Correlation between Salivary and Serum CRP Levels

in Urticaria Patients

Martina Rahmi, Taufiq Hidayat and Herwinda Brahmanti

Department of Dermatology and Venereology, Faculty of Medicine, Universitas Brawijaya,Saiful Anwar General Hospital,

Malang, East java, Indonesia

Keywords: Urticaria, Crp, Serum, Saliva, Correlation.

Abstract: Urticaria are commonand has a detrimental effect on that adversely impacts the quality of life. Urticaria occurs

due to mast cell activation and subsequently followed by inflammatory response. C- reactive protein (CRP),

the prototypical acute-phase reactant has been used widely on-specific clinical indicator to assess systemic

inflammatory status. Development of salivary CRP assays that is non-invasive, stress- and pain-free may

constitute an alternative strategy. To the best knowledge of author, there have been no studies done on the

correlation of saliva and serum CRP in urticaria patients. The objective of this study was to find the correlation

between salivary and serum CRP levels in patients with urticaria. The study design was cross-sectional

observational analytic and 21 urticaria patients were recruited. Saliva and serum CRP levels were measured

within 48 hours of lesion onset using immunoturbidimetry and ELISA method. Statistical analysis of the

Pearson correlation coefficient was used Saliva CRP concentrations ranged from 3,00x10

-6

mg/L to 1,77x10

mg/l, mean values were 3,77x10

-4

mg/l (± 4,72x10

-4

). Serum CRP concentration ranged from 0,40

mg/lto17,40 mg/l, mean values 3,28 mg/l (±3,85). We found a verystrongassociation CRP measured in saliva

with serum CRP(r= .814, p <.05). Salivary CRP measurement may thus facilitate alternative method of CRP

serum to know inflammatory state in patients with urticaria.

1 INTRODUCTION

Urticariais a distressing disorder that adversely

impacts the quality of life; yet it spathogenesis is not

well delineated and, accordingly, thetreatment is

often palliative and therapeutic outcome is

suboptimal (Jain., 2014). Mast cell activation

accompanied by inflammatory response is associated

with urticaria, which may be manifested by increased

serum concentration of C- reactive protein (CRP)

(Kasperska et al, 2011).

It has been demonstrated that

circulating CRP concentration is increased in acute

and chronic urticaria, and furthermore CRP

concentrations correlate with the disease severity.

Therefore, characterization of CRP in urticaria may

be essential to gain better insight into the activity of

the disease and to assess the degree of inflammation

(Kasperska, 2012).

The presence of CRP molecules in saliva and

recent technical advances provides an opportunity for

development of non-invasive assessments of disease

which would enable research in large population

representative samples and in young people (Oullet,

2011). However, salivary CRP reference ranges and

their correlation with serum levels are not established.

In addition, although a correlation between serum and

salivary CRP concentration has been observed this

relationship has not been investigated in urticaria

subjects. The goal of the study reported here was to

investigate the relationship between salivary and

blood serum levels of this molecules in patients with

urticaria.

2 METHODS

2.1 Subjects and Sample Collection

Study participants were21urticaria patients (76.2%

women) aged between 19 and 55 years (mean (SD) =

34.7 (11.8)). None reported comorbid disease

(cardiovascular, Diabetes mellitus, autoimmune or

liver), vasculitis or pressure urticaria, pregnancy and

overweight. Moreover, no participant reported on

corticosteroid or systemic immunomodulator.

Rahmi, M., Hidayat, T. and Brahmanti, H.

Correlation between Salivary and Serum CRP Levels in Urticaria Patients.

DOI: 10.5220/0008149700140017

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 14-17

ISBN: 978-989-758-494-7

Participants were recruited from

Dermatovenereology outpatient department of Saiful

Anwar General Hospital. Participants gave informed

consent. The study protocol was approved by Saiful

Anwar General Hospital Research Ethics

Commmitte. The subjects were asked to fast for at

least 30 minutes prior to giving their blood and saliva

samples. Unstimulated whole saliva was obtained

using the passive drool method (approximately 5 ml)

and the saliva samples were immediately placed on

ice following collection and stored at -20 °C. Blood

samples were collected by venipuncture into

vacutainer tubes and were immediately centrifuged to

separate blood components and measured.

2.2 C-reactive Protein Measurement

The concentration of CRP in saliva was determined

using ELISA method. C-reactive protein (CRP) levels

in serum were determined using turbidimetry method

using semiautomated analyzer.

2.3 Statistical Analyses

The association between salivary with serum CRP

was investigated using parametric (Pearson r) and

nonparametric (Spearman r). Difference in variations

in salivary and serum CRP mean levels of various

variables were analyzed with One-way Anova and T-

test.

3 RESULTS

3.1 Descriptive Data

In the study, total numbers of patients were 21

urticaria patients. Salivary CRP concentrations

ranged from 3.0 pg/ml to 1769.67 pg/ml (mean (SD)

= 377.44 (471.7)). From the total sample (n = 21),

none of these participants had salivary CRP values

that exceeded from the mean reported in healthy

adults (6131.40 pg/ml) (Salimetrics, 2011). Higher

values were observed for serum CRP (range = .4–

17.48 mg/dl; mean (SD) = 3.28 (3.85)).) The CRP

levels differed little from some variables (Table 1).

The levels of CRP serum were higher in women. Both

salivary and serum CRP levels were significantly

higher in the presence of lesion in time of

measurement.

Table 1: Salivary and Serum CRP levels between Variables.

Subjects Characteristic

SalivaryCRP mean

(mg/l) ± SD

p-value*

Serum CRP

mean (mg/l) ±

p-value*

Age (years)

18 - 30

31 - 45

46 - 55

1,77x10

-4

± 1,67x10

-4

4,76x10

-4

± 5,83x10

-4

6,31x10

-4

± 6,20x10

-4

0,216

2,26 ± 1,93

3,18 ± 2,71

5,80 ± 7,74

0,323

Sex

Men

Women

7,10x10

-4

± 5,00x10

-4

2,74x10

-4

± 4,26x10

-4

0,070

7,28 ± 6,11

2,03 ± 1,66

0,004*

Family History

Yes

3,60x10

-4

± 4,90x10

-4

3,96x10

-4

± 4,77x10

-4

0,866

2,44 ± 1,79

4,21 ± 5,24

0,303

Antihistamin use

Yes

4,88x10

-4

± 5,92x10

-4

2,31x10

-4

± 1,76x10

-4

0,226

3,90 ± 4,83

2,46 ± 1,87

0,408

BMI

Underweight

Normoweight

2,40x10

-4

± 3,20x10

-4

3,92x10

-4

± 4,89x10

-4

0,675

1,05 ± 0,21

3,52 ± 3,98

0,402

Lesion

Presence

Absence

6,94x10

-4

± 7,63x10

-4

2,51x10

-4

± 2,23x10

-4

0,049*

5,92 ± 6,23

2,23 ± 1,76

0,044*

Correlation between Salivary and Serum CRP Levels in Urticaria Patients

Onset Last Lesion

<19 hours

>19 hours

3,32x10

-4

± 4,23x10

-4

6,51x10

-4

± 7,58x10

-4

0,290

2,66 ± 2,24

7,03 ± 8,98

0,066

Angioedema

Yes

3,54x10

-4

± 5,61x10

-4

3,95x10

-4

± 4,18x10

-4

0,850

2,58 ± 2,14

3,81 ± 4,78

0,482

Urticaria Type

Acute

Chronic

3,50x10

-4

± 4,42x10

-4

4,14x10

-4

± 5,33x10

-4

0,768

3,81 ± 4,85

2,58 ± 1,91

0,482

*Bold text indicates a statistically significant difference with a p-value less than 0.05

Figure 1: Correlation between salivary CRP and serum CRP in urticariapatients.x = serum CRP, y= salivary CRP, R=

Correlation Coefficient, R

= Coefficient of Determination.

3.2 Associations between Salivary with

Serum CRP Levels

As shown in Fig. 1, the correlation between salivary

and serum CRP was r = .81 (very strong). The saliva-

to-serum ratio was low (1:8700). The following

equation can be used to predict serum CRP from

saliva: y = 999.04x + 49.66 where y = salivary CRP

and x = serum CRP.

4 DISCUSSION

We observed a very strong association between CRP

measured in saliva and serum. Our study provides

supporting evidence suggesting that non-invasive

assessment of CRP in saliva allows the valid

prediction of serum CRP. Consistent with that result,

strong saliva and serum CRP correlations were

reported in animal studies, such as in healthy (r = .87)

and diseased dogs (r = .84) and in pigs (r = .73) (Parra

et al, 2005; Gutiérrez et al, 2009).

Our study was also

consistent with previous validation study that found

moderate to strong association in healthy subjects. Our

finding was however inconsistent with the absence of

association found between serum and salivary CRP in

medical students (Dillon et al, 2010).

The salivary CRP measure could be improved in

future studies by exploring three issues in this study.

First, there was significant difference in serum CRP

levels between men and women, probably due to one

men participant had a great extent of serum CRP

values than mean level (530%) with unclear

explanation. There was also significant difference in

salivary and serum CRP according to the presence of

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

lesion in time of measurement. Our finding suggests

that salivary CRP determination requires all the

patients show active urticaria at the time of

assessment.

Second, given the low saliva-to-serum CRP ratio,

it is possible that high-sensitivity ELISA may not be

sensitive enough to precisely quantify CRP in saliva,

particularly at low concentrations. Other analytical

methods have been used to determine CRP from

saliva, including time-resolved immunofluorometric

assays surface plasmon resonance immunosensor,

magnetic immunosensor, and lab-on-a-chip devices.

While these analytic strategies may be most remain

under development and thus are not readily accessible

to researchers, it should be explored further whether

the collection of larger saliva volume or parotid saliva

may optimize the measurement of CRP in the saliva.

Third, replication in larger samples is needed due to

large Standard of Deviation (SD) in the result of our

study.

This study provides supporting evidence for the

validation of salivary CRP as an alternative marker

for inflammation using a broadly available

technology adapted to saliva specimens. Saliva

sampling is non-invasive, stress-free, can be easily

performed in the participants’ natural settings and can

be repeated over time. Moreover, saliva collection has

considerable economical and logistic advantages over

venipuncture because it does not require immediate

manipulations, access to specialized laboratory

equipment’s and qualified personnel (Oullet et al,

2011).

Furthermore, future studies should extent the

present findings and correlate measurement of

salivary CRP with urticaria clinical severity as well

as therapy evaluation.

5 CONCLUSIONS

This study demonstrates a very strong positive

correlation between salivary and serum CRP in

urticaria patients.

ACKNOWLEDGEMENT

We are grateful to the participants and to laboratory

technician for technical assistance. Our thanks to the

Laboratory of Physiology Sciences, Faculty of

Medicine Universitas Brawijaya and Saiful Anwar

General Hospital Central Laboratory, Malang, East

java, Indonesia.

REFERENCES

Jain, S., 2014. Pathogenesis of chronic urticaria: An

overview. Dermatology Research and Practice.

doi:10.1155/2014/674709

Kasperska-Zajac, A., Sztylc, J., Machura, E., Jop, G., 2011.

Plasma IL-6 concentration correlates with clinical

disease activity and serum C-reactive protein

concentration in chronic urticaria patients. Clinical and

Experimental Allergy 41, 1386–1391.

doi:10.1111/j.1365-2222.2011.03789.x

Kasperska-Zajac, a, 2012. Acute-phase response in chronic

urticaria. Journal of the European Academy of

Dermatology and Venereology: JEADV 26, 665–72.

doi:10.1111/j.1468-3083.2011.04366.x

Ouellet-Morin, I., Danese, A., Williams, B., Arseneault, L.,

2011. Validation of a high-sensitivity assay for C-

reactive protein in human saliva. Brain, Behavior, and

Immunity 25, 640–646. doi:10.1016/j.bbi.2010.12.020

Salimetrics, SalivaBio. Saliva collection and handling

advice. 2011. Availableat www. salimetrics. com.

Parra, M.D., Tecles, F., Martínez-Subiela, S., Cerón, J.J.,

2005. C-reactive protein measurement in canine saliva.

Journal of Veterinary Diagnostic Investigation 17,

139–144. doi:10.1177/104063870501700207

Gutiérrez, A.M., Martínez-Subiela, S., Eckersall, P.D.,

Cerón, J.J., 2009. C-reactive protein quantification in

porcine saliva: A minimally invasive test for pig health

monitoring. Veterinary Journal 181, 261–265.

doi:10.1016/j.tvjl.2008.03.021

Dillon, M.C., Opris, D.C., Kopanczyk, R., Lickliter, J.,

Cornwell, H.N., Bridges, E.G., Nazar, A.M., Bridges,

K.G., 2010. Detection of homocysteine and C-reactive

protein in the saliva of healthy adults: Comparison with

blood levels. Biomarker Insights 2010, 57–61.

doi:10.4137/BMI.S5305

Correlation between Salivary and Serum CRP Levels in Urticaria Patients