T-786C single nucleotide polymorphism of the endothelial nitric oxide synthase gene as a risk factor for endothelial dysfunction in polymyalgia rheumatica

OBJECTIVES

We investigated the association of the T-786C single nucleotide polymorphism (SNP) of the endothelial nitric oxide synthase gene (NOS3), which is characterised by reduced expression of the enzyme in response to shear stress or interleukin-10 stimulation and significantly associated with coronary heart disease or rheumatoid arthritis, with the occurrence of isolated polymyalgia rheumatica.

METHODS

A cohort of 78 patients who had presented at a rheumatological specialist practice in Heidelberg was tested for the T-786C SNP by means of restriction fragment length polymorphism analysis, and the result was compared with the data of a control cohort (n=2061) compiled from the genotyping of umbilical cord arteries from newborns. Patients were tested for an association with the genotype and their clinical characteristics obtained at the time of the initial presentation and during the first year of treatment.

RESULTS

The T-786C SNP of the NOS3 gene was significantly associated with isolated PMR (p=0.0009; OR 2.475). The C-allele frequency in patients with PMR was higher than in patients with rheumatoid arthritis, who also showed a significant association with the T-786C SNP (PMR 0.481 vs. 0.422 RA). A significant association with clinical features of the patients could not be detected.

CONCLUSIONS

The T-786C SNP of the NOS3 gene, which predisposes towards the development of endothelial dysfunction, is significantly associated with polymyalgia rheumatica manifesting itself without any clinically detectable vascular involvement.

"I suddenly felt I'd aged": a qualitative study of patient experiences of polymyalgia rheumatica (PMR)

OBJECTIVES

To explore patient experiences of living with, and receiving treatment for, PMR.

METHODS

Semi-structured qualitative interviews, with 22 patients with PMR recruited from general practices in South Yorkshire. Thematic analysis using a constant comparative method, ran concurrently with the interviews and was used to derive a conceptual framework.

RESULTS

5 Key themes emerged highlighting the importance of: (1) pain, stiffness and weakness, (2) disability, (3) treatment and disease course, (4) experience of care, (5) psychological impact of PMR. Patients emphasised the profound disability experienced that was often associated with fear and vulnerability, highlighting how this was often not recognised by health care professionals. Patients' experiences also challenge medical convention, particularly around the concept of 'weakness' as a symptom, the use of morning stiffness as a measure of disease activity and the myth of full resolution of symptoms with steroid treatment. Treatment decisions were complex, with patients balancing glucocorticoid side effects against persistent symptoms.

CONCLUSIONS

Patients often described their experience of PMR in terms of disability rather than focussing on localised symptoms. The associated psychological impact was significant.

PRACTICE IMPLICATIONS

Recognising this is key to achieving shared understanding, reaching the correct diagnosis promptly, and formulating a patient-centred management plan.

Polymyalgia rheumatica in a patient with splenic marginal zone lymphoma - a case report

Polymyalgia rheumatica (PMR) is a common inflammatory disease in elderly people. We present a case of a 49-year-old woman diagnosed with PMR. The treatment with prednisone resulted in a rapid resolution of clinical symptoms. However, inflammatory markers remained elevated. Ultrasonography and computed tomography revealed the presence of a large splenic lesion. A cyst was suspected but, because of the high risk of splenic rupture, a splenectomy was performed. The histopathological examination revealed the presence of splenic marginal zone lymphoma. Inflammatory markers returned to normal after splenectomy. Prednisone was tapered but clinical symptoms of PMR reappeared after lowering the dose of prednisone <10 mg/day. Thus, treatment with methotrexate was started, which allowed for further tapering of prednisone.

Polymylagia rheumatica: common disease, elusive diagnosis

Polymyalgia rheumatica (PMR) is a common inflammatory rheumatic disease with little known about its etiology or incidence. Frequently found in older adult women, this disease can be debilitating, painful, and dangerous. Diagnosing PMR can be elusive due to lack of specific laboratory tests, and treatment with use of long-term glucocorticoids can be difficult due to side effects. The following article describes the pathophysiology, diagnosis, signs and symptoms, and treatment of PMR, as well as implications for home healthcare.

[RHEUMATIC POLYMYALGIA: CASE REPORT]

This case report demonstrates the diagnostic potential of outpatient examination of patients with rheumatic polymyalgia and describes an algorithm for differential diagnostics. The report is also of interest as an example of long-term (10 year) remission that can be interpreted as a complete recovery.

Clinical practice. Giant-cell arteritis and polymyalgia rheumatica

A 79-year-old woman presents with new-onset pain in her neck and both shoulders. She takes 7.5 mg of prednisone per day for giant-cell arteritis. Occipital tenderness and diplopia developed 11 months before presentation. At that time, her erythrocyte sedimentation rate was elevated, at 78 mm per hour, and a temporal-artery biopsy revealed granulomatous arteritis. The diplopia resolved after 6 days of treatment with 60 mg of prednisone daily. Neither headache nor visual symptoms developed when the glucocorticoids were tapered. How should this patient’s care be managed?

Influence of interleukin 10 promoter polymorphisms in polymyalgia rheumatica: disease susceptibility and functional consequences

OBJECTIVES

To investigate the functional consequences of IL10 (-592C/A and -1082A/G) gene polymorphisms and their association with susceptibility to, and disease phenotype, in patients with polymyalgia rheumatica (PMR).

METHODS

A total number of 168 with PMR and 124 age-matched controls were genotyped using allele-specific primers and restriction fragment length polymorphism analysis. The levels of circulating IL10 and the production of IL10 by PBMCs after in vitro stimulation were studied by Cytometric Bead Array.

RESULTS

No significant differences were observed in genotype or allele frequency distribution between patients and controls. The clinical characteristics and prognosis of these patients were also unrelated to the presence of these polymorphisms. No significant differences between PMR patients with low ESR (<40 mm/hr) and classic PMR (>40 mm/hr) were found. Furthermore, we did not observe any influence of circulating IL10 with the intensity of the acute phase response. In both, PMR patients and age-matched controls, no differences in circulating IL10 levels or IL10 production were observed depending on the genotypes of the IL10 gene.

CONCLUSIONS

These results do not support the impact of IL10 variants in susceptibility or clinical phenotype of PMR patients. In this aged population no functional association was found between IL10 gene variants and IL10 production.

Polymyalgia rheumatica: clinical update

BACKGROUND

Polymyalgia rheumatica is a relatively common inflammatory rheumatic disease. There are no validated international guidelines available for the diagnosis and treatment of PMR; however, diagnostic and classification criteria are currently being developed.

OBJECTIVE

The aim of this article is to summarise the main management options suggested by American College of Rheumatology and discusses the role of the general practitioner in the diagnosis and early management of PMR.

DISCUSSION

Diagnosis is made on the basis of a combination of clinical and laboratory findings. Patients typically present with shoulder and hip girdle pain with pronounced stiffness. Inflammatory markers are usually elevated and an ultrasound and MRI of the shoulder and hip can be done to localise inflamed tissues. Response to steroids should not be used as a defining feature of PMR but treatment with low dose prednisone should be considered. PMR has an excellent prognosis if diagnosis is prompt and therapy adequate.

[Polymyalgia rheumatica and aortic involvement]

Polymyalgia rheumatica (PMR) is an inflammatory disorder that affects people over 50 years of age, characterized by pain and stiffness in the neck and shoulder and pelvic girdles. PMR may occur as an isolated condition or concomitantly with giant cell arteritis. Similar to other inflammatory rheumatic disorders, PMR is associated with an increased cardiovascular risk due to inflammatory changes in large arterial vessels, which result in an increased chance of developing aneurysms and dissections. International guidelines do not provide specific indications about the management of PMR patients with aortic wall inflammation. In this review, we propose a diagnostic pathway for the management of PMR patients with aortic involvement based on literature data and personal experience.

[Peripheral arthritis in polymyalgia rheumatica]

Polymyalgia rheumatica is characterized by aching and stiffness of the shoulder, the pelvic girdles and the neck. Peripheral joint involvement is less recognized by the medical community as a sign of the disease. In this article we present two patients whose disease was manifested by peripheral symptoms. The frequency, manifestations and the pathogenesis of the disorder are discussed and the importance of recognition of these symptoms and signs of the disease is stressed.

Large-vessel involvement in giant cell arteritis and polymyalgia rheumatica

Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are closely related disorders that affect people of middle age and older, and frequently occur together. With the widespread use of newer vascular imaging modalities, large-vessel involvement (LVI) has increasingly been recognised in patients with GCA and less often in those with PMR. LVI in GCA can result in complications such as aortic aneurysm and dissection, aortic arch syndrome, and limb arteries stenosis, while vascular complications in PMR are exceedingly rare. It is still controversial which patients should be investigated for LVI, and how LVI should be diagnosed, monitored and managed. In this review, we will try to address six important issues regarding LVI in GCA and PMR.

"In sickness and in health": the peculiar occurrence of polymyalgia rheumatica in married cohabiting couples--a case series and review of the literature

Polymyalgia rheumatica (PMR) is an inflammatory rheumatic disorder in elderly people. It is frequently associated with giant-cell arteritis (GCA), although it is still debated if they are the same disease or two distinct pathologies. The etiology of PMR remains challenging, although current knowledge supports the role of both genetic and environmental factors. Among these, there is evidence that infectious agents could trigger the disease's onset in some cases. We describe the peculiar case where PMR occurred in two Italian married and cohabiting couples and provide a review of the literature for similar cases. This is the first reported occurrence of PMR in two conjugal pairs in Italy. Moreover, in the second case, the wife presented PMR associated with GCA. To date, seven cases of PMR and two of GCA in married couples are described in the literature. The occurrence of PMR in both a husband and a wife supports the pathogenetic role of an environmental factor.

Polymyalgia rheumatica--diagnosis and classification

Polymyalgia rheumatica is the most common inflammatory rheumatic disease of the elderly, and shares many pathogenetic and epidemiological features with giant cell arteritis. The typical symptoms are bilateral aching of the shoulder girdle, associated with morning stiffness. The neck and hip girdle may also be involved. The diagnosis of polymyalgia rheumatica is made primarily on clinical grounds. There is no single diagnostic test, but sets of diagnostic or classification criteria have been suggested by several groups of investigators, based on the typical clinical presentation and laboratory evidence of acute-phase reaction. Other conditions that may mimic polymyalgia rheumatic, such as elderly-onset rheumatoid arthritis, must be excluded by appropriate testing and close monitoring of the disease course. Glucocorticoids at low doses (15-20 mg prednisone per day initially) are the mainstay of treatment.

Left atrial myxoma detected after an initial diagnosis of polymyalgia rheumatica

We herein report the case of a 69-year-old woman with left atrial myxoma detected following treatment with glucocorticoids for an initial diagnosis of polymyalgia rheumatica (PMR). The glucocorticoids markedly improved the patient's symptoms, and the tumor was excised after rapidly tapering the glucocorticoid dose. The PMR-like symptoms did not recur and the inflammatory marker levels returned to normal after surgery. The patient's clinical course indicated that the initial PMR-like symptoms were entirely caused by the left atrial myxoma. This case demonstrates that glucocorticoid treatment for suspected PMR can mask the symptoms of myxoma, leading to a delay in diagnosis.

Recognition and management of polymyalgia rheumatica and giant cell arteritis

Polymyalgia rheumatica affects proximal muscles and joints, causing disability in older adults. Giant cell arteritis affects medium and large arteries and can result in blindness. These conditions overlap significantly, often occurring together. Despite the similarities, each has distinct symptoms, corticosteroid dosing requirements, and prognosis. The hallmark of both conditions is inflammation. Polymyalgia rheumatica primarily affects the shoulders, neck, and hips with prominent bilateral pain. Systemic findings such as fatigue and weight loss are common, and there is no definitive diagnostic test. Moderate-dose corticosteroid therapy with a slow taper rapidly resolves symptoms. Management of patients responding to treatment can occur in the primary care setting, if there is no concomitant giant cell arteritis. The clinical presentation of giant cell arteritis varies widely, from new-onset headache and constitutional symptoms, to jaw claudication, to less common isolated visual changes and upper extremity claudication. Treatment requires higher dosages of corticosteroids and urgent referral to a rheumatologist. Relapse is common in both diseases. Surveillance is important, as is monitoring for long-term complications of corticosteroid use. Osteoporosis management and gastrointestinal ulcer prophylaxis should be initiated. The primary care physician's coordination of care with a rheumatologist and with other subspecialists, if needed, is essential in the management of giant cell arteritis.

Update on polymyalgia rheumatica

Polymyalgia rheumatica is an inflammatory disease of unknown etiology affecting individuals aged fifty years and older, mainly of Caucasian ethnicity. Polymyalgia rheumatica is associated with giant cell arteritis more frequently than expected by chance alone. In both conditions, females are affected two to three times more often than males. The clinical hallmark manifestations of polymyalgia rheumatica are aching and morning stiffness in the shoulder girdle and often in the pelvic girdle and neck. Serum inflammatory markers are typically elevated, while the most consistent abnormal finding on imaging studies is bursitis in the symptomatic areas. A dramatic response to glucocorticoids is characteristic of polymyalgia rheumatica. Many patients are able to discontinue glucocorticoids six months to two years after the onset of clinical symptoms, but some patients may require longstanding glucocorticoid treatment. Glucocorticoid-sparing agents may be helpful in patients with chronic relapsing courses and those at high risk of glucocorticoid-related adverse events.

Discontinuation of therapies in polymyalgia rheumatica and giant cell arteritis

Glucocorticoids are highly effective in treating polymyalgia rheumatica and giant cell arteritis, but their use is associated with numerous adverse events. Therefore, it is important to use them for the shortest period of time possible. The published evidence suggests that discontinuation of GC is feasible in a substantial number of patients with polymyalgia rheumatica and giant cell arteritis after an adequate period of treatment, provided that glucocorticoids are tapered gradually. Recurrences are relatively infrequent in polymyalgia rheumatica and somewhat more common in giant cell arteritis. Immunosuppressive agents may be used in patients with frequently relapsing or recurring disease to decrease exposure to glucocorticoids.

Polymyalgia rheumatica and giant cell arteritis: how best to approach these related diseases

Each of these painful disorders can be challenging to diagnose, and many patients have both. Adequate glucocorticoid dosing and gradual tapering are key to treatment success.

Polymyalgia rheumatica in 2011

Polymyalgia Rheumatica (PMR) is an inflammatory rheumatic disease that commonly affects individuals over 50 years of age, characterised by pain and morning stiffness of the shoulder and pelvic girdle. PMR can present as 'isolated' form or may be associated with giant cell arteritis. The progress of imaging techniques has helped in understanding different clinical patterns: subclinical vasculitis can occur in at least one-third of PMR patients, causing ischaemic complications. It is considered a polygenic disease and environmental factors may play a role in its pathogenesis, such as viral or bacterial triggers, both in the 'wide' form or assembled with adjuvants in vaccines. The response to steroid therapy is generally dramatic and side effects may occur, as well as the development of glucocorticoid resistance. The optimisation of therapy may require steroid-sparing agents as well as modified-release prednisone as 'nighttime' replacement therapy.

Giant cell arteritis

GCA is the prime medical emergency in ophthalmology because it may result in loss of vision in 1 or both eyes. This vision loss is preventable if patients are diagnosed early and treated immediately with high doses of corticosteroids.

Polymyalgia rheumatica

Polymyalgia rheumatica is a chronic, inflammatory disorder of unknown cause that affects people over age 50 years. Classic symptoms include pain and long-term morning stiffness of the neck, shoulders, hips, upper arms, and thighs. Although markers of inflammation are often raised, no specific laboratory test exists for the disorder and the diagnosis is based on clinical assessment. Provisional classification criteria were published in April, 2012, by a collaborative initiative of the European League Against Rheumatism and the American College of Rheumatology. Several other disorders can mimic polymyalgia rheumatica. In particular, clinical manifestations can be difficult to differentiate from other forms of inflammatory arthritis such as spondyloarthritis and rheumatoid arthritis. Imaging studies such as ultrasonography and MRI typically show a predominantly periarticular inflammatory process. A subset of patients has an associated inflammatory vasculopathy affecting large arteries (giant cell arteritis). The standard treatment is low-dose glucocorticoids, which provide symptomatic relief for most patients. However, disease relapses are common, and treatment with glucocorticoids is associated with substantial morbidity. Improved understanding of disease pathogenesis might allow for more targeted immunotherapy.

The epidemiology of polymyalgia rheumatica in primary care: a research protocol

BACKGROUND

Polymyalgia Rheumatica (PMR) is the commonest inflammatory condition seen in older patients in primary care. To date, however, research has been focused on secondary care cohorts rather than primary care where many patients are exclusively managed. This two year prospective inception cohort study of PMR patients will enable us to understand the full spectrum of this condition.

METHODS

Patients diagnosed with PMR in primary care will be identified via Read codes and mailed a series of postal questionnaires over a two-year period to assess their levels of pain, stiffness and functioning, as well as medication usage and other health-related and socio-demographic characteristics. In addition, participants will be asked for permission to link their survey data to their general practice electronic medical record and to national mortality and cancer registers.

DISCUSSION

This will be the first large-scale, prospective, observational cohort of PMR patients in primary care. The combination of survey data with medical records and national registers will allow for a full investigation of the natural history and prognosis of this condition in the primary care setting, in which the majority of patients are treated, but where little research on the treatment and outcome of consultation has been undertaken. This will provide information that may lead to improved primary care management of PMR.

2012 provisional classification criteria for polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative

The objective of this study was to develop EULAR/ACR classification criteria for polymyalgia rheumatica (PMR). Candidate criteria were evaluated in a 6-month prospective cohort study of 125 patients with new onset PMR and 169 non-PMR comparison subjects with conditions mimicking PMR. A scoring algorithm was developed based on morning stiffness >45 minutes (2 points), hip pain/limited range of motion (1 point), absence of RF and/or ACPA (2 points), and absence of peripheral joint pain (1 point). A score ≥4 had 68% sensitivity and 78% specificity for discriminating all comparison subjects from PMR. The specificity was higher (88%) for discriminating shoulder conditions from PMR and lower (65%) for discriminating RA from PMR. Adding ultrasound, a score ≥5 had increased sensitivity to 66% and specificity to 81%. According to these provisional classification criteria, patients ≥50 years old presenting with bilateral shoulder pain, not better explained by an alternative pathology, can be classified as having PMR in the presence of morning stiffness>45 minutes, elevated CRP and/or ESR and new hip pain. These criteria are not meant for diagnostic purposes.

Refractory polymyalgia rheumatica as presenting manifestation of large-vessel vasculitis associated to sarcoidosis. Successful response to adalimumab

Sarcoidosis may present with musculoskeletal features or mimic rheumatic diseases. We report on a patient who had been initially diagnosed as having polymyalgia rheumatica. Because of refractory disease associated to atypical features such as severe inflammatory low back pain, dull and achy pain in the thighs, claudication of the lower limbs and bad response to corticosteroids and methotrexate (MTX), an 18F-fluorodeoxyglucosepositron emission tomography with CT (FDG PET/CT) was performed. This technique disclosed data suggestive of arteritis of large vessels involving the ascending, arch and descending aorta as well as high FDG uptake in the femoral and posterior tibial arteries of both lower extremities. Also, increased FDG uptake was observed in the right paratracheal, retrotracheal, subcarinal, gastrohepatic ligament, coeliac and right renal hilar lymph nodes. Four lymph nodes, taken during mediastinoscopy, confirmed a diagnosis of sarcoidosis. Treatment with adalimumab (40 mg every 2 weeks subcutaneously) along with prednisone and MTX was initiated yielding progressive improvement of symptoms and normalisation of laboratory abnormalities. Five months after the onset of adalimumab a new FDG PET/CT showed complete absence of uptake of lymph nodes as well as decrease of vascular FDG uptake. To our knowledge, this is the first patient treated with adalimumab because of a large-vessel vasculitis in the setting of sarcoidosis refractory to conventional therapy. This case reinforces the claim that sarcoidosis should be considered a diagnostic challenge in the assessment of patients presenting with inflammatory musculoskeletal symptoms.

Polymyalgia rheumatica as presenting manifestation of vasculitis involving the lower extremities in a patient with ulcerative colitis

Extraintestinal features may be observed in patients with ulcerative colitis (UC). We describe a 69-year-old woman who was initially diagnosed as having polymyalgia rheumatica (PMR). Prednisone was progressively tapered to complete discontinuation a year and a half after PMR diagnosis. However, at that time, she started to complain of asthenia, abdominal cramping and pain on the left side, weight loss and bloody diarrhoea. A colonoscopy confirmed a diagnosis of left-sided UC. She experienced several flares of the disease that required admission and treatment with high-dose corticosteroids and azathioprine. Colectomy was performed as the disease became refractory to these therapies. Four months after surgery, when the patient was not receiving any corticosteroid therapy, she started to feel dull and achy pain in the thighs along with claudication of the lower limbs. An 18F-fluorodeoxyglucosepositron emission tomography with CT (FDG PET/CT) disclosed an inflammatory process with mild-moderate diffuse increased metabolism in the thoracic aorta and markedly increased FDG uptake in the in the femoral and posterior tibial arteries on both sides. Treatment with the anti-TNF-alpha monoclonal antibody-adalimumab (40 mg every 2 weeks subcutaneously) along with prednisone (initial dose 15 mg/day) yielded rapid improvement of symptoms. Also, a new FDG PET/CT performed 4 months later disclosed marked decrease of FDG uptake in the involved arteries.This report emphasises the importance of suspecting the presence of large- and medium-vessel vasculitis in a patient with UC presenting with musculoskeletal features. It also highlights the beneficial effect of TNF-antagonists in vasculitis associated to UC.

Polymyalgia rheumatica -- diagnosis and management

BACKGROUND

Polymyalgia rheumatica (PMR) is a common inflammatory rheumatic disease and an indication for long term treatment with oral steroids. Its incidence rises progressively beyond the age of 50 years. For the most part, PMR is managed in primary care.

OBJECTIVE

This article highlights the main points in the British Society for Rheumatology and the British Health Professionals in Rheumatology guidelines that may be useful to general practitioners in the primary care setting.

DISCUSSION

Different levels of awareness of the condition between practitioners, and a lack of uniform diagnostic criteria may impede correct diagnosis and management of PMR. Updated international guidelines produced by the British Society for Rheumatology and the British Health Professionals in Rheumatology can aid diagnosis and direct treatment and disease monitoring.