SeminarPolymyalgia rheumatica
Section snippets
Epidemiology and diagnostic criteria
Few population-based studies have assessed the epidemiological aspects of polymyalgia rheumatica because there is a lack of a diagnostic hallmark and universally accepted diagnostic and classification criteria.4, 5, 6, 7, 8, 9 Like giant-cell arteritis, polymyalgia rheumatica is extremely rare in people under 50 years. The incidence of polymyalgia increases with age and the disease affects women more than men in all age-groups. The incidence of polymyalgia rheumatica is higher in populations of
Association between giant-cell arteritis and polymyalgia rheumatica
In the past 30 years, a clear association between polymyalgia rheumatica and giant-cell arteritis has been reported. In giant-cell arteritis clinical series, polymyalgia rheumatica has been found in 40–60% of cases. Conversely, in polymyalgia rheumatica series there was a large range in the frequency of giant-cell arteritis of between 0% and 80%.14 The causes of the different values reported include: the different attitude towards taking a temporary artery biopsy sample from patients with
Clinical findings
The combination of persistent pain (at least 1 month) with pronounced morning stiffness in neck, shoulder, and pelvic girdles is pathognomonic of polymyalgia rheumatica. The discomfort is bilateral, involves most of the proximal part of the limbs rather than joints, and, generally, becomes severe enough to interfere with usual activities and may confine patients to bed. Most (70–95%) patients present with shoulder pain. Hips and neck are less commonly (50–70%) involved.11, 19 The discomfort may
Pathology
Meliconi and colleagues16 assessed the characteristics of synovitis associated with polymyalgia rheumatica and the phenotype of infiltrating mononuclear cells in arthroscopic synovial biopsy samples from shoulders of patients with active polymyalgia rheumatica. The synovitis was mild and its immunological features were: CD68+ macrophage predominance; paucity of neutrophils; absence of B cells, γδ T cells, and natural-killer cells; CD4+ (CD8–) T cells predominance over CD8+ cells; predominance
Aetiology and pathogenesis
The sudden onset of symptoms of polymyalgia rheumatica, the presence of antibodies to intermediate filaments, and the increased prevalence of antibodies to adenovirus and respiratory syncytial virus in polymyalgia rheumatica have been interpreted as evidence of a possible infectious cause of the disease.23 A Danish study showed concurrence of peaks in incidence of polymyalgia rheumatica or giant-cell arteritis and epidemics of Mycoplasma pneumoniae, Parvovirus B19, and Chlamydia pneumoniae.8
Differential diagnosis
The typical clinical features of polymyalgia rheumatica allow differentiation from other systemic painful rheumatic diseases of the elderly. The pronounced symmetric peripheral involvement, the seropositivity, and the development of joint erosions differentiate early-onset rheumatoid arthritis from polymyalgia rheumatica. Further similarities exist between polymyalgia rheumatica and the syndrome of remitting distal-extremity swelling with pitting oedema, as described by McCarty and colleagues27
Laboratory findings
An erythrocyte sedimentation rate of at least 40 mm/h was judged to be a clear indicator for diagnosis of polymyalgia rheumatica. In a study by Helfgott and Kieval,30 polymyalgia rheumatica with a normal erythrocyte sedimentation rate at diagnosis accounted for up to 20% of the patients examined. Also, during a 16-year study in Italy,31 we identified 16 (10·5%) of 152 patients with normal erythrocyte sedimentation rate (<30 mm/h by the Westergren technique) at diagnosis. C-reactive protein was
Therapy and follow-up
Corticosteroids are the drug of choice to treat polymyalgia rheumatica. An initial dose of 10–20 mg/day of prednisone or an equivalent is adequate in the absence of cranial signs and symptoms. If giant-cell arteritis is associated with the disease the dose must be raised to 40–60 mg/day. In some patients with mild disease, a short course of non-steroidal anti-inflammatory drugs may be tried. If these drugs do not adequately control signs and symptoms in 2–4 weeks, corticosteroids are required.
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Pleural and pericardial effusion in a patient with polymyalgia rheumatica: A case presentation
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2009, Journal of PainFever of Unknown Origin in Rheumatic Diseases
2007, Infectious Disease Clinics of North AmericaCitation Excerpt :Elevated erythrocyte sedimentation rate and C-reactive protein are seen in most patients [20,21]. The finding of a normal erythrocyte sedimentation rate, however, is not incompatible with the diagnosis of polymyalgia rheumatica and giant cell arteritis when other clinical findings suggest these diagnoses [15,16,21]. Most patients have anemia of chronic disease; thrombocytosis; and sometimes abnormal liver-function tests (particularly elevation of alkaline phosphatase levels) [21].
Fever of Unknown Origin in Older Adults
2007, Clinics in Geriatric MedicineCitation Excerpt :Although tenderness on palpation of axial muscles or pain on motion of joints may be seen, physical findings usually are unremarkable. A markedly elevated sedimentation rate commonly is associated with PMR but its absence should not rule out this disease [48]. In several reports, up to 22% of patients who had PMR had an ESR that either was normal or slightly increased at diagnosis, supporting the notion that an increased ESR should not be necessary for its diagnosis.
Polymyalgia rheumatica: diagnosis and treatment
2006, Joint Bone SpineCitation Excerpt :Polymyalgia rheumatica (PMR) is characterized by inflammatory pain and stiffness of the shoulder and/or pelvic girdles accompanied with laboratory evidence of severe inflammation in a patient older than 50 years of age [1–4]. Although this independent entity carries a good prognosis, it can occur as a manifestation of a number of diseases, some of which are serious or require immediate treatment [1–4]. The distinction is often impossible to achieve given the absence of pathognomonic signs, and nosological confusion probably contributes substantially to the differences in reported manifestations and treatments of PMR.