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Heras-Recuero E, Blázquez-Sánchez T, Landaeta-Kancev LC, Martínez de Bourio-Allona M, Torres-Roselló A, Rengifo-García F, Caraballo-Salazar C, Largo R, Castañeda S, González-Gay MÁ. Positron Emission Tomography/Computed Tomography in Polymyalgia Rheumatica: When and for What-A Critical Review. Diagnostics (Basel) 2024; 14:1539. [PMID: 39061676 PMCID: PMC11275637 DOI: 10.3390/diagnostics14141539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Revised: 07/14/2024] [Accepted: 07/15/2024] [Indexed: 07/28/2024] Open
Abstract
Polymyalgia rheumatica (PMR) is an inflammatory disease common in people aged 50 years and older. This condition is characterized by the presence of pain and stiffness involving mainly the shoulder and pelvic girdle. Besides the frequent association with giant cell arteritis (GCA), several conditions may mimic PMR or present with PMR features. Since the diagnosis is basically clinical, an adequate diagnosis of this condition is usually required. Positron emission tomography/computed tomography (PET-CT) has proved to be a useful tool for the diagnosis of PMR. The use of 18F-FDG-PET imaging appears promising as it provides detailed information on inflammatory activity that may not be evident with traditional methods. However, since PET-CT is not strictly necessary for the diagnosis of PMR, clinicians should consider several situations in which this imaging technique can be used in patients with suspected PMR.
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Affiliation(s)
- Elena Heras-Recuero
- Division of Rheumatology, IIS-Fundación Jiménez Díaz, 28040 Madrid, Spain; (E.H.-R.); (T.B.-S.); (A.T.-R.); (F.R.-G.); (C.C.-S.); (R.L.)
| | - Teresa Blázquez-Sánchez
- Division of Rheumatology, IIS-Fundación Jiménez Díaz, 28040 Madrid, Spain; (E.H.-R.); (T.B.-S.); (A.T.-R.); (F.R.-G.); (C.C.-S.); (R.L.)
| | - Laura Cristina Landaeta-Kancev
- Department of Nuclear Medicine, Fundación Jiménez Díaz University Hospital, 28040 Madrid, Spain; (L.C.L.-K.); (M.M.d.B.-A.)
| | | | - Arantxa Torres-Roselló
- Division of Rheumatology, IIS-Fundación Jiménez Díaz, 28040 Madrid, Spain; (E.H.-R.); (T.B.-S.); (A.T.-R.); (F.R.-G.); (C.C.-S.); (R.L.)
| | - Fernando Rengifo-García
- Division of Rheumatology, IIS-Fundación Jiménez Díaz, 28040 Madrid, Spain; (E.H.-R.); (T.B.-S.); (A.T.-R.); (F.R.-G.); (C.C.-S.); (R.L.)
| | - Claritza Caraballo-Salazar
- Division of Rheumatology, IIS-Fundación Jiménez Díaz, 28040 Madrid, Spain; (E.H.-R.); (T.B.-S.); (A.T.-R.); (F.R.-G.); (C.C.-S.); (R.L.)
| | - Raquel Largo
- Division of Rheumatology, IIS-Fundación Jiménez Díaz, 28040 Madrid, Spain; (E.H.-R.); (T.B.-S.); (A.T.-R.); (F.R.-G.); (C.C.-S.); (R.L.)
| | - Santos Castañeda
- Division of Rheumatology, Hospital Universitario de La Princesa, IIS-Princesa, 28006 Madrid, Spain;
| | - Miguel Ángel González-Gay
- Division of Rheumatology, IIS-Fundación Jiménez Díaz, 28040 Madrid, Spain; (E.H.-R.); (T.B.-S.); (A.T.-R.); (F.R.-G.); (C.C.-S.); (R.L.)
- Medicine and Psychiatry Department, University of Cantabria, 39008 Santander, Spain
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Salvarani C, Padoan R, Iorio L, Tomelleri A, Terrier B, Muratore F, Dasgupta B. Subclinical giant cell arteritis in polymyalgia rheumatica: Concurrent conditions or a common spectrum of inflammatory diseases? Autoimmun Rev 2024; 23:103415. [PMID: 37625672 DOI: 10.1016/j.autrev.2023.103415] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 08/20/2023] [Indexed: 08/27/2023]
Abstract
Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are common conditions in older adults. Their clinical connection has been recognized over time, with many patients experiencing both conditions separately, simultaneously or in temporal sequence to each other. Early GCA detection is essential to prevent vascular damage, but identifying subclinical GCA in PMR patients remains a challenge and routine screening is not standard practice. Subclinical GCA prevalence in newly diagnosed PMR patients ranges from 23 to 29%, depending on the screening method. Vessel wall imaging and temporal artery biopsy can detect subclinical GCA. Epidemiology and trigger factors show similarities between the two conditions, but PMR is more common than GCA. Genetic and pathogenesis studies reveal shared inflammatory mechanisms involving dendritic cells, pro-inflammatory macrophages, and an IL-6 signature. However, the inflammatory infiltrates differ, with extensive T cell infiltrates seen in GCA while PMR shows an incomplete profile of T cell and macrophage-derived cytokines. Glucocorticoid treatment is effective for both conditions, but the steroid requirements vary. PMR overall mortality might be similar to the general population, while GCA patients with aortic inflammatory aneurysms face increased mortality risk. The GCA-PMR association warrants further research. Considering their kinship, recently the term GCA-PMR Spectrum Disease (GPSD) has been proposed.
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Affiliation(s)
- Carlo Salvarani
- Rheumatology Unit, Azienda USL-IRCCS di Reggio Emilia and Università di Modena and Reggio Emilia, Reggio Emilia, Italy
| | - Roberto Padoan
- Rheumatology Unit, Department of Medicine DIMED, University of Padova, Padova, Italy.
| | - Luca Iorio
- Rheumatology Unit, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Alessandro Tomelleri
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Hospital, Milan, Italy
| | - Benjamin Terrier
- Department of Internal Medicine, Hôpital Cochin, AP-HP, Paris, France
| | - Francesco Muratore
- Rheumatology Unit, Azienda USL-IRCCS di Reggio Emilia and Università di Modena and Reggio Emilia, Reggio Emilia, Italy
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3
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Espígol-Frigolé G, Dejaco C, Mackie SL, Salvarani C, Matteson EL, Cid MC. Polymyalgia rheumatica. Lancet 2023; 402:1459-1472. [PMID: 37832573 DOI: 10.1016/s0140-6736(23)01310-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 06/04/2023] [Accepted: 06/22/2023] [Indexed: 10/15/2023]
Abstract
Polymyalgia rheumatica is an inflammatory disease producing pain and stiffness, mainly in the shoulders and pelvic girdle, in people older than 50 years. Elevation of acute phase reactants is common due to the inflammatory nature of the disease. Since there are no specific diagnostic tests, diagnosis requires the exclusion of other diseases with similar presentations. Imaging has helped to identify the pathological substrate of polymyalgia rheumatica and it is increasingly used to support clinical diagnosis or to detect coexistent giant cell arteritis. Although polymyalgia rheumatica does not clearly impair survival or organ function, it can have a detrimental effect on quality of life. Glucocorticoids at 12·5-25·0 mg prednisone per day are effective in inducing remission in most individuals but, when tapered, relapses occur in 40-60% of those affected and side-effects are common. Assessment of disease activity can be difficult because pain related to common comorbidities such as osteoarthritis and tendinopathies, can return when glucocorticoids are reduced, and acute phase reactants are increased less during flares in individuals undergoing treatment or might increase for other reasons. The role of imaging in assessing disease activity is not yet completely defined. In the search for more efficient and safer therapies, tocilizumab and sarilumab have shown efficacy in randomised controlled trials and additional targeted therapies are emerging. However, judicious risk-benefit balance is essential in applying therapeutic innovations to people with polymyalgia rheumatica.
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Affiliation(s)
- Georgina Espígol-Frigolé
- Department of Autoimmune Diseases, Hospital Clínic de Barcelona, Barcelona, Spain; Department of Medicine, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Christian Dejaco
- Department of Rheumatology, Medical University Graz, Graz, Austria; Department of Rheumatology, Hospital of Brunico (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical University, Brunico, Italy
| | - Sarah L Mackie
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Carlo Salvarani
- Division of Rheumatology, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy; Azienda Ospedaliera-Universitaria di Modena, University of Modena and Reggio Emilia, Reggio Emilia, Italy
| | - Eric L Matteson
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clínic de Barcelona, Barcelona, Spain; Department of Medicine, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.
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4
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Ohmura H, Kondo M, Uenomachi M, Ariyama H, Ito M, Tsuchihashi K, Ayano M, Niiro H, Akashi K, Baba E. Case Report: Resolution of remitting seronegative symmetrical synovitis with pitting edema during nivolumab therapy for gastric cancer. Front Oncol 2023; 13:1260818. [PMID: 37869081 PMCID: PMC10586790 DOI: 10.3389/fonc.2023.1260818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 09/13/2023] [Indexed: 10/24/2023] Open
Abstract
The anti-programmed cell death-1 (PD-1) antibody nivolumab has been shown to significantly prolong the survival of patients with unresectable advanced or recurrent gastric cancer (AGC). However, immune-related adverse events (irAEs), which show different profiles from those of cytotoxic agents or conventional molecular-targeted drugs including tyrosine kinase inhibitors, have been reported. Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) is a rare autoimmune disorder with acute-onset, rheumatoid factor-negative, symmetric synovitis associated with limb edema observed in elderly persons. A case of RS3PE syndrome that developed after administration of nivolumab for advanced gastric cancer is reported. This is the first report of a case of RS3PE syndrome as an irAE caused by nivolumab in a patient with gastric cancer.
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Affiliation(s)
- Hirofumi Ohmura
- Department of Oncology and Social Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Moe Kondo
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Masato Uenomachi
- Department of Diabetes Mellitus and Endocrinology, Nanpuh Hospital, Kagoshima, Japan
| | - Hiroshi Ariyama
- Department of Oncology, Kitakyushu Municipal Medical Center, Fukuoka, Japan
| | - Mamoru Ito
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Kenji Tsuchihashi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Masahiro Ayano
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Hiroaki Niiro
- Department of Medical Education, Kyushu University Faculty of Medical Sciences, Fukuoka, Japan
| | - Koichi Akashi
- Department of Medicine and Biosystemic Science, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
| | - Eishi Baba
- Department of Oncology and Social Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Japan
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Tomelleri A, van der Geest KSM, Khurshid MA, Sebastian A, Coath F, Robbins D, Pierscionek B, Dejaco C, Matteson E, van Sleen Y, Dasgupta B. Disease stratification in GCA and PMR: state of the art and future perspectives. Nat Rev Rheumatol 2023:10.1038/s41584-023-00976-8. [PMID: 37308659 DOI: 10.1038/s41584-023-00976-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 06/14/2023]
Abstract
Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are closely related conditions characterized by systemic inflammation, a predominant IL-6 signature, an excellent response to glucocorticoids, a tendency to a chronic and relapsing course, and older age of the affected population. This Review highlights the emerging view that these diseases should be approached as linked conditions, unified under the term GCA-PMR spectrum disease (GPSD). In addition, GCA and PMR should be seen as non-monolithic conditions, with different risks of developing acute ischaemic complications and chronic vascular and tissue damage, different responses to available therapies and disparate relapse rates. A comprehensive stratification strategy for GPSD, guided by clinical findings, imaging and laboratory data, facilitates appropriate therapy and cost-effective use of health-economic resources. Patients presenting with predominant cranial symptoms and vascular involvement, who usually have a borderline elevation of inflammatory markers, are at an increased risk of sight loss in early disease but have fewer relapses in the long term, whereas the opposite is observed in patients with predominant large-vessel vasculitis. How the involvement of peripheral joint structures affects disease outcomes remains uncertain and understudied. In the future, all cases of new-onset GPSD should undergo early disease stratification, with their management adapted accordingly.
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Affiliation(s)
- Alessandro Tomelleri
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Hospital, Milan, Italy
| | - Kornelis S M van der Geest
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | | | - Alwin Sebastian
- Department of Rheumatology, University Hospital Limerick, Limerick, Ireland
| | - Fiona Coath
- Rheumatology Department, Mid and South Essex University Hospitals NHS Foundation Trust, Southend University Hospital, Westcliff-on-sea, UK
| | - Daniel Robbins
- Medical Technology Research Centre, School of Allied Health, Anglia Ruskin University, Chelmsford, UK
| | - Barbara Pierscionek
- Faculty of Health Education Medicine and Social Care, Medical Technology Research Centre, Anglia Ruskin University, Chelmsford Campus, Chelmsford, UK
| | - Christian Dejaco
- Department of Rheumatology, Hospital of Bruneck (ASAA-SABES), Teaching Hospital of the Paracelsus Medical University, Bruneck, Italy
- Department of Rheumatology and Immunology, Medical University of Graz, Graz, Austria
| | - Eric Matteson
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Yannick van Sleen
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Bhaskar Dasgupta
- Rheumatology Department, Mid and South Essex University Hospitals NHS Foundation Trust, Southend University Hospital, Westcliff-on-sea, UK.
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Wu J, Yang F, Ma X, Lin J, Chen W. Elderly-onset rheumatoid arthritis vs. polymyalgia rheumatica: Differences in pathogenesis. Front Med (Lausanne) 2023; 9:1083879. [PMID: 36714116 PMCID: PMC9879490 DOI: 10.3389/fmed.2022.1083879] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 12/28/2022] [Indexed: 01/13/2023] Open
Abstract
Rheumatoid arthritis is a chronic autoimmune disease that mainly affects the facet joints. Elderly-onset rheumatoid arthritis appears to exhibit symptoms similar to those of polymyalgia rheumatica, characterized by morning stiffness and pain in the shoulder and hip joints. Both diseases develop in the elderly, and it is sometimes challenging to distinguish them. Here, we identify the differences in pathogenesis between elderly-onset rheumatoid arthritis and polymyalgia rheumatica to assist with a clear differential diagnosis and effective early intervention.
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[Polymyalgia rheumatica in 18-fluorodeoxyglucose-positron-emission-tomography/computed tomography : Improvement in diagnostic accuracy and differentiation from rheumatoid arthritis]. Z Rheumatol 2023; 82:91-101. [PMID: 34851442 PMCID: PMC9981502 DOI: 10.1007/s00393-021-01133-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The diagnosis of patients with polymyalgia rheumatica (PMR) has relied upon the clinical examination of symptoms and laboratory parameters of inflammation until now. Currently, the use of different imaging modalities is being explored, including ultrasound, MRI and PET. OBJECTIVES The aim was to evaluate the diagnostic value of 18-fluorodeoxyglucose-positron-emission-tomography/computed tomography (18F-FDG-PET/CT) for PMR, in order to improve the sensitivity and specificity of diagnosing PMR and to improve the differential diagnosis of rheumatoid arthritis (RA). MATERIALS AND METHODS Examinations using 18F-FDG-PET/CT of 284 rheumatological patients, including 97 patients with PMR, were retrospectively evaluated over a 44-month period. Furthermore, 13 regions changed by inflammation were analysed via a three-dimensional region of interest (ROI) measurement with determination of maximum standardized uptake values (SUVmax), followed by statistical analyses. RESULTS AND DISCUSSION Patients with PMR presented significantly elevated uptake in all regions examined (p < 0.001), compared with a control group treated for rheumatological diseases. The method with the highest diagnostic relevance was represented by the combination of four SUVmax values of both anterolateral hip capsules and both ischial tuberosities, reaching a sensitivity of 91.3% and a specificity of 97.6% with a cut-off of 11.0 SUV at the initial diagnosis of PMR patients who had not yet received any immunosuppressive therapy. Patients with RA could be significantly distinguished from those with PMR at initial diagnosis in the same anatomical regions (p < 0.001).
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Abstract
Polymyalgia rheumatica (PMR) is the most common inflammatory rheumatic disease affecting people older than 50 years and is 2-3 times more common in women. The most common symptoms are pain and morning stiffness in the shoulder and pelvic girdle and the onset may be acute or develop over a few days to weeks. General symptoms such as fatigue, fever and weight loss may occur, likely driven by systemic IL-6 signalling. The pathology includes synovial and periarticular inflammation and muscular vasculopathy. A new observation is that PMR may appear as a side effect of cancer treatment with checkpoint inhibitors. The diagnosis of PMR relies mainly on symptoms and signs combined with laboratory markers of inflammation. Imaging modalities including ultrasound, magnetic resonance imaging and positron emission tomography with computed tomography are promising new tools in the investigation of suspected PMR. However, they are still limited by availability, high cost and unclear performance in the diagnostic workup. Glucocorticoid (GC) therapy is effective in PMR, with most patients responding promptly to 15-25 mg prednisolone per day. There are challenges in the management of patients with PMR as relapses do occur and patients with PMR may need to stay on GC for extended periods. This is associated with high rates of GC-related comorbidities, such as diabetes and osteoporosis, and there are limited data on the use of disease-modifying antirheumatic drugs and biologics as GC sparing agents. Finally, PMR is associated with giant cell arteritis that may complicate the disease course and require more intense and prolonged treatment.
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Affiliation(s)
- Ingrid E Lundberg
- Division of Rheumatology, Department of Medicine, Solna, Karolinska Institutet and Rheumatology, Karolinska University Hospital, Stockholm, Sweden
| | - Ankita Sharma
- Rheumatology, Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden
| | - Carl Turesson
- Rheumatology, Department of Clinical Sciences, Malmö, Lund University, Malmö, Sweden.,Department of Rheumatology, Skåne University Hospital, Lund-Malmö, Sweden
| | - Aladdin J Mohammad
- Department of Rheumatology, Skåne University Hospital, Lund-Malmö, Sweden.,Rheumatology, Department of Clinical Sciences, Lund, Lund University, Lund, Sweden.,Department of Medicine, University of Cambridge, Cambridge, UK
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Reitsema RD, Jiemy WF, Wekema L, Boots AMH, Heeringa P, Huitema MG, Abdulahad WH, van Sleen Y, Sandovici M, Roozendaal C, Diepstra A, Kwee T, Dasgupta B, Brouwer E, van der Geest KSM. Contribution of pathogenic T helper 1 and 17 cells to bursitis and tenosynovitis in polymyalgia rheumatica. Front Immunol 2022; 13:943574. [PMID: 36032100 PMCID: PMC9402989 DOI: 10.3389/fimmu.2022.943574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 07/22/2022] [Indexed: 11/13/2022] Open
Abstract
Background Although polymyalgia rheumatica (PMR) is a very common rheumatic inflammatory disease, current insight into the pathobiology of PMR is limited and largely based on studies in blood. We investigated T helper 1 (TH1) and T helper 17 (TH17) cell responses in blood, synovial fluid and bursa tissue of patients with PMR. Materials and methods Blood samples were collected from 18 patients with new-onset PMR and 32 healthy controls. Synovial fluid was aspirated from the inflamed shoulder bursae or biceps tendon sheath of 13 patients. Ultrasound-guided biopsies of the subacromial-subdeltoid (SASD) bursa were obtained from 11 patients. T cells were examined by flow cytometry, immunohistochemistry and immunofluorescence staining. Results Besides an increase of TH17 (CD4+IL-17+IFN-γ-) cells and T cytotoxic 17 (TC17; CD8+IL-17+IFN-γ-) cells, no other major changes were noted in the circulating T cell compartment of patients with PMR. Absolute numbers of CD4+ and CD8+ T cells were similar in blood and synovial fluid of patients with PMR. Synovial fluid T cells showed an effector-memory (CD45RO+CCR7-) phenotype. Percentages of TH1 (CD4+IFN-γ+IL-17-) cells and TH1/TH17 (CD4+IFN-γ+IL-17+) cells, but not TH17 or TC17 cells, were increased in the synovial fluid. Bursa tissue biopsies contained a small number of T cells, which were mostly CD8 negative. The majority of bursa tissue T cells produced IFN-γ but not IL-17. For comparison, B cells were scarcely detected in the bursa tissue. Conclusion Although the circulating TH17 cell pool is expanded in patients with PMR, our findings indicate that TH1 cells are involved in the inflammation of bursae and tendon sheaths in this condition. Our study points towards the TH1 cell pathway as a potential target for therapy in PMR.
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Affiliation(s)
- Rosanne D. Reitsema
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - William F. Jiemy
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Lieske Wekema
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Annemieke M. H. Boots
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Peter Heeringa
- Department of Pathology and Medical Biology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Minke G. Huitema
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Wayel H. Abdulahad
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
- Department of Pathology and Medical Biology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Yannick van Sleen
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Maria Sandovici
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Caroline Roozendaal
- Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Arjan Diepstra
- Department of Pathology and Medical Biology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Thomas Kwee
- Medical Imaging Center, Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Bhaskar Dasgupta
- Department of Rheumatology, Southend University Hospital, Westcliff-on-Sea, United Kingdom
| | - Elisabeth Brouwer
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Kornelis S. M. van der Geest
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
- *Correspondence: Kornelis S. M. van der Geest,
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Review of Periscapular and Upper Back Pain in the Athlete Current PM&R Reports—Sports Section. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2022. [DOI: 10.1007/s40141-022-00361-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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11
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van der Geest KSM, Sandovici M, Nienhuis PH, Slart RHJA, Heeringa P, Brouwer E, Jiemy WF. Novel PET Imaging of Inflammatory Targets and Cells for the Diagnosis and Monitoring of Giant Cell Arteritis and Polymyalgia Rheumatica. Front Med (Lausanne) 2022; 9:902155. [PMID: 35733858 PMCID: PMC9207253 DOI: 10.3389/fmed.2022.902155] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 05/13/2022] [Indexed: 12/26/2022] Open
Abstract
Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are two interrelated inflammatory diseases affecting patients above 50 years of age. Patients with GCA suffer from granulomatous inflammation of medium- to large-sized arteries. This inflammation can lead to severe ischemic complications (e.g., irreversible vision loss and stroke) and aneurysm-related complications (such as aortic dissection). On the other hand, patients suffering from PMR present with proximal stiffness and pain due to inflammation of the shoulder and pelvic girdles. PMR is observed in 40-60% of patients with GCA, while up to 21% of patients suffering from PMR are also affected by GCA. Due to the risk of ischemic complications, GCA has to be promptly treated upon clinical suspicion. The treatment of both GCA and PMR still heavily relies on glucocorticoids (GCs), although novel targeted therapies are emerging. Imaging has a central position in the diagnosis of GCA and PMR. While [18F]fluorodeoxyglucose (FDG)-positron emission tomography (PET) has proven to be a valuable tool for diagnosis of GCA and PMR, it possesses major drawbacks such as unspecific uptake in cells with high glucose metabolism, high background activity in several non-target organs and a decrease of diagnostic accuracy already after a short course of GC treatment. In recent years, our understanding of the immunopathogenesis of GCA and, to some extent, PMR has advanced. In this review, we summarize the current knowledge on the cellular heterogeneity in the immunopathology of GCA/PMR and discuss how recent advances in specific tissue infiltrating leukocyte and stromal cell profiles may be exploited as a source of novel targets for imaging. Finally, we discuss prospective novel PET radiotracers that may be useful for the diagnosis and treatment monitoring in GCA and PMR.
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Affiliation(s)
- Kornelis S. M. van der Geest
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Maria Sandovici
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Pieter H. Nienhuis
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Riemer H. J. A. Slart
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- Department of Biomedical Photonic Imaging Group, University of Twente, Enschede, Netherlands
| | - Peter Heeringa
- Department of Pathology and Medical Biology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Elisabeth Brouwer
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - William F. Jiemy
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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12
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Osada A, Sakuragi C, Toya C, Mitsuo A. New-onset Polymyalgia Rheumatica Following the Administration of the Pfizer-BioNTech COVID-19 Vaccine. Intern Med 2022; 61:749-753. [PMID: 34897152 PMCID: PMC8943385 DOI: 10.2169/internalmedicine.8651-21] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
We herein report the case of an 80-year-old Japanese woman who presented to our hospital with bilateral pain in the shoulders and hips lasting for a month since 2 days after the second dose of the BNT162b2 COVID-19 vaccine. Her physical findings, laboratory data, and ultrasonographic findings of bilateral biceps tenosynovitis and lateral subacromial bursitis were consistent with a diagnosis of polymyalgia rheumatica (PMR). She was successfully treated with oral prednisolone 15 mg/day. Although a causal relationship could not be definitively confirmed, PMR should be considered as a differential diagnosis in cases of persistent myalgia after administration of the BNT162b2 vaccine.
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Affiliation(s)
- Atsumu Osada
- Division of Rheumatology, National Hospital Organization Disaster Medical Center, Japan
| | - Chinatsu Sakuragi
- Division of Rheumatology, National Hospital Organization Disaster Medical Center, Japan
| | - Chisashi Toya
- Division of Cardiology, National Hospital Organization Disaster Medical Center, Japan
| | - Akiko Mitsuo
- Division of Rheumatology, National Hospital Organization Disaster Medical Center, Japan
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13
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Lorenzo MM, Devlin J, Saini C, Cho KS, Paschalis EI, Chen DF, e Silva RN, Chen SH, Margeta MA, Ondeck C, Valle DSD, Chodosh J, Ciolino JB, Pineda R, Pasquale LR, Shen LQ. The Prevalence of Autoimmune Diseases in Patients with Primary Open-Angle Glaucoma Undergoing Ophthalmic Surgeries. Ophthalmol Glaucoma 2022; 5:128-136. [PMID: 34416426 PMCID: PMC8854449 DOI: 10.1016/j.ogla.2021.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/16/2021] [Accepted: 08/03/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE To assess the prevalence of autoimmune disease (AiD) in patients with primary open-angle glaucoma (POAG) undergoing ophthalmic surgery. DESIGN Retrospective, cross-sectional study. PARTICIPANTS Patients with POAG undergoing any ophthalmic surgery and control subjects undergoing cataract surgery at the Massachusetts Eye and Ear from March 2019 to April 2020. METHODS All available medical records with patient demographics, ocular, and medical conditions were reviewed. Differences in AiD prevalence were assessed and adjusted for covariates using multiple logistic regression. Additionally, a subgroup analysis comparing the POAG patients with and without AiD was performed. MAIN OUTCOME MEASURES To assess the prevalence of AiD based on the American Autoimmune Related Diseases Association list. RESULTS A total of 172 patients with POAG and 179 controls were included. The overall prevalence of AiD was 17.4% in the POAG group and 10.1% in the controls (P = 0.044); 6.4% of POAG patients and 3.4% of controls had more than 1 AiD (P = 0.18). The most prevalent AiDs in POAG group were rheumatoid arthritis (4.6%) and psoriasis (4.1%), which were also the most common in controls (2.8% each). In a fully adjusted multiple logistic regression analysis accounting for steroid use, having an AiD was associated with 2.62-fold increased odds of POAG relative to controls (95% confidence interval, 1.27-5.36, P = 0.009); other risk factors for POAG derived from the analysis included age (odds ratio [OR], 1.04, P = 0.006), diabetes mellitus (OR, 2.31, P = 0.008), and non-White ethnicity (OR, 4.75, P < 0.001). In a case-only analysis involving the eye with worse glaucoma, there was no statistical difference in visual field mean deviation or retinal nerve fiber layer (RNFL) thickness in POAG patients with AiD (n = 30) and without AiD (n = 142, P > 0.13, for both). CONCLUSIONS A higher prevalence of AiD was found in POAG patients compared with control patients undergoing ophthalmic surgery. The presence of AiD was associated with increased risk for POAG after adjusting for covariates. Additional factors may have prevented a difference in RNFL thickness in POAG patients with and without AiD. Autoimmunity should be explored further in the pathogenesis of POAG.
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Affiliation(s)
- Maltish M. Lorenzo
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States
| | - Julia Devlin
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States
| | - Chhavi Saini
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States
| | - Kin-Sang Cho
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States.,Schepens Eye Research Institute of Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States
| | - Eleftherios I. Paschalis
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States.,Schepens Eye Research Institute of Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States
| | - Dong Feng Chen
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States.,Schepens Eye Research Institute of Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States
| | | | - Sherleen H. Chen
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States
| | - Milica A. Margeta
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States
| | - Courtney Ondeck
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States.,VA Boston Hospital, Boston, MA, United States
| | - David Solá-Del Valle
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States
| | - James Chodosh
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States
| | - Joseph B. Ciolino
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States
| | - Roberto Pineda
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States
| | - Louis R. Pasquale
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Lucy Q. Shen
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States
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14
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Hysa E, Gotelli E, Sammorì S, Cimmino MA, Paolino S, Pizzorni C, Sulli A, Smith V, Cutolo M. Immune system activation in polymyalgia rheumatica: Which balance between autoinflammation and autoimmunity? A systematic review. Autoimmun Rev 2021; 21:102995. [PMID: 34798314 DOI: 10.1016/j.autrev.2021.102995] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 11/14/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Polymyalgia rheumatica (PMR) is an inflammatory rheumatic disease that is common in elderly people. Its classification in the spectrum of autoinflammatory and autoimmune diseases is difficult because of its only partially understood immune-mediated mechanisms. The literature concerning the innate and adaptive immune system activation in PMR was systematically reviewed highlighting the relative weight of autoinflammation and autoimmunity in its pathogenesis and disease progression. METHODS A literature search on PubMed Central and Embase scientific databases was performed by two independent reviewers. To be eligible, the studies needed to fully satisfy our initial PICO framework: a primary diagnosis of PMR as a population, the search for immune/inflammatory cells, cytokines and autoantibodies as an intervention, a control group consisting in healthy controls, patients with other inflammatory rheumatic diseases or PMR patients in remission after treatment and as outcomes the results of the investigations in the analyzed tissue samples. The most relevant data of the included papers were extracted by using a standardized template. RESULTS Of the 933 screened abstracts, 52 papers were included in the systematic review and categorized depending on their primary research objectives. The hyper-activity of neutrophils and monocytes, expressing toll-like receptor 7 in active disease, an impaired phagocytosis and endothelial dysfunction, as well as an increased count of innate T cells in patients with remission emerged among the major derangements of the innate immune response in PMR. Among the cytokines profile, interleukin-6 plays a key role but other pro-inflammatory mediators and angiogenesis markers such as chemokines, B-cell activating factor, vascular endothelial growth factor and angiopoietins seem to be involved in refractory or glucocorticoid-resistant PMR. The aberrant adaptive immune response was documented by tissue and serum findings of polarized T cells towards T helper 1 and 17 phenotypes, an increased expression of immunosenescent surface markers and a downregulated immunoregulatory response. The altered distribution of peripheral B cells, detected during active disease, suggested their peripheral migration towards unidentified sites. The interaction between innate and adaptive immune response was documented by a synovial infiltrate of macrophages and T cells. Despite multiple autoantibodies have been detected in PMR patients, none proved to correlate with disease activity seeming to be reactive to the marked inflammation or antigenic determinants provided by environmental triggers or tissue/cell damage. CONCLUSIONS The complex network between innate and adaptive immune system in PMR is supported by findings at molecular and cellular levels. By considering both the ends of the pathophysiological spectrum of immune-mediated rheumatic diseases, PMR may be regarded as an inflammatory immune-mediated disease with mixed mechanisms in a background of genetic and epigenetic factors together with immunological and endocrine senescence.
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Affiliation(s)
- Elvis Hysa
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, Italy - IRCCS San Martino Polyclinic, Genoa, Italy
| | - Emanuele Gotelli
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, Italy - IRCCS San Martino Polyclinic, Genoa, Italy
| | - Silvia Sammorì
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, Italy - IRCCS San Martino Polyclinic, Genoa, Italy
| | - Marco Amedeo Cimmino
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, Italy - IRCCS San Martino Polyclinic, Genoa, Italy
| | - Sabrina Paolino
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, Italy - IRCCS San Martino Polyclinic, Genoa, Italy.
| | - Carmen Pizzorni
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, Italy - IRCCS San Martino Polyclinic, Genoa, Italy.
| | - Alberto Sulli
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, Italy - IRCCS San Martino Polyclinic, Genoa, Italy.
| | - Vanessa Smith
- Department of Internal Medicine, Ghent University, Department of Rheumatology, Ghent University Hospital; Unit for Molecular Immunology and Inflammation, VIB Inflammation Research Center (IRC), Corneel Heymanslaan 10, 9000 Ghent, Belgium.
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, Italy - IRCCS San Martino Polyclinic, Genoa, Italy.
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15
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Sandovici M, van der Geest KSM, Boots MAMH, Brouwer E. Encouraging data on rituximab in polymyalgia rheumatica. THE LANCET. RHEUMATOLOGY 2021; 3:e738-e739. [PMID: 38297517 DOI: 10.1016/s2665-9913(21)00279-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/03/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Maria Sandovici
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen 9700 RB, Netherlands
| | - Kornelis S M van der Geest
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen 9700 RB, Netherlands
| | - Mieke A M H Boots
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen 9700 RB, Netherlands
| | - Elisabeth Brouwer
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen 9700 RB, Netherlands.
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16
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Nakajima S, Chiba A, Makiyama A, Hayashi E, Murayama G, Yamaji K, Kobayashi S, Tamura N, Takasaki Y, Miyake S. Association of mucosal-associated invariant T cells with different disease phases of polymyalgia rheumatica. Rheumatology (Oxford) 2021; 59:2939-2946. [PMID: 32125422 DOI: 10.1093/rheumatology/keaa054] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 01/20/2020] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES Although T cells are thought to be involved in the pathogenesis of PMR, whether innate-like T cells are involved in the process remains unknown. METHODS The serum levels of 27 cytokines/chemokines in patients with PMR were measured by a multiplex immunoassay (Bio-Plex Assay). The cytokine-producing capacity of T and innate-like T cells was assessed by intracellular cytokine staining and flow cytometry. The frequency and activated status of T and innate-like T cells were investigated by flow cytometry and their associations with clinical parameters were assessed. RESULTS The levels of inflammatory cytokines were associated with disease activity in PMR. The cytokine-producing capacity by CD8+ T and innate-like T cells was associated with disease activity. The frequency of HLA-DR+ CD38+ cells among CD8+ T cells was increased in patients with active disease. The frequencies of HLA-DR+ CD38+ cells among CD4+ T, mucosal-associated invariant T (MAIT) and γδ T cells were higher in patients with inactive disease. The frequency of HLA-DR+ CD38+ MAIT cells was associated with the PMR activity score and CRP levels in patients in remission. CONCLUSION The inflammatory cytokine-producing capacity and expression of activation markers of CD8+ T and innate-like T cells were associated with the disease activity of PMR. MAIT cell activation in patients in remission may contribute to the subclinical activity of the disease.
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Affiliation(s)
- Shihoko Nakajima
- Department of Immunology, Juntendo University School of Medicine, Tokyo, Japan.,Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Asako Chiba
- Department of Immunology, Juntendo University School of Medicine, Tokyo, Japan
| | - Ayako Makiyama
- Department of Immunology, Juntendo University School of Medicine, Tokyo, Japan.,Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Eri Hayashi
- Department of Immunology, Juntendo University School of Medicine, Tokyo, Japan.,Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Goh Murayama
- Department of Immunology, Juntendo University School of Medicine, Tokyo, Japan.,Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Ken Yamaji
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Shigeto Kobayashi
- Department of Internal Medicine, Juntendo University Koshigaya Hospital, Tokyo, Japan
| | - Naoto Tamura
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Yoshinari Takasaki
- Department of Internal Medicine, Juntendo University Koshigaya Hospital, Tokyo, Japan
| | - Sachiko Miyake
- Department of Immunology, Juntendo University School of Medicine, Tokyo, Japan
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17
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Carvajal Alegria G, Boukhlal S, Cornec D, Devauchelle-Pensec V. The pathophysiology of polymyalgia rheumatica, small pieces of a big puzzle. Autoimmun Rev 2020; 19:102670. [DOI: 10.1016/j.autrev.2020.102670] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 04/23/2020] [Indexed: 11/16/2022]
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18
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Horikoshi H, Nakanishi T, Tamura K, Kimura F, Itoh K. 18F-fluorodeoxyglucose-positron emission tomography/computed tomography for the diagnosis of polymyalgia-like illnesses: a retrospective study. BMC Rheumatol 2020; 4:21. [PMID: 32346670 PMCID: PMC7181584 DOI: 10.1186/s41927-020-00121-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 02/13/2020] [Indexed: 11/10/2022] Open
Abstract
Background Various inflammatory conditions may present with musculoskeletal symptoms similar to those of polymyalgia rheumatica (PMR). We investigated findings on 18F-fluorodexoxyglucose (FDG)-positron emission tomography/computed tomography (PET/CT) images that may differentiate PMR from polymyalgia-like illnesses. Methods We analyzed data from 25 patients with new-onset polymyalgia-like illnesses who fulfilled Bird's diagnostic criteria for PMR and had undergone FDG-PET/CT scan. To assess the uptake by major joints and synovial bursae, particularly at PMR-specific sites (shoulder, sternoclavicular, and hip joints, interspinous bursae, ischial tuberosities, and greater trochanters), we used visual scoring system to score FDG uptake: 0, no uptake (same as bone); 1, slight uptake; 2, moderate uptake (same as the liver); 3, greater uptake than the liver; and 4, uptake as strong as in the cerebellum. Results The final diagnoses were PMR in 17 patients and non-PMR in eight patients (three malignancies, two infections, one cholesterol crystal embolism, one ANCA-associated vasculitis, and one undefined diagnosis). Although the serum MMP-3 levels were significantly higher in patients with PMR, C-reactive protein and erythrocyte sedimentation rate mean values did not differ between the two groups. In PMR-specific sites, FDG accumulations were observed in all cases of PMR, with a high PET-positive score of 2.00 (range, 0-3), but it was low in non-PMR cases, with a PET-positive score of 1.00 (range, 0-3). Conclusions The FDG accumulation patterns in polymyalgia-like illness differ from those in PMR, despite the similar clinical presentations of both conditions. An FDG-PET/CT scan is useful for differentiating PMR from other polymyalgia-like illnesses.
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Affiliation(s)
- Hideyuki Horikoshi
- 1Division of Hematology and Rheumatology, Department of Internal Medicine, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513 Japan
| | - Takashi Nakanishi
- 1Division of Hematology and Rheumatology, Department of Internal Medicine, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513 Japan
| | - Katsumi Tamura
- Tokorozawa PET Diagnostic Imaging Clinic, 7-5 Higashi Sumiyoshi, Tokorozawa, Saitama, 359-1124 Japan
| | - Fumihiko Kimura
- 1Division of Hematology and Rheumatology, Department of Internal Medicine, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513 Japan
| | - Kenji Itoh
- 1Division of Hematology and Rheumatology, Department of Internal Medicine, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama, 359-8513 Japan
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19
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Owen CE, Liew DFL, Buchanan RRC. Musculotendinous Inflammation: The Defining Pathology of Polymyalgia Rheumatica? J Rheumatol 2019; 46:1552-1555. [PMID: 31787593 DOI: 10.3899/jrheum.190367] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Claire E Owen
- Department of Rheumatology, Austin Health, Heidelberg, Victoria, and Department of Medicine, University of Melbourne, Parkville, Victoria;
| | - David F L Liew
- Department of Rheumatology, and Department of Clinical Pharmacology, Austin Health, Heidelberg, Victoria, and Department of Medicine, University of Melbourne, Parkville, Victoria
| | - Russell R C Buchanan
- Department of Rheumatology, Austin Health, Heidelberg, Victoria, and Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
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20
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Manzo C, Emamifar A. Polymyalgia Rheumatica and Seronegative Elderly-Onset Rheumatoid Arthritis: Two Different Diseases with Many Similarities. EUROPEAN MEDICAL JOURNAL 2019. [DOI: 10.33590/emj/10313508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Polymyalgia rheumatica (PMR) and seronegative elderly-onset rheumatoid arthritis (SEORA) are two of the most frequent inflammatory rheumatologic diseases in elderly patients. At first presentation, there are many similarities between PMR and SEORA, that may lead to a real diagnostic conundrum. The most relevant similarities and differences between PMR and SEORA are discussed in this review. In addition to the acute involvement of the shoulder joints, important features characterising both diseases are morning stiffness longer than 45 minutes, raised erythrocyte sedimentation rate, and a good response to low doses of prednisone. Some findings (such as erosive arthritis or symmetrical involvement of metacarpophalangeal and/or proximal interphalangeal joints) can help to make the diagnosis of SEORA, whereas shoulder and hip ultrasonography and 18-FDG PET/CT seem to be less specific. However, in several patients only long-term follow-ups confirm the initial diagnosis. A definite diagnosis of PMR or SEORA has significant therapeutic implications, since patients with PMR should be treated with long-term glucocorticoids, and sometimes throughout life, which predisposes the patients to serious side effects. On the contrary, in patients with SEORA, short-term treatment with glucocorticoids should be considered when initiating or changing disease modifying antirheumatic drugs, followed by rapid tapering.
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Affiliation(s)
- Ciro Manzo
- Internal and Geriatric Medicine Department, Rheumatologic Outpatient Clinic Hospital “Mariano Lauro”, Sant’Agnello, Italy
| | - Amir Emamifar
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark; Diagnostic Center, Svendborg Hospital, Odense University Hospital, Svendborg, Denmark
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21
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Treatment of polymyalgia rheumatica. Biochem Pharmacol 2019; 165:221-229. [DOI: 10.1016/j.bcp.2019.03.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Accepted: 03/18/2019] [Indexed: 12/13/2022]
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22
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Kermani TA, Dasgupta B. Current and emerging therapies in large-vessel vasculitis. Rheumatology (Oxford) 2018; 57:1513-1524. [PMID: 29069518 DOI: 10.1093/rheumatology/kex385] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Indexed: 11/14/2022] Open
Abstract
GCA shares many clinical features with PMR and Takayasu arteritis. The current mainstay of therapy for all three conditions is glucocorticoid therapy. Given the chronic, relapsing nature of these conditions and the morbidity associated with glucocorticoid therapy, there is a need for better treatment options to induce and sustain remission with fewer adverse effects. Conventional immunosuppressive treatments have been studied and have a modest effect. There is a keen interest in biologic therapies with studies showing the efficacy of IL-6 antagonists in PMR and GCA. Recently the first two randomized clinical trials in Takayasu arteritis have been completed. A major challenge for all of these conditions is the lack of standardized measures to assess disease activity. Long-term studies are needed to evaluate the impact of biologic therapies showing potential on important clinical outcomes such as vascular damage, cost-effectiveness and quality of life. The optimal duration of treatment also needs to be assessed.
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Affiliation(s)
- Tanaz A Kermani
- Division of Rheumatology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Bhaskar Dasgupta
- Department of Rheumatology, Southend University Hospital & Anglia Ruskin University, Westcliff-on-sea, UK
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23
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Lunagariya A, Rupareliya C, Bollu PC, Mahuwala Z. Temporal Arteritis Presenting as an Isolated Bilateral Abducens Nerve Palsy: A Rare Case of a 65-year-old Male. Cureus 2018; 10:e2667. [PMID: 30042918 PMCID: PMC6054368 DOI: 10.7759/cureus.2667] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Giant cell arteritis (GCA) or temporal arteritis (TA) is a granulomatous inflammation of medium to large-sized arteries. It may have a diverse presentation. The most common presenting symptoms of GCA are fever, malaise, unilateral headache, jaw claudication, polymyalgia rheumatica (PMR) and ophthalmoplegia. Most severe sequelae of GCA could be blindness. We report a case of a 65-year-old Caucasian male who presented for the third time with recurrent episodes of diplopia. Neurologic exam showed bilateral cranial nerve (CN) VI palsy, slightly worse on the right than the left side. Other focal neurological deficits were absent. GCA was considered and biopsy of the temporal artery was performed which showed necrotizing pan-arteritis, consistent with GCA. The patient was empirically treated with intravenous (IV) methylprednisolone while awaiting the biopsy results which resulted in the resolution of the symptoms. As far as we know, this is the second case in the literature about the bilateral sixth CN involvement in the background of GCA.
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Affiliation(s)
| | | | - Pradeep C Bollu
- Department of Neurology, University of Missouri, Columbia, USA
| | - Zabeen Mahuwala
- Department of Neurology, University Of Kentucky College of Medicine
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24
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González-Gay MA, Matteson EL, Castañeda S. Polymyalgia rheumatica. Lancet 2017; 390:1700-1712. [PMID: 28774422 DOI: 10.1016/s0140-6736(17)31825-1] [Citation(s) in RCA: 155] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 06/09/2017] [Accepted: 06/19/2017] [Indexed: 12/12/2022]
Abstract
Polymyalgia rheumatica is an inflammatory disease that affects the shoulder, the pelvic girdles, and the neck, usually in individuals older than 50 years. Increases in acute phase reactants are typical of polymyalgia rheumatica. The disorder might present as an isolated condition or in association with giant cell arteritis. Several diseases, including inflammatory rheumatic and autoimmune diseases, infections, and malignancies can mimic polymyalgia rheumatica. Imaging techniques have identified the presence of bursitis in more than half of patients with active disease. Vascular uptake on PET scans is seen in some patients. A dose of 12·5-25·0 mg prednisolone daily or equivalent leads to rapid improvement of symptoms in most patients with isolated disease. However, relapses are common when prednisolone is tapered. Methotrexate might be used in patients who relapse. The effectiveness of biological therapies, such as anti-interleukin 6, in patients with polymyalgia rheumatica that is refractory to glucocorticoids requires further investigation. Most population-based studies indicate that mortality is not increased in patients with isolated disease.
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Affiliation(s)
- Miguel A González-Gay
- Division of Rheumatology and Epidemiology, Genetics and Atherosclerosis Research Group on Systemic Inflammatory Diseases, Hospital Universitario Marqués de Valdecilla, Instituto de Investigación Marqués de Valdecilla, University of Cantabria, Santander, Spain; Cardiovascular Pathophysiology and Genomics Research Unit, School of Physiology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Eric L Matteson
- Division of Rheumatology and Division of Epidemiology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Santos Castañeda
- Rheumatology Division, Hospital de La Princesa, Instituto de Investigación Sanitaria-Princesa, Universidad Autónoma de Madrid, Madrid, Spain
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Radenska-Lopovok SG, Kotenko ON, Frolova NF, Zagrebneva AI, Stolyarevich ES, Volodina EV, Chervinko VI, Kryukov EV, Zubkin ML. [A rare concurrence of polymyalgia rheumatica and AA-amyloidosis]. Arkh Patol 2017; 79:53-57. [PMID: 28418359 DOI: 10.17116/patol201779253-57] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Polymyalgia rheumatica (PMR) is a rare chronic inflammatory disease. It predominantly affects the elderly. The disease has a slow onset, pain and stiffness in the muscles of the shoulder and pelvic girdle, fever, weight loss, and a high acute-phase inflammatory response. The disease is concurrent with giant cell arteritis in a quarter of cases, which allows some authors to consider them as two different manifestations of the same pathological process. The kidneys are rarely involved. This disease is rarely complicated by AA amyloidosis. The authors describe a case of RPM in a patient who has developed secondary AA amyloidosis.
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Affiliation(s)
- S G Radenska-Lopovok
- I.M. Sechenov First Moscow State Medical University, Moscow, Russia; Russian Medical Academy of Postgraduate Education, Ministry of Health of the Russian Federation, Moscow, Russia
| | - O N Kotenko
- Moscow City Clinical Hospital Fifty-Two, Moscow Healthcare Department, Moscow, Russia
| | - N F Frolova
- Moscow City Clinical Hospital Fifty-Two, Moscow Healthcare Department, Moscow, Russia
| | - A I Zagrebneva
- Moscow City Clinical Hospital Fifty-Two, Moscow Healthcare Department, Moscow, Russia
| | - E S Stolyarevich
- Moscow City Clinical Hospital Fifty-Two, Moscow Healthcare Department, Moscow, Russia
| | - E V Volodina
- G.N. Gabrichevsky Moscow Research Institute of Epidemiology and Microbiology, Russian Federal Service for Supervision of Consumer Rights Protection and Human Welfare, Moscow, Russia
| | - V I Chervinko
- Branch, S.M. Kirov Military Medical Academy, Ministry of Defense of the Russian Federation, Moscow, Russia
| | - E V Kryukov
- N.N. Burdenko Main Military Clinical Hospital, Ministry of Defense of the Russian Federation, Moscow, Russia
| | - M L Zubkin
- Moscow City Clinical Hospital Fifty-Two, Moscow Healthcare Department, Moscow, Russia; G.N. Gabrichevsky Moscow Research Institute of Epidemiology and Microbiology, Russian Federal Service for Supervision of Consumer Rights Protection and Human Welfare, Moscow, Russia; Branch, S.M. Kirov Military Medical Academy, Ministry of Defense of the Russian Federation, Moscow, Russia
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Eginli AN, Bagayoko CW, McMichael AJ. A Case of Frontal Fibrosing Alopecia in a Patient with Primary Biliary Cirrhosis and Polymyalgia Rheumatica. Skin Appendage Disord 2016; 2:79-82. [PMID: 27843932 DOI: 10.1159/000447493] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 06/07/2016] [Indexed: 12/19/2022] Open
Abstract
Frontal fibrosing alopecia (FFA) is a form of scarring hair loss that is characterized by hair follicle destruction in a fronto-temporo-parietal distribution. Its etiology is unknown; however, most authors presently favor an immune pathogenesis. Associated autoimmune connective tissue diseases have been reported in patients with FFA. We present a case of FFA in a woman with primary biliary cirrhosis and polymyalgia rheumatica, suggesting an association between these clinical entities and supporting a potential autoimmune etiology of FFA.
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Dejaco C, Duftner C, Buttgereit F, Matteson EL, Dasgupta B. The spectrum of giant cell arteritis and polymyalgia rheumatica: revisiting the concept of the disease. Rheumatology (Oxford) 2016; 56:506-515. [DOI: 10.1093/rheumatology/kew273] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Indexed: 01/17/2023] Open
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Banerjee S, Stapleton PP, Dasgupta B. Emerging therapies in large vessel vasculitis. Int J Rheum Dis 2016; 19:741-6. [DOI: 10.1111/1756-185x.12963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Siwalik Banerjee
- Department of Rheumatology; Southend University Hospital; Essex UK
| | | | - Bhaskar Dasgupta
- Department of Rheumatology; Southend University Hospital; Essex UK
- University of Essex; Colchester UK
- Anglia Ruskin University; Essex UK
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Owen CE, Buchanan RRC, Hoi A. Recent advances in polymyalgia rheumatica. Intern Med J 2015; 45:1102-8. [DOI: 10.1111/imj.12823] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Accepted: 05/25/2015] [Indexed: 12/20/2022]
Affiliation(s)
- C. E. Owen
- Department of Rheumatology; Austin Health; Melbourne Victoria Australia
- Department of Medicine; Austin Health; The University of Melbourne; Melbourne Victoria Australia
| | - R. R. C. Buchanan
- Department of Rheumatology; Austin Health; Melbourne Victoria Australia
| | - A. Hoi
- Department of Rheumatology; Austin Health; Melbourne Victoria Australia
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Abstract
The diagnosis of polymyalgia rheumatica (PMR) is based on the typical clinical symptoms and elevated inflammatory markers in blood; however, both are unspecific and the differential diagnosis of the disease still represents a challenge for clinicians. The new consensus classification criteria of the European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR) established in 2012 have a high sensitivity (92.6 %) and specificity (91.2 %) and therefore contribute to improved diagnostics. Glucocorticoids are still the standard treatment with methotrexate and as an alternative and possibly anti-interleukin (anti-IL) 6 therapy in the future.
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Lee SS. Korean Epidemiologic Study of Polymyalgia Rheumatica. JOURNAL OF RHEUMATIC DISEASES 2015. [DOI: 10.4078/jrd.2015.22.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Shin-Seok Lee
- Division of Rheumatology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
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Disturbed B Cell Homeostasis in Newly Diagnosed Giant Cell Arteritis and Polymyalgia Rheumatica. Arthritis Rheumatol 2014; 66:1927-38. [DOI: 10.1002/art.38625] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Accepted: 03/06/2014] [Indexed: 01/08/2023]
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Pipitone N, Salvarani C. Update on polymyalgia rheumatica. Eur J Intern Med 2013; 24:583-9. [PMID: 23579169 DOI: 10.1016/j.ejim.2013.03.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Revised: 03/02/2013] [Accepted: 03/06/2013] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Nicolò Pipitone
- Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy
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Álvarez-Rodríguez L, López-Hoyos M, Calvo-Alén J, Aurrecoechea E, Villa I, Martínez-Taboada VM. Phagocyte dysfunction in polymyalgia rheumatica and other age-related, chronic, inflammatory conditions. J Leukoc Biol 2013; 94:1071-8. [PMID: 23904438 DOI: 10.1189/jlb.0113034] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
This study was conducted to evaluate phagocyte function in patients with age-related chronic inflammatory conditions. It included 95 patients with PMR, 17 with GCA, 40 with EORA, and 25 age-matched HCs. Serum IL-8 was determined with a bead array. The chemotactic capacity, phagocytic ability, and oxidative burst activity of circulating leukocytes were determined with flow cytometry kits. Patients with active chronic inflammatory diseases showed a significant increase in circulating levels of IL-8 that remained elevated in patients with PMR or EORA, despite treatment. No correlation was found between circulating IL-8 and the migratory capacity of neutrophils. Neutrophils from patients with active EORA without stimulus and after fMLP stimuli showed a higher capacity to migrate than those of the HCs (P=0.033). The phagocytic activity of granulocytes in the patients with GCA was significantly higher than in the HCs and the patients with PMR or EORA (P<0.05). The percentage and MFI of phagocytes that produce ROIs when stimulated with Escherichia coli was significantly reduced in neutrophils and monocytes from the patients with age-restricted inflammatory conditions. We concluded that the effector functions of phagocytes, determined to be chemotaxis, phagocytosis, and oxidative burst, are deregulated in age-restricted inflammatory disorders and may have a pathogenic role.
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Affiliation(s)
- Lorena Álvarez-Rodríguez
- 1.Facultad de Medicina. Universidad de Cantabria, Avda. Valdecilla s/n. 39008. Santander, Spain.
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Cimmino MA, Camellino D, Paparo F, Morbelli S, Massollo M, Cutolo M, Sambuceti G. High frequency of capsular knee involvement in polymyalgia rheumatica/giant cell arteritis patients studied by positron emission tomography. Rheumatology (Oxford) 2013; 52:1865-72. [PMID: 23850896 DOI: 10.1093/rheumatology/ket229] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Peripheral arthritis has been described in up to 50% of PMR patients, with knee involvement in the majority. This study was designed to evaluate by PET/CT the knees of patients with PMR and GCA and to identify the knee structures involved by inflammation. METHODS Twenty-five consecutive patients with PMR (19) or GCA (6) were studied in comparison with 25 age- and sex-matched controls who underwent PET/CT for initial staging of cancer. Clinical features, ESR and CRP were evaluated. Simultaneous FDG-PET and CT imaging from the skull base to the knee was performed after injection of 4.8-5.2 MBq of [(18)F]FDG per kilogram body weight. The knee anatomical structures being evaluated included joints, fibrous capsule, synovial recesses and bursae. RESULTS At PET/CT, 21/25 patients (84%) showed bilateral diffuse uptake at the knees. The tracer clearly outlined the contour of the fibrous capsule. In 50 knees, 90% of capsular sites were involved by inflammation in comparison with 23% of intracapsular sites and 4.7% of extracapsular sites (P < 0.0001). No correlation was found between PET/CT results and ESR or CRP. FDG uptake, with a pattern similar to that observed in 96% of PMR/GCA patients, was seen in 20% of controls (P = 0.03). CONCLUSION Our findings suggest that bilateral capsulitis of the knee is detectable in most PMR/GCA patients if a sensitive imaging technique such as PET/CT is used.
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Affiliation(s)
- Marco A Cimmino
- Clinica Reumatologica, Dipartimento di Medicina Interna e Specialità Mediche, Viale Benedetto XV, 6, 16132 Genova, Italy.
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Abstract
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.
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Affiliation(s)
- Tanaz A Kermani
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Takeshima E, Morishita Y, Ogura M, Ito C, Saito O, Takemoto F, Ando Y, Muto S, Yumura W, Kusano E. A case of diffuse endocapillary proliferative glomerulonephritis associated with polymyalgia rheumatica. CASE REPORTS IN NEPHROLOGY AND UROLOGY 2012; 2:158-64. [PMID: 23326256 PMCID: PMC3542932 DOI: 10.1159/000345280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A 70-year-old man complained of muscle pain in his neck, shoulders and pelvic girdle. Proteinuria and hematuria subsequently developed. Blood analysis showed increased acute phase reactants. The histology of renal biopsy showed diffuse endocapillary proliferative glomerulonephritis. There were no signs of autoimmune diseases, malignancies and bacterial or viral infections. His extrarenal symptoms and the results of blood analysis fulfilled three different criteria of polymyalgia rheumatica (PMR). Therefore, diffuse endocapillary proliferative glomerulonephritis associated with PMR was diagnosed. After low-dose prednisolone (10 mg/day) treatment, the muscle pain disappeared, acute phase reactants decreased and hematuria and proteinuria improved. The renal complication of PMR is rare but important to be considered early in the right clinical context.
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Affiliation(s)
- Eri Takeshima
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-shi, Japan
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Kreiner FF, Galbo H. Activity of the neuroendocrine axes in patients with polymyalgia rheumatica before and after TNF-α blocking etanercept treatment. Arthritis Res Ther 2012; 14:R186. [PMID: 22894827 PMCID: PMC3580582 DOI: 10.1186/ar4017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Accepted: 08/15/2012] [Indexed: 11/10/2022] Open
Abstract
Introduction In this study, we evaluated the activity of the neuroendocrine axes in patients with polymyalgia rheumatica (PMR) before and after tumor necrosis factor (TNF)-α-blocking etanercept treatment, which previously has been shown to reduce interleukin 6 (IL-6) and C-reactive protein (CRP) markedly in PMR. Methods Plasma samples were collected from 10 glucocorticoid-naïve patients with PMR and 10 matched controls before and after etanercept treatment (25 mg biweekly for 2 weeks). The primary end points were pre- and posttreatment levels of adrenocorticotropic hormone (ACTH), cortisol, adrenaline, thyroid-stimulating hormone (TSH), follicle-stimulating hormone (FSH), prolactin, and insulin-like growth factor 1 (IGF-1). Results Before TNF-α-blocking treatment, plasma TNF-α, ACTH, and cortisol levels were higher in patients versus controls (P < 0.05 and P < 0.001, respectively); during TNF-α blockade in patients, levels of both hormones decreased (P < 0.05 and P < 0.01, respectively), whereas levels in controls increased (P < 0.05), abolishing the pretreatment differences. Pretreatment adrenaline levels were more than twice as high in patients than in controls (P < 0.01); after treatment in patients, levels had decreased (P < 0.05) but remained higher versus controls (P < 0.05). Levels of the other hormones never differed significantly between groups (P > 0.05). Conclusions In PMR, TNF-α may increase the activities of the hypothalamic-pituitary-adrenal and the hypothalamic-sympthoadrenomedullary axes. Secretion of TSH, FSH, prolactin, and IGF-1 is not clearly changed in PMR. Trial registration ClinicalTrials.gov (NCT00524381).
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Ghosh P, Borg FA, Dasgupta B. Current understanding and management of giant cell arteritis and polymyalgia rheumatica. Expert Rev Clin Immunol 2011; 6:913-28. [PMID: 20979556 DOI: 10.1586/eci.10.59] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are linked conditions that occur in the elderly. GCA is a vasculitis of large- and medium-sized vessels causing critical ischemia. It is a medical emergency owing to the high incidence of neuro-ophthalmic complications. PMR is an inflammatory disease characterized by abrupt-onset pain and stiffness of the shoulder and pelvic girdle muscles. Both conditions are associated with a systemic inflammatory response and constitutional symptoms. The pathogeneses are unclear. The initiating step may be the recognition of an infectious agent by activated dendritic cells. The key cell type involved is CD4(+) T cells and the key cytokines are IFN-γ (implicated in granuloma formation) and IL-6 (key to the systemic response). The pathogenesis of PMR may be similar to that of GCA, however, PMR exhibits less clinical vascular involvement. The mainstay of therapy is corticosteroids, and disease-modifying therapy is indicated in relapsing disease. This article reviews recent guidelines on early recognition, investigations and management of these diseases, as well as advances in imaging.
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Affiliation(s)
- Parasar Ghosh
- Department of Rheumatology, Southend University Hospital, Prittlewell Chase, Westcliff-on-Sea, Essex, SS0 0RY, UK
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Camellino D, Cimmino MA. Imaging of polymyalgia rheumatica: indications on its pathogenesis, diagnosis and prognosis. Rheumatology (Oxford) 2011; 51:77-86. [PMID: 21565899 DOI: 10.1093/rheumatology/keq450] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Imaging is one of the most appealing techniques to explore PMR, a disease whose causes, development mechanisms and anatomical targets of inflammatory damage are still scarcely known. This review is concerned with an appraisal of PMR with different imaging modalities with a view to highlighting possible clues to its pathogenesis, diagnosis and prognosis. METHODS A systematic literature research was performed searching PubMed until July 2010. The Cochrane Library was searched for the relevant reviews, and the abstracts of the ACR and European League Against Rheumatism congresses of the period 2005-10 were reviewed. RESULTS A total of 1059 papers were retrieved, 46 of which were selected at the end of the review process; 6 of them were concerned with two different imaging techniques. Of these papers, 6 (11.5%) were concerned with conventional radiology; 8 (15.4%) with scintigraphy; 17 (32.7%) with ultrasonography (US); 15 (28.8%) with MRI; and 6 (11.5%) with PET. MRI, US and PET appeared to be the most promising imaging techniques. Bilateral subacromial bursitis, biceps long head tenosynovitis and trochanteric bursitis were particularly consistent findings. In addition, MRI and PET showed interspinous bursitis and PET frequently showed large-vessel vasculitis. Few papers have addressed the role of imaging for diagnosis, differential diagnosis and prognosis of PMR. CONCLUSIONS Imaging plays an important role in the comprehensive evaluation of PMR, including its pathogenesis, diagnosis and prognosis. Most of its potential is still unexplored, which fact should stimulate further research.
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Affiliation(s)
- Dario Camellino
- Dipartimento di Medicina Interna, Clinica Reumatologica, Università di Genova, Viale Benedetto XV, 6, 16132 Genova, Italy
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Kreiner F, Langberg H, Galbo H. Increased muscle interstitial levels of inflammatory cytokines in polymyalgia rheumatica. ACTA ACUST UNITED AC 2011; 62:3768-75. [PMID: 20812339 DOI: 10.1002/art.27728] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Polymyalgia rheumatica (PMR) is characterized by aching of the proximal muscles and increased blood levels of markers of inflammation. Despite the muscle complaints, the current view is that symptoms are caused by inflammation in synovial structures. The purpose of this study was to elucidate the disease mechanisms in symptomatic muscles by measuring interstitial levels of cytokines before and after prednisolone treatment. METHODS Twenty glucocorticoid-naive patients newly diagnosed as having PMR and 20 control subjects were studied before and after 14 days of prednisolone therapy (20 mg/day). Interstitial concentrations of interleukin-1α/β (IL-1α/β), IL-1 receptor antagonist, IL-6, IL-8, tumor necrosis factor α (TNFα), and monocyte chemoattractant protein 1 were measured in symptomatic vastus lateralis and trapezius muscles using the microdialysis technique. Plasma levels were measured simultaneously. RESULTS Prednisolone abolished symptoms in all of the PMR patients within 1-2 days; the erythrocyte sedimentation rate and C-reactive protein levels were normalized on day 14. In both muscles, interstitial concentrations of all cytokines were markedly higher (P < 0.05) in the PMR patients than in the controls before treatment. In both patients and controls, interstitial levels of most cytokines were higher than plasma levels, with the exception of IL-1α and TNFα, which were lower in both groups. In the PMR patients, interstitial concentrations were normalized after prednisolone treatment. CONCLUSION This study introduces a novel view of PMR, indicating that increased interstitial levels of inflammatory cytokines in symptomatic muscles play a role in the pathophysiology of the disease and that cytokines may be released locally. To explore the disease specificity, similar studies in other primary inflammatory conditions are warranted.
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Affiliation(s)
- Frederik Kreiner
- Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
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Kreiner F, Galbo H. Elevated muscle interstitial levels of pain-inducing substances in symptomatic muscles in patients with polymyalgia rheumatica. Pain 2011; 152:1127-1132. [PMID: 21388741 DOI: 10.1016/j.pain.2011.01.032] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Accepted: 01/18/2011] [Indexed: 11/16/2022]
Abstract
Polymyalgia rheumatica (PMR) is characterized by aching proximal muscles and systemic inflammation. We explored the pain-eliciting mechanisms by measuring interstitial levels in muscle of potentially pain-inducing substances as well as local blood flow. Twenty glucocorticoid-naive patients with newly diagnosed PMR and 20 controls were examined before and after 14 days of prednisolone (20 mg/day). Concentrations of glutamate, prostaglandin E(2) (PGE(2)), bradykinin, serotonin, adenosine triphosphate, lactate, pyruvate, and potassium as well as extraction of (3)H(2)O were measured in symptomatic vastus lateralis and trapezius muscles using microdialysis. Plasma levels were measured simultaneously. To be considered potentially pain inducing, interstitial concentrations of candidates should be higher in patients vs. controls, be normalized by prednisolone, and be higher in muscle vs. plasma. Prednisolone abolished symptoms in all patients within 2 days. Before treatment glutamate in both muscles (vastus: 60±7 vs. 38±7 μmol/L; trapezius: 60±6 vs. 43±7 μmol/L) and PGE(2) in vastus (911±200 vs. 496±122 pg/mL) were higher in patients than in controls (P<0.05), and higher in muscle than in plasma (P<0.05). Prednisolone abolished the differences between patients and controls. No other candidate completely fulfilled the predefined requirements for pain-inducing substances in PMR. (3)H(2)O extraction was identical between groups. In conclusion, local release of glutamate and PGE(2), but not ischemia, may contribute to the muscle pain in PMR. This supports the view that intramuscular mechanisms are important in PMR.
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Affiliation(s)
- Frederik Kreiner
- Department of Rheumatology, Institute of Inflammation Research, Rigshospitalet, Copenhagen, Denmark
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Cimmino MA, Parodi M, Zampogna G, Barbieri F, Garlaschi G. Polymyalgia rheumatica is associated with extensor tendon tenosynovitis but not with synovitis of the hands: a magnetic resonance imaging study. Rheumatology (Oxford) 2010; 50:494-9. [PMID: 21071481 DOI: 10.1093/rheumatology/keq367] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To study with MRI the hands of consecutive PMR patients, who were not selected on the basis of peripheral arthritis, with a correlation to clinical and laboratory findings. METHODS Twenty-six hands of 15 PMR patients and 26 hands of 13 healthy controls were studied by extremity-dedicated MRI for the presence of synovitis, tenosynovitis, soft-tissue oedema, bone marrow oedema and erosions. RESULTS Sixteen (61.6%) of the 26 PMR hands and 4 (15.4%) of the 26 control hands showed tenosynovitis (P = 0.001). Extensor tendon tenosynovitis was seen in 9 (34.6%) of the 26 PMR hands, but in only 1 (3.8%) control hand (P = 0.002) and flexor tenosynovitis was seen in 12 (46.1%) of the 26 PMR hands and in 4 (15.4%) of the 26 control hands (P = 0.03). All other features were similar in the two groups. CONCLUSIONS Our data support the view that tenosynovitis, especially of the extensor tendons, is a frequent event in PMR, unrelated to clinical involvement of the hand. This finding is in agreement with the concept of PMR as a disease of extra-articular structures.
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Affiliation(s)
- Marco A Cimmino
- Dipartimento di Medicina Interna e Specialità Mediche, Clinica Reumatologica, Viale Benedetto XV 6, 16132 Genova, Italy.
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Boutry N, Cotten A. Apport de l’échographie dans les rhumatismes inflammatoires (polyarthrite rhumatoïde, pseudopolyarthrite rhizomélique et spondylarthropathies). Rev Med Interne 2010; 31:29-40. [DOI: 10.1016/j.revmed.2009.03.365] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2008] [Revised: 03/02/2009] [Accepted: 03/17/2009] [Indexed: 01/08/2023]
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Gonzalez-Gay MA, Vazquez-Rodriguez TR, Lopez-Diaz MJ, Miranda-Filloy JA, Gonzalez-Juanatey C, Martin J, Llorca J. Epidemiology of giant cell arteritis and polymyalgia rheumatica. ACTA ACUST UNITED AC 2009; 61:1454-61. [PMID: 19790127 DOI: 10.1002/art.24459] [Citation(s) in RCA: 363] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Camellino D, Sambuceti G, Morbelli S, Cimmino MA. Clinical images: The multifaceted pathogenesis of polymyalgia rheumatica/giant cell arteritis. ACTA ACUST UNITED AC 2009; 60:2771. [DOI: 10.1002/art.24770] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Braun N, Fritz P, Rieth A, Schroth W, Kimmel M, Biegger D, Zakim D, Alscher MD. Predictors for treatment success and expression of glucocorticoid receptor in giant cell arteritis and polymyalgia rheumatica. J Rheumatol 2009; 36:2269-76. [PMID: 19684157 DOI: 10.3899/jrheum.090075] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) generally respond well to treatment with glucocorticoids (GC). We sought to determine the value of clinical, histopathologic, immunohistochemical, and genetic findings and the expression of the glucocorticoid receptor (GR) for discriminating between patients who achieve complete remission, or partial remission, or who do not improve with glucocorticoid treatment. METHODS We examined biopsies of the temporal artery from 60 patients, of whom 27 had GCA, 13 PMR, and 20 arteriosclerosis. RESULTS Of the clinical variables evaluated, jaw claudication was correlated with the histologic classification of the biopsies (p < 0.0001). Erythrocyte sedimentation rate was significantly higher in patients with PMR and GCA than in patients with arteriosclerosis (p < 0.0001). There were significant differences between patients with GCA versus PMR in the numbers of CD3-, CD8-, and CD4-positive T cells, in CD68-positive monocytes (p < 0.0001), and antigen-presenting cells (p < 0.0001). CD138-positive and CD20-positive cells were absent in patients with PMR but present in patients with GCA (p < 0.0001). In GCA and chronic inflammation most monocytes and lymphocytes expressed GR (88.9%). The number of CD68-positive cells and the extent of GR-staining in chronic inflammation reflected the success of treatment in logistic regression analysis (p < 0.05). GR polymorphism showed that more than 90% of patients had the wild-type (homozygote) of the R23K or N363S polymorphism. There was no evidence that this polymorphism influenced response to treatment with GC (Fisher's exact test 1.0). CONCLUSION Expression of GR and the presence of CD20-, CD3-, CD4-, CD8-, CD68-, CD138-positive cells and antigen-presenting cells differ between GCA and PMR. The presence of CD68-positive cells and the extent of GR-staining in chronic inflammation are suitable to predict complete remission in GCA.
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Affiliation(s)
- Niko Braun
- Division of General Internal Medicine and Nephrology, Department of Internal Medicine, Robert-Bosch Hospital Stuttgart, 70376 Stuttgart, Germany.
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Chatelain D, Duhaut P, Loire R, Bosshard S, Pellet H, Piette JC, Sevestre H, Ducroix JP. Small-vessel vasculitis surrounding an uninflamed temporal artery: A new diagnostic criterion for polymyalgia rheumatica? ACTA ACUST UNITED AC 2008; 58:2565-73. [DOI: 10.1002/art.23700] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Polymyalgia rheumatica and giant-cell arteritis are closely related disorders that affect people of middle age and older. They frequently occur together. Both are syndromes of unknown cause, but genetic and environmental factors might have a role in their pathogenesis. The symptoms of polymyalgia rheumatica seem to be related to synovitis of proximal joints and extra-articular synovial structures. Giant-cell arteritis primarily affects the aorta and its extracranial branches. The clinical findings in giant-cell arteritis are broad, but commonly include visual loss, headache, scalp tenderness, jaw claudication, cerebrovascular accidents, aortic arch syndrome, thoracic aorta aneurysm, and dissection. Glucocorticosteroids are the cornerstone of treatment of both polymyalgia rheumatica and giant-cell arteritis. Some patients have a chronic course and might need glucocorticosteroids for several years. Adverse events of glucocorticosteroids affect more than 50% of patients. Trials of steroid-sparing drugs have yielded conflicting results. A greater understanding of the molecular mechanisms involved in the pathogenesis should provide new targets for therapy.
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Affiliation(s)
- Carlo Salvarani
- Unit of Rheumatology, Arcispedale S Maria Nuova, Reggio Emilia, Italy.
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