[Polymyalgia rheumatica]

Polymyalgia rheumatica is a disorder that affects people over 50 years of age. The etiology of the disease has not been hitherto clarified exactly. Its incidence among people over 50 is in the range of 0.1-0.5%. The incidence rate peaks in the age group of 60-70 years. It is also found in younger people, but far less frequently. The diagnosis is based primarily on locomotor complains--namely on pronounced pain, morning stiffness of the shoulder girdle, pelvic girdle and neck. Complaints relating to the arms and legs (such as muscular weakness, oedema, tendonitis etc.) are also observed, however, in one third of the cases. The diagnostic criteria are defined empirically. Polymyalgia rheumatica was formerly considered to be a form of elderly onset rheumatoid arthritis. The progressive erosion process is absent in the case of polymyalgia rheumatica unlike in the case of rheumatoid arthritis. Numerous factors are known, which point to a link between polymyalgia rheumatica and giant cell vasculitis, arthritis, but the precise nature of this relationship remains unknown. Both conditions affect the same age group in the general population and they are even found--not infrequently--in the same patient. Polymyalgia rheumatica can be found in 40% of the patients suffering from arthritis while the histological examination detected mild vasculitis in approximately 10% of the patients suffering for "isolated" polymyalgia rheumatica. The response to be given to the acute phase is similar in both disorders. Scandinavian authors consider polymyalgia rheumatica as the appearance of generalised arthritis. Arthroscopic, nuclear magnetic resonance imaging as well as isotopic studies show unequivocally, that in the background of the osteo-muscular symptoms, complaints, inflammation is to be found partly of the joints but primarily that of the periarticular synovial structures. The above mentioned--dominant--proximal symptoms can often mask the distal locomotor disorders (pitting oedema of the hands and feet, tendonitis, tendosynovitis, carpal tunnel syndrome). The disorder may be accompanied by atypical generalised symptoms (loss of appetite, weight loss, fever, fatigue). An excellent indicators of the acute phase reactions are erythrocyte sedimentation rate, C-reactive protein and interleukin-6. These are suitable for monitoring the effectiveness of the therapy, for indicating a relapse/recurrence. It should be noted, that polymyalgia rheumatica may also be present if the erythrocyte sedimentation rate and C-reactive protein values are low. This disorder is also characterised by fast and effective response to corticosteroid, which should be administered for 1-2 years. In some individual cases a different dosage regime may be necessary: steroid administered in low dosage over a longer period of time. Administration of methotrexate and anti-tumor necrotic factor-alpha may also be considered as alternative or adjuvant therapy for lowering the quantity of corticosteroid. Further multicenter, double blind studies should, however, be performed on large number of patients in this regard.

Peripheral Musculoskeletal Manifestations in Polymyalgia Rheumatica

OBJECTIVES

The objectives of this study were to evaluate the frequency and characteristics of the peripheral musculoskeletal manifestations in polymyalgia rheumatica (PMR), evaluate if PMR with peripheral synovitis represents a subset with a more severe disease, and examine for clinical and laboratory characteristics at onset of PMR that might later predict rheumatoid arthritis (RA).

PATIENTS AND METHODS

Patients were diagnosed with PMR according to the 1982 Chuang criteria. Patients were followed up between 1990 and 2002. The following musculoskeletal manifestations at onset and during the follow up were considered: peripheral synovitis, distal extremity swelling with pitting edema, carpal tunnel syndrome, and distal tenosynovitis.

RESULTS

Thirty-eight of the 74 patients (51%) showed distal musculoskeletal symptoms: 29 (39%) had peripheral synovitis, 4 (5%) presented pitting edema, 4 (5%) experienced carpal tunnel syndrome, and one (1.3%) had distal tenosynovitis. These manifestations resolved completely after corticosteroid therapy was initiated. Peripheral synovitis was oligoarticular and often transient. The joints most frequently involved were the wrist, metacarpophalangeal, and knee. Erythrocyte sedimentation rate (ESR) was normal in 7 patients. When comparing patients with PMR with and without peripheral synovitis, no statistically significant differences were found in the studied variables. Through the first year of follow up, 7 patients fulfilled the American College of Rheumatology 1987 criteria for RA, 2 patients developed giant cell arteritis, and 3 had associated malignancy. Patients who developed RA had statistically significantly increased presence of persistent synovitis and a smaller decrease in mean ESR after treatment with corticosteroids.

CONCLUSION

Fifty-one percent of the patients with PMR presented distal musculoskeletal manifestations, with peripheral synovitis being the most frequent one. Patients with PMR with peripheral synovitis did not represent a high-risk subgroup with more severe disease. Seven patients who developed criteria for seronegative RA within the first year of follow up had presented statistically significant persistent synovitis compared with those who continued as PMR and also showed a smaller initial decrease in mean ESR after steroid treatment was initiated. The absence of persistent arthritis and the benign course of the arthritis permit the distinction of PMR from other inflammatory arthropathies.

The early history of giant cell arteritis and polymyalgia rheumatica: first descriptions to 1970

Giant cell arteritis and polymyalgia rheumatica were described separately more than 100 years ago. However, the original reports of both conditions were neglected for many years. After the article by Horton et al on giant cell arteritis in the 1930s and studies published by others in the 1940s, giant cell arteritis began to be recognized as a specific disease. In the 1950s and 1960s, many of the numerous presentations and complications of giant cell arteritis were recorded. In a somewhat similar fashion, physicians became cognizant of polymyalgia rheumatica only after several independent descriptions in the 1940s and 1950s. The rapid response of both syndromes to glucocorticoid therapy was discovered shortly after cortisone's effect on rheumatoid arthritis was described. The origin of the proximal aching and stiffness in polymyalgia rheumatica was more difficult to understand. The relatively minor findings in the joints on physical examination seemed insufficient to account for the severe discomfort. As the link between polymyalgia rheumatica and giant cell arteritis became apparent, some thought the aching in polymyalgia rheumatica was related to vasculitis. The debate about whether proximal synovitis or vasculitis was the cause of the symptoms continued after 1970. Although the reason these 2 conditions were associated was not considered by 1970, the establishment of the syndromes as clinically linked entities provided the groundwork for further progress in the next decades.

Lesiones cutáneas por aplicación de ventosas con fines terapéuticos

The application of suction cups or cupping is a medicinal practice that is very widespread in Asian countries. The presence of circular areas of erythema, ecchymosis or blood blisters symmetrically distributed on the shoulders, back, thorax or lumbar area should suggest the use of this technique. The number of followers of traditional Chinese medicine is increasing in the Western world, so we should be familiar with these practices in order to prevent social and/or legal conflicts that may arise from mistaken diagnoses of abuse. We present the case of a 65-year-old male with multiple circular, erythematous, bullous lesions, symmetrically distributed, which occurred after the application of suction cups in the context of polymyalgia rheumatica.

Lack of association of a functional -94ins/delATTG NFKB1 promoter polymorphism with susceptibility and clinical expression of biopsy-proven giant cell arteritis in northwest Spain

OBJECTIVE

Giant cell arteritis (GCA) is a vasculitis preferentially involving large and middle-sized arteries in the elderly. The nuclear factor of k-light polypeptide gene enhancer in B cells (NF-kB) is a family of 5 proteins expressed in most cells that function to regulate gene transcription. NFKB1 gene plays a critical role in the coordination of the immune system by regulating the transcription of a broad variety of genes implicated in the immune response. A NFKB1 promoter polymorphism consisting of a common insertion/deletion (-94ins/delATTG) located between 2 putative key promoter regulatory elements and showing functional effects on the transcription of the NFKB1 gene has been described. Since GCA is a polygenic disease, we sought to assess the potential role of the -94ins/delATTG NFKB1 promoter polymorphism in susceptibility to GCA and to determine if this polymorphism is implicated in the clinical expression of this vasculitis.

METHODS

Ninety-six patients with biopsy-proven GCA and 204 ethnically matched Caucasian controls from the Lugo region (Northwest Spain) were studied. Genotyping of the -94ins/delATTG NFKB1 promoter polymorphism was performed by fluorescent polymerase chain reaction (PCR).

RESULTS

No significant differences in allele or genotype frequencies for this NFKB1 promoter polymorphism were observed between patients with GCA and controls even when patients were stratified according to gender, presence of polymyalgia rheumatica (n = 38), severe ischemic manifestations (n = 49), or other clinical manifestations of GCA.

CONCLUSION

Our results do not support a role for -94ins/delATTG NFKB1 promoter polymorphism in susceptibility and clinical expression of GCA in a Northwestern Spanish population.

Steroid-reversible parkinsonism as presentation of polymyalgia rheumatica

Polymyalgia rheumatica (PMR) is an inflammatory disorder typically affecting elderly people, characterized by pain and stiffness in the neck and in the shoulder and pelvic girdless with prompt clinical response to low doses of corticosteroids. PMR is closely related to giant cell arteritis (GCA), likely sustained by a "subclinical vasculitis". Whereas in GCA both the central and peripheral nervous systems may be involved, only a PMR case of global, steroid-reversible dementia has been hitherto described. We report two elderly patients who abruptly developed, as PMR presenting symptom, an akinetic-rigid parkinsonian syndrome that promptly and completely resolved after corticosteroid treatment.

Vertebrobasilar ischemia and structural abnormalities of the vertebral arteries in active temporal arteritis and polymyalgia rheumatica--an ultrasonographic case-control study

OBJECTIVE

Temporal arteritis (TA) affects large arteries, including the vertebral arteries in up to 15% of cases. High resolution ultrasonography (US) is widely used for noninvasive imaging of the extracranial vertebral arteries. We assessed the prevalence of vertebrobasilar ischemia and structural abnormalities of the extracranial vertebral arteries by US in patients with TA and polymyalgia rheumatica (PMR) and in healthy controls.

METHODS

This prospective study included clinical and US data from 93 patients with TA and 34 with PMR. A comparison was made with US findings in a population based, age matched group of 203 elderly subjects.

RESULTS

Vertebrobasilar ischemia in 4 patients with TA was less frequent (4.3%) than neuroophthalmological complications (27.9%). In all 4 patients vertebrobasilar ischemia was associated with proximal vertebral artery occlusive disease. The rate of stenosis (> 50%) and occlusions of the vertebral arteries was significantly higher in the TA patients (12.9%) than in the PMR patients (2.9%) and controls (3%). Concentric hypoechogenic mural thickening of the proximal segments V0/V1 of the vertebral artery was found in only one PMR patient and 2 TA patients.

CONCLUSION

Vertebrobasilar ischemia is an uncommon complication of TA. Color duplex sonography can help to detect temporal arteritis of the vertebral arteries. Hypoechogenic mural thickening in TA can be indistinguishable from wall hematoma caused by vertebral artery dissection and atherothrombotic occlusive disease.

TNF-alpha blockade induce clinical remission in patients affected by polymyalgia rheumatica associated to diabetes mellitus and/or osteoporosis: a seven cases report

Polymyalgia rheumatica (PMR) is a chronic inflammatory condition of the elderly, characterized by aching and morning stiffness in the cervical region, shoulders and pelvic girdles. A steroid treatment course of 6-24 months is often required, but, due to important side effects, it is troublesome if the PMR patient is also affected by diabetes mellitus (DM) and/or osteoporosis. Aim of our study is to test anti-TNF alpha treatment as a steroid sparing tool in PMR patients affected by DM or osteoporosis. In particular, we hypothesise that TNF alpha blockade can be useful not only in remission maintaining, but also in the induction of clinical remission without corticosteroids in this kind of patients. In a six months follow up, patients had clinical improvement, confirmed by physical medical examination, and a statistically significant reduction in ESR and CRP mean values. Anti-TNF alpha treatment was well tolerated by all patients. These preliminary data suggest than Infliximab can be useful in the treatment of PMR patients, not only for steroid sparing purposes, but also as first line therapy in PMR patients with severe comorbidity, such as diabetes mellitus or osteoporosis.

Polymyalgia rheumatica and colon malignacy: case report

Polymyalgia rheumatica (PMR) is a relatively common disorder in the elderly. Whereas the relationship between polymyalgia rheumatica and giant cell arteritis (GCA) is well recognized, there is still controversy about PMR and malignancy. We are presenting a patient with PMR and adenocarcinoma of the sygmoid colon and hypothesize a paraneoplastic relationship.

[Aortic involvement in patients with temporal arteritis and polymyalgia rheumatica]

In 4 patients with temporal arteritis or polymyalgia rheumatica, women aged 60, 57, 83 and 73 years respectively, signs of aortic involvement were established. The first patient presented with signs of systemic inflammation without signs of temporal arteritis or aortitis. In the second, an acute symptomatic thoracoabdominal aneurysm developed. In the third, temporal arteritis was associated with chronic progressive dilatation ofthe thoracic aorta. The fourth developed signs of intermittent claudication of the extremities. The clinical manifestations in all patients were attributed to chronic inflammation of the aorta caused by giant cell arteritis. Aortic giant cell arteritis frequently accompanies temporal arteritis, but is rarely diagnosed. Up to 75% of patients with temporal arteritis may have some degree of aortic involvement. Thoracic aneurysms, complicated by rupture or dissection, are the most serious complications. Aortic disease associated with signs of systemic inflammation should trigger the suspicion of giant cell arteritis. Corticosteroids are the most important part of treatment. Three patients recovered following treatment; the first two received an endoprosthesis; in the woman aged 83 years, this was not technically possible; she died after 1.5 years.

Complex wound or complex patient? Strategies for treatment

There is no simple definition of what constitutes a complex wound, but in practice the term tends to refer wounds with one or more complicating factors, e.g. exudate, infection, comorbidity, polypharmacy. Management of complex wounds is based on the same principles as non-complex wounds, i.e. holistic assessment and addressing the issues identified. This article presents three case studies in which these principles are applied.

Inflammatory changes of hip synovial structures in polymyalgia rheumatica

OBJECTIVE

To investigate the hip inflammatory lesions and to evaluate the accuracy of clinical examination compared to magnetic resonance imaging (MRI) in patients with polymyalgia rheumatica (PMR) with pelvic girdle symptoms. Secondary end-point was to evaluate the sensitivity and specificity of ultrasonography (US) compared to MRI in the assessment of hip lesions.

METHODS

Case-control study of 20 consecutive PMR patients and 40 controls with different rheumatic conditions. Both groups were clinically assessed for the presence of hip synovitis, trochanteric, iliopsoas and ischiogluteal bursitis. Hip MRI was performed in all case-patients and in 10 controls. Both groups were examined by US. An additional group of 10 healthy controls was examined by hip US.

RESULTS

Both MRI and US detected trochanteric bursitis in 100% of PMR patients, bilateral in 18/20 (90%), and in 12/40 (30%) controls (p < 0.001). Hip synovitis was detected in 17/20 (85%) by MRI and in 9/20 (45%) by US (p < 0.02) in case-patients and in 18/40 (45%) controls. In PMR, MRI and US showed iliopsoas bursitis in 10/20 (50%) and 6/20 (30%) and ischiogluteal bursitis in 5/20 (25%) and 4/20 (20%) with no differences compared to controls. Clinical examination showed a good accuracy for hip synovitis, trochanteric and ischiogluteal bursitis, while it overestimated the presence of iliopsoas bursitis. US was less sensitive than MRI for the detection of hip synovitis and iliopsoas bursitis (53% and 60%).

CONCLUSION

Trochanteric bursitis represents the most frequent hip lesion in PMR. A careful physical examination allows to detect all inflammatory lesions excluding iliopsoas bursitis. US is less sensitive than MRI in the assessment of hip synovitis and iliopsoas bursitis.

Polymyalgia rheumatica in primary Sjögren's syndrome

The aim of the study was to describe the clinical and laboratory aspects of primary Sjögren's syndrome (pSS) associated with polymyalgia rheumatica (PMR). The retrospective study compares the clinical and laboratory aspects of patients with pSS associated with PMR on a relatively large cohort of patients (n=16) and pSS patients without PMR (n=531). The prevalence of PMR among pSS patients was 3%, while in the average population, the prevalence of PMR is only 0.75%. PMR developed 8.7 years after the diagnosis of pSS in the older female pSS population (over 50 years of age), and in those with only glandular features. Interestingly the pSS/PMR patients had hypo gammaglobuline levels, while in the pSS patient group hypergammaglobulinaemia presented. Furthermore, positive ANA serology was more frequent among pSS/PMR patients. Since the clinical management of pSS/PMR is different from pSS, a better understanding of this clinical entity is essential.

Relapse in a population based cohort of patients with polymyalgia rheumatica

OBJECTIVE

To determine the incidence and the clinical, laboratory, and treatment related predictors of relapse in polymyalgia rheumatica (PMR).

METHODS

Using the population based resources of the Rochester Epidemiology Project, we assembled an incidence cohort of subjects with PMR first diagnosed between January 1, 1970, and December 31, 1999. For inclusion, subjects were required to fulfill 3 criteria: (1) age > or = 50 years; (2) bilateral aching and morning stiffness in neck, shoulders, or hip girdle regions; and (3) erythrocyte sedimentation rate (ESR) > or = 40 mm/h. In subjects who fulfilled the first 2 criteria but had a normal ESR, a rapid response to low dose corticosteroids (CS) served as the third criterion. Patients were followed until permanent remission, migration, or a maximum of 5 years after their incidence date. Relapse was defined as an exacerbation of PMR symptoms requiring an adjustment of CS dose (> or = 5 mg) occurring at least 30 days after the incidence date. Time to relapse was modeled using the Kaplan-Meier method. CS treatment patterns were modeled using linear and nonlinear models. Cox regression models were used to evaluate predictors of time to first and subsequent relapses.

RESULTS

The study population included 364 patients with a mean age of 73.4 years and 244 (67%) were women. Among the 284 patients treated with CS, a higher initial CS dose and faster CS tapering rate were significant predictors of future relapses, after adjusting for age, sex, ESR, giant cell arteritis at PMR diagnosis, and the intensity of rheumatologist care. Every 5 mg/day increase in initial CS dose was associated with a 7% increase in the risk of relapse [hazard ratio (HR) 1.07, 95% CI 1.02, 1.13]. The hazard of having a relapse was 4-fold higher when the CS tapering rate was fast (HR 4.27, 95% CI 2.84, 6.44), and 2-fold higher when the CS tapering rate was medium (HR 2.19, 95% CI 1.54, 3.11) compared to slow tapering.

CONCLUSION

Higher initial CS doses and faster tapering are significant predictors of future relapses. Our results suggest that efforts should be made to minimize initial CS dose and taper CS slowly in order to avoid disease relapses.

[Polymyalgia rheumatica and giant-cell arteritis]

The subjects of the study were 112 patients with rheumatic polymyalgia (RPM) and giant-cell arteritis (GSA). The study shows that RPM and GSA are complicated by cerebral flow disturbances and myocardial infarction. Therapy with prednisolone and non-steroid antiinflammatory drugs reduces the risk of these complications and lethal outcome in patients with RPM and GSA.