Paediatrica Indonesiana
VOLUME 52
Original Article
Correlation between C-reactive protein and serum
iron levels in children with pneumonia
I Gd. Oka Novi Purnawan1, Ida Bagus Subanada1, Sri Mulatsih2
Abstract
Background 3QHXPRQLDLVDQLQIHFWLRXVGLVHDVHRIWHQRFFXULQJ
LQ FKLOGUHQ XQGHU ILYH \HDUV RI DJH $W WKH WLPH RI LQIHFWLRQ
pro-inflammatory cytokines are released. It is thought that these
pro-inflammatory cytokines cause changes to iron homeostasis
in the body.
Objective 7RGHWHUPLQHDFRUUHODWLRQEHWZHHQ&53DQGVHUXP
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Methods An analytical, cross-sectional study was performed
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Results)URPFKLOGUHQZLWKVHYHUHSQHXPRQLDFKLOGUHQ
January  NUMBER 1
3
neumonia is an infectious disease that often
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high morbidity and mortality rates.1 'XULQJ
infection, cytokines such as pro-inflammatory
interleukin-1 (IL-1), interleukin-6 (IL-6) and tumor
necrotizing factor-D (TNF-D) are released. It is
thought that these pro-inflammatory cytokines may
lead to a change in iron homeostasis in the body.
Acute phase proteins, as products of pro-inflammatory
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measure for these cytokines.
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tration in the blood as a non-specific immune
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Conclusion ,Q FKLOGUHQ ZLWK VHYHUH SQHXPRQLD &53 OHYHO
FRUUHODWHVQHJDWLYHO\ZLWKVHUXPLURQOHYHOV[Paediatr Indones.
2012;52:38-42].
Keywords: CRP, serum iron, pneumonia
38Paediatr Indones, Vol. 52, No. 1, January 2012
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cytokines, especially IL-6, that are released in areas
RI LQIODPPDWLRQ /DERUDWRU\ H[DPLQDWLRQ RI &53
concentration is often performed in patients with
pneumonia.4
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+HDOWK0HGLFDO6FKRRO*DGMDK0DGD8QLYHUVLW\'U6DUGMLWR+RVSLWDO
Yogyakarta, Indonesia.2
Reprint requests to:,*G2ND1RYL3XUQDZDQ'HSDUWPHQWRI&KLOG
+HDOWK 0HGLFDO 6FKRRO 8GD\DQD 8QLYHUVLW\ 6DQJODK +RVSLWDO -DODQ
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(PDLOgedeokanovi@yahoo.com
 I Gd. Oka Novi Purnawan et al: &UHDFWLYHSURWHLQDQGVHUXPLURQOHYHOVLQFKLOGUHQZLWKSQHXPRQLD
,Q 6HUELD 1DVWDVLMHYLF et al. 5 found iron
deficiency in adult patients suffering from community-
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despite the absence of iron supplementation, and
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in children. The aim of our study was to determine
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Methods
This cross-sectional, analytical study was conducted
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The number of required subjects was calculated
using the single correlation test sample. We included
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examinations were collected at the time patients
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concentration was measured by Beckman Coulter
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Results
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Among the excluded 46 children, 5 children had
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SQHXPRQLDRUVHYHUHSQHXPRQLDZLWKFRQFRPLWDQW of preterm birth and low birth weight, and 11
systemic diseases, post-surgery and burns; 2) a children had other systemic diseases (4 children with
history of preterm birth, low birth weight, and twin FRQJHQLWDOKHDUWGLVHDVHFKLOGZLWKOLYHUGLVHDVH
SUHJQDQFLHVIRRGDEVRUSWLRQSUREOHPVDQHPLD 1 child with a malignancy, 2 children with brain
SUHYLRXVLURQWKHUDS\LQFRPSOHWHGDWDDQGODFN infections, 1 child with post-laparotomy surgery, and
RISDUHQWJXDUGLDQFRQVHQW7KLVVWXG\ZDVDSSURYHG 2 children with sepsis).
by the Research Ethics Committee of Sanglah 7KH PHGLDQ FRQFHQWUDWLRQ RI &53 ZDV 
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Clinical examinations were performed by FRQFHQWUDWLRQZDVJG/UDQJHWR
doctors in the emergency unit, outpatient ward, as shown in Table 1.

Table 1. Basic characteristics of subjects

Subject characteristics n = 23
Median age, months (minimum-maximum) 13.0 (6.0-58.0)
Sex
Male 13
Nutritional status
Well-nourished 10
Undernourished 8
Overweight 5
#VTKUMQHKTQPFGEKGPE[FWGVQFKGV 23
Median laboratory parameters, (minimum-maximum)
Hemoglobin,g/dL 11.8 (11-13.9)
WBC, x103 /L 11.2 (6.09-29.2)
Absolute neutrophil, x103 /L 5.74 (1.82-20.8)
CRP, mg/L 9.22 (0.22-53.5)
Iron serum, g/dL 25.55 (9.13-76.46)
Median time of CRP and serum iron measurement 4.0 (2.0-7.0)
after symptom onset, days (minimum-maximum)

Paediatr Indones, Vol. 52, No. 1, January 2012 39

 I Gd. Oka Novi Purnawan et al: &UHDFWLYHSURWHLQDQGVHUXPLURQOHYHOVLQFKLOGUHQZLWKSQHXPRQLD

Observed
80.00 Quadratic

Serum iron level (ug/dL)

60.00

40.00

R Square line = 0.316

20.00

0.00
0.00 10.00 20.00 30.00 40.00 50.00 60.00

CRP level (mg/L)

Figure 1. Scatter plot correlation of CRP and serum iron levels in children with severe
pneumonia.

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normalize this data distribution, we performed data
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mg/L in cases of pneumonia accompanied by empyema
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OHYHOVLVVKRZQLQFigure 1. Scatter plots showed that
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was non-linear. The quadratic model was statistically
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that the cause of pneumonia in most of our subjects
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precise than linear model. Scatter plot also showed
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Discussion
In pneumonia patients, infection and tissue damage
in the lung parenchyma may stimulate the immune
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&53OHYHOVDUHRIWHQVHHQLQFDVHVRISQHXPRQLDGXH
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to distinguish bacterial infections from other causes
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40Paediatr Indones, Vol. 52, No. 1, January 2012
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The inflammatory process may disrupt iron
homeostasis. Impaired iron homeostasis begins
with increased uptake and retention of iron in
reticuloendothelial cells. Iron from the circulation is
stored in the reticuloendothelial system, where its use
is limited to stem cell erythropoiesis. Stimulation of
pro-inflammatory cytokines (TNF-D, IL-1, IL-6) leads
to the retention of iron in macrophages. Furthermore,
down-regulation of ferroportin production withholds
the release of ferrous iron from duodenum enterocytes
into the circulation. Kemna et al. found that after
 I Gd. Oka Novi Purnawan et al: &UHDFWLYHSURWHLQDQGVHUXPLURQOHYHOVLQFKLOGUHQZLWKSQHXPRQLD

humans were injected with lipopolysaccharide, serum
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The median serum iron concentration of in our
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strength. This difference may be due to different
etiologies of pneumonia. In Serbia, most infections
were bacterial, while most infections in our study
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g/dL, lower than that of a Serbian study which
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dL).5 This difference may be due to subjects age
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the Serbian subjects were adults.5
A study of serum iron profiles reported mean
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malnourished children with no acute respiratory
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malnourished children with acute respiratory infection
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higher than that in our study (25.55 g/dL). This
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infections in their study (upper acute respiratory
infections), compared to acute lower respiratory
infections in our study.15
Iron homeostasis disruption occurs during the
inflammatory process. In our study, we determined
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stimulation, especially IL-6. We determined iron
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etiology. We only performed blood cultures, not lung
tissue or pleural fluid. Blood cultures were sterile
for all subjects. Blood culture results do not rule
out the possibility that bacteria caused our subjects
pneumonia, since there is generally a low incidence
of bacteremia during pneumonia.
Another limitation of our research was that
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initiation of therapy. So we do not know if serum
iron spontaneously increased after therapy. Since the
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the data distribution was abnormal. Also, we did
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for iron deficiency due to their dietary status. Since
serum ferritin was not examined in our study, we do
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were caused by infection alone, or influenced by low
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impact of lower respiratory tract infection on iron
metabolism.
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with pneumonia correlated to decreased serum iron Acknowledgments
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rapid examination was at 2 days and the least was at
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of pneumonia.
We found the correlation strength to be weaker
than that of the Serbian study, which was of medium
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statistical analysis in this study.
References
 %U\FH - %RVFKL3LQWR & 6KLEX\D . %ODFN 5( :+2
estimates of the causes of death in children. Lancet.

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LQIHFWLRQ1XWU5HY 
Paediatr Indones, Vol. 52, No. 1, January 2012 41
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4. Kratz A, Lewandrowski EL. The plasma protein. In: Kenneth
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pneumonia, for the community-acquired pneumonia. Chest.
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1$,66
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Radiographic, clinical, and prognostic features of complicated
and uncomplicated community-acquired lobar pneumonia in
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pneumonia in children. J Microbiol Immunol Infect.

42Paediatr Indones, Vol. 52, No. 1, January 2012

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in early childhood in the United States: risk factors and racial/
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15. Rahman MA, Mannan MA, Rahman MH, Aretin KE, Azad
AK. Influence of acute respiratory infection on iron profile
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