High mobility group box protein-1 (HMGB-1) as a new diagnostic marker in patients with acute appendicitis
© Albayrak et al; licensee BioMed Central Ltd. 2011
Received: 25 January 2011
Accepted: 20 April 2011
Published: 20 April 2011
The aim of this prospective study was therefore to evaluate the diagnostic value of preoperative serum High Mobility Group Box Protein-1 (HMGB-1) levels in patients with Acute Appendicitis (AA) who show normal white blood cell count (WBC) counts.
Our study was carried out from October 2010 through November 2010 and included 20 healthy control group participants and 60 patients who presented at the emergency department of Erzurum Training and Research Hospital in Turkey with acute abdominal pain complaints, who were pathologically diagnosed with AA after laparotomy, and who agreed to participate in the study.
Of the 60 patients who underwent appendectomies, 36 were male and 24 were female, and of the healthy group, 12 were male and 8 female. The age averages of the patients in Groups 1, 2 and 3 were, respectively, 31.3+15.4, 34.0+16.3 and 31.0+13.1 years. The WBC averages of Groups 1, 2 and 3 were, respectively, 7.41+2.02 (x109/L), 15.71+2.85 (x109/L) and 8.51+1.84 (x109/L). The HMGB-1 levels for Groups 1 (healthy persons), 2 (AA patients with high WBC counts ) and 3 (AA patients with normal WBC counts) were, respectively, 21.71 ± 11.36, 37.28+13.37 and 36.5 ± 17.73 ng/ml. The average HMGB-1 level of the patients with AA was 36.92 ± 15.43 ng/ml while the average HMGB-1 value of the healthy group was 21.71 ± 11.36 ng/ml.
The significantly higher levels of HMGB-1 in AA patients compared to healthy persons infer that HMGB-1 might be useful in the diagnosis of AA. Use of HMGB-1, especially in patients with normal WBC counts, will reduce the number of unnecessary explorations.
Acute appendicitis (AA) is a common abdominal surgical emergency that can affect individuals of all ages, with a lifetime occurrence of approximately 7% [1, 2]. AA is commonly diagnosed through a combination of clinical information including symptoms and physical examination findings, traditional biomarkers (e.g., white blood cell count (WBC), mean platelet volume (MPV), absolute neutrophil count (ANC), and C-reactive protein (CRP)) and radiographic imaging (e.g., ultrasound and computed tomography scans) [3–6]. However, preoperative diagnostic difficulties still occur, resulting in a percentage of incorrect diagnoses that can reach up to 20% in the general population, and even up to 40% in women of reproductive age [7–9].
Despite the multiple modern diagnostic tools currently available, diagnosis of AA still depends primarily on patient history and physical examination. The result is that, even with access to laboratory and radiological diagnostic equipment capable of aiding diagnosis of AA, on occasion, patients without actual AA will still undergo unnecessary exploratory surgery. Therefore, the need is great for new, easily applied and inexpensive diagnostic tools that have high diagnostic value for AA and little operator dependence.
The most often used and most practical laboratory test for AA diagnosis is the WBC test. However, WBC counts can sometimes be normal in patients with AA, causing doctors to have difficulties in diagnosing AA. In the present study, we hypothesize that High Mobility Group Box Protein-1 (HMGB-1) could be a good candidate to aid in AA diagnosis. HMGB-1 is viewed as a proinflammatory cytokine due to its active secretion by innate immune cells such as neutrophils, monocytes and macrophages [10, 11]. The aim of this prospective study was therefore to evaluate the diagnostic value of preoperative serum HMGB1 levels in patients with AA who show normal WBC counts.
The protocol was approved by the Research Ethics Committee of Erzurum Region Education and Research Hospital. Our study was carried out from October 2010 through November 2010 and included 60 patients who presented at the emergency department of Erzurum Training and Research Hospital in Turkey with acute abdominal pain complaints, who were pathologically diagnosed with AA after laparotomy and who agreed to participate in the study. A healthy control group consisted of 20 healthy persons who came to the hospital just for purposes of a check-up in the Infection Diseases Clinics, who had no complaints and who did not conform to the exclusion criteria. Full blood counts were performed on patients who had a history of periumbilical or right lower quadrant pain, who exhibited nausea, vomiting, anorexia, or fever, who showed abdominal examination findings and/or whose condition was indicative of AA based on the general clinical intuition of the physician. Abdominal ultrasound scans were performed on all patients.
Inclusion and exclusion criteria
All of the patients underwent operations for appendicitis on the basis of the history, physical findings, and relevant clinical data. Postoperatively, the removed appendix was sent for histopathological examination. Cases where the histopathology was not consistent with appendicitis were excluded from the study. The exclusion criteria for entry into the study were heart failure, peripheral vascular disease, haematological disorders, acute or chronic infection, cancer, prior antibiotic therapy, an age < 10 years, pregnancy, hepatic diseases and other known inflammatory conditions. None of the patients had received prior anticoagulant medications, nonsteroidal anti-inflammatory drugs or oral contraceptives.
Blood samples were obtained from the patients upon admission to the hospital. Preoperative complete blood count (CBC) was performed using a Beckman Coulter analyzer (Bayer Healthcare LLC, Diagnostic Division, Tarrytown, New York). The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of these tests were calculated. All laboratory analyses were performed in the haematology laboratory of our hospital. Normal values for white blood cells (WBCs) were determined based on published reference ranges from the hospital's haematology laboratory. Preoperative blood samples were collected into Vacutainer tubes (BD, New Jersey), centrifuged at 1300 g for 10 min, and stored at -80°C until the analysis. HMGB1 levels were measured in duplicate using commercially available ELISA kits (HMGB1: Uscn Life Science Inc., Wuhan, China) following the manufacturer's instructions.
A total of 60 patients and 20 healthy persons were included in this study, and were separated into three groups. The first group (Group1) consisted of healthy persons (n = 20), the second group (Group 2) consisted of Acute Appendicitis patients with high WBC counts (n = 32), and the third group (Group 3) consisted of Acute Appendicitis patients with normal WBC counts (n = 28).
The Statistical Package for Social Sciences (SPSS) 16.0 for Windows was used to analyze the data in terms of mean ± standard deviation (SD). Group comparisons were performed using one-way ANOVA of repeated measurements. For post hoc analysis, the Tukey test was applied. AA and control groups were compared using Student t-tests. Receiver operating characteristic (ROC) curve analysis was used to identify optimal cut-off values of HMGB-1. Sensitivity, specificity, PPV and NPV were calculated according to standard methods. P values below 0.05 were considered statistically significant.
Clinical Characteristics of Acute Appendicitis Patients and Controls
Group 1 (n = 20)
Group 2 (n = 32)
Group 3 (n = 28)
7.41 ± 2.02
15.71 ± 2.85
8.51 ± 1.84
21.71 ± 11.36
37.28 ± 13.37
36.51 ± 17.74
Levels of HMGB-1 in controls and in acute appendicitis patients
In this study, we investigated potential variations in the blood levels of HMGB-1 levels that might occur in patients with AA when compared with healthy persons. The overall aim was to determine whether this blood component might have a place in the diagnosis of AA. To our knowledge, no studies reported in the literature have yet evaluated an association between HMGB-1 and AA.
In conclusion, although many auxiliary diagnostic tools are available for diagnosis of AA, this condition is sometimes difficult to diagnose. Misdiagnosis results in many persons undergoing unnecessary exploratory surgeries. Therefore, a need exists for new diagnostic tools that can support a diagnosis of AA. The significantly higher levels of HMGB-1 in AA patients compared to healthy persons infer that HMGB-1 might be useful in the diagnosis of AA. We believe that the use of HMGB-1, especially in patients with normal WBC counts, will reduce the number of unnecessary explorations.
High Mobility Group Box Protein-1
white blood cell count
mean platelet volume
absolute neutrophil count
positive predictive value
negative predictive value
Receiver operating characteristic
macrophage inflammatory protein 1
acute respiratory distress syndrome.
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