Ultrasonography of the glenohumeral joints – a helpful instrument in differentiation in elderly onset rheumatoid arthritis and polymyalgia rheumatica

In a prospective study, the glenohumeral joints of 51 patients (aged 60 or above) were examined, using ultrasonography. Twenty-two patients were suffering from characteristic polymyalgia rheumatica (PMR) symptoms. In contrast, 29 other patients initially had similar complaints, but were diagnosed as having elderly onset rheumatoid arthritis (EORA, rheumatoid factor negative) upon development of typical symptoms. Ultrasound examination revealed glenohumeral joint inflammation in 40.9% (9/22) of the patients with PMR and 65.5% (19/29) of the patients with EORA. A discrete symmetrical biceps tendon sheath effusion was found in only three patients and unilateral in six patients with PMR. In contrast, 12 patients with EORA presented a massive effusion of the biceps tendon sheath, in some cases combined with a bilateral subdeltoid bursitis, and an intraarticular (i.a.) effusion/synovitis. To summarize our results: an i.a. effusion/synovitis, subdeltoid bursitis and biceps tendon sheath effusion were more frequent in patients with EORA, with a predominate symmetry and signs for massive inflammation. The typical ultrasonographic result in patients with PMR was a unilateral inflammation of the glenohumeral joint with predominate discrete biceps tendon sheath effusion and, in comparison with the EORA group, with signs of a low grade inflammation. We conclude that the results of our prospective study might be helpful in the differentiation of PMR and a rheumatoid factor negative subgroup of EORA at the first time of manifestation where clinical overlaps can be observed. However, ultrasonography of the glenohumeral joints might be a good and helpful instrument of differentiation in both diseases. Received: 29 February 2000 / Accepted: 2 March 2000     

Clinical utility of anti-CCP antibodies in the differential diagnosis of elderly-onset rheumatoid arthritis and polymyalgia rheumatica

BACKGROUND: In a significant number of patients the differential diagnosis between elderly-onset rheumatoid arthritis (EORA) and polymyalgia rheumatica (PMR) is very difficult because of the lack of specific serum markers. Anti-cyclic citrullinated peptide antibodies (anti-CCP Abs) have recently been shown to be highly specific for rheumatoid arthritis (RA). This is the first study addressing the utility of these antibodies in the differential diagnosis between EORA and PMR. METHODS: Serum samples from 57 EORA patients and 49 PMR patients were studied for the presence of anti-CCP Abs and rheumatoid factor (RF). As controls, samples from 41 RA patients (age at onset <60 yr) and 24 aged healthy subjects were analysed. RESULTS: Sixty-five per cent of EORA patients had anti-CCP Abs, whereas none of the PMR patients or the aged healthy subjects was positive for those antibodies. Ten of the EORA patients started with polymyalgic symptoms and two of them were positive for anti-CCP Abs. Interestingly, there was a significant correlation between anti-CCP Abs and RF in EORA but not in young RA patients. CONCLUSIONS: The presence of anti-CCP Abs in a patient with clinical symptoms of PMR must be interpreted as highly suggestive of EORA.     

A seasonal pattern in the onset of polymyalgia rheumatica.

The seasonal distribution in the onset of polymyalgia rheumatica (PMR) was determined in 58 patients with the disease and compared with that in 44 patients affected by rheumatoid arthritis of elderly onset (EORA). Thirty six (62%) cases of PMR developed during May to August; by contrast, only 14 (31%) cases of EORA developed in the same months, this latter disease failing to show any seasonal clustering. The monthly distribution of PMR correlated with outside temperature and hours of sunshine. These data suggest that PMR might be triggered by such factors as actinic damage of superficial vessels or infective agents with a seasonal cycle. Finally, the summer clustering of PMR may be helpful in the differential diagnosis from EORA.     

The role of anticyclic citrullinated peptide antibodies in the differential diagnosis of elderly-onset rheumatoid arthritis and polymyalgia rheumatica

There are clinical difficulties to differentiate elderly-onset rheumatoid arthritis (EORA) patients from those with polymyalgia rheumatica (PMR), especially when dealing with EORA-like PMR-onset, seronegative EORA, and PMR with peripheral synovitis, which constitute the subgroups presenting the greatest difficulties. Serum samples were obtained from two groups of patients, one with EORA diagnosis and another with a PMR diagnosis. Anticyclic citrullinated peptide (anti-CCP) antibodies (enzyme-linked immunosorbent assay method) and rheumatoid factor (RF; latex technique) were determined. Of the 16 EORA patients, 9 presented anti-CCP antibodies, 4 of whom tested positive for RF. Of the 12 EORA patients who remained negative to RF, 5 were positive for anti-CCP antibodies. Eight of the EORA patients started with polymyalgic symptoms. Three of these patients showed positive titles of anti-CCP antibodies with negative RF. All PMR patients presented negative anti-CCP antibodies, except one with weak positive titles, and all were negative for RF. Of 15 patients with PMR, 7 presented oligoarticular synovitis at the onset. After a mean follow-up of 3 months, two patients developed RA. When evaluating them for RF and anti-CCP antibodies, one tested negative, while the other was positive for both antibodies. We observed a tendency to higher values of anti-CCP antibodies in patients with extraarticular manifestations, radiological damage, and disease-modifying antirheumatic drugs. When compared to the PMR group, EORA patients presented positive anticitrulline antibodies at the beginning of the disease in a statistically significant amount. One third of the seronegative EORA patients presented positive anti-CCP antibodies at the onset.     

Cytidine deaminase in polymyalgia rheumatica and elderly onset rheumatoid arthritis

Serum cytidine deaminase (CD) as a marker of inflammatory disease was assessed in 44 patients and 47 controls to differentiate polymyalgia rheumatica (PMR) from elderly onset rheumatoid arthritis (EORA). The patients were divided into four groups: PMR with and without synovitis and seropositive and seronegative EORA. No statistically significant differences were found when serum CD levels of seropositive EORA patients were compared with serum CD of PMR patients without synovitis, neither when serum CD levels of all PMR patients were compared with a seronegative EORA group, nor when serum CD levels of PMR patients with synovitis were compared with those with EORA. Nevertheless, statistically significant differences were detected between EORAs serum CD levels and the control group (p=0.023). This difference was 10% when comparing CD levels of PMR patients with the control group (p=0.070). We did not demonstrate that serum CD levels could be a useful tool to differentiate PMR from EORA, but these findings could nevertheless reflect the presence of an inflammatory disease.     

The clinical features of elderly-onset rheumatoid arthritis. A comparison with younger-onset disease of similar duration

Patients with elderly-onset rheumatoid arthritis (EORA) may represent a clinical subset of individuals who differ prognostically and therapeutically from patients with younger-onset disease (YORA). In order to test this hypothesis, we reviewed the records of 212 patients with rheumatoid arthritis and grouped them according to age at onset above or below 60 years old. Seventy-eight EORA patients and 134 YORA patients with disease duration of less than or equal to 10 years were used for a comparison of presenting features and disease outcome. Abrupt onset occurred somewhat more frequently in EORA, but was not associated with a significantly different clinical course than was an insidious presentation in this older group. There were no differences between the EORA and YORA groups in terms of mean initial joint score, although the scores for the YORA group had wider variation. An initial clinical presentation resembling polymyalgia rheumatica (PMR) was 4 times as frequent in EORA. Elderly patients were less likely to have subcutaneous nodules or rheumatoid factor at disease onset. At the final examination, the EORA patients had lower joint scores and higher health assessments despite similar courses of treatment. These outcome differences persisted when patients with PMR-like presentations were excluded. Multivariate analyses indicated that joint scores and disease duration made important contributions to a better outcome of EORA, whereas PMR presentation and abrupt onset did not. After an adjustment was made for these 4 features, age at onset was an important contribution to joint score outcome. These results confirm the existence of important differences in onset, clinical features, and prognosis between patients with EORA and those with YORA.     

Serum cytokines and steroidal hormones in polymyalgia rheumatica and elderly-onset rheumatoid arthritis

BACKGROUND: Polymyalgia rheumatica (PMR) may create some difficulties in the differential diagnosis of elderly-onset rheumatoid arthritis (EORA) and of EORA with PMR-like onset (EORA/PMR). AIM: To investigate possible differences between three groups of patients, with regard to serum levels of inflammatory cytokines and steroidal hormones at baseline and after 1 month of treatment with glucocorticoids (prednisone 7.5-12.5 mg/day). PATIENTS AND METHODS: 14 patients with PMR, 15 with EORA and 14 with EORA/PMR, as well as 15 healthy, matched controls were analysed. Tumour necrosis factor alpha (TNFalpha), interleukin (IL)6, IL1 receptor antagonist (IL1Ra), cortisol, dehydroepiandrosterone sulphate (DHEAS) and 17-hydroxy-progesterone (PRG) were evaluated. RESULTS: Serum levels of both TNFalpha and IL6 were significantly higher in all three groups of patients than in controls (p<0.01). Serum IL6 levels were significantly higher in patients with both PMR and EORA/PMR than in patients with EORA (p<0.05). IL1Ra serum levels were significantly higher in patients with EORA than in controls (p<0.001) and in patients with PMR and EORA/PMR (p<0.05). DHEAS was significantly lower in patients with EORA/PMR than in those with EORA (p<0.05). PRG was significantly higher in all patient groups (p<0.05). After glucocorticoid treatment, serum TNFalpha and IL6 levels significantly decreased in all patient groups; IL1Ra significantly increased in patients with PMR and in those with EORA/PMR; cortisol, DHEAS, and PRG significantly decreased in patients with PMR and in those with EORA/PMR (p<0.05). CONCLUSIONS: Different cytokine and steroidal hormone patterns suggest that patients with PMR and those with EORA/PMR seem to be have a more intensive inflammatory reaction and are more efficient responders to glucocorticoid treatment than patients with EORA.     

多种自身抗体在老年类风湿关节炎诊断中的临床应用价值

目的：探讨抗环瓜氨酸（CCP）抗体、抗角蛋白（AKA）抗体、抗核周因子（APF）和RA33抗体在老年起病类风湿关节炎（EORA）诊断和鉴别诊断中的临床意义。方法：对95例EORA（EORA组）、69例风湿性多肌痛（PMR）患者（PMR组）和47例健康者（对照组）进行抗CCP抗体、AKA、APF和RA33抗体检测,其中抗CCP抗体和RA33抗体采用酶联免疫吸附法（ELISA法）检测,AKA和APF采用间接免疫荧光法（ⅡF）法检测。结果：①抗CCP抗体、AKA、APF和RA33抗体在EORA组的敏感性和特异性分别为（58．9％、95．8％）、（33．7％、91．4％）、（31．6％、89．4％）和（36．8％、86．7％）,显著高于PMR组和对照组（P〈0．01）。②EORA组抗CCP抗体的敏感性显著高于AKA、APF和RA33抗体（P〈0．05）。联合检测4种抗体,敏感性有所降低,但使阳性率提高至98．9％,且有更高的阳性预测值。③69例PMR患者中有6例患者CCP抗体阳性,3例AKA阳性,且与CCP抗体相重叠,2例APF阳性,2例RA33阳性,1年后3例重叠阳性的PMR患者确诊为EORA。结论：PMR与EORA有相似的临床症状和特征,临床上有时难以鉴别,极少数病例,在早期不典型时易误诊,但抗CCP抗体、AKA、APF和RA33抗体仍主要出现在EORA患者中,尤其抗CCP抗体有较高的敏感性和特异性,4种抗体联合检测有更高的特异性和阳性预测值,同时结合临床症状、影像学改变等,4种抗体联合检测对EORA的诊断和鉴别诊断有很高的临床应用价值。     

Clinical characteristics of polymyalgia rheumatica in Japanese patients: evidence of synovitis and extracapsular inflammatory changes by fat suppression magnetic resonance imaging

Polymyalgia rheumatica (PMR) is an inflammatory condition of unknown etiology characterized by diffuse pain and morning stiffness involving neck, shoulder, and pelvic girdles. To facilitate an understanding of PMR and its proper diagnosis, we evaluated clinical symptoms, laboratory data, and radiographic findings of 32 Japanese patients with it. Distal musculoskeletal manifestations were more frequently observed than had been thought before (81% of the patients), and peripheral arthritis was most common (75%). The joints most often affected were knees and wrists, and most episodes were presented as bilateral oligo- or polyarthritis. A swelling of hands was observed in 34% of the patients. Using contrast-enhanced fat suppression magnetic resonance imaging (MRI) of the shoulder, we found the evidence of subacromial and subdeltoid bursitis (100%), glenohumeral joint synovitis (93%), and biceps tenosynovitis (57%) in the PMR patients examined. Inflammatory changes in soft tissues around the joint capsule were prominent. By knee MRI, suprapatellar bursitis and joint synovitis were visualized in all cases examined, and extracapsular abnormalities were also prominent in 90% of the patients. Serum matrix metalloproteinase-3, a parameter of synovial inflammation, was significantly increased in PMR patients. Anticyclic citrullinated peptide antibody was useful for differential diagnosis between PMR and elderly onset rheumatoid arthritis. In conclusion, joint and periarticular synovitis seems to be commonly and primarily responsible for the proximal and distal musculoskeletal symptoms of PMR. The presence of the extracapsular change, probably a nonspecific extension of synovitis, can explain the severe discomfort that radiates toward the periphery. To avoid making a wrong diagnosis, we should be aware that peripheral synovitis is one of the hallmarks of PMR.     

Clinical characteristics of polymyalgia rheumatica in Japanese patients: evidence of synovitis and extracapsular inflammatory changes by fat suppression magnetic resonance imaging

Abstract

Polymyalgia rheumatica (PMR) is an inflammatory condition of unknown etiology characterized by diffuse pain and morning stiffness involving neck, shoulder, and pelvic girdles. To facilitate an understanding of PMR and its proper diagnosis, we evaluated clinical symptoms, laboratory data, and radiographic findings of 32 Japanese patients with it. Distal musculoskeletal manifestations were more frequently observed than had been thought before (81% of the patients), and peripheral arthritis was most common (75%). The joints most often affected were knees and wrists, and most episodes were presented as bilateral oligo- or polyarthritis. A swelling of hands was observed in 34% of the patients. Using contrast-enhanced fat suppression magnetic resonance imaging (MRI) of the shoulder, we found the evidence of subacromial and subdeltoid bursitis (100%), glenohumeral joint synovitis (93%), and biceps tenosynovitis (57%) in the PMR patients examined. Inflammatory changes in soft tissues around the joint capsule were prominent. By knee MRI, suprapatellar bursitis and joint synovitis were visualized in all cases examined, and extracapsular abnormalities were also prominent in 90% of the patients. Serum matrix metalloproteinase-3, a parameter of synovial inflammation, was significantly increased in PMR patients. Anticyclic citrullinated peptide antibody was useful for differential diagnosis between PMR and elderly onset rheumatoid arthritis. In conclusion, joint and periarticular synovitis seems to be commonly and primarily responsible for the proximal and distal musculoskeletal symptoms of PMR. The presence of the extracapsular change, probably a nonspecific extension of synovitis, can explain the severe discomfort that radiates toward the periphery. To avoid making a wrong diagnosis, we should be aware that peripheral synovitis is one of the hallmarks of PMR.     

Evidence for synovitis in active polymyalgia rheumatica: sonographic study in a large series of patients

OBJECTIVE: To determine the frequency and localization of synovitis and enthesitis in patients with active, untreated polymyalgia rheumatica (PMR) by ultrasonography (US). METHODS: Polyarticular sonographic evaluation was carried out in 50 consecutive patients with PMR at disease onset. Results were compared with 50 consecutive patients with seronegative spondyloarthropathies (SpA) and 50 with seronegative and seropositive rheumatoid arthritis (RA) at disease onset. RESULTS: Synovitis and/or effusion was detected, in at least one joint, in 100% of patients with PMR. The most frequent alterations observed in patients with PMR were effusion in the subacromial-subdeltoid (SA-SD) bursa in 70% of patients, tenosynovitis of the long head of the biceps tendon (LHBT) in 68%, glenohumeral joint effusion in 66%, tenosynovitis of the flexor tendons in the carpal tunnel in 38%, radiocarpal effusion in 18%, wrist extensors tenosynovitis in 18%, coxofemoral joint effusion in 40%. knee effusion in 38%, and ankle effusion in 10%. Enthesitis and tendonitis of the anchoring tendons were relatively rare in all the articular sites. Comparison of the SpA and PMR patients showed that enthesitis (mostly in the elbow, knee, and heel) was significantly more frequent in SpA. There was a significant difference in glenohumeral and coxofemoral effusion between the PMR and SpA patients (66% vs 16% and 40% vs 14%, respectively). Comparison of PMR and RA patients showed no significant difference in the involvement of entheses, shoulder, hip, or wrist flexor tendons in the carpal tunnel. Synovitis of the elbow, knee, and wrist was significantly more frequent in the SpA and RA patients than in those with PMR. CONCLUSION: Synovitis was detected in at least one site in 100% of patients with PMR. SA-SD bursitis, LHBT tenosynovitis, carpal tunnel syndrome, and glenohumeral, knee and hip synovitis were the most frequent alterations in PMR. Enthesitis was relatively rare at any articular site.     

Differences in fluorodeoxyglucose positron emission tomography/computed tomography findings between elderly onset rheumatoid arthritis and polymyalgia rheumatica

Abstract

Objectives. To compare the fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) findings in patients with elderly-onset rheumatoid arthritis (EORA) with those in patients with polymyalgia rheumatica (PMR), two conditions with similar clinical presentations.

Methods. We retrospectively analyzed the FDG-PET/CT findings in 10 patients with EORA and 27 patients with PMR admitted to our department between 2006 and 2012.

Results: No significant difference was observed in the median patient ages at the time of FDG-PET/CT scans in the EORA and PMR groups (73.5 vs. 78.0 years, respectively). Significant differences in both FDG uptake scores and standardized uptake values were observed between the two groups in the ischial tuberosities, spinous processes, and wrists. No significant differences were detected in the shoulders and hips. However, specific uptake patterns were observed in each group: circular and linear uptake patterns were observed around the humeral head in the EORA group, whereas focal and non-linear uptake patterns were observed in the PMR group. Moreover, focal uptake in front of the hip joint, indicating iliopectineal bursitis, tended to be limited to the PMR group. High sensitivity (92.6%) and specificity (90%) were observed for PMR diagnoses when at least three of the following five items were satisfied: characteristic findings of shoulder and iliopectineal bursitis, FDG uptake in ischial tuberosities and spinal spinous processes, and lack of FDG uptake in the wrists.

Conclusion. The differences in the degree of uptake at each lesion and in uptake patterns at the shoulders and hips are potentially useful for obtaining a definitive diagnosis.     

Clinical and laboratory features at onset of polymyalgia rheumatica (PMR) and elderly onset of rheumatoid arthritis in PMR-like presentation: a comparison of two groups of patients

The differential diagnosis between polymyalgia rheumatica (PMR) and elderly onset rheumatoid arthritis (EORA) in PMR-like presentation may represent several problems at the beginning of the disease, since the patterns of these pathologies may show largely overlapping areas. In this study we examined clinical and laboratory features of 21 patients with PMR and 22 patients with EORA PMR-like presentation, to identify eventual differences between the 2 diseases. EORA PMR-like presentation occurred more frequently in males (14 men and 8 women) than PMR (6 men and 15 women) (p = 0.046). In EORA PMR-like presentation we observed higher levels of gamma-globulins (p = 0,003), immunoglobulins IgC (p =0.004), IgA (p = 0.002) and IgM (p = 0.014) than in PMR. Fever (p = 0.022), asthenia (p = 0.007) and the contemporary involvement of the shoulder and pelvic girdle (p = 0.0054) were more frequent in PMR patients than EORA PMR-like presentation patients. Moreover, the involvement of the shoulder girdle only (p =0.0054) and arthritis of the peripheral joints (p = 0.045) were more frequent in EORA PMR-like presentation than in PMR patients. The results of this preliminary study revealed different clinical and laboratory features that may offer additional help in differential diagnosis at onset of the 2 diseases.     

Elderly‐ versus younger‐onset rheumatoid arthritis: Higher levels of ultrasound‐detected inflammation despite comparable clinical disease activity

Objective

To compare ultrasound‐verified joint inflammation between elderly‐onset rheumatoid arthritis (EORA) and younger‐onset rheumatoid arthritis (YORA) patients.

Methods

We conducted a retrospective analysis of 145 consecutive rheumatoid arthritis patients routinely assessed by sonography of wrists, metacarpophalangeal joints, and proximal interphalangeal joints, including semiquantitative scoring of synovial hypertrophy/effusion (SH/E) and power Doppler (PD) signals. Global ultrasound (GU) scores were calculated adding SH/E and PD results. EORA was defined by disease onset at age ≥60 years. Number of tender joints and swollen joints, global assessment of disease activity by physician or patient, Disease Activity Score in 28 joints (DAS28), Clinical Disease Activity Index (CDAI), and Simplified Disease Activity Index (SDAI) scores were recorded. Respective values for disease activity were accounted for in group comparisons using SPSS statistical software (version 18.0).

Results

Seventy patients were diagnosed with EORA (mean ± SD age 71.0 ± 7.3 years, 81.4% women) and 75 patients with YORA (mean ± SD age 46.8 ± 10.2 years, 86.7% women). EORA patients had higher GU scores (median 18.5 [interquartile range (IQR) 17.0] versus 12.0 [IQR 15.0], P = 0.009) and SH/E scores (median 12.0 [IQR 10.0] versus median 9.0 [IQR 9.0], P = 0.004) than patients with YORA. Patients with EORA were more likely to show PD signals in at least 1 joint than YORA patients (85% versus 72%; odds ratio 3.9 [95% confidence interval 1.3–11.5], P = 0.015). DAS28, CDAI, and SDAI scores did not differ between the groups. The sonographic pattern of joint involvement was similar in both groups, with active inflammation most commonly presenting at the wrists.

Conclusion

Ultrasound examination indicated higher inflammatory burden in EORA patients than in YORA patients despite similar clinical disease activity.     

三种自身抗体联合检测在老年起病类风湿关节炎诊断中的作用

目的 研究抗环瓜氨酸肽(cyclic citrulinated peptid,CCP)抗体、抗角蛋白抗体(anti-keratin antibody,AKA)和抗RA33抗体在老年起病的类风湿关节炎(EORA)中的临床意义,探讨3种自身抗体联合检测在EORA诊断中的作用. 方法 检测69例EORA、73例风湿性多肌痛(PMR)和65例老年骨关节炎(0A)患者体内3种抗体水平,抗CCP抗体和抗RA33抗体采用酶联免疫吸附试验法(ELISA),AKA采用间接免疫荧光法(IIF)检测. 结果 EORA患者3种抗体的敏感性和特异性分别为55.1%和94.3 0A、31.3%和91.5%、36.2%和95.4%,显著高于其他两组(P<0.05).3种抗体串联检测,EORA组的阳性率显著高于PMR组和OA组(均为P<0.05),3种抗体串联检测敏感性降低,但其特异性提高至100.0%,且有更高的阳性预测值. 结论 抗CCP抗体、AKA和抗RA33抗体在EORA患者中均可检出,抗CCP抗体有较高的敏感性和特异性,3种抗体联合检测有更高的特异性和阳性预测值;结合临床症状、影像学改变,3种抗体联合检测对EORA的诊断具有较高的临床应用价值.     

CD8 LYMPHOCYTE SUBSETS IN ACTIVE POLYMYALGIA RHEUMATICA: COMPARISON WITH ELDERLY-ONSET AND ADULT RHEUMATOID ARTHRITIS AND INFLUENCE OF PREDNISONE THERAPY

The aim of this study was to evaluate CD8 lymphocyte subsetsin active polymyalgia rhcumatica (PMR), to determine whetherlow percentages of CD8+ cells could be used to differentiatePMR from elderly-onset (EORA) and adult rheumatoid arthritis(RA), and to investigate the effects of prednisone on CD8 lymphocytesubsets. A significant reduction of percentages and absolutenumbers of CD8bright+ cells was observed in patients with activePMR. Both CD8bright+ , CD57– and CD8bright+, CD57+ subsetswere significantly reduced. Reduced percentages of CD8+ cellswere observed in 55% of patients with active PMR/giant cellarteritis (GCA), in 23% with EORA and in 44% with adult RA.Prednisone therapy in PMR patients, after only 1 week, increasedthe lymphocyte count and the absolute numbers of lymphocytesubsets significantly. However, the percentages of CD8bright+cells remained persistently low for the 2 yr study period in80% of the patients with low pre-treatment levels. Our resultsdemonstrate that CD8 cell percentage is a poor epidemiologicaldiscriminator for PMR diagnosis. Notwithstanding the rise inabsolute numbers of CD8 cell subsets induced by prednisone,the persistently low percentages of CD8+ cells in a group ofPMR patients indicate an abnormality connected with the disease. KEY WORDS: Polymyalgia rheumatica, Elderly-onset rheumatoid arthritis, Adult rheumatoid arthritis, CD8+ cell subsets, Prednisone     

老年类风湿关节炎患者43例临床分析

目的 探讨老年期发病的类风湿关节炎的临床特点。方法 对43例60岁以后发病的老年患者的临床特点进行分析，并与59例年青发病患者进行比较。结果 老年组男性发病多，急性起病较多；肩和膝等大关节作为首发关节者在老年组(37．2％)高于青中年组(11．8％)；老年组患者关节症状及关节功能障碍均重于青中年组患者，且并发心、肺疾患和骨关节炎者明显增多。结论 老年组在发病形式、首发受累关节均与青中年患者不同，且关节症状严重程度与青中年组患者显著不同，老年人并发症多于青中年人。     

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.     

Do patients with older-onset rheumatoid arthritis receive less aggressive treatment?

Rheumatoid arthritis among elderly people is an increasingly important health concern. Despite several cross-sectional studies, it has not been clearly established whether there are important clinical differences between elderly-onset rheumatoid arthritis (EORA) and younger-onset rheumatoid arthritis (YORA). The aim of this study was to compare disease activity and treatment in EORA and YORA, using the Consortium of Rheumatology Researchers of North America (CORRONA) registry, a database generated by rheumatologist investigators across the USA. From the CORRONA registry database of 9381 patients with rheumatoid arthritis, 2101 patients with disease onset after the age of 60 years (EORA) were matched, on the basis of disease duration, with 2101 patients with disease onset between the ages of 40 and 60 years (YORA). The primary outcome measures were the proportion of patients on methotrexate, multiple disease-modifying antirheumatic drugs (DMARD) and biological agents (etanercept, infliximab, adalimumab and kineret) in each group. Disease activity and severity differed slightly between the EORA and YORA groups: Disability Index of the Health Assessment Questionnaire: 0.30 v 0.35; tender joint count: 3.7 v 4.7; swollen joint count: 5.3 v 5.2; Disease Activity Score 28: 3.8 v 3.6; patient global assessment: 29.1 v 30.9; physician global assessment: 24.9 v 26.3; patient pain assessment: 31.4 v 34.9. Regarding treatment, the use of methotrexate use was slightly more common among patients with EORA (63.9%) than among those with YORA (59.6%), although the mean methotrexate dose among the YORA group was higher than that in the EORA group. The percentage of patients with EORA who were on multiple DMARD treatment (30.9%) or on biological agents (25%) was considerably lower than that of patients with YORA (40.5% and 33.1%, respectively; p<0.0001). Toxicity related to treatment was very minimal in both groups, whereas toxicities related to methotrexate were more common in the YORA group. Patients with EORA receive biological treatment and combination DMARD treatment less frequently than those with YORA, despite identical disease duration and comparable disease severity and activity.     

Arthritic disease is more severe in older rats in a kaolin/carrageenan-induced arthritis model

This study examined in an arthritis animal model whether elderly onset rheumatoid arthritis (EORA) is a more severe disease than younger onset rheumatoid arthritis. Arthritis was induced by injecting 5% kaolin/carrageenan into the left tibiotarsal ankles of 18-month-old and 4-week-old rats. Various parameters were measured to evaluate the arthritic progression of kaolin/carrageenan-induced arthritis in the rats. Immunohistochemical staining of arthritic joints was performed to determine the degree of inflammation in old and young rats. Measurements of ankle volume and thickness, arthritic index, number of squeaks, and the paw pressure test showed the 18-month-old rats had more severe disease than the young rats in a kaolin/carrageenan-induced arthritis model. The degree of inflammation and MMP-1 expression of arthritic joints in old rats was significantly higher than that of young rats based on histological evaluation with hematoxylin and eosin (H&E) staining and immunochemistry. More severe disease symptoms were found in old rats with EORA, but the molecular mechanisms still remain to be elucidated. Understanding the molecular mechanisms will be helpful to develop clinical protocols to efficiently treat patients with EORA, which is difficult to control with current protocols.