Procalcitonin

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Procalcitonin
Author: Jiun-Lih (Jerry) Lin, MBBS; Chief Editor: Eric B Staros, MD more...
Updated: Feb 11, 2013

Reference Range
Procalcitonin (PCT), a protein that consists of 116 amino acids, is the peptide precursor of calcitonin, a hormone that
is synthesized by the parafollicular C cells of the thyroid and involved in calcium homeostasis. Procalcitonin arises
from endopeptidase-cleaved preprocalcitonin.
The reference value of procalcitonin in adults and children older than 72 hours is 0.15 ng/mL or less.
Reference values have not been established in infants younger than 72 hours.
In healthy adults, the reference range of procalcitonin is below the level of detection.[1]
The half-life of procalcitonin is 25-30 hours (not significantly altered in individuals with renal dysfunction).[2]

Interpretation
Conditions associated with mildly elevated serum procalcitonin (PCT) levels (0.15-2 ng/mL) include the following:
Localized mild-to-moderate bacterial infection
Noninfectious systemic inflammatory response
Untreated end-stage renal failure
Conditions associated with elevated serum procalcitonin levels (>2 ng/mL) include the following:
Bacterial sepsis
Severe localized bacterial infection (eg, severe pneumonia, meningitis, peritonitis)
Severe noninfectious inflammatory stimuli (eg, major burns, severe trauma, acute multiorgan failure, major
abdominal or cardiothoracic surgery)
Medullary thyroid carcinoma (may exceed 10,000 ng/mL)
In neonates aged less than 72 hours, a procalcitonin level of more than 1 ng/mL at birth, 100 ng/mL or more at age 24
hours, and 50 ng/mL or more at age 48 hours suggests serious bacterial infection.
In children with urinary tract infection, a procalcitonin level of more than 0.5 ng/mL suggests renal involvement.

Collection and Panels

Specifics for procalcitonin (PCT) collection and panels are as follows:
Specimen type: Blood serum
Container: Vacutainer, red top
Collection method: Venipuncture
Specimen volume: 0.5 mL
Related tests include complete blood cell (CBC) count, C-reactive protein (CRP), blood culture, and cerebrospinal
fluid (CSF) analysis.

Background
Description
Procalcitonin (PCT), a protein that consists of 116 amino acids, is the peptide precursor of calcitonin, a hormone that
is synthesized by the parafollicular C cells of the thyroid and involved in calcium homeostasis. Procalcitonin arises
from endopeptidase-cleaved preprocalcitonin.
Procalcitonin is also produced by the neuroendocrine cells of the lung and intestine and is released as an acute-phase
reactant in response to inflammatory stimuli, especially those of bacterial origin. This raised procalcitonin level during
inflammation is associated with bacterial endotoxin and inflammatory cytokines.[2, 1] Increased levels of serum
procalcitonin in response to viral infections and noninfectious inflammatory stimuli such as autoimmune disease and
chronic inflammatory processes are much less pronounced, rarely exceeding 0.5 ng/mL. Procalcitonin released as an
acute-phase reactant does not result in increased serum calcitonin levels.
The physiological importance and regulation of procalcitonin production is not well understood. Several hypotheses
suggest that procalcitonin may be involved in metabolism of calcium, cytokine network, and modulation of nitric oxide
(NO) synthesis, as well as pain-relieving effects.[3] No enzymes in the plasma break down procalcitonin. Therefore, if
procalcitonin enters the circulation, it remains unchanged, with a half-life of around 30 hours, with no evidence that
serum procalcitonin binds to cellular receptors of calcitonin or any specific procalcitonin receptors.[3]
Studies have shown that, in patients with sepsis, higher procalcitonin levels are associated with a greater risk of
progression to severe sepsis and septic shock, worsening the survival prognosis. Local bacterial infections and
abscesses do not significantly raise procalcitonin levels.[4] Procalcitonin levels fall with successful treatment of severe
bacterial infection and severe noninfectious inflammatory stimuli. Persistent or recurrent procalcitonin elevation in the
latter setting should prompt suspicion of secondary infection.

Indications/Applications
Indications for serum procalcitonin measurement include the following:
To aid in the diagnosis and risk stratification of bacterial sepsis[5, 6]

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To aid in the diagnosis of renal involvement in children with urinary tract infection
To aid in distinguishing bacterial from viral infections, including meningitis[7]
To monitor therapeutic response to antibacterial therapy and reduce antibiotic exposure[8, 9, 10, 11, 12]
To aid in the diagnosis of systemic secondary infection after surgery and in severe trauma, burns, and
multiorgan failure[13]
To aid diagnosis of infected necrosis and associated systemic complications in acute pancreatitis [14]
Proposed applications of serum procalcitonin measurement include the following:
To aid the choice and timing of the initiation of antibiotic treatment (Procalcitonin Algorithm)
To assist with elucidating prognosis of severe localized infections (eg, pneumonia)[15]
To aid with elucidating prognosis of critically ill patients with systemic infection
Predicting the need of antibiotic treatment in sepsis and to shorten the duration of antibiotics required[16]
Use as independent predictor of graft failure late after renal transplantation[17]
Procalcitonin versus C-reactive protein
CRP is the most common laboratory marker used in the clinical setting to evaluate systemic inflammatory response to
an infectious agent. It is routinely used as a diagnostic, predictor, and monitoring marker in patients with acute sepsis.
Several recent comparison studies have aimed to determine the use of PCT in conjunction with CRP or independent
of it in the setting of severe bacterial infections.
Procalcitonin is a more useful diagnostic inflammation parameter than CRP in patients with pediatric neutropenic fever,
both in estimating the severity of infection and the duration and origin of the fever.[18]
Procalcitonin is a more reliable parameter than other markers in the diagnosis of bacterial sepsis, allowing better
differentiation among sepsis-related fatalities.[19]
Procalcitonin is a useful early diagnostic marker for detection of bacteremia in febrile neutropenia and has better
diagnostic value than CRP.[20]

Considerations
Procalcitonin levels may also be elevated in medullary thyroid carcinoma[21] and small-cell lung carcinoma,[21]
paralytic/vascular ileus[18] exhibiting paraneoplastic production, and renal failure.[21]
Procalcitonin, although useful in bacterial sepsis, has no value in the assessment of fungal or viral infections and
shows no response to intracellular microorganisms (ie, Mycoplasma) or in local infections with no systemic response.
Similar to CRP, clinical conditions associated with high baseline procalcitonin levels include burns, major surgery, and
systemic inflammatory processes.
To date, the use of procalcitonin, both as an indicator of severe infection and predictor of antibiotic choices/duration,
has been center-specific, with insufficient data from multicenter/multinational studies to support its use as a routine
laboratory marker in clinical practice.

Contributor Information and Disclosures

Author
Jiun-Lih (Jerry) Lin, MBBS Resident Medical Officer, Royal North Shore Hospital, NSW
Disclosure: Nothing to disclose.
Coauthor(s)
Swee Leong Yap, MBBS Intern, Western Health Melbourne, Australia
Disclosure: Nothing to disclose.
Chief Editor
Eric B Staros, MD Associate Professor of Pathology, St Louis University School of Medicine; Director of Clinical
Laboratories, Director of Cytopathology, Department of Pathology, St Louis University Hospital
Eric B Staros, MD is a member of the following medical societies: American Medical Association, American Society
for Clinical Pathology, Association for Molecular Pathology, and College of American Pathologists
Disclosure: Nothing to disclose.

References
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