Ans. is 'b' i.e., Multiple myelomaFactors affecting ESR 1. Plasmao RBCs carry a negative electric charge, whereas plasma carries a postive charge.o Any condition in plasma that increases its positive charge, increases rouleaux formation and increases ESR by lengthening stage I.o Following factors increase positive charge and ESR : -i) Fibrinogen ----> Any condition which increases fibrinogen level will increase ESR - e.g.,a) Infectionb) Inflammationc) TBii) Globulin --> Conditions which increases globulin level will increase ESR.a) Kala azarb) Multiple myelomac) Some lymphoproliferative disordersd) Rheumatic feveriii) Cholesterol --> Hypercholesterolemia increases ESR.o Any condition in plasma that decreases its positive charge, decreases rouleaux formation and decreases ESR.i) Albumin --> Hyperalbuminemia decreases ESR.ii) Decreased fibrinogen ---> In afibrinogenemia, ESR is zero.2. RBCso Increase in blood count as in polycythemia decreases ESR due to the jostling (or pushing one another) effect on the cells.o Anemia increases the ESR by opposite effect, there are two exceptions.i) Sickle cell anemiaii)Microcytic hypochromic anemia (iron deficiency, Thalassemia)o In last two types of anemia, ESR decreases because altered red cell shape prevents rouleux formation.3. Physiological variationso ESR is low in infancyo ESR is high at pubeyo ESR is greater in women than man.4. Ohterso ESR is decreased in congestive hea failureo ESR is increased in acute myocardial infarction.