach 15-25oC At least 15 minutes to reach 18-30oC

Controls Black Calibration, White Calibration, 2 levels control Automatic calibration, 2 levels Afinion Controls
 CRP POINT OF CARE TESTING - AFINION

§ 2.5 µL sample volume

§ 3 minute test time
§ Sample materials whole blood, serum or plasma
§ Highly accurate results
§ with automatic hematocrit correction
§ Measuring range whole blood; 5-200 mg/L
§ No interference from common antibiotics and painkillers
§ 4 week room temperature storage
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TAKE HOME MESSAGE
CRP merupakan acute phase reactant yang diproduksi
terhadap infeksi/inflamasi, merupakan marker inflamasi
(termasuk infeksi bakterial, nekrosis jaringan, autoimun)

CRP dapat digunakan sebagai skrining respiratory tract

infection

Di era pandemi Covid-19, CRP dapat sebagai terjadinya

derajat penyakit yang berat

Diperlukan analisis menyeluruh dengan kondisi klinis,

biomarker lain serta radiologis untuk tatalaksana diagnosis
respiratory tract infection

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 Berbagai Panduan COVID-19 oleh PDS PatKLIn
TANGGAL PANDUAN
7 Maret 2020 Manajemen Spesimen Dan Diagnosis Laboratorium Kasus
Suspek 2019-ncov
7 Maret 2020 Pencegahan Dan Pengendalian Infeksi Pada Suspek Infeksi
2019-ncov
19 Maret 2020 Press Release Kewaspadaan Tes Cepat (Rapid Test)
COVID-19 Igm/Igg Berbasis Serologi
21 Maret 2020 Alur Pemeriksaan Rapid Test Sars-Cov-2 (COVID-19)
Usulan PDS Patklin
25 Maret 2020 Panduan Tatalaksana Pemeriksaan Rapid Test Antibody
Sars-cov-2 Metode Imunokromatografi
20 April 2020 Daftar Rapid Test Serologi COVID-19 Yang Sudah
Terdaftar di FDA Negara
21 April 2020 Revisi Panduan Pemeriksaan Rapid Test Antibodi Metode
Imunokromatografi
22 April 2020 Panduan Tatalaksana Pemeriksaan Tes Cepat Molekuler
(TCM) dan Polymerase Chain Reaction (PCR) SARS-CoV-2
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TERIMA KASIH

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