[Rituximab in the treatment of acquired haemophilia A in a patient with polymyalgia rheumatica]

Acquired hemophilia A is a rare but potentially life-threatening bleeding disorder. It is caused by the development of autoantibodies directed against coagulation factor VIII in adults or elderly patients, who do not have a personal or family history of bleeding.

CASE

A man (age: 76 years) on prednisone and leflunomide for polymyalgia rheumatica developed spontaneous severe haematomas. The patient was diagnosed with acquired factor VIII deficiency (FVIII activity 1.2%, FVIII inhibitor 31.7 BU). Due to the active bleeding diathesis, treatment was administered with activated prothrombin complex concentrates (FEIBA®, Baxter). Immunosuppressive treatment with a combination of oral prednisone (1 mg/kg daily) and cyclophosphamide (1,5 mg/kg daily) was administered to reduce the FVIII inhibitor. However, after two weeks of treatment, FVIII was only 3% and no clinical improvement was observed. Treatment with the anti CD20 monoclonal antibody rituximab intravenously at 375 mg/m2 once weekly for four consecutive weeks was started. The patient showed rapid clinical improvement following rituximab treatment. He achieved a complete remission defined as return to normal FVIII activity and undetectable FVIII inhibitor titer. After a follow-up of six months no relapse occurred.

CONCLUSION

Rituximab appears an effective and well-tolerated treatment for patients with acquired haemophilia.

A case of apoplectic lymphocytic hypophysitis complicated by polymyalgia rheumatica

A case of apoplectic lymphocytic hypophysitis complicated by polymyalgia rheumatica (PMA) is described. A 72-year-old man was admitted to our hospital due to severe headache. Two months prior to admission, the patients had exhibited recent-onset stiffness and myalgia of shoulder and pelvic girdle that was compatible with PMR. Magnetic resonance imaging revealed a mass lesion in the pituitary fossa with focal hemorrhage. Endocrinologic studies demonstrated hypopituitarism. The headache and myalgia were improving with corticosteroid treatment; however, a trans-sphenoidal surgery was performed due to visual field loss. A white-colored mass was resected, and histologic examination showed diffuse infiltration of lymphocytes and plasma cells consistent with lymphocytic hypophysitis. Post-operatively, the headache and visual field loss resolved completely. This is the first documented case of apoplectic lymphocytic hypophysitis complicating PMR, and a possible mechanism for this rare association was discussed.

Cancer risk in patients hospitalized with polymyalgia rheumatica and giant cell arteritis: a follow-up study in Sweden

OBJECTIVES

Studies reporting cancer risk after PMR and GCA are few, but it remains an issue of both concern and controversy. We examined the overall and specific cancer risks among Swedish subjects following hospitalization for these diseases.

METHODS

PMR and GCA patients were identified from the Swedish Hospital Discharge Register and by linking them with the Cancer Registry. Follow-up of patients was carried out from the last hospitalization through year 2006. Standardized incidence ratios (SIRs) were calculated in these patients compared with subjects without the diseases.

RESULTS

A total of 35 918 patients were hospitalized for PMR and GCA during the years 1965-2006; the hospitalization rate increased towards late age. A total of 3941 patients developed subsequent cancer, giving an overall SIR of 1.19; and for cancer diagnosed later than 1 year of follow-up, the SIR was 1.06. A significant excess was noted for skin (squamous cell carcinoma and melanoma), stomach, lung, prostate, kidney, nervous system and endocrine gland tumours, and additionally for non-Hodgkin's lymphoma, myeloma and leukaemia. Decreased risk was noted for endometrial cancer.

CONCLUSIONS

Patients hospitalized for PMR and GCA had a marginally increased risk of cancer, with the highest risk noted for the first year after hospitalization. However, for specific cancers, such as skin cancer and leukaemia, the increases were still significant for patients diagnosed later than 1 year after hospitalization, suggesting that these could be true associations, but the mechanisms remain to be established.

[Polymyalgia rheumatica and giant cell arteritis: what's new?]

Polymyalgia rheumatica (PMR) and temporal arteritis (TA) are 2 common conditions in the elderly patient. Early diagnosis and rapid introduction of treatment with corticosteroids is critical, in order to avoid potentially serious complications. The diagnosis is largely clinical for PMR, whereas it is both clinical and histopathological for TA. Certain situations may require complementary investigations such as ultrasound or PET-CT. Bilateral subacromial/subdeltoid bursitis is extremely frequent in patients with PMR, but rarely present in healthy subjects. Intravenous bolus corticosteroids may be useful at presentation with TA, particularly when associated with visual symptoms. There may be a role for disease-modifying antirheumatic drugs (DMARD) such as methotrexate in reducing the requirement for corticosteroids. Finally, clinical and radiological follow-up is important in order to detect aortic aneurysms or large vessel involvement.

Diagnosing joint pain in the older people

There are many potential causes of joint pain in older patients. The most likely aetiology is OA. However, the differential diagnosis includes conditions which should not be missed such as septic arthritis and inflammatory disease. The pattern of joint involvement points to the diagnosis. Bilateral symmetrical small joint pain, swelling and stiffness should arouse the suspicion of RA. The wrist and knee are commonly affected by pseudogout and the first metatarsophalangeal joint or knee joint involvement may represent gout. Stiffness in the shoulder and hip girdles, worse in the morning, suggests polymyalgia rheumatica. In straightforward cases of OA no specific investigations are required. If doubt exists, however, tests may be necessary including FBC, ESR and CRP, uric acid for suspected gout and X-rays of the affected joints especially following trauma, or pseudogout. Patients with OA should be offered education and advice as well as strengthening exercises and aerobic fitness training (if physically possible). If the patient is overweight, weight loss is critical, especially in OA of the knee. Paracetamol and topical NSAIDs are the first-line drug treatments. Elderly onset RA differs from younger onset RA in the following ways: a more balanced gender distribution; a higher frequency of acute onset; an association with systemic features; more frequent involvement of the shoulder girdle and higher disease activity. DMARD therapy should be used according to disease severity, as in younger onset RA. The current approach is for early, intensive intervention with combination therapy. Corticosteroids may be very effective in the elderly, however, prolonged use and/or high dosage may lead to marked toxicity especially osteoporosis and diabetes.

Polymyalgia rheumatica as the first presentation of metastatic lymphoma

A 48-year-old HIV-positive woman presented with progressive pain and stiffness of both shoulders and hips. She was given the diagnosis of polymyalgia rheumatica (PMR) due to high erythrocyte sedimentation rate. However, a 1-week course of prednisolone failed to improve her symptoms. She later discovered a breast lump of which histopathological tissue was consistent with a diffuse large B-cell lymphoma. Whole body bone scan revealed multiple bony metastases. The presence of atypical features of PMR and lack of dramatic response to steroids should prompt physicians to raise the probability of differential diagnoses other than PMR, and in particular, malignancy.

Prognosis of giant cell arteritis including temporal arteritis and polymyalgia rheumatica. A follow-up study on ninety patients treated with corticosteroids

Ninety patients with giant cell arteritis (GCA) were followed 3-10 years after the diagnosis. The mean observation time was 63 months. Thirteen patients died. Corticosteroids were administered to all but one patient; 35 were still on treatment after a mean observation period of 59 months. In 38 patients, 94 flare-ups of the disease were recorded during corticosteroid treatment, most of them occurring during the first year of treatment and when a low dose of prednisolone had been given. Thirty-three relapses, 76% within 3 months, occurred in 28 patients after withdrawal of treatment. One patient relapsed after more than ten years of disease. Polymyalgia rheumatica was the most common symptom of flare-up or relapse, regardless of the clinical picture at the time of diagnosis. The duration of treatment should be individualized. One year of treatment is enough in a few patients, whereas others need steroid therapy for more than four years. The rate of intercurrent disease and complications of GCA or its treatment was low. No patient developed severe eye damage due to GCA. The mortality rate was in fact lower than expected with regard to age and sex.

Coronary ischaemia and occlusion in giant cell (temporal) arteritis

Reports of coronary artery involvement in giant cell (temporal) arteritis--polymyalgia rheumatica (GC(T)A--PMR) together with other large arteries arising from the aorta have been numerous over the past 40 years, but on this the specialist cardiac literature has been virtually silent. This article summarises that evidence, and records nine additional patients from a large group of cases with both GC(T)A--PMR and ischaemic heart disease (IHD) observed since a previous report in 1960. The case histories illustrate the benefit from corticosteroids and the hazards of non-diagnosis and premature cessation of such treatment. It seems that many patients with arteritic IHD (and claudication) are not being identified before or after death. Possible reasons for this oversight by clinicians and pathologists are offered, and suggestions are made with regard to points in history-taking and important physical signs which may help to alert the clinician. There is autopsy evidence from Malmö, Sweden, that the prevalence of GC(T)A--PMR is much higher than at present suspected on clinical grounds.

Long-term survival in giant cell arteritis including temporal arteritis and polymyalgia rheumatica. A follow-up study of 90 patients treated with corticosteroids

Ninety patients with giant cell arteritis (GCA) were followed for 9-16 years after diagnosis. Corticosteroids were given to all but one patient. Forty-two patients died during the observation period (27 women and 15 men). The survival was compared with that in the general population and found not to be reduced among the GCA patients. In fact, we found a lower mortality than expected after five years from diagnosis (p less than 0.05). We did not see any increase in deaths due to vascular or malignant diseases in our patients.

Pericardial tamponade in a patient with polymyalgia rheumatica

We report a patient who developed pericarditis and pericardial tamponade coinciding with polymyalgia rheumatica onset. Our patient did not show any clinical sign of vasculitis; temporal artery biopsies were negative for giant cell arteritis. Pericardial biopsy in our case shows inflammatory perivascular lymphocytary infiltrates thus we believe pericardial effusion has an inflammatory-immunologic origin. Cardiac manifestations are exceptional in polymyalgia rheumatica, though it should be considered in the differential diagnosis in patients with pericarditis over 50 years. The recognition of this uncommon manifestation is very important due to the good response to corticosteroid treatment.

Toll-like receptor 4 (TLR4) gene polymorphisms in giant cell arteritis

OBJECTIVE

To investigate potential associations between toll-like receptor 4 (TLR4) gene polymorphisms and susceptibility to, and clinical features of giant cell arteritis (GCA).

METHODS

A total of 155 patients with biopsy-proven GCA who were residents of Reggio Emilia, Italy, and 210 population-based controls from the same geographical area were genotyped for two coding single nucleotide polymorphisms of TLR4 (Asp299Gly and Thr399Ile) by molecular methods. The patients were subgrouped according to the presence or absence of polymyalgia rheumatica and severe ischemic complications (visual loss and/or cerebrovascular accidents).

RESULTS

The distribution of allele and genotype frequencies did not differ significantly between GCA patients and healthy controls. Carriers of the -299 G allele (G/A+ G/G) [odds ratio (OR) 1.78, 95% confidence intervals (CI) 0.90-3.50)] were more frequent among GCA patients than among the controls, but the difference was not statistically significant. No significant associations were found when GCA patients with and without PMR or with and without severe ischemic complications were compared.

CONCLUSION

Our data suggest that the TLR4 gene polymorphisms are not associated with susceptibility to, and clinical expression of, GCA in Italian patients.

Polymyalgia rheumatica in a renal transplant patient

A 56-year-old African American woman who was on triple immunosuppressive therapy (which includes tacrolimus, mycophenolate mofetil, and prednisone) for a renal transplant that she had received 10 years ago presented with malaise, low-grade fevers and severe bilateral pain in her shoulder, neck and thigh muscles. There was serological evidence of an acute inflammatory syndrome, including a very high erythrocyte sedimentation rate (ESR) and high interleukin-6 and C-reactive protein levels. An extensive workup for infection and malignancy was negative, and a muscle biopsy was normal. Under a working diagnosis of polymyalgia rheumatica (PMR) her prednisone dose was increased, leading to a complete remission.; her symptoms resolved and the ESR normalized. The occurrence of PMR in an immunosuppressed patient is unusual, but should be considered in the differential diagnosis in the appropriate clinical setting.

[Fasting as part of a naturopathic treatment approach for polymyalgia rheumatica]

A 67-year-old woman with proven diagnosis of giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) was admitted to stationary treatment twice to receive a complex therapy with methods of natural medicine comprising fasting as its main treatment element. Both times, a discrepancy between the course of markers of the acute phase on the one hand, and subjective as well as objective clinical outcome on the other hand could be observed. This may point to special conditions of this chronic inflammatory disease as compared to e.g.rheumatoid arthritis, but also to specific problems in assessing possible effects of the treatments chosen, particularly fasting therapy, as compared to effects of conventional therapies.

-463 G/A myeloperoxidase promoter polymorphism in giant cell arteritis

OBJECTIVE

To investigate potential associations between-463 G/A myeloperoxidase (MPO) promoter polymorphism and susceptibility to, and clinical features of giant cell arteritis (GCA).

METHODS

A total of 156 patients with biopsy-proven GCA who were residents of Reggio Emilia, Italy, and 235 population-based controls from the same geographic area were genotyped for-463 G/A promoter polymorphism of the MPO gene by molecular methods. The patients were subgrouped according to the presence or absence of polymyalgia rheumatica and severe ischaemic complications (visual loss and/or cerebrovascular accidents).

RESULTS

The distribution of the MPO-G/A genotype differed significantly between patients with GCA and the controls (p(corr) = 0.003). Allele G was significantly more frequent in patients with GCA than in the controls (p(corr) = 0.0002, OR 2.0, 95% CI 1.4 to 2.9). Homozygosity for the G allele was significantly more frequent in patients with GCA than in controls (p(corr) = 0.0002, OR 2.2, 95% CI 1.4 to 3.4). No significant associations were found when patients with GCA with and without polymyalgia rheumatica or with and without severe ischaemic complications were compared.

CONCLUSIONS

Our findings show that the-463 G/A promoter polymorphism of the MPO gene is associated with GCA susceptibility and support a role for MPO in the pathophysiology of GCA.

Development of ischemic complications in patients with giant cell arteritis presenting with apparently isolated polymyalgia rheumatica: study of a series of 100 patients

Several studies suggest that patients with giant cell arteritis (GCA) presenting with isolated polymyalgia rheumatica (PMR) with no cranial symptoms are at low risk of suffering GCA-related ischemic events. However, the issue remains controversial. In the current study we assessed the development of ischemic events in a large series of GCA patients who suffered from apparently isolated PMR during the main course of their disease. One hundred GCA patients presenting with PMR only for at least 2 months were selected from among 347 individuals with biopsy-proven GCA. Clinical manifestations and their chronologic appearance before diagnosis were recorded. Seventy-three patients presented with isolated PMR for a median of 8 months (range, 2 mo-5 yr) and later developed cranial symptoms for a median of 3 weeks (range, 0 wk-1 yr), which eventually led to GCA diagnosis (Group 1). The remaining 27 patients, after presenting a self-limiting course of dismissed mild cranial symptoms lasting for a median of 2 weeks (range, 1 wk-4 mo), developed PMR, which was their chief complaint for a median of 3 months (range, 2 mo-1.5 yr) and the reason for medical evaluation (Group 2). Twenty (27.4%) patients in Group 1 suffered disease-related ischemic complications at the time of diagnosis. No patient in Group 2 developed ischemic events. Patients with GCA presenting with apparently isolated PMR are not a benign subset and have a significant risk of developing ischemic complications. Among them, the only patients who appear to be at low risk of developing ischemic events are those in whom a self-limiting episode of cranial symptoms can be recorded.

Cardiovascular autonomic dysfunction in systemic lupus, rheumatoid arthritis, primary Sjögren syndrome and other autoimmune diseases

Neurological manifestations are known to occur in patients with autoimmune diseases, often subclinically, but autonomic nervous system (ANS) involvement has rarely been studied, and studies have shown conflicting results. We performed cardiovascular ANS assessment in 125 patients with autoimmune diseases in this case-control study, including 54 patients with systemic lupus erythematosus (SLE), 39 with rheumatoid arthritis (RA), 20 with primary Sjbgren syndrome (pSS), eight patients with polymyalgia rheumatica (PR), four patients with scleroderma (Ssc) and 35 healthy control subjects. The control group was formed to approximately match the mean age of SLE, RA and pSS patients; controls did not differ significantly by gender from the autoimmune pations. All patients with were in stable condition. Autonomic nervous system dysfunction was diagnosed by applying cardiovascular reflex tests according to Ewing, and was considered to exist if at least two tests were positive. Vagal dysfunction was established by applying three tests: Valsalva manoeuvre, deep breathing test, and heart rate response to standing. Sympathetic dysfunction was examined by applying two tests: blood pressure response to standing and handgrip test. In all cardiovascular reflex tests, frequencies of abnormal results were significantly higher among the patients than among the controls (P < 0.05). The difference between the autoimmune patients and the controls was particularly significant in sympathetic and parasympathetic tests, with P < 0.0001. No correlation was found between disease duration, clinical manifestations, cardiovascular risk factors and diseases activity on the one hand, and ANS dysfunction on the other hand. Cardiovascular autonomic dysfunction was revealed in the majority of autoimmune patients.

Late onset undifferentiated spondyloarthritis presenting with polymyalgia rheumatica features: description of seven cases

To underline the importance of considering a diagnosis of undifferentiated spondyloarthritis (uSpA) in patients presenting polymyalgia rheumatica (PMR) features. All patients with late onset uSpA meeting criteria for PMR at the onset of their disease seen in the Rheumatology Division of Xeral-Calde Hospital of Lugo, Spain during a 5 year period, and in the Rheumatology Department of Lucania, Italy in a two and a half year period, were studied. Six patients with late onset uSpA showing PMR symptoms at the onset were seen during the study periods in the two centres. Another patient had previously been observed in Lugo in a study dealing with the spectrum of conditions mimicking PMR. Of the seven patients, five had manifestations of SpA at the beginning of the disease and two developed these in the following 6 months. All seven met the Amor and/or the ESSG criteria for classifying and diagnosing SpA. The possibility that late onset uSpA may have PMR-like features at the beginning of the disease should be taken into account. The diagnosis is not difficult if the entire clinical spectrum of SpA is considered.

A case of polymyalgia rheumatica, microscopic polyangiitis, and B-cell lymphoma

BACKGROUND

A 73-year-old, previously well woman was admitted to an emergency department because of a 3-month history of severe proximal girdle pain and stiffness with loss of appetite and weight. She was referred to a rheumatologist 10 days after her initial presentation. Within 4 weeks she presented to an outpatient clinic with nausea, vomiting, shortness of breath, painful mouth ulcers, rash on her legs and a further decline in appetite; she was readmitted to hospital. Within 4 months of initial presentation she became jaundiced.

INVESTIGATIONS

At initial presentation, physical examination, biochemical, hematological and autoimmune screening, radiography of the pelvis, an abdominal ultrasound, and electromyography were conducted. At referral to a rheumatologist similar tests were repeated. At presentation to the outpatient clinic, hematological and biochemical screening, and a urine dipstick test were conducted. At readmittance to hospital, infectious and autoimmune screening, radiography of the chest, electrocardiogram, ultrasound of the abdomen, and renal biopsy were conducted. At the time of development of jaundice, biochemical and hematological screening, CT of the abdomen and ultrasound-guided biopsy of a pancreatic mass were conducted.

DIAGNOSIS

Polymyalgia rheumatica, antineutrophil-cytoplasmic-antibody-positive microscopic polyangiitis with renal involvement and B-cell lymphoma of the head of the pancreas.

MANAGEMENT

The patient received oral prednisolone 15 mg daily for polymyalgia rheumatica along with alendronate 70 mg weekly. The patient received intravenous cyclophosphamide 500 mg and methylprednisolone 500 mg every 2 weeks for her microscopic polyangiitis with renal involvement. For B-cell lymphoma of the head of the pancreas, the patient received cyclophosphamide, doxorubicin, vincristine and prednisolone once monthly.