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 onset rheumatoid arthritis complicated by polymyalgia rheumatica

We report herein the case of a 70-year-old patient with elderly onset rheumatoid arthritis associated with severe muscle pain in shoulder and pelvic girdle. The patient revealed erosive polyarthritis with high titers of rheumatoid factor. Muscle pain started one month after the onset of rheumatoid arthritis followed by muscle weakness and muscle atrophy. Synovial effusion and edema in the soft tissue outside of the articular capsule in the knee joint were confirmed ultrasonographically. Administration of prednisolone at 20 mg/day dramatically abolished the muscular manifestations. The coexistence of an early stage of elderly onset rheumatoid arthritis and polymyalgia rheumatica was considered due to the presence of seropositive erosive arthritis and severe muscle manifestations at the same time.     

Elderly onset rheumatoid arthritis and polymyalgia rheumatica: ultrasonographic study of the glenohumeral joints

The glenohumeral joints of 32 patients (aged 60 or above) were examined using ultrasonography. Thirteen patients were suffering from characteristic polymyalgia rheumatica (PMR) symptoms. In contrast 19 other patients initially had similar complaints, but were diagnosed as having elderly onset rheumatoid arthritis (EORA) upon development of typical symptoms. Ultrasound examination revealed glenohumeral joint inflammation in 61% (8 out of 13) of the patients with PMR and 63.2% (12 out of 19) of the patients with EORA. These findings suggest that a subgroup of patients with PMR and EORA suffers from shoulder joint inflammation and this synovitis/bursitis/intraarticular effusion might play an important role in the understanding of their symptoms. We conclude that overlapping forms of PMR and a predominate rheumatoid factor negative subgroup of EORA might exist and should be further characterized. Received: 25 August 1997 / Accepted 9 January 1998     

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 relation of polymyalgia rheumatica to rheumatoid arthritis

Sixty-four patients with the onset of rheumatoid arthritis (RA) after age 60 were followed for at least three years (mean 6.3 years); 33 patients had rheumatoid factor and 31 did not. Twenty-five of the 31 seronegative patients had an excellent response to low dose prednisone and did not require any additional medication. Six of these patients also had an episode diagnosed as polymyalgia rheumatica (PMR). These findings suggest that the synovitis currently diagnosed as seronegative RA in many older patients may not be the same disease as seropositive RA, but may be more closely related to or identical with PMR.     

Ultrasound assessment of new onset bilateral painful shoulder in patients with polymyalgia rheumatica and rheumatoid arthritis

The aim of our study was to investigate by ultrasound (US) the anatomical structures affected during a new episode of bilateral painful shoulder in patients with polymyalgia rheumatica (PMR) and rheumatoid arthritis (RA) and to compare the findings between these two conditions. PMR and RA patients complaining of new onset bilateral painful shoulder were included. Subjects without any known rheumatic condition with a new onset unilateral painful shoulder were assessed as a control group. US evaluation includes the depiction subacromial–subdeltoid (SAD) bursitis, long head biceps (LHB) tenosynovitis and/or gleno-humeral (GH) synovitis. Thirty patients with PMR, 30 with RA, and 60 controls were included for a total of 60 shoulders per group. Unilateral SAD bursitis and LHB tenosynovitis were significantly more frequent in patients with PMR when compared to those with RA (p?<?0.0001 and p?<?0.01, respectively) and controls (p?<?0.001 and p?<?0.01, respectively). Unilateral GH synovitis was more common in RA than in PMR and controls (p?<?0.05 and p?<?0.01, respectively). Bilateral SAD bursitis was significantly more frequent in patients with PMR than in those with RA (p?<?0.01) as was bilateral LHB tenosynovitis (p?<?0.01). No significant differences were found in bilateral GH synovitis. US-detected periarticular inflammatory involvement more frequently in PMR both unilaterally and bilaterally and intra-articular inflammatory involvement was commonly in RA but only unilaterally.     

Late-onset rheumatoid arthritis vs polymyalgia rheumatica: making the diagnosis

Differentiating polymyalgia rheumatica from the onset of rheumatoid arthritis in the elderly has been the cause of much unnecessary confusion. Differential diagnosis of these disorders can be straightforward. A strategy is outlined, comprising a complete history, attention to clinical signs, and appropriate use of laboratory diagnostics. The clinical picture of each disorder is discussed, as are common obstacles to diagnosis.     

Coexistence of temporal arteritis/polymyalgia rheumatica and rheumatoid arthritis

Summary A patient with biopsy proven temporal arteritis/polymyalgia rheumatica and erosive rheumatoid arthritis is presented. Only 15 such patients have previously been documented in the literature. The coexistence has been thought to be extremely infrequent, but could merely by chance appear in far more patients than previously reported.     

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.     

Prednisolone pharmacokinetics in patients with rheumatoid arthritis,polymyalgia rheumatica and asthma

Summary The pharmacokinetic profile of a single 10 mg oral dose of prednisolone was studied in three groups of six patients with rheumatoid arthritis (RA), polymyalgia rheumatica (PMR) and bronchial asthma (BA) who were already receiving steroid therapy. A fourth group of age and sex-matched normal controls was also studied. Kinetic parameters (including elimination half-life, area under the plasma concentration curve, apparent volume of distribution and total body clearance) were similar for all four groups but there was considerable intersubject variability. The correlations between these kinetic parameters and age, body weight and serum albumin were poor. The results suggest that any differences in the effects of corticosteroids in these inflammatory diseases are unlikely to be due to pharmacokinetic factors. The duration of steroid therapy and the reduction in patient mobility would appear to be more likely explanations for the reduction in bone mass observed in patients with RA.     

Serious infections in people with polymyalgia rheumatica (PMR) or giant cell arteritis (GCA): a time-trend national US study

Clinical Rheumatology - To assess incidence, time-trends, and outcomes of serious infections in people with polymyalgia rheumatica (PMR) or giant cell arteritis (GCA). We examined the...     

Clinical characteristics and prognostic factors for relapse in patients with polymyalgia rheumatica (PMR)

Polymyalgia rheumatica (PMR) is a common inflammatory disease of the elderly in western countries, but the prevalence is apparently different between races and countries. Until now, an epidemiologic study of PMR is limited in Korea. We retrospectively evaluated the clinical data of 78 patients with PMR who were treated in 5 tertiary hospitals, and analyzed initial laboratory data, symptoms, therapeutic responses, and prognostic factors for relapse 1 year after treatments. Sixty percent of patients had pain in both shoulder and hip girdles with 10.6 weeks of duration, 75.9 ± 32.7 mm/h of erythrocyte sedimentation rate (ESR), and 6.2 ± 6.4 mg/dl of C-reactive protein. The rate of relapse and remission at 1 year was 38.4 and 2.5 %, respectively. The rate of overall relapse was 46.1 %, and the relapse occurred mostly in a year, especially between 6 and 12 months after diagnosis. There were more female in relapse group (88.9 %, p = 0.037), and cumulative steroid dose of 1 year was significantly higher in relapse group (5.5 ± 2.7 vs. 4.4 ± 2.5 g, p = 0.018). Independent risk factors for relapse were initial CRP ≥ 2.5 mg/dl (OR 6.296, p = 0.047) and the use of hydroxychloroquine (OR 6.798, p = 0.035). Initial dosage or tapering speed of steroid did not influence on prognosis. In Korean patients with PMR, baseline clinical characteristics and relapse rate were similar to previous studies, but our patients accompanied no giant cell arteritis and showed lower remission rate as well as delayed therapeutic response and later occurrence of relapse. More aggressive management would be needed according to the clinical status of patients.     

Late onset undifferentiated spondyloarthritis presenting with polymyalgia rheumatica features: description of seven cases

To underline the importance of considering a diagnosis of undifferentiated spondyloarthritis (uSpA) in patients presenting polymyalgia rheumatica (PMR) features. All patients with late onset uSpA meeting criteria for PMR at the onset of their disease seen in the Rheumatology Division of Xeral-Calde Hospital of Lugo, Spain during a 5 year period, and in the Rheumatology Department of Lucania, Italy in a two and a half year period, were studied. Six patients with late onset uSpA showing PMR symptoms at the onset were seen during the study periods in the two centres. Another patient had previously been observed in Lugo in a study dealing with the spectrum of conditions mimicking PMR. Of the seven patients, five had manifestations of SpA at the beginning of the disease and two developed these in the following 6 months. All seven met the Amor and/or the ESSG criteria for classifying and diagnosing SpA. The possibility that late onset uSpA may have PMR-like features at the beginning of the disease should be taken into account. The diagnosis is not difficult if the entire clinical spectrum of SpA is considered.     

Altered T-cell subtypes in spondyloarthritis, rheumatoid arthritis and polymyalgia rheumatica

The objective of the present study was to assess the prevalences of naive, memory, memory/effector, regulatory and activated T-cells in peripheral blood (PB) and synovial fluid (SF) of patients with spondyloarthritis (SpA), rheumatoid arthritis (RA), polymyalgia rheumatica/giant cell arteritis (PMR/GCA) and healthy controls (HC). Twenty-two patients with SpA, 15 patients with RA, 38 patients with PMR/GCA and 17 HC were prospectively enrolled. The expression of differentiation and activation markers (CD3, CD4, CD8, CD25, CD28, CD45RA, CD45RO) characterizing T-cell subsets were analyzed by flow cytometry. The frequency of CD3⁺CD4⁺CD28⁻ memory/effector T-cells was increased in PB of patients with SpA (median 1.1%, range 0.1–69.6), RA (2.5%, 0–42.9) and PMR/GCA (2.7%, 0–49.5) when compared with HC (0.7%, 0–38.0) and tended to be higher in SF of SpA patients (4.5%, 0.2–7.2, P = 0.084). CD28⁺CD45RA⁺CD4⁺ (9.6%, 4.1–10.3) and CD28⁺CD45RA⁺CD8⁺ naive T-cells (15.0%, 12.9–26.2) were reduced and CD28⁺CD45RO⁺CD4⁺ (93.5%, 51.0–99.0), CD28⁺CD45RO⁺CD8⁺ memory (81.2%, 38.9–83.5), CD8⁺CD25⁺ activated T-cells (10.9%, 2.7–13.8) and CD4⁺CD25^hi TREGs (10.2%, 7.0–13.3) were increased in SF compared to PB (P < 0.05 each). These findings demonstrate altered T-cell subsets in patients with immune-mediated disease, particularly at sites of inflammation.     

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.     

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.