The Spectrum of Polymyalgia Rheumatica

Giant cell arteritis: disease patterns of clinical presentation in a series of 240 patients

Classically, patients with giant cell arteritis (GCA) present with cranial ischemic manifestations that are directly related to vascular involvement. However, a variable proportion of GCA patients may present without obvious vascular manifestations. Since a high index of suspicion of this condition in individuals over the age of 50 years is needed to prevent the development of severe complications, we have studied the different patterns of disease presentation in a series of 240 patients with biopsy-proven GCA diagnosed at the single hospital for the well-defined population of Lugo, Spain, between January 1, 1981, and June 15, 2004. During the study period, 203 (86.4%) GCA patients presented with headache. Patients with headache were found to have an abnormal temporal artery on physical examination more commonly than the other GCA patients (79.8% versus 35.1%; p < 0.001). Compared with the other GCA patients, those who presented with polymyalgia rheumatica (PMR) were younger (73.4 +/- 6.3 versus 75.6 +/- 6.9 yr; p = 0.013) and had a longer delay to diagnosis (13.4 +/- 12.2 versus 8.3 +/- 10.0 wk; p = 0.013). One hundred thirty-one (54.6%) patients presented with severe ischemic manifestations. Abnormal temporal artery on physical examination (odds ratio, 2.25) and anemia at the time of disease diagnosis (odds ratio, 0.53) were found to be the best predictors for severe ischemic manifestations of GCA. Eighteen (7.5%) patients presented without overt ischemic manifestations of GCA. Patients younger than 70 years of age at the time of diagnosis had a longer delay to diagnosis and exhibited PMR more commonly than older patients. Our observations confirm the presence of different disease patterns of clinical presentation in GCA and emphasize the importance of an abnormal temporal artery on physical examination and anemia as factors that may predict the risk of severe ischemic complications related to GCA.

Giant cell arteritis and polymyalgia rheumatica: two different but often overlapping conditions

OBJECTIVES

Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are common and frequently overlapping diseases. In this manuscript similarities and differences between these conditions have been assessed.

METHODS

A retrospective review of the literature was conducted. Reports emphasizing features in common and possible differences are reviewed.

RESULTS

GCA and PMR are characterized by late age at disease onset, are more common in women, exhibit evidence of a systemic inflammatory response, and generally respond well to corticosteroids. In biopsy-proven GCA, PMR manifestations are observed in up to 50% of cases. PMR may be the presenting feature in patients who later develop typical cranial manifestations of GCA. However, PMR manifestations may be observed in diverse conditions other than GCA. Patients with isolated PMR are younger than those with PMR associated to biopsy-proven GCA and exhibit milder inflammatory disease as shown by significantly less abnormality in most laboratory findings. Recent observations have shown that the frequency of pathologic features of GCA in temporal artery biopsies of patients with clinically isolated PMR is less than that previously reported. Besides different steroid requirements, GCA is associated with more vascular complications. Genetic differences, in particular different HLA-DRB1 associations, also have been observed.

CONCLUSIONS

Polymyalgia manifestations may be observed in patients with biopsy-proven GCA, but isolated PMR may be the only clinical feature or the phenotypic expression of a number of conditions. Clinical features and immunogenetic studies show subtle differences between GCA and PMR.

Clinical and laboratory findings with giant cell arteritis

Out of 66 patients who were diagnosed as suffering from polymyalgia rheumatica (PMR; n = 40), temporal arteritis (AT; n = 14) or both (n = 12) in a 6.5 year period (incidence 3.4/100,000 per year), 9 died and 49 were followed up for an average period of 28 months. Exacerbations of the illness (n = 24) and complications in the course (n = 32) were more frequent with an initial ESR greater than 90 mm/h. Postural vertigo (n = 11), amaurosis fugax (n = 11) and polyneuropathy (n = 8) were the most frequent neurological complications. Persisting unilateral blindness and aromatic anosmia developed in 2 patients each. Complications were significantly more frequent in patients with initial symptoms of AT (chi 2 P less than 0.001). CRP-levels correlated better with persisting symptoms in the course than did the ESR. Recurrences after treatment were significantly more frequent when the length of corticosteroid-therapy was less than 20 months (chi 2 P less than 0.009). On follow up there were normal values for neopterin, tumour necrosis factor and antibodies against Borrelia burgdorferi.

Surgical pathology of cranial arteritis and polymyalgia rheumatica

In both clinical and histological terms cranial arteritis is one of the most distinctive of all vascular disorders. The dense granulomatous inflammatory infiltrates which characterize the acute stages of the disease resemble those of Takayasu's arteritis or granulomatous angiitis of the central nervous system, but the clinicopathological features in patients with positive temporal artery biopsies are diagnostic. Well over a third of patients with classical signs and symptoms of cranial arteritis have negative temporal artery biopsies, and focal involvement of arteries of the head and neck is the probable explanation for this. Pathologists should be aware of the wide spectrum of histological changes that occur in muscular arteries as part of normal ageing and must not interpret these as evidence of healed arteritis. The histological changes of healed arteritis include medial chronic inflammation with ingrowth of new blood vessels, focal medial scarring and a bizarre pattern of intimal fibrosis. Although ultrastructural and immunohistochemical studies have provided some insight into the underlying pathological changes, they have not contributed directly to the diagnosis of cranial arteritis. Between 15 and 55% of patients with polymyalgia rheumatica have positive temporal artery biopsies, but apart from an elevated ESR there are no other laboratory investigations or biopsy procedures that contribute to diagnosis.