Polymyalgia rheumatica in 2011

Why is polymyalgia rheumatica a disease of older adults? Explanations through etiology and pathogenesis: a narrative review

Polymyalgia rheumatica is one of the most common inflammatory rheumatic conditions in older adults. The disease is characterized by pain and stiffness in the shoulder and pelvic girdle. Polymyalgia rheumatica is almost always observed in adults over the age of 50. The current article aimed to provide explanations for the age preference of polymyalgia rheumatica by reviewing the literature regarding disease etiology and pathogenesis. Potential factors related to the association between polymyalgia rheumatica and aging include immunosenescence/inflammaging, increased risk of infections by aging, endocrinosenescence, and age-related changes in gut microbiota. These factors and their potential contributions to immune-mediated inflammation will be discussed.

Incidence of cardiovascular events in polymyalgia rheumatica and giant cell arteritis amongst an Asian population: Propensity score matched cohort study

BACKGROUND

The hypothesis that patients with polymyalgia rheumatica (PMR) or giant cell arteritis (GCA) have a high risk for future cardiovascular diseases has not been adequately tested. The aim of this study is to evaluate this hypothesis in Japan, where the prevalence and severity of PMR and GCA are the lowest.

METHODS

A propensity score matched cohort study was conducted at St. Luke's International Hospital, Tokyo, Japan, from 2003 to 2016. We included all patients who were diagnosed as PMR or GCA cases and matched comparators with a proportion of 1 : 2. Our primary outcome was newly diagnosed cardiovascular disease. The propensity score was calculated using logistic regression with forward stepwise selection in 30 variables. Kaplan-Meier curves were drawn and the log-rank test and Cox proportional hazard model were performed for survival analyses. Two types of sensitivity analyses were conducted to confirm the results.

RESULTS

Among 2461 potential patients, the propensity score identified 504 (168 cases and 336 comparators) patients. During follow up (median 839.5 days), 110 (21.8%) developed cardiovascular diseases. The Kaplan-Meier curves between those with and without PMR or GCA were not significantly different (P = 0.85). The Cox proportional hazard model calculated the hazard ratio (HR) of those with PMR or GCA compared to those without as 0.96 (95% CI: 0.64-1.46). The results from sensitivity analyses were consistent (HR 0.70-1.06).

CONCLUSION

Patients with PMR or GCA may not have a higher risk of future cardiovascular diseases among the Japanese population. The sensitivity analyses and sample size calculation supported the results.

Characteristics of Korean Patients with Polymyalgia Rheumatica: a Single Locomotive Pain Clinic Cohort Study

BACKGROUND

Polymyalgia rheumatica (PMR) is a common systemic inflammatory disease of the elderly; however, the clinical characteristics and therapeutic response of PMR in Korea have been rarely studied.

METHODS

We reviewed the medical records of 54 Korean patients diagnosed with PMR between January 2009 and February 2017 in a locomotive pain clinic of one tertiary referral hospital. We analyzed epidemiologic and clinical characteristics, therapeutic responses, and prognostic factors for remission-failure at one-year after oral prednisolone treatment.

RESULTS

In 54 patients with PMR, 32 (59.3%) were female. The average age at diagnosis was 65.0 ± 10.5 years. Duration of symptoms before diagnosis was 8.1 ± 8.6 months. All patients had shoulder pain (54 patients, 100.0%); 49 patients (90.7%) had hip girdle pain, while 19 patients (35.2%) had peripheral joint pain. Four patients (7.4%) were accompanied by the giant cell arteritis (GCA). There was no seasonal preference for symptom development. Only 19 patients were diagnosed with PMR at initial symptom presentation. At one-year follow-up after oral prednisolone treatment, the remission rate was 35.3% (12/34). Multivariate analysis showed that history of relapse (odds ratio, 6.81; 95% confidence interval, 1.035-44.804) was a significant predictor of remission-failure.

CONCLUSION

The rate of remission (35.3%) after oral prednisolone treatment was similar to previous reports in western countries; and GCA is not a rare condition in Korean PMR patients. Misdiagnosis of PMR is common, and heightened consideration for PMR is needed in elderly patients who present inflammatory features of bilateral shoulder pain.

Temporal small arterial inflammation is common in patients with giant cell arteritis

Giant cell arteritis (GCA) primarily involves medium-to-large arteries. Small-vessel inflammation is a recognized phenomenon occurring in association with GCA. However, its significance is poorly elucidated. Histologic sections and medical records of105 temporal artery specimens were retrospectively reviewed between 2008 and 2017 to examine associated clinical manifestations and laboratory data including antinuclear antibody and p-antineutrophilic cytoplasmic antibody titers. Immunohistochemical staining for CD4 and CD8 was performed in select cases to assess the nature of the inflammatory response. Seventy-eight patients meeting the diagnostic criteria of temporal arteritis were included in the analysis. Twenty-eight specimens demonstrated temporal arteritis with small arterial inflammation (SAI), and 50 specimens showed temporal arteritis without SAI. Eight (28.6%) of 28 patients with SAI presented with jaw claudication, whereas 5 (17.9%) were febrile at presentation. In contrast, in 50 patients without SAI, jaw claudication and fever were seen in 11 and 2 cases, respectively (P = .01 and P = .0047, respectively). No statistically significant difference was noted between other symptoms and laboratory indices between the 2 groups. Elevated p-antineutrophilic cytoplasmic antibody titers in GCA may be associated with concomitant polymyalgia rheumatica or treatment-resistant disease. We also identified a higher count of CD4 and CD8 T cells in SAI cases, although the ratio of CD4/CD8 T lymphocytes was within normal limits. In conclusion, simultaneous involvement of arterioles and medium- to large-sized arteries is common in GCA and may be associated with treatment-refractory disease. Documentation of small arterial involvement in GCA will help the clinicians to manage the disease more effectively.

Proliferative Synovitis of the Shoulder Bursae is a Key Feature for Discriminating Elderly Onset Rheumatoid Arthritis Mimicking Polymyalgia Rheumatica From Polymyalgia Rheumatica

Semiquantitative scoring for subacromial bursa (SAB), subdeltoid bursa (SDB), and subcoracoid bursa by both gray-scale (GS) and power Doppler (PD) ultrasonography was performed in 15 patients with polymyalgia rheumatica (PMR) (72.6 ± 7.7 years old) and 15 patients with elderly onset rheumatoid arthritis with PMR-like onset (pm-EORA) (70.7 ± 7.0 years old) before starting treatment. The GS grades of SAB were significantly higher in the shoulders with pm-EORA than in the shoulders with PMR. The GS and PD scores of SAB and the PD scores of SDB were significantly higher in pm-EORA than in PMR cases. The sums of GS and/or PD scores for the three bursae were significantly higher in pm-EORA than in patients with PMR. The sums of GS and PD scores for SAB were significantly higher in pm-EORA than in PMR cases. Moderate to severe proliferative synovitis of the shoulder bursae, especially in SAB, is a key feature for discriminating pm-EORA from PMR.

Proliferative Synovitis of the Shoulder Bursae is a Key Feature for Discriminating Elderly Onset Rheumatoid Arthritis Mimicking Polymyalgia Rheumatica From Polymyalgia Rheumatica

Semiquantitative scoring for subacromial bursa (SAB), subdeltoid bursa (SDB), and subcoracoid bursa by both gray-scale (GS) and power Doppler (PD) ultrasonography was performed in 15 patients with polymyalgia rheumatica (PMR) (72.6 ± 7.7 years old) and 15 patients with elderly onset rheumatoid arthritis with PMR-like onset (pm-EORA) (70.7 ± 7.0 years old) before starting treatment. The GS grades of SAB were significantly higher in the shoulders with pm-EORA than in the shoulders with PMR. The GS and PD scores of SAB and the PD scores of SDB were significantly higher in pm-EORA than in PMR cases. The sums of GS and/or PD scores for the three bursae were significantly higher in pm-EORA than in patients with PMR. The sums of GS and PD scores for SAB were significantly higher in pm-EORA than in PMR cases. Moderate to severe proliferative synovitis of the shoulder bursae, especially in SAB, is a key feature for discriminating pm-EORA from PMR.

Semiquantitative Evaluation of Extrasynovial Soft Tissue Inflammation in the Shoulders of Patients with Polymyalgia Rheumatica and Elderly-Onset Rheumatoid Arthritis by Power Doppler Ultrasound

Objectives. To develop a scoring system for evaluating the extrasynovial soft tissue inflammation of the shoulders in patients with polymyalgia rheumatica (PMR) and elderly-onset rheumatoid arthritis with PMR-like onset (pm-EORA) using ultrasound. Methods. We analyzed stored power Doppler (PD) images obtained by the pretreatment examination of 15 PMR patients and 15 pm-EORA patients. A semiquantitative scoring system for evaluating the severity of PD signals adjacent to the anterior aspect of the subscapularis tendon was designed. Results. A four-point scale scoring for the hyperemia on the subscapularis tendon was proposed as follows in brief: 0 = absent or minimal flow, 1 = single vessel dots or short linear-shape signals, 2 = long linear-shape signals or short zone-shape signals, or 3 = long zone-shape signals. This scoring system showed good intra- and interobserver reliability and good correlation to quantitative pixel-counting evaluation. By using it, we demonstrated that inflammation in PMR is dominantly localized in extrasynovial soft tissue as compared with pm-EORA. Conclusions. We proposed a reliable semiquantitative scoring system using ultrasound for the evaluation of extrasynovial soft tissue inflammation of the shoulders in patients with both PMR and pm-EORA. This system is simple to use and can be utilized in future investigations.

Patients' views on the causes of their polymyalgia rheumatica: a content analysis of data from the PMR Cohort Study

OBJECTIVE

To explore primary care polymyalgia rheumatica (PMR) patient beliefs about the causes of their PMR.

DESIGN

Qualitative content analysis was conducted on patients' written responses to the question of what they thought had caused their PMR. All data were coded and emergent categories of causal beliefs identified.

SETTING

Community patients receiving primary care at general practitioner (GP) practices across England.

PARTICIPANTS

Participants were recruited from a primary care PMR inception cohort (n=654). Between June 2012 and June 2014 GPs referred 739 people with a new PMR diagnosis in the past 3 years into the study. Patients were mailed a baseline self-completion questionnaire, which included the question, 'What do you think caused your PMR?'. Responses to this question form the data set for the present study.

RESULTS

296 (45%) patients gave a possible cause for their PMR, while 276 (42%) respondents wrote 'no idea'. Common attributions include ageing (45, 18%), medication (18, 5%) and personal stress (53, 14%). 24 respondents (6%) thought their PMR was as a result of another medical condition.

CONCLUSIONS

This is the first study to examine causation beliefs in PMR, identifying a number of possible causes such as ageing, stress and as a complication of other medical problems. Understanding these patient beliefs may impact on treatment adherence and patient outcome.

MRI findings of the shoulder and hip joint in patients with polymyalgia rheumatica

OBJECTIVES

The purpose of this study is to evaluate magnetic resonance imaging (MRI) findings of the shoulder and hip joint in patients with polymyalgia rheumatica (PMR).

METHODS

MR images of a total of 25 PMR patients (23 shoulders and 6 hips), 43 rheumatoid arthritis (RA) patients (22 shoulders and 22 hips), and 50 control patients (25 shoulders and 25 hips) were examined. The following MRI findings were evaluated: In the shoulder, thickness and abnormalities of the supraspinatus tendon, effusion around the glenohumeral joint, subacromial-subdeltoid bursa, and the biceps tendon; In the hip, effusion around the acetabulofemoral joint, iliopsoas bursa, and trochanteric bursa. Periarticular soft-tissue edema and bone findings were also analyzed.

RESULTS

The supraspinatus tendon was significantly thicker in PMR patients than in RA patients and control patients (p < 0.05). Severe rotator cuff tendinopathy was frequently observed in PMR patients (p = 0.002). The scores for the amount of effusions (joint, bursa, and tendon sheath in the shoulder and bursa in the hip) were much higher in PMR patients (p < 0.05). Periarticular soft tissue edema was detected more frequently in PMR patients than in RA patients and control patients (p < 0.05).

CONCLUSIONS

Thick supraspinatus tendon, severe rotator cuff tendinopathy, effusion around the joints, and periarticular soft tissue edema can be good indicators for the diagnosis of PMR.

[Polymyalgia rheumatica in daily routine practice]

DEFINITION AND EPIDEMIOLOGY

Polymyalgia rheumatica (PMR) is a very painful inflammatory disease which regularly affects the shoulder region but in 70% of cases the pelvic girdle region is also affected. The disease occurs in people over the age of 50 years and reaches a peak at 72 years old. Women are affected twice as often as men. The prevalence is estimated to be 0.3-0.7% in the Caucasian population over 50 years old.

DIAGNOSTICS AND CLASSIFICATION

Misdiagnosis of PMR is common. The differential diagnosis primarily includes impingement syndrome, osteoarthritis of the shoulders, calcifying tendinitis of the rotator cuff, bursitis, omarthritis or inflammatory rheumatic diseases, such as rheumatoid arthritis. Taking a structured medical history and performing a thorough clinical examination are crucial. The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels are usually highly elevated and should be investigated particularly in patients who present with new onset bilateral shoulder pain and pronounced general impairment of movement. Imaging shows characteristic inflammatory changes around the shoulders and hip joints. The new European League Against Rheumatism and American College of Rheumatology (EULAR/ACR) classification criteria of PMR including ultrasound imaging are superior to previous classification and diagnostic criteria in terms of positive and negative predictive values.

THERAPY

Glucocorticoids are still the mainstay of treatment. Recommended daily prednisolone starting doses are between 15 mg and 25 mg with a weekly dose reduction until 10 mg/day and then further dose reductions of 1 mg per month. Methotrexate can aid reducing prednisolone doses in patients who fail to reach doses below the Cushing threshold quickly enough, which can have major side effects.

Positron emission tomography findings in a patient with multiple myeloma of polymyalgia rheumatica-like symptoms caused by paraneoplastic syndrome

A 50-year-old Japanese man was referred to our department with pain in his limb joints persisting for 3 months. Although his joints showed no redness, swelling or tenderness, he had a limited range of motion of his hip and shoulder joints, suggesting a diagnosis of polymyalgia rheumatica (PMR). However, his relatively young age and subacute course along with the absence of morning stiffness made the diagnosis uncertain. We performed positron emission tomography/CT, which revealed 18F-fluorodeoxyglucose uptake in bilateral upper and lower joints, consistent with PMR. There was also uptake by a sacral tumour, suggesting a diagnosis of paraneoplastic syndrome. Immunoglobulin A-κ type M protein was detected in serum and bone marrow aspiration/biopsy identified diffuse proliferation of atypical plasma cells, confirming a diagnosis of multiple myeloma. The patient received chemotherapy, which alleviated his limb pain, and achieved stringent complete remission after autologous peripheral blood stem cell transplantation.

Ocular inflammatory disease in patients with polymyalgia rheumatica: A case series and review of the literature

Scleritis and uveitis are potentially blinding conditions that can be associated with systemic inflammatory diseases. Polymyalgia rheumatica (PMR) is a common rheumatic disorder of the elderly of uncertain etiology. Although there are a few published reports of scleritis and uveitis in PMR patients, the association of PMR to ocular inflammation has not been well established. The aim of this study is to report a series of PMR patients with scleritis and/or uveitis and review the prior published reports of this potential association. We retrospectively reviewed the medical charts of patients with PMR and scleritis or uveitis who were examined in the Ocular Immunology Service of Massachusetts Eye and Ear Infirmary. We also performed a systematic literature search (PubMed; January 1990 until January 2014) to identify earlier published reports. Seven PMR patients with ocular inflammatory disease (OID) were included in our study: two with scleritis, three with anterior uveitis, and two with panuveitis. The onset of PMR preceded the occurrence of OID in six patients, and in one patient uveitis developed 2 months prior to PMR. Five patients demonstrated a temporal association between flares of PMR and OID. In four patients, OID flares developed during tapering of systemic prednisone prescribed for PMR. Four of the five patients who had relapsing PMR had recurrent or persistent uveitis over the course of follow-up. PMR may be associated with both scleritis and uveitis and should be considered as a possible underlying cause of OID.