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Moreel L, Betrains A, Boeckxstaens L, Molenberghs G, Van Laere K, De Langhe E, Vanderschueren S, Blockmans D. Polymyalgia rheumatica is a risk factor for more recalcitrant disease in giant cell arteritis: A retrospective cohort study. Semin Arthritis Rheum 2024; 68:152499. [PMID: 38968729 DOI: 10.1016/j.semarthrit.2024.152499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Revised: 05/24/2024] [Accepted: 06/11/2024] [Indexed: 07/07/2024]
Abstract
OBJECTIVES To evaluate differences in presentation and outcome of giant cell arteritis (GCA) patients with and without polymyalgia rheumatica (PMR) symptoms. METHODS Consecutive patients diagnosed with GCA between 2000 and 2020 and followed for ≥12 months at the University Hospitals Leuven (Belgium), were included retrospectively. RESULTS We included 398 GCA patients, of which 181 (45%) with PMR symptoms. Patients with PMR symptoms had a longer symptom duration (11 vs 6 weeks, p < 0.001). They less frequently reported fever (19% vs 28%, p = 0.030) and fatigue (52% vs 64%, p = 0.015) and tended to have less permanent vision loss (12% vs 19%, p = 0.052). There was no difference in the cumulative oral GC dose at 2 years (4.4 vs 4.3 g methylprednisolone, p = 0.571). However, those with PMR symptoms were treated with higher GC doses during subsequent follow-up (p < 0.05 from 38 months after diagnosis) and had a lower probability of stopping GC (62% vs 71%, HR 0.74 [95%CI 0.58-0.94], p = 0.018) with a longer median duration of GC treatment (29 vs 23 months, p = 0.021). In addition, presence of PMR symptoms was associated with an increased risk of relapse (64% vs 51%, HR 1.38 [95%CI 1.06-1.79], p = 0.017) with a higher number of relapses (1.47 [95%CI 1.30-1.65] vs 1.16 relapses [95%CI 1.02-1.31], p = 0.007). Patients with PMR symptoms less frequently developed thoracic aortic aneurysms during follow-up (3% vs 11%, p = 0.005). CONCLUSION GCA patients with PMR symptoms had more recalcitrant disease with a higher risk of relapse and longer duration of GC treatment with need for higher GC doses.
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Affiliation(s)
- Lien Moreel
- Department of General Internal Medicine, UZ Leuven, Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium.
| | - Albrecht Betrains
- Department of General Internal Medicine, UZ Leuven, Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium
| | - Lennert Boeckxstaens
- Department of Nuclear Medicine, UZ Leuven, Leuven, Belgium; Department of Imaging and Pathology, Nuclear Medicine and Molecular Imaging, KU Leuven, Belgium
| | - Geert Molenberghs
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics (l-BioStat), KU Leuven and Hasselt University, Leuven, Belgium
| | - Koen Van Laere
- Department of Nuclear Medicine, UZ Leuven, Leuven, Belgium; Department of Imaging and Pathology, Nuclear Medicine and Molecular Imaging, KU Leuven, Belgium
| | - Ellen De Langhe
- Department of Rheumatology, UZ Leuven, Leuven, Belgium; Department of Development and Regeneration, KU Leuven, Leuven, Belgium; European Reference Network for Immunodeficiency, Autoinflammatory, Autoimmune and Pediatric Rheumatic disease (ERN-RITA), Utrecht, The Netherlands
| | - Steven Vanderschueren
- Department of General Internal Medicine, UZ Leuven, Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium; European Reference Network for Immunodeficiency, Autoinflammatory, Autoimmune and Pediatric Rheumatic disease (ERN-RITA), Utrecht, The Netherlands
| | - Daniel Blockmans
- Department of General Internal Medicine, UZ Leuven, Leuven, Belgium; Department of Microbiology, Immunology, and Transplantation, KU Leuven, Leuven, Belgium; European Reference Network for Immunodeficiency, Autoinflammatory, Autoimmune and Pediatric Rheumatic disease (ERN-RITA), Utrecht, The Netherlands
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González-García A, Fabregate M, Serralta G, de Miguel Campo B, Noblejas-Mozo A, Robles-Marhuenda Á. The utility of 18F-FDG-PET/CT in detecting extracranial large vessel vasculitis in rheumatic polymyalgia or giant cell arteritis. A systematic review and meta-analysis. Rev Clin Esp 2024; 224:445-456. [PMID: 38852739 DOI: 10.1016/j.rceng.2024.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 04/25/2024] [Indexed: 06/11/2024]
Abstract
OBJECTIVE Systematic review of current evidence to analyze the prevalence of extracranial large vessel vasculitis (LVV) using 18F-FDG PET/CT in patients with polymyalgia rheumatica (PMR) or giant cell arteritis (GCA). MATERIALS AND METHODS PubMed and EMBASE were searched and the results were screened by two reviewers. Study quality was assessed using a modified version of the Newcastle-Ottawa scale. Heterogeneity between studies was assessed using the I2 statistic and the Q test. Further subgroup analyses were performed by disease type, study quality, and 18F-FDG PET/CT uptake criteria. Publication bias was assessed by funnel plot and Egger's test. RESULTS 268 publications were identified, of which 17 met the selection criteria and were included in the meta-analysis. The overall pooled prevalence of extracranial LVV by 18F-FDG PET/CT was 54.5% [95% CI: 42.6%-66.1%]. In patients with GCA the prevalence was significantly higher than in patients with PMR (60.1% vs. 41.8%, P = 0.006). Likewise, studies with a lower risk of bias reported a higher prevalence of extracranial LVV (61.1% vs. 46.9%; P = 0.010). No publication bias was observed. CONCLUSIONS The 18F-FDG PET/CT test may be useful in the detection of extracranial LVV, both in patients with PMR or GCA. Such involvement is more frequent in patients with GCA, and may vary depending on the quality of the studies.
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Affiliation(s)
- Andrés González-García
- Unidad de Enfermedades Autoinmunes Sistémicas, Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain.
| | - Martín Fabregate
- Unidad de Enfermedades Autoinmunes Sistémicas, Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Gonzalo Serralta
- Servicio de Medicina Interna, Hospital Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
| | - Borja de Miguel Campo
- Unidad de Enfermedades Autoinmunes Sistémicas, Servicio de Medicina Interna, Hospital 12 de Octubre, Madrid, Spain
| | - Ana Noblejas-Mozo
- Unidad de Enfermedades Autoinmunes Sistémicas, Servicio de Medicina Interna, Hospital La Paz, Madrid, Spain
| | - Ángel Robles-Marhuenda
- Unidad de Enfermedades Autoinmunes Sistémicas, Servicio de Medicina Interna, Hospital La Paz, Madrid, Spain
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Schmidt WA. [Polymyalgia rheumatica: What's new?]. Dtsch Med Wochenschr 2024; 149:1051-1055. [PMID: 39146754 DOI: 10.1055/a-2144-8222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2024]
Abstract
Currently, only 25% of all polymyalgia rheumatica (PMR) patients are referred to specialists. An expert committee has recently recommended confirmation of diagnosis by specialist care. This can help to avoid misdiagnoses and hospital stays and can result in lower glucocorticoid doses.Using ultrasound, magnetic resonance imagining (MRI), or positron emission tomography-computed tomography (PET-CT), typical periarticular inflammatory changes are observed, especially in the shoulder and pelvic girdle area. However, for clinical use, ultrasound is usually sufficient.In 20-25% of newly diagnosed PMR patients without symptoms of giant cell arteritis (GCA), GCA can be detected through vascular ultrasound. These patients require higher glucocorticoid doses in analogy to GCA therapy. There is growing awareness of a joint GCA-PMR spectrum disease.Glucocorticoids remain the primary treatment. The interleukin-6 inhibitor Sarilumab has recently been approved in the USA for patients with recurrent PMR. Studies have also demonstrated the effectiveness of Tocilizumab in PMR.
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Affiliation(s)
- Wolfgang A Schmidt
- Klinik für Innere Medizin, Rheumatologie und Klinische Immunologie, Immanuel Krankenhaus Berlin, Berlin-Buch, Deutschland
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Hysa E, Casabella A, Gotelli E, Campitiello R, Schenone C, Genova C, Tanda ET, Sulli A, Smith V, Cimmino MA, Paolino S, Cutolo M. Polymyalgia rheumatica and giant cell arteritis induced by immune checkpoint inhibitors: A systematic literature review highlighting differences from the idiopathic forms. Autoimmun Rev 2024; 23:103589. [PMID: 39117006 DOI: 10.1016/j.autrev.2024.103589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 08/03/2024] [Accepted: 08/04/2024] [Indexed: 08/10/2024]
Abstract
INTRODUCTION An altered immune tolerance disturbed by immune checkpoint inhibitors (ICIs) may contribute to new-onset polymyalgia rheumatica (PMR) and giant cell arteritis (GCA). This systematic literature review (SLR) examines the characteristics of PMR and GCA-like syndromes following anticancer treatment with ICIs, summarizing their demographic, clinical and treatment-related features to provide insights whether they differ from the idiopathic forms. METHODS The SLR was conducted in Medline and EMBASE databases from inception to July 2024, and in the EULAR/ACR abstract database (2021-2023). ICI-induced PMR and GCA syndromes were compared to the primary forms of the diseases using data from studies that included both groups as comparators. For manuscripts lacking direct comparisons, we summarized the main findings and discussed the differences using systematic reviews or large observational studies on the primary forms. RESULTS From 1237 screened abstracts, 46 met the inclusion criteria, involving 358 patients (314 with ICI-PMR and 44 with ICI-GCA). ICI-PMR had an estimated pooled prevalence of 0.1% [95% CI: 0.07%, 0.14%] among ICI recipients and 15.9% [95% CI: 12.6%, 19.9%] among patients experiencing rheumatic immune-related adverse events. Patients with ICI-PMR had a male-to-female ratio of 1.7:1 and a mean age of 71 ± 4 years. Most cases were associated with PD1/PDL1 blockers (87%). Clinical features included inflammatory pain in the girdles (100%), though pelvic girdle involvement was under-reported in some cases (3/28 studies). Peripheral arthritis was present in 35% of patients. Laboratory tests showed normal or slightly elevated inflammatory markers in 26% of cases. Glucocorticoids (GCs) led to symptom improvement in 84% of cases although 20% required immunosuppressive treatment and 14% experienced relapses. ICI-GCA had a prevalence of 0.06% among ICI recipients, with equal gender distribution and a mean age of 71 ± 5 years. Most patients received anti-PD1/PDL1 blockers (57%). Clinical manifestations included cephalic symptoms (75%), permanent visual loss (23%) and symptoms related to large-vessel involvement (54%). High-dose GCs were effective, with 96% achieving remission, though 17% experienced relapses. CONCLUSIONS ICI-induced PMR and GCA may have distinct clinical profiles compared to idiopathic forms, with potentially milder symptoms and better treatment responses. Further studies are needed to confirm these findings and better understand the long-term outcomes and pathophysiology of these conditions.
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Affiliation(s)
- Elvis Hysa
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genoa, Italy; Department of Experimental Medicine (DIMES), University of Genova, Genoa, Italy
| | | | - Emanuele Gotelli
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genoa, Italy
| | - Rosanna Campitiello
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Carlotta Schenone
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genoa, Italy
| | - Carlo Genova
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy; Academic Oncology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy; Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genoa, Italy
| | - Enrica Teresa Tanda
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy; UOC Medical Oncology Clinic 2, Department of Internal Medicine, University of Genova, Genoa, Italy; Department of Internal Medicine and Medical Specialties (DiMI), School of Medicine, University of Genova, Genoa, Italy
| | - Alberto Sulli
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, 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
| | - Marco Amedeo Cimmino
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genoa, Italy
| | - Sabrina Paolino
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
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Lee JI, Park JW, Jung Y, Shin K, Choi SR, Kang EH, Lee YJ, Yoo JJ, Ha YJ. Clinical characteristics and courses of Korean patients with giant cell arteritis: a multi-center retrospective study. JOURNAL OF RHEUMATIC DISEASES 2024; 31:160-170. [PMID: 38957359 PMCID: PMC11215252 DOI: 10.4078/jrd.2024.0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 04/15/2024] [Accepted: 04/27/2024] [Indexed: 07/04/2024]
Abstract
Objective Giant cell arteritis (GCA) is a large-vessel vasculitis that primarily affects elderly individuals. However, data regarding Korean patients with GCA are scarce owing to its extremely low prevalence in East Asia. This study aimed to investigate the clinical characteristics of Korean patients with GCA and their outcomes, focusing on relapse. Methods The medical records of 27 patients with GCA treated at three tertiary hospitals between 2007 and 2022 were retrospectively reviewed. Results Seventeen (63.0%) patients were females, and the median age at diagnosis was 75 years. Large vessel involvement (LVI) was detected in 12 (44.4%) patients, and polymyalgia rheumatica (PMR) was present in 14 (51.9%) patients. Twelve (44.4%) patients had fever at onset. The presence of LVI or concurrent PMR at diagnosis was associated with a longer time to normalization of the C-reactive protein level (p=0.039) or erythrocyte sedimentation rate (p=0.034). During follow-up (median 33.8 months), four (14.8%) patients experienced relapse. Kaplan-Meier analyses showed that relapse was associated with visual loss (p=0.008) and the absence of fever (p=0.004) at onset, but not with LVI or concurrent PMR. Conclusion Concurrent PMR and LVI were observed in approximately half of Korean patients with GCA, and the elapsed time to normalization of inflammatory markers in these patients was longer. The relapse rate in Korean GCA is lower than that in Western countries, and afebrile patients or patients with vision loss at onset have a higher risk of relapse, suggesting that physicians should carefully monitor patients with these characteristics.
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Affiliation(s)
- Jee-In Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jun Won Park
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Department of Internal Medicine, Seoul, Korea
| | - Youjin Jung
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Hospital, Department of Internal Medicine, Seoul, Korea
| | - Kichul Shin
- Division of Rheumatology, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Korea
| | - Se Rim Choi
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Eun Ha Kang
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Division of Rheumatology, Department of Internal Medicine, Seoul University College of Medicine, Seoul, Korea
| | - Yun Jong Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Division of Rheumatology, Department of Internal Medicine, Seoul University College of Medicine, Seoul, Korea
| | - Jong Jin Yoo
- Division of Rheumatology, Department of Internal Medicine, Kangdong Sacred Heart Hospital, Seoul, Korea
| | - You-Jung Ha
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
- Division of Rheumatology, Department of Internal Medicine, Seoul University College of Medicine, Seoul, Korea
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Schmidt WA, Schäfer VS. Diagnosing vasculitis with ultrasound: findings and pitfalls. Ther Adv Musculoskelet Dis 2024; 16:1759720X241251742. [PMID: 38846756 PMCID: PMC11155338 DOI: 10.1177/1759720x241251742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 04/10/2024] [Indexed: 06/09/2024] Open
Abstract
Rheumatologists are increasingly utilizing ultrasound for suspected giant cell arteritis (GCA) or Takayasu arteritis (TAK). This enables direct confirmation of a suspected diagnosis within the examination room without further referrals. Rheumatologists can ask additional questions and explain findings to their patients while performing ultrasound, preferably in fast-track clinics to prevent vision loss. Vascular ultrasound for suspected vasculitis was recently integrated into rheumatology training in Germany. New European Alliance of Associations for Rheumatology recommendations prioritize ultrasound as the first imaging tool for suspected GCA and recommend it as an imaging option for suspected TAK alongside magnetic resonance imaging, positron emission tomography and computed tomography. Ultrasound is integral to the new classification criteria for GCA and TAK. Diagnosis is based on consistent clinical and ultrasound findings. Inconclusive cases require histology or additional imaging tests. Robust evidence establishes high sensitivities and specificities for ultrasound. Reliability is good among experts. Ultrasound reveals a characteristic non-compressible 'halo sign' indicating intima-media thickening (IMT) and, in acute disease, artery wall oedema. Ultrasound can further identify stenoses, occlusions and aneurysms, and IMT can be measured. In suspected GCA, ultrasound should include at least the temporal and axillary arteries bilaterally. Nearly all other arteries are accessible except the descending thoracic aorta. TAK mostly involves the common carotid and subclavian arteries. Ultrasound detects subclinical GCA in over 20% of polymyalgia rheumatica (PMR) patients without GCA symptoms. Patients with silent GCA should be treated as GCA because they experience more relapses and require higher glucocorticoid doses than PMR patients without GCA. Scores based on intima-thickness (IMT) of temporal and axillary arteries aid follow-up of GCA, particularly in trials. The IMT decreases more rapidly in temporal than in axillary arteries. Ascending aorta ultrasound helps monitor patients with extracranial GCA for the development of aneurysms. Experienced sonologists can easily identify pitfalls, which will be addressed in this article.
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Affiliation(s)
- Wolfgang A. Schmidt
- Immanuel Krankenhaus Berlin, Medical Centre for Rheumatology Berlin-Buch, Lindenberger Weg 19, Berlin 13125, Germany
| | - Valentin S. Schäfer
- Department of Rheumatology and Clinical Immunology, Clinic of Internal Medicine III, University Hospital Bonn, Bonn, Nordrhein-Westfalen, Germany
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Camellino D, Matteson EL. Referral of patients with suspected polymyalgia rheumatica: how complete is our view of 'planet PMR?'. Ann Rheum Dis 2024:ard-2023-225217. [PMID: 38418203 DOI: 10.1136/ard-2023-225217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Accepted: 02/19/2024] [Indexed: 03/01/2024]
Affiliation(s)
- Dario Camellino
- Division of Rheumatology, Department of Medical Specialties, Azienda Sanitaria Locale 3 Genovese, Arenzano, Italy
| | - Eric L Matteson
- Division of Rheumatology and Department of Health Sciences Research, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
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Barde F, Ascione S, Pacoureau L, Macdonald C, Salliot C, Boutron-Ruault MC, Seror R, Nguyen Y. Accuracy of self-reported diagnoses of polymyalgia rheumatica and giant cell arteritis in the French prospective E3N- EPIC cohort: A validation study. Semin Arthritis Rheum 2024; 64:152298. [PMID: 38000317 DOI: 10.1016/j.semarthrit.2023.152298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/26/2023] [Accepted: 10/26/2023] [Indexed: 11/26/2023]
Abstract
OBJECTIVES To assess the accuracy of self-reported giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) diagnoses in a large French population-based prospective cohort, and to devise algorithms to improve their accuracy. METHODS The E3N-EPIC cohort study (Etude Epidémiologique auprès des femmes de la Mutuelle Générale de l'Education Nationale) includes 98,995 French women born between 1925 and 1950, recruited in 1990 to study risk factors of cancer and chronic diseases. They completed biennially mailed questionnaires to update their health-related information and lifestyle characteristics. In three questionnaires, women could self-report a diagnosis of GCA/PMR. Those women were additionally sent a specific questionnaire, designed to ascertain self-reported diagnoses of GCA/PMR. Four algorithms were then devised to improve their identification. Accuracies of self-reported diagnoses and of each algorithm were calculated by comparing the diagnoses with a blinded medical chart review. RESULTS Among 98,995 participants, 1,392 women self-reported GCA/PMR. 830 women sent back the specific questionnaire, and 202 women provided medical charts. After independent review of the 202 medical charts, 87.6 % of the self-reported diagnoses of GCA/PMR were accurate. Using additional data from a specific questionnaire (diagnosis confirmation by a physician, and self-report of >3-month of glucocorticoids), and from a reimbursement database (at least two deliveries of glucocorticoids in less than 3 consecutive months) improved their accuracy (91.8 % to 92.8 %). CONCLUSION The accuracy of self-reported diagnosis of GCA/PMR was high in the E3N-cohort but using additional data as a specific GCA/PMR questionnaire and/or corticosteroid reimbursement database further improved this accuracy. With nearly 600 detected cases of GCA/PMR, we will be able to investigate risk factors for GCA/PMR in women.
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Affiliation(s)
- François Barde
- Université Paris-Saclay, UVSQ, Inserm, Gustave Roussy, CESP, 94805, Villejuif, France
| | - Sophia Ascione
- Université Paris-Saclay, UVSQ, Inserm, Gustave Roussy, CESP, 94805, Villejuif, France
| | - Lucas Pacoureau
- Université Paris-Saclay, UVSQ, Inserm, Gustave Roussy, CESP, 94805, Villejuif, France
| | - Conor Macdonald
- Université Paris-Saclay, UVSQ, Inserm, Gustave Roussy, CESP, 94805, Villejuif, France
| | - Carine Salliot
- Université Paris-Saclay, UVSQ, Inserm, Gustave Roussy, CESP, 94805, Villejuif, France; Department of Rheumatology, Centre Hospitalier Régional d'Orléans, Orléans, France
| | | | - Raphaèle Seror
- Université Paris-Saclay, UVSQ, Inserm, Gustave Roussy, CESP, 94805, Villejuif, France; Department of Rheumatology and National Reference Center for Rare Systemic Autoimmune Diseases, AP-HP, Hôpital Bicêtre, Université Paris-Saclay, INSERM UMR1184, Le Kremlin Bicêtre, France.
| | - Yann Nguyen
- Université Paris-Saclay, UVSQ, Inserm, Gustave Roussy, CESP, 94805, Villejuif, France; Department of Rheumatology and National Reference Center for Rare Systemic Autoimmune Diseases, AP-HP, Hôpital Bicêtre, Université Paris-Saclay, INSERM UMR1184, Le Kremlin Bicêtre, France; Department of Internal Medicine, AP-HP. Nord, Hôpital Beaujon, Université de Paris, Clichy, France
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De Miguel E, Macchioni P, Conticini E, Campochiaro C, Karalilova R, Monti S, Ponte C, Klinowski G, Monjo-Henry I, Falsetti P, Batalov Z, Tomelleri A, Hocevar A. Prevalence and characteristics of subclinical giant cell arteritis in polymyalgia rheumatica. Rheumatology (Oxford) 2024; 63:158-164. [PMID: 37129541 DOI: 10.1093/rheumatology/kead189] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/28/2023] [Accepted: 04/16/2023] [Indexed: 05/03/2023] Open
Abstract
OBJECTIVE The main objective of this study was to analyse the prevalence and characteristics of subclinical GCA in patients with PMR. METHODS This was a cross-sectional multicentre international study of consecutive patients with newly diagnosed PMR without symptoms or signs suggestive of GCA. All patients underwent US of the temporal superficial, common carotid, subclavian and axillary arteries. Patients with halo signs in at least one examined artery were considered to have subclinical GCA. The clinical, demographic and laboratory characteristics of the PMR group without subclinical vasculitis were compared with subclinical GCA, and the pattern of vessel involvement was compared with that of a classical single-centre GCA cohort. RESULTS We included 346 PMR patients, 267 (77.2%) without subclinical GCA and 79 (22.8%) with subclinical GCA. The PMR patients with subclinical GCA were significantly older, had a longer duration of morning stiffness and more frequently reported hip pain than PMR without subclinical GCA. PMR with subclinical GCA showed a predominant extracranial large vessel pattern of vasculitic involvement compared with classical GCA, where the cranial phenotype predominated. The patients with PMR in the classical GCA group showed a pattern of vessel involvement similar to classical GCA without PMR but different from PMR with subclinical involvement. CONCLUSION More than a fifth of the pure PMR patients had US findings consistent with subclinical GCA. This specific subset of patients showed a predilection for extracranial artery involvement. The optimal screening strategy to assess the presence of vasculitis in PMR remains to be determined.
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Affiliation(s)
- Eugenio De Miguel
- Rheumatology Department, Hospital Universitario La Paz, Madrid, Spain
| | | | - Edoardo Conticini
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Corrado Campochiaro
- Unit of Immunology, Rheumatology Department, Allergy and Rare Diseases (UnIRAR), San Raffaele Scientific Institute, Milan, Italy
| | - Rositsa Karalilova
- Rheumatology Department, Medical University of Plovdiv, University Hospital Kaspela, Plovdiv, Bulgaria
| | - Sara Monti
- Department of Rheumatology, IRCCS Policlinico S Matteo Fondazione, University of Pavia, Pavia, Italy
| | - Cristina Ponte
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar Universitario Lisboa Norte EPE, Lisboa, Portugal
| | - Giulia Klinowski
- Department of Rheumatology, IRCCS-S.Maria Nuova, Reggio Emilia, Italy
| | - Irene Monjo-Henry
- Rheumatology Department, Hospital Universitario La Paz, Madrid, Spain
| | - Paolo Falsetti
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Zguro Batalov
- Rheumatology Department, Medical University of Plovdiv, University Hospital Kaspela, Plovdiv, Bulgaria
| | - Alessandro Tomelleri
- Unit of Immunology, Rheumatology Department, Allergy and Rare Diseases (UnIRAR), San Raffaele Scientific Institute, Milan, Italy
| | - Alojzija Hocevar
- Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
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Nielsen AW, Hemmig AK, de Thurah A, Schmidt WA, Sattui SE, Mackie SL, Brouwer E, Dejaco C, Keller KK, Mukhtyar CB. Early referral of patients with suspected polymyalgia rheumatica - A systematic review. Semin Arthritis Rheum 2023; 63:152260. [PMID: 37639896 DOI: 10.1016/j.semarthrit.2023.152260] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/11/2023] [Accepted: 08/15/2023] [Indexed: 08/31/2023]
Abstract
INTRODUCTION Prompt diagnosis and treatment of polymyalgia rheumatica (PMR) is crucial to prevent long-term complications and improve patient outcomes. However, there is currently no standardized approach to referral of suspected PMR patients to rheumatologists, leading to inconsistent management practices. The objective of this systematic review was to clarify the existing evidence regarding the following aspects of early management strategies in patients with suspected PMR: diagnostic strategies, GCA screening, glucocorticoid initiation prior to referral, value of shared care and value of fast track clinic. METHODS Two authors performed a systematic literature search, data extraction and risk of bias assessment independently. The literature search was conducted in Embase, MEDLINE (PubMed) and Cochrane. Studies were included if they contained cohorts of suspected PMR patients and evaluated the efficacy of different diagnostic strategies for PMR, screening for giant cell arteritis (GCA), starting glucocorticoids before referral to secondary care, shared care, or fast-track clinics. RESULTS From 2,437 records excluding duplicates, 14 studies met the inclusion criteria. Among these, 10 studies investigated the diagnostic accuracy of various diagnostic strategies with the majority evaluating different clinical approaches, but none of them showed consistently high performance. However, 4 studies on shared care and fast-track clinics showed promising results, including reduced hospitalization rates, lower starting doses of glucocorticoids, and faster PMR diagnosis. CONCLUSION This review emphasizes the sparse evidence of early management and referral strategies for patients with suspected PMR. Additionally, screening and diagnostic strategies for differentiating PMR from other diseases, including concurrent GCA, require clarification. Fast-track clinics may have potential to aid patients with PMR in the future, but studies will be needed to determine the appropriate pre-referral work-up.
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Affiliation(s)
- A W Nielsen
- Department of Rheumatology, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - A K Hemmig
- Department of Rheumatology, University Hospital Basel, Basel, Switzerland
| | - A de Thurah
- Department of Rheumatology, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - W A Schmidt
- Medical Centre for Rheumatology, Klinik für Innere Medizin, Rheumatologie und Klinische Immunologie Berlin-Buch, Immanuel Krankenhaus, Berlin, Germany
| | - S E Sattui
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA (S.E.S.)
| | - S L Mackie
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, and NIHR Leeds Biomedical Research Centre, University of Leeds, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - E Brouwer
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - C Dejaco
- Rheumatology, Medical University of Graz, Graz, Austria; Department of Rheumatology, Hospital of Bruneck, Bruneck, Italy
| | - K K Keller
- Department of Rheumatology, and Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - C B Mukhtyar
- Vasculitis service, Rheumatology Department, Norfolk and Norwich University Hospital, Norwich, Norfolk, UK
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11
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Keller KK, Mukhtyar CB, Nielsen AW, Hemmig AK, Mackie SL, Sattui SE, Hauge EM, Dua A, Helliwell T, Neill L, Blockmans D, Devauchelle-Pensec V, Hayes E, Venneboer AJ, Monti S, Ponte C, De Miguel E, Matza M, Warrington KJ, Byram K, Yaseen K, Peoples C, Putman M, Lally L, Finikiotis M, Appenzeller S, Caramori U, Toro-Gutiérrez CE, Backhouse E, Oviedo MCG, Pimentel-Quiroz VR, Keen HI, Owen CE, Daikeler T, de Thurah A, Schmidt WA, Brouwer E, Dejaco C. Recommendations for early referral of individuals with suspected polymyalgia rheumatica: an initiative from the international giant cell arteritis and polymyalgia rheumatica study group. Ann Rheum Dis 2023:ard-2023-225134. [PMID: 38050004 DOI: 10.1136/ard-2023-225134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 11/14/2023] [Indexed: 12/06/2023]
Abstract
OBJECTIVE To develop international consensus-based recommendations for early referral of individuals with suspected polymyalgia rheumatica (PMR). METHODS A task force including 29 rheumatologists/internists, 4 general practitioners, 4 patients and a healthcare professional emerged from the international giant cell arteritis and PMR study group. The task force supplied clinical questions, subsequently transformed into Population, Intervention, Comparator, Outcome format. A systematic literature review was conducted followed by online meetings to formulate and vote on final recommendations. Levels of evidence (LOE) (1-5 scale) and agreement (LOA) (0-10 scale) were evaluated. RESULTS Two overarching principles and five recommendations were developed. LOE was 4-5 and LOA ranged between 8.5 and 9.7. The recommendations suggest that (1) each individual with suspected or recently diagnosed PMR should be considered for specialist evaluation, (2) before referring an individual with suspected PMR to specialist care, a thorough history and clinical examination should be performed and preferably complemented with urgent basic laboratory investigations, (3) individuals with suspected PMR with severe symptoms should be referred for specialist evaluation using rapid access strategies, (4) in individuals with suspected PMR who are referred via rapid access, the commencement of glucocorticoid therapy should be deferred until after specialist evaluation and (5) individuals diagnosed with PMR in specialist care with a good initial response to glucocorticoids and a low risk of glucocorticoid related adverse events can be managed in primary care. CONCLUSIONS These are the first international recommendations for referral of individuals with suspected PMR, which complement the European Alliance of Associations for Rheumatology/American College of Rheumatology management guidelines for established PMR.
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Affiliation(s)
- Kresten Krarup Keller
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus Universitet, Aarhus, Denmark
| | - Chetan B Mukhtyar
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
| | - Andreas Wiggers Nielsen
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus Universitet, Aarhus, Denmark
| | | | - Sarah Louise Mackie
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sebastian Eduardo Sattui
- Medicine, Division of Rheumatology and Clinical Immunology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ellen-Margrethe Hauge
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus Universitet, Aarhus, Denmark
| | - Anisha Dua
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Toby Helliwell
- School of Medicine, University of Staffordshire, Stafford, UK
| | - Lorna Neill
- Patient Charity Polymyalgia Rheumatica and Giant Cell Arteritis Scotland, Dundee, UK
| | - Daniel Blockmans
- Clinical Department of General Internal Medicine Department, Research Department of Microbiology and Immunology, Laboratory of Clinical Infectious and Inflammatory Disorders, University Hospitals Leuven, Leuven, Belgium
- Universitaire Ziekenhuis Gasthuisberg, Leuven, Belgium
| | | | - Eric Hayes
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
| | - Annett Jansen Venneboer
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Sara Monti
- Rheumatology, Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo Pavia, Pavia, Italy
| | - Cristina Ponte
- Rheumatology, Centro Hospitalar Universitario Lisboa Norte EPE, Lisboa, Portugal
- Rheumatology Research Unit, Instituto de Medicina Molecular, Lisboa, Portugal
| | | | - Mark Matza
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Kevin Byram
- Vanderbilt Rheumatology, Vanderbilt Health, Nashville, Tennessee, USA
| | - Kinanah Yaseen
- Orthopedic and Rheumatologic Insitute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Christine Peoples
- Medicine, Division of Rheumatology and Clinical Immunology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael Putman
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lindsay Lally
- Hospital for Special Surgery, New York, New York, USA
| | - Michael Finikiotis
- University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Simone Appenzeller
- Departamento de Clínica Médica, Facultade de Ciências Medicas da UNICAMP, Universidade Estadual de Campinas, Campinas, Brazil
| | - Ugo Caramori
- Department of Public Health, State University of Campinas, Campinas, Brazil
| | - Carlos Enrique Toro-Gutiérrez
- Reference Center in Osteoporosis, Rheumatology & Dermatology, Pontificia Universidad Javeriana Cali Facultad de Ciencias de la Salud, Cali, Colombia
| | | | | | | | | | - Claire Elizabeth Owen
- Rheumatology, Austin Health, Heidelberg, Victoria, Australia
- Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Thomas Daikeler
- Clinic for Rheumatology, University Hospital, Basel, Switzerland
| | - Annette de Thurah
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus Universitet, Aarhus, Denmark
| | | | - Elisabeth Brouwer
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Christian Dejaco
- Rheumatology, Brunico Hospital, Brunico, Italy
- Rheumatology, Medical University of Graz, Graz, Austria
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12
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Schmidt WA. Vascular ultrasound in rheumatology practice. Best Pract Res Clin Rheumatol 2023; 37:101847. [PMID: 37419758 DOI: 10.1016/j.berh.2023.101847] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/19/2023] [Indexed: 07/09/2023]
Abstract
Rheumatologists are increasingly using vascular ultrasound. Several guidelines now recommend ultrasound as the first diagnostic modality in giant cell arteritis (GCA). The German curriculum for rheumatology training has recently included ultrasound for the acute diagnosis of vasculitis. Recent studies have shown that ultrasound of temporal, axillary, subclavian, and vertebral arteries has sensitivities and specificities of >90%. Vascular ultrasound detects subclinical GCA in approximately 20% of patients with "pure" polymyalgia rheumatica. GCA fast-track clinics might regularly include these patients. A new score based on the intima-media thickness of the temporal and axillary arteries allows the monitoring of structural changes with treatment. The score decreases faster for the temporal arteries than it does for the axillary arteries. Measuring the diameter of the ascending aorta and the aortic arch might become a fast and cost-effective tool for the long-term monitoring of aortic aneurysms in extracranial GCA. Vascular ultrasound also has a role for Takayasu arteritis, thrombosis, Behçet's syndrome, and Raynaud's phenomenon.
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Affiliation(s)
- Wolfgang A Schmidt
- Immanuel Krankenhaus Berlin, Medical Center for Rheumatology Berlin-Buch, Lindenberger Weg 19, 13125 Berlin, Germany.
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13
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Nielsen AW, Frølund LL, Våben C, Bonde AR, Gormsen LC, de Thurah AL, Hauge EM, Keller KK. Response: Co-occurrence of giant cell arteritis in patients with polymyalgia rheumatica. Reply letter to Castañeda and González-Gay (Letter to the Editor: Concurrent baseline diagnosis of giant cell arteritis and polymyalgia rheumatica - A systematic review and meta-analysis. Semin Arthritis Rheum. 2022;56:152069.). Semin Arthritis Rheum 2023; 58:152155. [PMID: 36580855 DOI: 10.1016/j.semarthrit.2022.152155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Andreas Wiggers Nielsen
- Department of Rheumatology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus 8200, Denmark; Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, Aarhus 8200, Denmark; Diagnostic Centre, Silkeborg Regional Hospital, Falkevej 1, Silkeborg 8600, Denmark.
| | - Line Lier Frølund
- Department of Rheumatology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus 8200, Denmark
| | - Christoffer Våben
- Department of Rheumatology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus 8200, Denmark
| | - Asta Roos Bonde
- Department of Rheumatology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus 8200, Denmark
| | - Lars Christian Gormsen
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, Aarhus 8200, Denmark; Department of Nuclear Medicine and PET, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus 8200, Denmark
| | - Annette Ladefoged de Thurah
- Department of Rheumatology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus 8200, Denmark; Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, Aarhus 8200, Denmark
| | - Ellen-Margrethe Hauge
- Department of Rheumatology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus 8200, Denmark; Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, Aarhus 8200, Denmark
| | - Kresten Krarup Keller
- Department of Rheumatology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus 8200, Denmark; Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, Aarhus 8200, Denmark
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14
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Castañeda S, González-Gay MA. Co-occurrence of giant cell arteritis in patients with polymyalgia rheumatica. Comment on the article by Nielsen AW, et al. Semin Arthritis Rheum 2023; 58:152157. [PMID: 36580852 DOI: 10.1016/j.semarthrit.2022.152157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022]
Affiliation(s)
- Santos Castañeda
- Rheumatology Department, Hospital Universitario de la Princesa, Fundación de Investigación Biomédica (FIB), Instituto de Investigación Sanitaria-Princesa (IIS-Princesa), 28006-Madrid, Spain.
| | - Miguel Angel González-Gay
- Rheumatology Department, Hospital Universitario Marqués de Valdecilla, IDIVAL, Universidad de Cantabria, Santander, Spain
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15
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Yamashita M, Aoki A, Kobayashi H, Wakiya M, Nakatsugawa M. [A case of giant cell arteritis after prednisolone dose reduction during treatment of polymyalgia rheumatica]. Nihon Ronen Igakkai Zasshi 2023; 60:440-447. [PMID: 38171762 DOI: 10.3143/geriatrics.60.440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Giant cell arteritis (GCA) is closely associated with polymyalgia rheumatica (PMR). We herein report an 82-year-old woman who developed GCA during PMR treatment. She initially presented with shoulder pain and was diagnosed with PMR based on elevated serum C-reactive protein (CRP) levels and bursitis detected in both shoulders on ultrasonography (US). Treatment was initiated with a daily dose of 15 mg prednisolone (PSL), which led to rapid symptom alleviation, and the dosage was tapered to 1 mg/day. One month later, she developed myalgia extending from the lumbar region to the thigh and tenderness in the left temporal region. However, no abnormalities in the temporal artery were observed on US. Although the PSL dose was increased to 2 mg for relapse of PMR, the symptoms did not improve. One week later, she developed occipital pain with an increased CRP level of 9 mg/dL. She was diagnosed with GCA based on the 1990 ACR Classification Criteria. Fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) detected anomalous accumulations in the bilateral superficial temporal and vertebral arteries, but not in the larger vessels. We therefore diagnosed her with cranial-type GCA. At this time point, we repeated US and found a halo sign in the temporal artery. Although epithelioid and giant cells were not observed in the temporal artery biopsy, vascular inflammatory findings such as disruption of the internal elastic lamina and chronic inflammatory cell infiltration were noted. Symptoms improved immediately and CRP levels decreased after the PSL dose was increased to 30 mg daily. To mitigate the risk of steroid-induced diabetes, tocilizumab was introduced, and gradual tapering of PSL was implemented. In conclusion, we encountered a case of GCA that developed after PSL reduction during the course of PMR. PET/CT confirmed intracranial artery inflammation and facilitated a definitive diagnosis. Although PET/CT cannot be routinely performed for diagnose in Japan, we consider it useful as an adjunctive diagnostic tool.
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Affiliation(s)
- Mayu Yamashita
- Post-graduate Clinical Training Center, Tokyo Medical University Hachioji Medical Center
| | - Akiko Aoki
- Department of Rheumatology, Tokyo Medical University Hachioji Medical Center
| | - Hiroshi Kobayashi
- Department of Rheumatology, Tokyo Medical University Hachioji Medical Center
| | - Midori Wakiya
- Department of Pathology, Tokyo Medical University Hachioji Medical Center
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16
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Colaci M, Dichiara J, Aprile ML, Ippolito M, Schinocca C, Guggino G, Malatino L. Use of 18F-fluorodeoxyglucose positron emission tomography-computed tomography in patients affected by polymyalgia rheumatica and persistent increase of acute phase reactants. Front Med (Lausanne) 2022; 9:1042620. [PMID: 36465900 PMCID: PMC9709413 DOI: 10.3389/fmed.2022.1042620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 10/31/2022] [Indexed: 07/28/2023] Open
Abstract
Polymyalgia rheumatica (PMR) is an inflammatory disease affecting older adults characterized by aching pain and morning stiffness of the shoulder and pelvic girdles. Moreover, PMR can be associated with giant cell arteritis (GCA). Generally, PMR is highly responsive to steroids, reaching complete remission in the majority of cases. However, the possibility of occult diseases, including extra-cranial GCA, should be excluded. 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) is able to detect the presence of peri-/articular or vascular inflammation, which may be both present in PMR, thus representing a useful diagnostic tool, mainly in presence of extra-cranial GCA. We retrospectively evaluated all consecutive patients who received the diagnosis of PMR in our rheumatology clinic, classified according to the 2012 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) criteria, in the period between April 2020 and May 2022. Among this case series, we selected the patients who underwent 18F-FDG-positron emission tomography (PET) because of the persistent increase of acute phase reactants (APR) besides the steroid therapy. Eighty patients were diagnosed with PMR. Nine out of them also presented arthritis of the wrists during the follow-up, whereas none showed signs of cranial GCA at the diagnosis. Seventeen out of eighty subjects (mean age 71.5 ± 7.5 years; M/F 2/15) presented persistent increase of erythrocyte sedimentation rate (mean ESR 44.2 ± 20.8 mm/h) and/or C-reactive protein (mean CRP 25.1 ± 17 mg/l), thus they underwent total body 18F-FDG-PET/CT. Large vessel 18F-FDG uptake indicating an occult GCA was found in 5/17 (29.4%) cases. Twelve out of seventeen (70.6%) patients showed persistence of peri-/articular inflammation, suggesting a scarce control of PMR or the presence of chronic arthritis. Finally, in 2 cases, other inflammatory disorders were found, namely an acute thyroiditis and a hip prosthesis occult infection. 18F-FDG-PET/CT in PMR patients with persistent increase of APR is a useful diagnostic technique in order to detect occult GCA, persistence of active PMR or other misdiagnosed inflammatory diseases.
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Affiliation(s)
- Michele Colaci
- Rheumatology Clinic, Internal Medicine Unit, Azienda Ospedaliera per l’Emergenza (AOE) Cannizzaro, University of Catania, Catania, Italy
| | - Jessika Dichiara
- Rheumatology Clinic, Internal Medicine Unit, Azienda Ospedaliera per l’Emergenza (AOE) Cannizzaro, University of Catania, Catania, Italy
| | - Maria Letizia Aprile
- Rheumatology Clinic, Internal Medicine Unit, Azienda Ospedaliera per l’Emergenza (AOE) Cannizzaro, University of Catania, Catania, Italy
| | - Massimo Ippolito
- Nuclear Medicine Unit, Azienda Ospedaliera per l’Emergenza (AOE) Cannizzaro, Catania, Italy
| | - Claudia Schinocca
- Rheumatology Unit, Policlinico “P. Giaccone”, University of Palermo, Palermo, Italy
| | - Giuliana Guggino
- Rheumatology Unit, Policlinico “P. Giaccone”, University of Palermo, Palermo, Italy
| | - Lorenzo Malatino
- Rheumatology Clinic, Internal Medicine Unit, Azienda Ospedaliera per l’Emergenza (AOE) Cannizzaro, University of Catania, Catania, Italy
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17
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Henes JC, Saur S. Diagnostik und Therapie der
Großgefäßvaskulitiden – Wo stehen wir
aktuell? AKTUEL RHEUMATOL 2022. [DOI: 10.1055/a-1931-3989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ZusammenfassungDie beiden Großgefäßvaskulitiden unterscheiden sich in
mehrfacher Hinsicht, vor allem aber durch das Alter der betroffenen Patienten
bei Erstmanifestation. Die Riesenzellarteriitis (RZA) ist eine Erkrankung des
älteren Patienten wohingegen die Takayasu Arteriitis per definitionem
vor dem 40 Lebensjahr auftritt. Die Diagnosen sind in den letzten Jahren durch
verbesserte Bildgebung und Therapieoptionen mehr ins Bewusstsein
gerückt. Neben der klassischen Steroidtherapie – welche bis
heute Mittel der ersten Wahl ist – steht uns mit Tocilizumab, einem
monoklonalen Antikörper gegen IL6-Rezeptor, zumindest für die
RZA, eine zusätzliche hocheffektive Therapie zur Verfügung.
Andere vielversprechende Substanzen befinden sich derzeit in Erprobung. Dieser
Artikel soll einen Überblick zu Diagnostik und Therapie, aber auch einen
Ausblick zu möglicherweise kommenden medikamentösen Optionen
bieten.
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Affiliation(s)
- Joerg Christoph Henes
- Centre for Interdisciplinary Clinical Immunology, Rheumatology and
Auto-inflammatory Diseases and Internal Medicine II, University Hospital
Tuebingen, Tuebingen, Germany
| | - Sebastian Saur
- Centre for Interdisciplinary Clinical Immunology, Rheumatology and
Auto-inflammatory Diseases and Internal Medicine II, University Hospital
Tuebingen, Tuebingen, Germany
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