Polymyalgia rheumatica, temporal arteritis and malignancy

The use of steroid therapy in polymyalgia rheumatica and temporal arteritis is necessary and usually effective, but may mask coexisting disease. The importance of early consideration of other disorders in such patients is illustrated by three case histories.

Anticardiolipin antibodies in the polymyalgia rheumatica-temporal arteritis syndromes

A series of seven patients with the polymyalgia rheumatica-temporal arteritis (PMR-TA) complex is presented, each of whom during the clinical course demonstrated the presence of anticardiolipin antibodies (ACLs). Presenting symptoms consisted of proximal myalgias and stiffness characteristic of PMR in five patients and of visual symptoms and headache suspicious for TA in two patients. Two of the five PMR patients later developed jaw claudication characteristic of TA. Six of the seven cases demonstrated clinical evidence of a vasculopathic process such as a cerebrovascular infarct or a vasculitic syndrome. Previous studies have suggested an association between ACLs and PMR-TA, and this series of patients appears to provide more supporting evidence. Even patients who only manifested PMR symptoms without suggestion of accompanying TA developed vascular complications. An increasing range of symptoms have been recognized in association with ACLs, and the vasculitic syndromes of PMR-TA should be included as a possible association. While this series together with previous studies may suggest that the presence of ACLs in patients with PMR-TA symptoms may serve as a marker for the development of vascular complications, larger longitudinal studies will be necessary in the future.

[Giant-cell arteritis. Comments on the case histories of 30 patients]

This survey deals with the main clinical aspects at the diagnosis and during the follow-up of thirty consecutive patients with giant-cell arteritis (temporal arteritis and rheumatic polymyalgia), controlled over a period of 15 years. The work aimed at verifying the diagnostic accuracy with regard to a more underestimated than rare disease. We believe that such a consideration is a useful introduction to a wider research into the epidemiological and biological aspects of the disease which are still to be determined.

[Polymyalgia rheumatica and temporal arteritis. New aspects of diagnosis, treatment, prognosis and risk of cancer]

The incidence of polymyalgia rheumatica and temporal arteritis is increasing, mainly in elderly people. The risk of cancer during a lifetime is high in patients with positive biopsy of the temporal artery, but polymyalgia rheumatica and temporal arteritis are not to be considered as paraneoplastic syndromes. Temporal arteritis can appear in patients under treatment for polymyalgia rheumatica, and polymyalgia rheumatica can be accompanied by arthritis. Various new aspects of diagnoses and treatment are discussed.

An association of polymyalgia rheumatica with myelodysplastic syndromes

Myelodysplastic syndromes are a group of clonal hematopoietic stem cell disorders leading to peripheral cytopenias and a high probability of leukemic transformation. Immunological abnormalities, both humoral and cell mediated immunity, as well as vasculitis, a "lupus-like syndrome," neuropathy, and arthritis have been described in association with myelodysplastic syndromes. We describe 3 cases of polymyalgia rheumatica (PMR) developing within 4 months of detection of cytopenia. The possible association of myelodysplastic syndromes and PMR has not been previously recognized.

Polymyalgia rheumatica: a comprehensive review of this debilitating disease

Polymyalgia rheumatica (PMR) is a cause of moderate to severe musculoskeletal pain in older people. This debilitating disease is characterized by bilateral proximal aching and morning stiffness in the neck, shoulders, upper arms, lower back, hips, and thighs. This article includes specific assessments related to PMR and an associated disease, giant cell arteritis (GCA). A comprehensive review of the incidence, etiology, duration of illness, pertinent laboratory studies, and medical treatment is provided for health care practitioners. A patient teaching handout summarizes key concepts. Specific clues that help the practitioner recognize the disease in patients and associated treatments are emphasized.

Fatal myocardial infarction resulting from coronary arteritis in a patient with polymyalgia rheumatica and biopsy-proved temporal arteritis. A case report and review of the literature

Giant cell arteritis is frequently an attendant complication of polymyalgia rheumatica. While involvement of other arterial beds is occasionally identified, this syndrome is most frequently recognized when symptomatic involvement of the temporal arteries occurs. We describe such a patient who despite initial treatment with high-dose intravenous and standard (5-day) orally administered corticosteroid therapy suffered a fatal myocardial infarction, which at autopsy was shown to be a consequence of granulomatous coronary arteritis. The literature is reviewed and the clinical implications of this case are discussed.

[Relationships between rhizomelic pseudo-polyarthritis and mitochondrial myopathy. 24 cases]

OBJECTIVES

Diagnosis of polymyalgia rheumatica requires the elimination of other inflammatory diseases due to the lack of a specific diagnostic criteria. Since results of muscle biopsy have been considered non-specific, we evaluated the full spectrum of histological, histochemical and biochemical data observed in 24 patients with suspected polymyalgia rheumatica.

METHODS

From January 1989, the diagnosis of polymyalgia rheumatica was suspected in 24 patients (4 males, 20 females; mean age 67.8 years, range 50-88) hospitalized in our unit for inflammatory joint and muscle pain with a current duration of 6-30 months. Muscle biopsies were obtained in each case.

RESULTS

Based on the histological, histo-enzymatic, ultrastructural and biochemical analyses, 19 patients fulfilled the criteria defining mitochondrial myopathies. After favourable outcome (reduced pain, involution of biochemical inflammatory syndrome) following prednisone therapy (0.5 mg/kg/day) a second muscle biopsy revealed identical abnormalities.

CONCLUSION

These muscular diseases have been described mainly as hereditary encephalo-myopathies, but in our series the mitochondrial myopathy may have preceded the polymyalgia rheumatica or been acquired, aggravating the inflammatory process. Muscle biopsy might act as a referee for diagnosis.

Polymyalgia rheumatica and thyroid papillary carcinoma

This is a case report of a 64-year-old woman with polymyalgia rheumatica (PMR) and thyroid papillary carcinoma. Peripheral blood lymphocyte response to pokeweed mitogen, concanavalin A and phytohemagglutinin was increased compared to controls during aggravation of PMR. These responses were normalized to control values after low-dose corticosteroid therapy (prednisolone 10 mg; 7 days and 7.5 mg; 3 days) and PMR symptoms disappeared. The patient had undergone total neck thyroidectomy and metastatic neck lymph node dissection three and six years after the onset of PMR, respectively. Nine months after the removal of metastatic lymph nodes, she was free of symptoms of PMR and peripheral blood lymphocyte response to mitogens was within the control range. PMR appeared to be a component of the long-standing paraneoplastic syndrome, induced by the tumor which had impaired cell-mediated immunity.

[4 cases of Horton's temporal arteritis. Hypothesis on the possible correlations with rheumatic polymyalgia]

Giant cell arteritis (GCA) or temporal arteritis is an entity of unknown aetiology and uncertain autonomy for the close relationship with polymyalgia rheumatica (PMR). This work describes four patients with GCA alone. All patients had clinical and laboratoristic evidence of the disease and were treated with steroids. The distribution of HLA antigens showed an increased occurrence of DR4 and B8 antigens. Unfortunately, the small number of patients and the short period of observation don't allow to prove the exact nature of the link between GCA and PMR.

Gastropleural fistula following pulmonary resection

A 77 year old man with an eight month history of polymyalgia rheumatica treated by steroids underwent left lower lobectomy for a non-small cell carcinoma. Following discharge he developed a pneumothorax, empyema, septicaemia, and acute renal failure. Reinvestigation and reoperation showed this to be caused by a non-malignant non-traumatic direct gastropleural fistula.

The clinical and laboratory course of polymyalgia rheumatica/giant cell arteritis after the first two months of treatment

OBJECTIVES

To examine the clinical course of polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) in a prospective study, after the initial two months.

METHODS

Seventy four patients with PMR/GCA were followed for a median of 60 weeks. Detailed clinical and laboratory records were made on each visit.

RESULTS

Twenty per cent of patients with PMR developed GCA and 24% of patients with GCA developed PMR from the onset of symptoms. After two months, most patients experienced at least one relapse. Relapses and persistence of abnormal symptoms and signs were most common in patients with both PMR and GCA and least common in those with GCA alone. Relapses were most common in the first year and 54% occurred in association with steroid reduction. Major complications were rare. Laboratory parameters and temporal artery histology were not helpful in predicting relapse. Only 24% of patients were able to stop steroid treatment after two years.

CONCLUSIONS

Clinicians should consider more frequent review in patients at times of steroid reduction and especially within the first six months of treatment.

[Giant cell arteritis and aortic dissection in 2 siblings]

We present the case of two female siblings with temporal arteritis, polymyalgia and type B aortic dissection. Aortic aneurysms in families are well known in Marfan's and Ehlers-Danlos syndrome; they can, however, occur without signs of a collagen disorder. In patients with arteritis temporalis the incidence of aortic aneurysms is higher than normal. In a retrospective survey of 20,591 autopsies there were 443 aortic aneurysms (2%), 30 (7%) being a consequence of arteritis. Arteritic processes caused 15% of the thoracic and 5% of the abdominal aneurysms. This is the first description of temporal arteritis, polymyalgia and aortic dissection in siblings. The observation illustrates the danger of aneurysmatic aortic dilatation and/or dissection at a later or chronic stage of arteritis.

Polymyalgia rheumatica and giant cell arteritis in emergency department patients

Elderly patients with undiagnosed polymyalgia rheumatica and giant cell arteritis are not uncommon, and they may present to the emergency department with nonspecific physical complaints. We describe the cases of two patients who had the "typical" constellation of symptoms. It is important that emergency physicians consider the diagnosis and provide appropriate testing, therapy, and follow-up.

Cancer in association with polymyalgia rheumatica and temporal arteritis

In our prospective controlled study, a total of 185 patients with polymyalgia rheumatica (PMR) and temporal arteritis (TA) diagnosed during 1978-83 and their 925 matched controls were cross checked with the data files at the Cancer Registry of Norway at the end of 1987. Malignancy was registered in 27 patients (14.6%) and 131 controls (14.2%) between 1953 and the end of 1987. Malignancy was registered in 16 (24.6%) of the patients with biopsy demonstrating arteritis temporalis. The hazard rate for developing malignancy after diagnosis for the whole patient population was not significantly different from the controls. The hazard rate for developing malignancy in patients with positive biopsy, however, was 2.35 times higher than in the controls (p = 0.036) and 4.40 times higher than the rest of the patient population (p = 0.007) (Cox proportional hazards model). The general long interval between diagnosis of PMR and/or TA and registration of malignancy (mean 6.5 years) is not consistent with a paraneoplastic mechanism.

[Giant cell arteritis and polymyalgia rheumatica presenting as subclavian artery obstruction]

Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are common diseases in the elderly. The arteritis usually affects medium sized vessels, but large vessel involvement can also occur leading to arm claudication, bruits, loss of pulses and pallor of the upper extremities. The differential diagnosis of large vessel arteritis includes atherosclerosis and Takayasu's disease. Atherosclerosis, which affects patients of similar age to GCA is usually confined to the lower limbs and can be differentiated on the basis of the clinical setting and investigations such as the ESR, arteriography and temporal artery biopsy. Takayasu's arteritis' although histologically and arteriographically indistinguishable from GCA, is predominantly a disease of young women. A patient is described who presented with upper limb ischemia. A clinical examination revealed absence of right radial pulses and presence of murmurs at level of the carotids. The blood pressure was unrecordable in the upper right limb. The ESR was 102 mm/hr and the C-reactive protein was 11.66 mg/dl. A selective arteriography of the aortic arch and its branches revealed a right subclavian artery obstruction with good collateral circulation and a left subclavian artery stenosis. The biopsy of left temporal artery showed a typical GCA in acute stage. Treatment with prednisolone 30 mg/day was started and four weeks later, the ESR had fallen to normal. In addition this case confirms that PMR implies a systemic arteritis.

[Prevalence of hypothyroidism and hyperthyroidism in temporal arteritis and rhizomelic pseudopolyarthritis. A controlled study of 104 cases]

The aim of this study was to assess the prevalence of hyperthyroidism and hypothyroidism in giant cell arteritis and polymyalgia rheumatica. The prevalence of thyroid dysfunction in giant cell arteritis and polymyalgia rheumatica patients was determined retrospectively from 1976 through 1984 and prospectively from 1984 through 1991. A control group was composed of patients over 55 years of age consecutively admitted to the same hospital department for another condition. Patients were screened for thyroid dysfunction using a thyrotropin assay. Abnormal results were evaluated by T3 and T4 assays and, if needed, a TRH test. Among the 68 giant cell arteritis patients (mean age 72.6 +/- 7 years), of which 41 were included in the prospective arm of the study, 6 had hypothyroidism and 3 had hyperthyroidism. Corresponding figures were 4 and 4 among the 36 patients with polymyalgia rheumatica (mean age 71.7 +/- 8.3 years), of which 18 were evaluated prospectively. Among the 305 controls (mean age 71.6 +/- 9.4 years), 16 had hypothyroidism and 10 had hyperthyroidism. Prevalences of hypothyroidism, hyperthyroidism, and antithyroid antibodies were not significantly different in the control and case groups. Data fail to support previous suggestions that giant cell arteritis or polymyalgia rheumatica patients may be an increased risk for hypothyroidism or hyperthyroidism. They lend no indirect support to the hypothesis that giant cell arteritis and polymyalgia rheumatica may be autoimmune disorders.

Increased RAHA titer and interleukin-6 levels in the synovial fluid in a patient with polymyalgia rheumatica

We report a patient with polymyalgia rheumatica (PMR) accompanied by an increased Rheumatoid Arthritis Hemagglutinin Test (RAHA) titer and interleukin-6 level in the synovial fluid. A 60-year-old female was admitted because of polymyalgia, a body temperature of 39.2 degrees C, and an erythrocyte sedimentation rate increased to 94 mm/h. Since a muscle biopsy failed to show a specific finding, she was diagnosed as PMR. The titer of RAHA and the interleukin-6 level were increased only in the synovial fluid; prednisolone treatment decreased both. The present case raised the possibility that a similar mechanism in rheumatoid arthritis may involve the development of synovitis in PMR.