Polymyalgia rheumatica: A separate rheumatic entity?

The spectrum of giant cell arteritis through a rheumatology lens

Treatment of giant cell arteritis (GCA) aims initially to prevent acute visual loss, and subsequently to optimise long-term quality of life. Initial prevention of acute visual loss in GCA is well-standardised with high-dose glucocorticoid therapy but in the longer term optimising quality of life requires tailoring of treatment to the individual. The licensing of the IL-6 receptor inhibitor tocilizumab combined with advances in vascular imaging have resulted in many changes to diagnostic and therapeutic practice. Firstly, GCA is a systemic disease that may involve multiple vascular territories and present in diverse ways. Broadening of the "spectrum" of what is called GCA has been crystallised in the 2022 GCA classification criteria. Secondly, the vascular inflammation of GCA frequently co-exists with the extracapsular musculoskeletal inflammation of the related disease, polymyalgia rheumatica (PMR). Thirdly, GCA care must often be delivered across multiple specialities and healthcare organisations requiring effective interprofessional communication. Fourthly, both GCA and PMR may follow a chronic or multiphasic disease course; long-term management must be tailored to the individual patient's needs. In this article we focus on some areas of current rheumatology practice that ophthalmologists need to be aware of, including comprehensive assessment of extra-ocular symptoms, physical signs and laboratory markers; advanced imaging techniques; and implications for multi-speciality collaboration.

Clinical and pathologic studies of synovitis in polymyalgia rheumatica

Clinically detectable joint swelling was found in 10 of 13 fully evaluated patients considered to have polymyalgia rheumatica. Five patients had some joint findings at disease onset. Knees were most commonly affected. Sternoclavicular involvement was seen in 3 patients. Joint effusions in 8 patients had 300-5,700 leukocytes/mm3 with a mean of 2,900. Six synovial biopsy specimens studied by light microscopy revealed mild to moderate synovial proliferation and chronic inflammation that was generally less severe than in typical rheumatoid arthritis. Electron microscopy identified microvascular changes and large amounts of vesicular and granular debris in lining cells. In 1 patient, a "fingerprint" pattern in the granular material was suggestive of the findings in some immune complexes. This still unexplained synovitis may, as previously suggested, be important in the pathogenesis of the polymyalgia rheumatica syndrome.