Sex differences in temporal arteritis and polymyalgia rheumatica

OBJECTIVE: Sex-specific differences in treatment outcomes have been observed in polymyalgia rheumatica (PMR) and temporal arteritis (TA), with a significantly longer course of treatment in women than in men. We analyzed whether these sex differences are related to differences in disease presentation and severity of the inflammatory response. METHODS: The records of 163 cases of PMR and/or TA diagnosed over a 15 year period were reviewed. A comparative study of clinical and laboratory features between men and women was performed. RESULTS: Of 163 patients, 90 had isolated PMR and 73 had TA. Among patients with TA, 49 women and 24 men were identified, with a ratio of 2. While there were no differences in the frequency of classic disease manifestations, the presence of constitutional syndrome (malaise, anorexia, and weight loss) and fever were significantly more frequent in women than in men. Of note, evaluation of laboratory measures at time of diagnosis also revealed more marked laboratory abnormalities reflecting inflammation in the female group. Among patients with isolated PMR, 58 women and 32 men were identified, a ratio of 1.8. Comparing the clinical features at presentation, significant sex differences were also found, with a higher frequency of constitutional syndrome and lower values of hemoglobin in women. Moreover, women also had higher erythrocyte sedimentation rate values, and higher prevalence of fever and hepatic involvement, although the difference did not reach statistical significance. CONCLUSION: Modest differences were found in disease expression between women and men with TA and/or PMR. In both conditions, the inflammatory response seemed to be more severe in women. The strong inflammatory response in women could explain the longer duration of treatment reported in this subgroup of patients.     

No permanent reduction in bone mineral density during treatment of polymyalgia rheumatica and temporal arteritis using low dose corticosteroids

The objective of the study was to examine bone mineral density (BMD) in patients with polymyalgia rheumatica (PMR) or temporal arteritis (TA) currently or previously treated with prednisolone. BMD (using single or dual x-ray absorptiometry) was measured in radius, spine, and hip in 26 currently and 28 previously prednisolone treated patients with PMR (n = 38) or TA (n = 16). The prednisolone treated patients were compared to 30 newly diagnosed PMR (n = 26) or TA patients (n=4) examined prior to start of prednisolone, and 70 healthy controls. No statistically significant differences were found between the groups regarding age, height, weight, and gender. For current users of prednisolone, the mean daily dose was 6.5 mg, the mean cumulative dose 7.7 grams, and for previous users 5.6 mg and 6.6 grams, respectively. No statistically significant differences in BMD at the different measurement sites were found between prednisolone treated patients and the two control groups. Similarly, no significant differences in BMD were found between current and previous users of prednisolone and between the prednisolone treated PMR and TA patients. In conclusion, BMD is not substantially reduced in PMR and TA patients currently or previously treated with mean low dose prednisolone. However, a tendency to a lower BMD was found in PMR/TA patients currently treated with prednisolone and in the prednisolone treated TA patients.     

Polymyalgia rheumatica and temporal arteritis: the endocrine relations and the pathogenesis. Review

Polymyalgia rheumatica (PMR) and giant cell or temporal arteritis (TA) are related chronic inflammatory conditions which typically affect the aged subjects. Typical features of PMR include general symptoms of inflammation as well as severe muscle pain in shoulder and pelvic girdle. The manifestation of TA depends on localization of affected artery, usually branch vessels of the aortic arch. Etiology of PMR and TA remains unclear. The association with HLA system and characteristics of the inflammatory response are discussed in this paper. Age related changes in neuroendocrine system could also represent a pathogenic factor in genetically disposed individuals. Complex bi-directional neuroendocrine-immune relations are further modified by ongoing chronic inflammation. Good clinical response to glucocorticoids in PMR patients supports the assumption that the actual levels of cortisol are lower than would be expected during ongoing inflammation. Moreover, decreased levels of adrenal androgens have been observed in PMR and thus possible adrenal androgens supplementation during glucocorticoid treatment sketches new prospects for the treatment of PMR and TA.     

No increased frequency of malignant neoplasms in polymyalgia rheumatica and temporal arteritis. A prospective longitudinal study of 398 cases and matched population controls

OBJECTIVE: To determine the prevalence and incidence of cancer in patients with polymyalgia rheumatica (PMR) and temporal arteritis (TA) compared to matched population controls. METHODS: In a population based study 1987-97, 398 patients were diagnosed with PMR or TA. Each patient was randomly assigned 4 age and sex matched controls from the same county, totaling 1592 controls. All patients and controls were cross-checked with data files at the Cancer Registry of Norway, for cancers registered up to the end of 1998. RESULTS: Prior to inclusion, cancer was diagnosed in 32 patients with PMR or TA (8.0%) and 153 controls (9.6%) (OR 0.82, 95% CI 0.55-1.22, p = 0.3). After inclusion, malignant neoplasms were discovered in 34 patients with PMR or TA (9.3%) compared to 143 controls (10.8%) (relative risk 0.86, 95% CI 0.59-1.26, p = 0.4). Thus there was no difference between patients with PMR or TA and their controls regarding prevalence or incidence of cancer. The interval between inclusion and the time of diagnosis of malignant neoplasm did not differ between patients and controls. No significant difference in types or localization of malignant neoplasms was found in patients compared to controls. CONCLUSION: No differences were found in frequencies or types of malignant neoplasms between patients with PMR or TA and population controls. Neither PMR nor TA as defined by present diagnostic criteria appears associated with cancer.     

Polymyalgia rheumatica and temporal arteritis: A retrospective study of 111 patients

Summary There is no unanimity as to whether polymyalgia rheumatica (PMR) and temporal arteritis (TA) are two distinct diseases or different features of one disease.The objective of this study was to assess the value of histological findings of temporal artery biopsy and the efficacy and complications of drug therapy as well as the frequency of malignancies. It was carried out as a retrospective follow-up study. One hundred eleven patients (89 PMR, 14 TA and 8 PMR+TA) were studied. In 56 patients with PMR a temporal artery biopsy was performed; in none of these biopsies was active arteritis found. Of the 19 patients with TA or PMR+TA, where a temporal artery biopsy was performed, arteritis was found in 15 patients. Reactivation occurred in 27 patients: 4 patients using NSAIDs and 23 patients using corticosteroids. Side effects of the medication included vertebral compression in 10 patients, most of whom were using corticosteroids.Malignancies were diagnosed in 12 of the 111 patients. Most malignancies were diagnosed long before or after the diagnosis of PMR.In case of a PMR diagnosed by the clinician a biopsy of the temporal artery has no value, while the yield of this diagnostic procedure is high in TA. Reactivation was seen quite often and warrants a prolonged period of medical treatment.     

Musculoskeletal manifestations in polymyalgia rheumatica and temporal arteritis

OBJECTIVE: To evaluate the incidence and characteristics of musculoskeletal manifestations in polymyalgia rheumatica (PMR) and temporal arteritis (TA). METHODS: The records of 163 cases of PMR or TA diagnosed over a 15 year period in one area of Spain were reviewed for the presence and type of musculoskeletal manifestations. RESULTS: Of 163 patients, 90 had isolated PMR and 73 had TA. Eighteen of the 90 patients (20%) with isolated PMR developed distal peripheral arthritis either at diagnosis or during the course of the disease. When it occurred, synovitis was mild, monoarticular or pauci-articular, asymmetrical, transient, and not destructive. Other distal manifestations observed in these patients were carpal tunnel syndrome and distal extremity swelling with pitting oedema. In all cases these manifestations occurred in conjunction with active PMR. As expected, PMR was the most frequent musculoskeletal manifestation in patients with TA, occurring in 56% of cases. On the contrary, only 11% of patients with TA developed peripheral arthritis. An important finding was that peripheral arthritis in these patients appears to be linked only temporally to the presence of simultaneous PMR and is not observed in its absence. Distal extremity swelling or defined polyarthritis were not observed. CONCLUSION: The spectrum of distal musculoskeletal manifestations of PMR in our series is similar to that reported in other populations. By contrast, distal musculoskeletal symptoms are uncommon in TA. The almost complete absence of distal musculoskeletal manifestations in patients with pure TA suggests different mechanisms of disease in PMR and TA, supporting the view of two separate conditions or one common disease in which host susceptibility influences the clinical expression.     

Involvement of arterial trunks of the upper limbs in giant cell arteritis. Apropos of 7 cases

On 91 patients with temporal arteritis (TA) and/or polymyalgia rheumatica (PMR), we observed 7 females aged 62 to 73 years with upper extremities ischemia. Arm claudication and/or Raynaud's phenomenon were the initial manifestations of the disease in 2 cases, or appeared simultaneously with other symptoms in 2 cases, or complicated decreasing corticosteroid therapy in 3 cases. A temporal artery biopsy was performed on 6 patients with, in all of them, typical giant cell granulomatous arteritis pathology findings. Angiograms showed, in all cases, multiple bilateral smooth stenosis and/or obliterations of post vertebral subclavian arteries and/or axillary arteries. Symptoms always improved on corticosteroid treatment and no patient needed reconstructive surgery. In conclusion, large arteries involvement, which can occur in TA and/or PMR, affect in our experience most commonly the subclavian and axillary arteries, with female predominance as found in Takayasu's arteries. These disorders should be considered in cases of occlusive disease of the arms in elderly women and the response to steroids is usually adequate to eliminate the need for early surgical intervention. Early recognition of asymptomatic large artery involvement by Doppler evaluation, in all TA and/or PMR patients, and transient anticoagulant therapy might prevent vessels occlusions.     

Polymyalgia rheumatica

Polymyalgia rheumatica (PMR) is a common chronic inflammatory rheumatic disease with unknown aetiology, affecting predominately people of middle age and older. Besides clinical symptoms and diagnostics, imaging techniques including sonography and magnetic resonance imaging may provide evidence of typical inflammatory lesions with bilateral bursitis subdeltoidea or subacromialis, tenosynovitis of the biceps tendon sheath and/or synovitis of the shoulder joints and thus may support the diagnosis of this disease in difficult cases. Corticosteroids are the cornerstone of treatment of PMR, but adverse events because of chronic corticosteroid use are observed in more than 50% of treated patients. Whether immunosuppressants, such as methotrexate and tumour necrosis factor-α inhibitors are effective in the therapy of PMR has still not yet been clarified.     

Whole-body fluorodeoxyglucose positron emission tomography/computed tomography in patients with active polymyalgia rheumatica: evidence for distinctive bursitis and large-vessel vasculitis

Abstract

Objectives To investigate fluorodeoxyglucose (FDG) accumulation in large joints, bursas, and large vessels in patients with polymyalgia rheumatica (PMR) using 18-FDG positron emission tomography/computed tomography (PET/CT) and to differentiate PMR from similar diseases.

Methods Fourteen untreated patients with active PMR and 17 control patients with rheumatoid arthritis (n = 11) or other active rheumatic diseases (n = 6) underwent 18-FDG PET/CT. FDG uptake in large joints, bursas and vertebral spinous processes was evaluated by calculating maximum standardised uptake values and by visual scoring (scale 0–4). PET scan images were scored in seven vascular regions, and total vascular scores (range 0–21) were calculated.

Results Polymyalgia rheumatica patients showed increased FDG uptake in ischial tuberosities, greater trochanters, and lumbar spinous processes. Positive results at two or more of these sites showed high sensitivity (85.7%) and specificity (88.2%) for the diagnosis of PMR, and shoulder or hip-joint involvement showed low disease specificity. High FDG accumulations were found in the aortas and subclavian arteries of two PMR patients who were asymptomatic for temporal arteritis and scanty synovium and perisynovium, based on FDG uptake. PET/CT images of the 12 PMR patients without apparent vascular involvement showed synovitis and/or perisynovitis.

Conclusions Fluorodeoxyglucose-PET/CT may be useful for the detection of PMR lesions, which are difficult to identify using other methods.     

Whole-body fluorodeoxyglucose positron emission tomography/computed tomography in patients with active polymyalgia rheumatica: evidence for distinctive bursitis and large-vessel vasculitis

Objectives

To investigate fluorodeoxyglucose (FDG) accumulation in large joints, bursas, and large vessels in patients with polymyalgia rheumatica (PMR) using 18-FDG positron emission tomography/computed tomography (PET/CT) and to differentiate PMR from similar diseases.

Methods

Fourteen untreated patients with active PMR and 17 control patients with rheumatoid arthritis (n?=?11) or other active rheumatic diseases (n?=?6) underwent 18-FDG PET/CT. FDG uptake in large joints, bursas and vertebral spinous processes was evaluated by calculating maximum standardised uptake values and by visual scoring (scale 0–4). PET scan images were scored in seven vascular regions, and total vascular scores (range 0–21) were calculated.

Results

Polymyalgia rheumatica patients showed increased FDG uptake in ischial tuberosities, greater trochanters, and lumbar spinous processes. Positive results at two or more of these sites showed high sensitivity (85.7%) and specificity (88.2%) for the diagnosis of PMR, and shoulder or hip-joint involvement showed low disease specificity. High FDG accumulations were found in the aortas and subclavian arteries of two PMR patients who were asymptomatic for temporal arteritis and scanty synovium and perisynovium, based on FDG uptake. PET/CT images of the 12 PMR patients without apparent vascular involvement showed synovitis and/or perisynovitis.

Conclusions

Fluorodeoxyglucose-PET/CT may be useful for the detection of PMR lesions, which are difficult to identify using other methods.     

Comparison of extracapsular changes by magnetic resonance imaging in patients with rheumatoid arthritis and polymyalgia rheumatica

OBJECTIVE: Joint inflammation in polymyalgia rheumatica is regarded primarily as a disease of the synovial cavities and bursae, but the adjacent capsules and soft tissues have not been evaluated using sensitive imaging methods. We used fat suppression magnetic resonance imaging (MRI) to determine anatomical sites of inflammatory change in the shoulders of patients with early polymyalgia rheumatica (PMR) and a control group of patients with rheumatoid arthritis (RA). METHODS: Fourteen patients with PMR and 14 with RA (a total of 20 shoulders in each group) were evaluated. T2 SPIR (fat suppressed) coronal oblique MRI sequences of the shoulders were performed. Scans were assessed for sites of joint effusion, bursitis, tenosynovitis, bone edema, and extracapsular soft tissue edema. Statistical analysis was performed using Fisher's test. RESULTS: Nine of 14 patients (10/20 joints) with PMR but only 2/14 (2/20 joints) with RA had prominent edema at extracapsular sites adjacent to the joint capsule or in the soft tissues (p = 0.02). Both groups had a comparable degree of joint effusion (18 PMR, 17 RA), bursitis (18 PMR, 16 RA), and tenosynovitis (3 PMR, 2 RA). CONCLUSION: The only significant difference between the 2 groups was the presence of inflammatory change outside the joint cavity in patients with PMR. This may contribute to the diffuse nature of symptoms in PMR and have implications for its pathogenesis.     

Synovial expression of vasoactive intestinal peptide in polymyalgia rheumatica

OBJECTIVE: Polymyalgia rheumatica (PMR) is an inflammatory disease that typically affects elderly people. Its clinical hallmark is the severity of pain in the shoulder and pelvic girdle. Mild to moderate synovitis and/or bursitis of the joints involved has been described. Neuropeptides are involved in nociception and modulation of inflammatory reaction. To evaluate whether neuropeptides have a role in PMR pathophysiology, we studied the expression of substance P (SP), calcitonin gene-related peptide (CGRP), vasoactive intestinal peptide (VIP) and somatostatin (SOM) in shoulder synovial tissues of PMR patients. METHODS: Synovial expression of neuropeptides was investigated by immunohistochemical analysis, in two groups of PMR patients: the first one at the onset of disease and the second one after corticosteroid treatment, and in other joint diseases, rheumatoid arthritis (RA) and osteoarthritis (OA). RESULTS: The only significant expression of VIP was found in PMR and, to a lesser extent, in RA synovial tissue. In PMR, we observed VIP immunostaining both in the lining layer and in the sublining area. In patients on corticosteroid treatment VIP lining layer expression was not significantly different while VIP positive cells in the sublining area were almost absent. CONCLUSION: Local VIP production in PMR synovial tissue might contribute to the typical musculoskeletal discomfort and it may have a role in the immunomodulation of synovial inflammation.     

Incidence of temporal arteritis in patients with polymyalgia rheumatica: a prospective study using colour Doppler ultrasonography of the temporal arteries.

OBJECTIVE: To determine the incidence of temporal arteritis (TA) in patients with polymyalgia rheumatica (PMR) using colour Doppler ultrasonography of the temporal arteries. METHODS: Ultrasonography was performed in all 127 consecutive patients with newly diagnosed, active PMR seen between 1994 and 2000 and in 127 age- and sex-matched controls. RESULTS: Of 102 patients with "pure" PMR, 8% had ultrasonographic findings arousing suspicion of concomitant active TA (specific halo sign and/or positive histology in 7%; histologically proven TA in 4%). Twenty-five patients had clinical signs of both PMR and TA. Histology and sonography were negative in three of these patients. Of the controls, none had a halo sign and four had stenoses. CONCLUSION: Ultrasonography of the temporal arteries is a new, non-invasive method of diagnosing concomitant TA in patients with PMR.     

A longitudinal study of calprotectin in patients with polymyalgia rheumatica or temporal arteritis: relation to disease activity

OBJECTIVE: Calprotectin is a granulocyte and monocyte cytosolic protein that is released during activation of these cells. The plasma level of calprotectin is raised in various inflammatory conditions and correlates with disease activity in a wide range of rheumatic diseases. We wanted to investigate whether calprotectin may be useful as a measure of disease activity in polymyalgia rheumatica (PMR) and temporal arteritis (TA). METHODS: Forty-seven patients with PMR and/or TA were followed up to 3 years in a prospective longitudinal design. Plasma calprotectin was correlated with acute phase parameters, erythrocyte sedimentation rate (ESR), and peroral steroid usage before start of treatment and at four subsequent time intervals. RESULTS: Thirty-three patients had PMR, 10 had TA, and four had both diagnoses. Calprotectin was highly correlated with the acute phase parameters and ESR during the study period. Calprotectin was significantly decreased after start of treatment with oral prednisolone, and correlated with the daily dosage of prednisolone (r = 0.36, p < 0.01). CONCLUSION: Calprotectin plasma levels were significantly associated with acute phase parameters, ESR, and prednisolone usage in PMR and TA, indicating that calprotectin may be a good measure of disease activity in these conditions.     

Fibrin(ogen)olysis in polymyalgia rheumatica and temporal arteritis: preliminary findings on association with disease activity.

Postulating an increased production of fibrin(ogen)olytic degradation products (FDP) and an abnormality of fibrinogen metabolism in polymyalgia rheumatica (PMR) and temporal arteritis (TA), we studied 16 PMR/TA patients and 10 control subjects using a sensitive radioimmunoassay for a specific type of FDP, namely, fibrin(ogen)-related D-antigen. Median serum D-antigen levels were increased five-fold in those 11 PMR/TA patients who were untreated compared with control subjects. In the five PMR/TA patients who were treated with prednisone the median D-antigen levels were not significantly different from those of the healthy controls. D-antigen concentration correlated significantly (r = 0.83) with ESR in the seven untreated PMR patients. In PMR patients prednisone therapy was followed by a reduction of serum D-antigen levels.     

Monocyte chemoattractant protein 1 (MCP-1) in temporal arteritis and polymyalgia rheumatica

OBJECTIVE: To examine the localisation of monocyte chemoattractant protein 1 (MCP-1) in the inflamed vessel wall in temporal arteritis (TA) and to measure MCP-1 in plasma both in patients with TA and patients with polymyalgia rheumatica (PMR). METHODS: By immunohistochemical techniques MCP-1 was localised to the vessel wall in patients with TA. In TA, PMR, and healthy controls MCP-1 was quantified by enzyme linked immunosorbent assay (ELISA) in plasma. RESULTS: MCP-1 was localised to the majority of mononuclear cells, some smooth muscle cells, and giant cells in the arterial biopsy specimens from 12 patients with histologically verified TA. In all sections, including the vasa vasorum, the endothelium stained positive. In the intima 73% (range 57-91%), in the media 49% (range 32-67%), and in the adventitia 74% (range of 62-91%) of all cells stained positive. In plasma MCP-1 was significantly raised in untreated TA (n=33) and untreated PMR (n=27) compared with healthy controls (n=12). Untreated TA plasma levels of MCP-1 (mean 391 pg/ml (range 82-778 pg/ml)) were similar to untreated PMR plasma levels (mean 402 pg/ml (range 29-1153 pg/ml)), and no significant difference was found between the two groups of patients. In both patients with TA and patients with PMR no correlation was found between the plasma level of MCP-1 and the erythrocyte sedimentation rate, haemoglobin concentration, and CD4/CD8 ratio. CONCLUSIONS: These results show that MCP-1 plays a part in the disease processes of TA and PMR.     

Restricted dose and duration of corticosteroid treatment in patients with polymyalgia rheumatica and temporal arteritis

To analyze whether corticosteroids in low doses during limited time periods could be safely used in the treatment of patients with polymyalgia rheumatica (PMR) or temporal arteritis (TA) the records of 91 patients diagnosed between 1980 and 1987 were reviewed. The mean initial prednisolone dose was in patients with PMR 18 mg/day and the mean duration of treatment was 17 months. In patients with TA the mean initial dose was 31 mg/day and the mean duration of treatment 16 months, and in all the corticosteroid treatment was terminated within 24 months. Patients with coexisting TA and PMR demanded longer treatment compared to patients with either TA or PMR and thus 18/91 patients were treated for more than 2 years. No visual or neurological complications occurred after treatment with corticosteroids had been initiated. Our study indicates that most patients with PMR or TA can be treated safely with an initial prednisolone dose of 10 mg given twice daily. With few exceptions corticosteroid treatment can be terminated within 24 months.     

Subclavian and axillary involvement in temporal arteritis and polymyalgia rheumatica

PURPOSE: We describe 10 female patients with temporal arteritis (TA) and/or polymyalgia rheumatica (PMR) who presented with upper-extremity ischemia. PATIENTS, METHODS, AND RESULTS: Arm claudication or Raynaud's phenomenon was the initial manifestation of the disease in four cases, appeared with classical symptoms in one case, or occurred during decreasing corticosteroid therapy in five cases. Temporal artery biopsy was performed in nine patients and showed typical giant-cell granulomatous arteritis in seven cases. Angiograms in all cases showed multiple bilateral smooth stenoses, or obliterations of postvertebral subclavian and/or axillary arteries, or both. Symptoms always improved with corticosteroid treatment and none of the patients required reconstructive surgery, although angiography performed after stabilization did not show revascularization of occluded vessels. CONCLUSION: We conclude that large-artery involvement in TA and PMR affects most commonly the subclavian and axillary arteries, with a female predominance comparable to that in Takayasu's arteritis. Both these disorders should be considered in elderly women with occlusive disease of the upper extremities. Although response to steroid therapy was sufficient in our series to avoid surgery, we believe it is preferable to recognize large-artery involvement as early as possible and recommend performance of ultrasonic Doppler examination when any sign of oncoming ischemia or stenosis is observed.     

Diagnosing late onset rheumatoid arthritis, polymyalgia rheumatica, and temporal arteritis in patients presenting with polymyalgic symptoms. A prospective longterm evaluation

OBJECTIVE:. To examine for demographic and clinical differences between late onset rheumatoid arthritis (LORA), polymyalgia rheumatica (PMR), and temporal arteritis (TA) patients presenting with polymyalgic symptoms (PMS) and to identify baseline clinical and laboratory features that would lead to a more accurate final diagnosis. METHODS: Three hundred forty-nine consecutive patients with new onset of symptoms suggestive of LORA, PMR, or TA presenting at or above age 60 years were enrolled in a prospective study. RESULTS: During followup, 9 patients diagnosed initially as PMR developed LORA (giving a final total of 145), 5 patients initially diagnosed as LORA changed diagnosis to PMR (final total 147), and 29 patients had PMS that predated TA symptoms (final total 57). The delay in diagnosis ranged from 1 to 30 months. DRB1*04 was associated with development of both LORA and TA. CONCLUSION: In about 10% of patients the correct diagnosis of LORA, PMR, and TA in those presenting with PMS may be delayed due to similarities in initial clinical presentation. Longterm followup is essential to establish correct diagnosis. Laboratory tests tend to be unhelpful, although a positive rheumatoid factor or persistently raised plasma viscosity despite steroids might indicate RA, and the presence of HLA-DRB1*04 may indicate underlying RA or TA.     

Polymyalgia rheumatica and temporal arteritis: a retrospective analysis of prognostic features and different corticosteroid regimens (11 year survey of 210 patients).

The treatment of polymyalgia rheumatica (PMR) and temporal arteritis (TA) is still controversial. To assess the influence on the course of these diseases of the clinical symptoms at initial presentation and of the starting dosage of corticosteroid (CS) treatment the data for 210 patients, who were diagnosed as having PMR or TA from 1976 to 1986 and were followed up closely, were reviewed. One hundred and thirty two patients were diagnosed as having 'clinically pure' PMR; prednisone starting doses of over 15 mg daily provided more CS related adverse effects without any advantage. The mean duration of treatment was 25.7 months. Nine patients later developed symptoms of TA, and there were no predictive features for this. None experienced visual or neurological complications. Seventy eight patients were diagnosed as having clinical TA. Twenty five patients treated with low starting doses of prednisone, ranging from 10 to 20 mg/d (mean 16.2 mg/d), developed less CS related adverse effects and did not have more visual or neurological complications than 53 patients treated with higher doses. The mean duration of treatment was 30.9 months. Fifteen patients experienced visual or neurological complications and men (10/30) developed these complications more frequently than women (5/48) (p less than 0.02). These results suggest that (a) clinically pure PMR is a benign disease requiring low doses of CS treatment; (b) low doses of CS seem an adequate treatment for most cases of TA; (c) a worse prognosis seems attached to the male sex in TA.