Chlamydia infection laboratory findings: Difference between revisions

Sexually transmitted diseases Main Page
	Chlamydia infection Microchapters
Home
Patient Information
Overview
Historical Perspective
Pathophysiology
Causes
C. trachomatis
Other Chlamydiae
Differentiating Chlamydia Infection from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
History and Symptoms
Physical Examination
Laboratory Findings
Ultrasound
Other Imaging Findings
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
Chlamydia infection laboratory findings On the Web
Most recent articles
Most cited articles
Review articles
CME Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Chlamydia infection laboratory findings All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Chlamydia infection laboratory findings
CDC on Chlamydia infection laboratory findings
Chlamydia infection laboratory findings in the news
Blogs on Chlamydia infection laboratory findings
Directions to Hospitals Treating Chlamydia infection
Risk calculators and risk factors for Chlamydia infection laboratory findings

VisualWikitext

Revision as of 18:25, 7 April 2017

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Aysha Anwar, M.B.B.S [2]

Overview

Laboratory findings consistent with the diagnosis of Chlamydial infection and its complications include:^[1]^[2]^[3]^[4]

Laboratory Findings

Laboratory findings consistent with the diagnosis of Chlamydial infection and its complications include:^[1]^[5]^[3]

Type of Chlamydia	Tests	Findings
Neonatal conjuctivitis	CBC	Normal
Neonatal conjuctivitis	ESR	Normal
Neonatal pneumonia^[6]^[7]	CBC	Absolute increase in eosinophil count (>400cells/mm3)^[8]
	ESR	Increased
	CRP	Increased
	ABGS	Mild to moderate hypoxemia
Genital infection^[1]^[9]^[3]	CBC	Increased leukocyte count
	Urinalysis	>5 WBCS per high power field
	ESR	Normal or increased
	CRP	Normal or increased
Atypical pneumonia^[10]	CBC	Increased or normal leukocyte count (lymphocytes)
Fitz Hugh Curtis Syndrome^[1]	CBC	Increased leukocytes
	LFTS	Normal
	ESR	Normal or increased
	D Dimer	Normal or increased

Other diagnostic tests

Other diagnostic tests that may be used to diagnose chlamydia infection include the following:

Culture

Gold standard for diagnosing chlamydial infection^[11]^[12]
Test of choice in cases of sexual abuse in boys^[8]
Used for urogenital specimens (from males) and extragenital sites such as rectum and pharynx (males and female)^[8]
Highly specific
Limitations include long incubation period, live cell culture requirement, specific transport methods

Direct Cytological test

Used for diagnosing acute inclusion conjuctivitis in neonates^[13]
Detects typical intracytoplasmic inclusions using giemsa stain
Insensitive for diagnosing adult conjuctival and genital infection

Antigen detection tests

Tests based on antigen detection tests include the following:

Nucleic acid amplification tests (NAATS)^[4]^[13]^[14]^[15]^[16]

These include PCR, ligase chain reaction, and transcription-mediated amplification of RNA
FDA-approved for vaginal and urinary specimens^[8]
Not FDA-approved for usage on extragenital sites and urogenital specimen in boys
Higher sensitivity and specificity than culture

Less accurate antigen detection tests

Nucleic acid hybridization tests
Enzyme immunoassay
Direct fluorescent antibody assay

FDA-cleared for conjuctival and nasopharyngeal specimen testing^[8]
Highest sensitivity and specificity for neonatal conjuctivitis

Antibody detection tests

Serological tests that may help in diagnosis of chlamydial infection include:^[11]

Microimmunofluorescence (mif) assay

Detect species-specific antibodies
Gold standard for chlamydia serology

Complement fixation tests

Used for diagnosing chlamydial respiratory infection
Replaced by microimmunofluorescence (mif)

References

↑ ^1.0 ^1.1 ^1.2 ^1.3 Yang HW, Jung SH, Han HY, Kim A, Lee YJ, Cha SW; et al. (2008). "[Clinical feature of Fitz-Hugh-Curtis syndrome: analysis of 25 cases]". Korean J Hepatol. 14 (2): 178–84. doi:10.3350/kjhep.2008.14.2.178. PMID 18617765.
↑ Peipert, Jeffrey F., et al. "Laboratory evaluation of acute upper genital tract infection." Obstetrics & Gynecology 87.5 (1996): 730-736.
↑ ^3.0 ^3.1 ^3.2 Stamm WE, Cole B (1986). "Asymptomatic Chlamydia trachomatis urethritis in men". Sex Transm Dis. 13 (3): 163–5. PMID 3764626.
↑ ^4.0 ^4.1 Centers for Disease Control and Prevention (2014). "Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae--2014". MMWR Recomm Rep. 63 (RR-02): 1–19. PMC 4047970. PMID 24622331.
↑ Peipert, Jeffrey F., et al. "Laboratory evaluation of acute upper genital tract infection." Obstetrics & Gynecology 87.5 (1996): 730-736.
↑ Tsai MH, Huang YC, Chen CJ, Lin PY, Chang LY, Chiu CH; et al. (2005). "Chlamydial pneumonia in children requiring hospitalization: effect of mixed infection on clinical outcome". J Microbiol Immunol Infect. 38 (2): 117–22. PMID 15843856.
↑ Mishra KN, Bhardwaj P, Mishra A, Kaushik A (2011). "Acute Chlamydia trachomatis respiratory infection in infants". J Glob Infect Dis. 3 (3): 216–20. doi:10.4103/0974-777X.83525. PMC 3162806. PMID 21887051.
↑ ^8.0 ^8.1 ^8.2 ^8.3 ^8.4 http://www.cdc.gov/std/tg2015/chlamydia.htm Accessed on September 14,2016
↑ Peipert, Jeffrey F., et al. "Laboratory evaluation of acute upper genital tract infection." Obstetrics & Gynecology 87.5 (1996): 730-736.
↑ Hayashi Y, Asano T, Ito G, Yamada Y, Matsuura T, Adachi S; et al. (1993). "[Study of cell populations of bronchoalveolar lavage fluid in patients with pneumonia due to Chlamydia psittaci and Mycoplasma pneumoniae]". Nihon Kyobu Shikkan Gakkai Zasshi. 31 (5): 569–74. PMID 8331841.
↑ ^11.0 ^11.1 Hattis D, Wasson JM, Page GS, Stern B, Franklin CA (1987). "Acid particles and the tracheobronchial region of the respiratory system--an "irritation-signaling" model for possible health effects". JAPCA. 37 (9): 1060–6. PMID 3327923.
↑ Gaydos CA, Roblin PM, Hammerschlag MR, Hyman CL, Eiden JJ, Schachter J; et al. (1994). "Diagnostic utility of PCR-enzyme immunoassay, culture, and serology for detection of Chlamydia pneumoniae in symptomatic and asymptomatic patients". J Clin Microbiol. 32 (4): 903–5. PMC 263160. PMID 8027341 : 8027341 Check |pmid= value (help).
↑ ^13.0 ^13.1 Chernesky MA (2005). "The laboratory diagnosis of Chlamydia trachomatis infections". Can J Infect Dis Med Microbiol. 16 (1): 39–44. PMC 2095010. PMID 18159527.
↑ Johnson RE, Newhall WJ, Papp JR, Knapp JS, Black CM, Gift TL; et al. (2002). "Screening tests to detect Chlamydia trachomatis and Neisseria gonorrhoeae infections--2002". MMWR Recomm Rep. 51 (RR-15): 1–38, quiz CE1-4. PMID 12418541.
↑ Peipert JF (2003). "Clinical practice. Genital chlamydial infections". N Engl J Med. 349 (25): 2424–30. doi:10.1056/NEJMcp030542. PMID 14681509.
↑ http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6302a1.htm Accessed on September 12, 2016

Template:WikiDoc Sources

[pmid18617765-1] 1.0 ^1.1 ^1.2 ^1.3 Yang HW, Jung SH, Han HY, Kim A, Lee YJ, Cha SW; et al. (2008). "[Clinical feature of Fitz-Hugh-Curtis syndrome: analysis of 25 cases]". Korean J Hepatol. 14 (2): 178–84. doi:10.3350/kjhep.2008.14.2.178. PMID 18617765.

[2] Peipert, Jeffrey F., et al. "Laboratory evaluation of acute upper genital tract infection." Obstetrics & Gynecology 87.5 (1996): 730-736.

[pmid3764626-3] 3.0 ^3.1 ^3.2 Stamm WE, Cole B (1986). "Asymptomatic Chlamydia trachomatis urethritis in men". Sex Transm Dis. 13 (3): 163–5. PMID 3764626.

[pmid24622331-4] 4.0 ^4.1 Centers for Disease Control and Prevention (2014). "Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae--2014". MMWR Recomm Rep. 63 (RR-02): 1–19. PMC 4047970. PMID 24622331.

[5] Peipert, Jeffrey F., et al. "Laboratory evaluation of acute upper genital tract infection." Obstetrics & Gynecology 87.5 (1996): 730-736.

[pmid15843856-6] Tsai MH, Huang YC, Chen CJ, Lin PY, Chang LY, Chiu CH; et al. (2005). "Chlamydial pneumonia in children requiring hospitalization: effect of mixed infection on clinical outcome". J Microbiol Immunol Infect. 38 (2): 117–22. PMID 15843856.

[pmid21887051-7] Mishra KN, Bhardwaj P, Mishra A, Kaushik A (2011). "Acute Chlamydia trachomatis respiratory infection in infants". J Glob Infect Dis. 3 (3): 216–20. doi:10.4103/0974-777X.83525. PMC 3162806. PMID 21887051.

[NC-8] 8.0 ^8.1 ^8.2 ^8.3 ^8.4 http://www.cdc.gov/std/tg2015/chlamydia.htm Accessed on September 14,2016

[9] Peipert, Jeffrey F., et al. "Laboratory evaluation of acute upper genital tract infection." Obstetrics & Gynecology 87.5 (1996): 730-736.

[pmid8331841-10] Hayashi Y, Asano T, Ito G, Yamada Y, Matsuura T, Adachi S; et al. (1993). "[Study of cell populations of bronchoalveolar lavage fluid in patients with pneumonia due to Chlamydia psittaci and Mycoplasma pneumoniae]". Nihon Kyobu Shikkan Gakkai Zasshi. 31 (5): 569–74. PMID 8331841.

[pmid3327923-11] 11.0 ^11.1 Hattis D, Wasson JM, Page GS, Stern B, Franklin CA (1987). "Acid particles and the tracheobronchial region of the respiratory system--an "irritation-signaling" model for possible health effects". JAPCA. 37 (9): 1060–6. PMID 3327923.

[pmid:_8027341-12] Gaydos CA, Roblin PM, Hammerschlag MR, Hyman CL, Eiden JJ, Schachter J; et al. (1994). "Diagnostic utility of PCR-enzyme immunoassay, culture, and serology for detection of Chlamydia pneumoniae in symptomatic and asymptomatic patients". J Clin Microbiol. 32 (4): 903–5. PMC 263160. PMID 8027341 : 8027341 Check |pmid= value (help).

[pmid18159527-13] 13.0 ^13.1 Chernesky MA (2005). "The laboratory diagnosis of Chlamydia trachomatis infections". Can J Infect Dis Med Microbiol. 16 (1): 39–44. PMC 2095010. PMID 18159527.

[pmid12418541-14] Johnson RE, Newhall WJ, Papp JR, Knapp JS, Black CM, Gift TL; et al. (2002). "Screening tests to detect Chlamydia trachomatis and Neisseria gonorrhoeae infections--2002". MMWR Recomm Rep. 51 (RR-15): 1–38, quiz CE1-4. PMID 12418541.

[pmid14681509-15] Peipert JF (2003). "Clinical practice. Genital chlamydial infections". N Engl J Med. 349 (25): 2424–30. doi:10.1056/NEJMcp030542. PMID 14681509.

[abcd-16] ttp://www.cdc.gov/mmwr/preview/mmwrhtml/rr6302a1.htm Accessed on September 12, 2016

[1]

[2]

[3]

[4]

[5]

[6]

[7]

[8]

[9]

[10]

[11]

[12]

[13]

[14]

[15]

[16]

@@ Line 7: / Line 7: @@
 ==Laboratory Findings==
-Laboratory findings consistent with the diagnosis of ''Chlamydial infection'' and its complications include:<ref name="pmid18617765">{{cite journal| author=Yang HW, Jung SH, Han HY, Kim A, Lee YJ, Cha SW et al.| title=[Clinical feature of Fitz-Hugh-Curtis syndrome: analysis of 25 cases]. | journal=Korean J Hepatol | year= 2008 | volume= 14 | issue= 2 | pages= 178-84 | pmid=18617765 | doi=10.3350/kjhep.2008.14.2.178 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18617765  }} </ref><ref>Peipert, Jeffrey F., et al. "Laboratory evaluation of acute upper genital tract infection." Obstetrics & Gynecology 87.5 (1996): 730-736.</ref><ref name="pmid3764626">{{cite journal| author=Stamm WE, Cole B| title=Asymptomatic Chlamydia trachomatis urethritis in men. | journal=Sex Transm Dis | year= 1986 | volume= 13 | issue= 3 | pages= 163-5 | pmid=3764626 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3764626  }} </ref>
+Laboratory findings consistent with the diagnosis of ''[[Chlamydial infection]]'' and its complications include:<ref name="pmid18617765">{{cite journal| author=Yang HW, Jung SH, Han HY, Kim A, Lee YJ, Cha SW et al.| title=[Clinical feature of Fitz-Hugh-Curtis syndrome: analysis of 25 cases]. | journal=Korean J Hepatol | year= 2008 | volume= 14 | issue= 2 | pages= 178-84 | pmid=18617765 | doi=10.3350/kjhep.2008.14.2.178 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18617765  }} </ref><ref>Peipert, Jeffrey F., et al. "Laboratory evaluation of acute upper [[UTI|genital tract infection]]." Obstetrics & Gynecology 87.5 (1996): 730-736.</ref><ref name="pmid3764626">{{cite journal| author=Stamm WE, Cole B| title=Asymptomatic Chlamydia trachomatis urethritis in men. | journal=Sex Transm Dis | year= 1986 | volume= 13 | issue= 3 | pages= 163-5 | pmid=3764626 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3764626  }} </ref>
 {|style="border: 0px; font-size: 90%; margin: 3px;" align=center
@@ Line 14: / Line 14: @@
 !style="background: #4479BA; padding: 5px 5px;"| {{fontcolor|#FFFFFF|Findings}}
 |-
-!rowspan="2" style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;"| Neonatal conjuctivitis
+!rowspan="2" style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;"| [[Neonatal conjuctivitis]]
-|style="padding: 5px 5px; background: #F5F5F5;"| CBC
+|style="padding: 5px 5px; background: #F5F5F5;"| [[CBC]]
 |style="padding: 5px 5px; background: #F5F5F5;"| Normal
 |-
-|style="padding: 5px 5px; background: #F5F5F5;"| ESR
+|style="padding: 5px 5px; background: #F5F5F5;"| [[ESR]]
 |style="padding: 5px 5px; background: #F5F5F5;"| Normal
 |-
 ! rowspan="4" style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;"| Neonatal pneumonia<ref name="pmid15843856">{{cite journal| author=Tsai MH, Huang YC, Chen CJ, Lin PY, Chang LY, Chiu CH et al.| title=Chlamydial pneumonia in children requiring hospitalization: effect of mixed infection on clinical outcome. | journal=J Microbiol Immunol Infect | year= 2005 | volume= 38 | issue= 2 | pages= 117-22 | pmid=15843856 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15843856  }} </ref><ref name="pmid21887051">{{cite journal| author=Mishra KN, Bhardwaj P, Mishra A, Kaushik A| title=Acute Chlamydia trachomatis respiratory infection in infants. | journal=J Glob Infect Dis | year= 2011 | volume= 3 | issue= 3 | pages= 216-20 | pmid=21887051 | doi=10.4103/0974-777X.83525 | pmc=3162806 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21887051  }} </ref>
-|style="padding: 5px 5px; background: #F5F5F5;"| CBC
+|style="padding: 5px 5px; background: #F5F5F5;"| [[CBC]]
-|style="padding: 5px 5px; background: #F5F5F5;"| Absolute increase in eosinophil count (>400cells/mm3)<ref name= NC>http://www.cdc.gov/std/tg2015/chlamydia.htm Accessed on September 14,2016</ref>
+|style="padding: 5px 5px; background: #F5F5F5;"| Absolute increase in [[eosinophil]] count (>400cells/mm3)<ref name= NC>http://www.cdc.gov/std/tg2015/chlamydia.htm Accessed on September 14,2016</ref>
 |-
-|style="padding: 5px 5px; background: #F5F5F5;" | ESR
+|style="padding: 5px 5px; background: #F5F5F5;" | [[ESR]]
 |style="padding: 5px 5px; background: #F5F5F5;" | Increased
 |-
-|style="padding: 5px 5px; background: #F5F5F5;" | CRP
+|style="padding: 5px 5px; background: #F5F5F5;" | [[CRP]]
 |style="padding: 5px 5px; background: #F5F5F5;" | Increased
 |-
-|style="padding: 5px 5px; background: #F5F5F5;" | ABGS
+|style="padding: 5px 5px; background: #F5F5F5;" | [[ABGS]]
 |style="padding: 5px 5px; background: #F5F5F5;" | Mild to moderate hypoxemia
 |-
 ! rowspan="4" style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;"| Genital infection<ref name="pmid18617765">{{cite journal| author=Yang HW, Jung SH, Han HY, Kim A, Lee YJ, Cha SW et al.| title=[Clinical feature of Fitz-Hugh-Curtis syndrome: analysis of 25 cases]. | journal=Korean J Hepatol | year= 2008 | volume= 14 | issue= 2 | pages= 178-84 | pmid=18617765 | doi=10.3350/kjhep.2008.14.2.178 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18617765  }} </ref><ref>Peipert, Jeffrey F., et al. "Laboratory evaluation of acute upper genital tract infection." Obstetrics & Gynecology 87.5 (1996): 730-736.</ref><ref name="pmid3764626">{{cite journal| author=Stamm WE, Cole B| title=Asymptomatic Chlamydia trachomatis urethritis in men. | journal=Sex Transm Dis | year= 1986 | volume= 13 | issue= 3 | pages= 163-5 | pmid=3764626 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3764626  }} </ref>
-|style="padding: 5px 5px; background: #F5F5F5;"| CBC
+|style="padding: 5px 5px; background: #F5F5F5;"| [[CBC]]
-|style="padding: 5px 5px; background: #F5F5F5;"| Increased leukocyte count
+|style="padding: 5px 5px; background: #F5F5F5;"| Increased [[leukocyte]] count
 |-
-|style="padding: 5px 5px; background: #F5F5F5;"| Urinalysis
+|style="padding: 5px 5px; background: #F5F5F5;"| [[Urinalysis]]
 |style="padding: 5px 5px; background: #F5F5F5;"| >5 WBCS per high power field
 |-
-|style="padding: 5px 5px; background: #F5F5F5;"| ESR
+|style="padding: 5px 5px; background: #F5F5F5;"| [[ESR]]
 |style="padding: 5px 5px; background: #F5F5F5;"| Normal or increased
 |-
-|style="padding: 5px 5px; background: #F5F5F5;"| CRP
+|style="padding: 5px 5px; background: #F5F5F5;"| [[CRP]]
 |style="padding: 5px 5px; background: #F5F5F5;"| Normal or increased
 |-
 !style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;"| Atypical [[pneumonia]]<ref name="pmid8331841">{{cite journal| author=Hayashi Y, Asano T, Ito G, Yamada Y, Matsuura T, Adachi S et al.| title=[Study of cell populations of bronchoalveolar lavage fluid in patients with pneumonia due to Chlamydia psittaci and Mycoplasma pneumoniae]. | journal=Nihon Kyobu Shikkan Gakkai Zasshi | year= 1993 | volume= 31 | issue= 5 | pages= 569-74 | pmid=8331841 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8331841  }} </ref>
-|style="padding: 5px 5px; background: #F5F5F5;"| CBC
+|style="padding: 5px 5px; background: #F5F5F5;"| [[CBC]]
-|style="padding: 5px 5px; background: #F5F5F5;"| Increased or normal leukocyte count (lymphocytes)
+|style="padding: 5px 5px; background: #F5F5F5;"| Increased or normal [[leukocyte]] count (lymphocytes)
 |-
 ! rowspan="4" style="padding: 5px 5px; background: #DCDCDC; font-weight: bold;"| Fitz Hugh Curtis Syndrome<ref name="pmid18617765">{{cite journal| author=Yang HW, Jung SH, Han HY, Kim A, Lee YJ, Cha SW et al.| title=[Clinical feature of Fitz-Hugh-Curtis syndrome: analysis of 25 cases]. | journal=Korean J Hepatol | year= 2008 | volume= 14 | issue= 2 | pages= 178-84 | pmid=18617765 | doi=10.3350/kjhep.2008.14.2.178 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18617765  }} </ref>
-|style="padding: 5px 5px; background: #F5F5F5;"| CBC
+|style="padding: 5px 5px; background: #F5F5F5;"| [[CBC]]
-|style="padding: 5px 5px; background: #F5F5F5;"| Increased leukocytes
+|style="padding: 5px 5px; background: #F5F5F5;"| Increased [[leukocytes]]
 |-
-|style="padding: 5px 5px; background: #F5F5F5;"| LFTS
+|style="padding: 5px 5px; background: #F5F5F5;"| [[PFTS|LFTS]]
 |style="padding: 5px 5px; background: #F5F5F5;"| Normal
 |-
-|style="padding: 5px 5px; background: #F5F5F5;"| ESR
+|style="padding: 5px 5px; background: #F5F5F5;"| [[ESR]]
 |style="padding: 5px 5px; background: #F5F5F5;"| Normal or increased
 |-