Polymyalgia Rheumatica in Association with Remitting Seronegative Sinovitis with Pitting Edema: a Neoplastic Warning

Polymyalgia rheumatica: An update (Review)

Polymyalgia rheumatica (PMR) is a chronic inflammatory disease which affects the connective vascular tissue, characterized by pain accompanied by morning stiffness, predominantly of the neck muscles, hip and shoulder girdle. Usually, patients with this disease are >50 years of age and biological inflammatory syndrome is present with an increase in both the erythrocyte sedimentation rate and C-reactive protein levels, aspects similar to giant cell arteritis. The aim of the present review was to depict the current pathogenic hypothesis, diagnostic and treatment approach for patients with PMR, and novelties since the development of the currently used 2012 European League Against Rheumatism and American College of Rheumatology provisional classification criteria. PMR is a prevalent disease that can occasionally prove difficult to diagnose and treat. Possibly, the most abundant type of evidence and data revealed over the past decade have been acquired through musculoskeletal imaging, with implications in diagnosis, disease monitoring and relapse, prognosis and changes with treatment. Further research on pathophysiology is required to gain a deeper understanding of the underlying processes, which will serve as the foundation for future personalized treatments. In addition, there is an increasing demand for improved diagnostic techniques, which should include a further development of various imaging modalities, in order to provide accurate diagnosis and appropriate therapy.

Idiopathic remitting seronegative symmetrical synovitis with pitting edema syndrome with underlying history of malignancy

Key Clinical Message

By reporting this case, we hope to emphasize the importance of maintaining a high index of clinical suspicion for the early recognition of RS3PE in patients presenting with atypical symptoms of PMR and underlying history of malignancy.

Abstract

Remitting seronegative symmetrical synovitis with pitting edema is a rare rheumatic syndrome of unknown etiology. It shares qualities with many other common rheumatological disorders such as rheumatoid arthritis and polymyalgia rheumatica, making diagnosis especially challenging. RS3PE has been speculated to be a paraneoplastic syndrome, and those cases associated with underlying malignancy have shown to respond poorly to conventional treatment. Therefore, it is advisable to routinely screen patients with malignancy and presenting with RS3PE for cancer recurrence, even if in remission.

Idiopathic remitting seronegative symmetrical synovitis with pitting edema syndrome mimicking symptoms of polymyalgia rheumatica: a case report

Background

Remitting seronegative symmetrical synovitis with pitting edema is a rare rheumatic condition of the elderly population that is well described but whose mechanisms remain little studied. This syndrome is characterized by symmetrical swelling located mainly on the dorsal part of the hands and the feet. Because of possible heterogeneous clinical presentation, it can easily mimic the onset of other rheumatic diseases or appear associated with them. Here we report a case of a patient who developed remitting seronegative symmetrical synovitis with pitting edema with preexisting shoulder and hip girdle pain associated with progressive fatigue, indicating a possible differential diagnosis of polymyalgia rheumatica. We reviewed and compared classification for remitting seronegative symmetrical synovitis with pitting edema and polymyalgia rheumatica and discussed other differential diagnoses.

Case presentation

An 84-year-old Caucasian woman presented to our General Medicine Unit with acute onset of symmetrical hands and feet edema, leading to functional limitation due to pain and stiffness. Additionally, she was complaining about neck, shoulder, and pelvic girdle pain present for about 2 months associated with worsening asthenia. Blood tests showed an elevated level of C-reactive protein and erythrocyte sedimentation rate, as well as absence of anti-cyclic citrullinated peptide antibodies and rheumatoid factor. As all criteria of remitting seronegative symmetrical synovitis with pitting edema syndrome were present, the patient was treated with low-dose prednisone, with a rapid and complete resolution of symptoms. She remains asymptomatic without treatment 2 years after the onset of symptoms, without any evident oncologic etiology.

Conclusions

This case is an example of a classic representation of remitting seronegative symmetrical synovitis with pitting edema syndrome with clinical elements suggesting a concomitant existing early stage of polymyalgia rheumatica. These two entities, classified in the group of seronegative arthritis, can coexist (up to 10% of cases), with remitting seronegative symmetrical synovitis with pitting edema appearing as an initial or late manifestation of polymyalgia rheumatica. It is essential to remind that remitting seronegative symmetrical synovitis with pitting edema is associated with a higher risk of cancer (30%). A proper diagnosis allows the clinician to precisely define the appropriate therapy duration to limit its side effects in the elderly and remain aware of the potential risk of underlying malignancy.

Incidence and Prevalence of Polymyalgia Rheumatica (PMR): The Importance of the Epidemiological Context. The Italian Case

OBJECTIVES

to evaluate incidence and prevalence rates of polymyalgia rheumatica (PMR) in Italy, depending on the epidemiological methodology used from time to time.

MATERIALS AND METHODS

A comprehensive literature search in MEDLINE and EMBASE was carried out. The following search terms were used: polymyalgia rheumatica, incidence, prevalence, epidemiology, general practitioner, family medicine, Italy. A search was also carried out in Google scholar using the search phrase: epidemiology of polymyalgia rheumatica in Italy. The period considered was between 1970 and March 2019. All articles containing data on incidence and prevalence of PMR in Italy were read in full. Reviews and non-original manuscripts were excluded as well as all the studies containing incidence and prevalence rates of giant cell arteritis (GCA), unless clearly distinct from data related to patients with PMR alone (isolated and pure PMR).

RESULTS

Five articles corresponded to inclusion and exclusion criteria. Two articles were excluded as they were review articles, and three articles were excluded because there were not clear data on incidence and prevalence rates of isolated PMR. Three articles reported data on the annual incidence of PMR (two of them published by the same group of investigators); two articles reported prevalence data. In one article, both incidence and prevalence were calculated. The annual rate of incidence of PMR was between 0.12 and 2.3 cases/1000 inhabitants aged over 50 years. In the two studies publishing prevalence data, they varied from 0.37% to 0.62%. The differences in incidence and prevalence rates were related to several factors such as the different set of diagnostic criteria used for identifying patients or the diagnostic difficulty for patients with atypical presentations, specifically those without raised erythrocyte sedimentation rate (ESR). In the study with higher annual rate of incidence and higher prevalence of PMR, the collaboration between general practitioner (GP) and the out-of-hospital public rheumatologist resulted in significantly different data than in the other studies. All the five articles presented data from monocentric cohorts.

CONCLUSION

Very few Italian studies addressed the epidemiology of PMR. The contribution of a specific professional figure represented by the out-of-hospital public rheumatologist, present in the Italian National Health System and absent in other countries, can make the Italian experience unique in its kind.

[Glucocorticoid sensitive bilateral leg swelling in an 85-year-old woman presenting with polymyalgia rheumatica: A case report]

INTRODUCTION

Polymyalgia rheumatica (PMR) can be associated with distal swelling indicating an associated RS3PE syndrome. We report a case of PMR associated with oedema of the lower limbs, which resolved rapidly under glucocorticoid therapy.

CASE REPORT

A 85-year-old woman presented with a 4 month history of PMR responding to the 2012 EULAR/ACR classification criteria. Examination of the lower limbs revealed pitting oedema bilaterally up to the knees, with mild erythema and warmth. Hypoalbuminemia (30g/L) was present. There was no cardiac, renal or hepatic cause to explain leg swelling. FDG-PET/CT demonstrated increased metabolism in the periarticular area of shoulders and hips. There was no sign of aortitis or neoplasia. Under treatment with prednisone 10mg/day leg swelling disappeared concomitantly to a weight loss of 8kg within 8days.

CONCLUSION

This case, the first to report leg swelling of inflammatory origin in the context of PMR, could indicate an increased vascular permeability caused by inflammation in the elderly.

Diagnosis of polymyalgia rheumatica in primary health care: favoring and confounding factors - a cohort study

Objectives

To evaluate in a primary care setting the favoring and confounding factors for the diagnosis of polymyalgia rheumatica (PMR).

Material and methods

Among 303 patients consecutively referred by their general practitioners (GPs) to our rheumatologic outpatient clinic, we identified three groups: group A – patients with confirmed diagnosis of PMR, group B – patients with unconfirmed diagnosis, group C – patients with unrecognized PMR. All the diagnostic confounding and favoring factors were discussed with GPs using an e-mail questionnaire. Participation in rheumatology training courses represented the final question. The collected data were statistically assessed in a blind way. In Fisher’s exact test and ANOVA test, a p-value was significant if < 0.05. The study was carried out in compliance with the Helsinki Declaration and approved by the Ethics Committee of Mariano Lauro Hospital. Every patient signed an informed consent form at the time of the first visit.

Results

All patients were Caucasian; 24.1% were male; mean age was 72.3 ±8.6 years (min. – 51, max. – 94). There were 41 patients in group A, 93 in group B and 169 in group C. The percentage of misdiagnoses was very high (87.1%): among 134 patients diagnosed with PMR by their GPs (group A + group B) confirmation was made in 41, and in 169 unrecognized PMR was found. Participation in training courses was very significant compared to the diagnostic accuracy (p < 0.0001 in χ² test) and to the diagnosis timing (24.3 days ±12.5 vs. 42.9 ±15.5 with p-value < 0.05 in the ANOVA test). When the percentages were assessed according to participation, an inadequate evaluation of some clinical manifestations favored over-diagnosis among the trained GPs.

Conclusions

The level of diagnostic accuracy for PMR must be improved in primary care. Participation in rheumatology training courses can be an important step.