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Musculoskeletal Manifestations in Polymyalgia Rheumatica and Temporal Arteritis

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Musculoskeletal Manifestations in Polymyalgia Rheumatica and Temporal Arteritis 1060 Ann Rheum Dis 2001;60:1060–1063 Ann Rheum Dis: first published as 10.1136/ard.60.11.1060 on 1 November 2001. Downloaded from Musculoskeletal manifestations in polymyalgia rheumatica and temporal arteritis J Narváez, J M Nolla-Solé, J A Narváez, M T Clavaguera, J Valverde-García, D Roig-Escofet Abstract erythrocyte sedimentation rate. The cause of Objective—To evaluate the incidence and musculoskeletal pain in PMR is not completely characteristics of musculoskeletal mani- understood, but inflammation in proximal festations in polymyalgia rheumatica joints and periarticular structures is a likely (PMR) and temporal arteritis (TA). basis for much of the discomfort since, to date, Methods—The records of 163 cases of there is little evidence to suggest that the PMR or TA diagnosed over a 15 year musculoskeletal symptoms are related to under- period in one area of Spain were reviewed lying vasculitis. Evidence of proximal articular for the presence and type of musculo- and periarticular synovitis has been demon- skeletal manifestations. strated by scanning, MRI, arthroscopy, and Results—Of 163 patients, 90 had isolated synovial biopsy.1–3 Moreover, an increasing PMR and 73 had TA. Eighteen of the 90 number of reports have underlined the presence patients (20%) with isolated PMR devel- of peripheral synovitis and other distal muscu- oped distal peripheral arthritis either at loskeletal manifestations in PMR, suggesting diagnosis or during the course of the that the spectrum of musculoskeletal involve- disease. When it occurred, synovitis was ment in this entity is not completely defined and mild, monoarticular or pauci-articular, is broader than has often been thought asymmetrical, transient, and not destruc- previously.4–8 The clinical predominance of tive. Other distal manifestations observed proximal symptoms in PMR has probably over- in these patients were carpal tunnel shadowed the less well characterised and more syndrome and distal extremity swelling variable distal musculoskeletal manifestations.4 with pitting oedema. In all cases these TA is a vasculitis of large and medium sized manifestations occurred in conjunction vessels with a predisposition to the cranial with active PMR. As expected, PMR was arteries in patients older than 50 years. the most frequent musculoskeletal mani- Although cranial and ocular symptoms are the Department of festation in patients with TA, occurring in most prominent manifestations in TA, Rheumatology, 56% of cases. On the contrary, only 11% of musculoskeletal findings, especially those of Hospital Príncipes de patients with TA developed peripheral PMR, are also common. However, controversy España, Ciudad arthritis. An important finding was that exists over the presence of distal musculoskel- http://ard.bmj.com/ Sanitaria y etal manifestations in TA and two recent stud- Universitaria de peripheral arthritis in these patients ap- Bellvitge, Barcelona, pears to be linked only temporally to the ies have produced conflicting results. Salvarini Spain presence of simultaneous PMR and is not et al, in a population based study at the Mayo J Narváez observed in its absence. Distal extremity Clinic, reported common and varied distal J M Nolla-Solé swelling or defined polyarthritis were not musculoskeletal symptoms in TA which sug- M T Clavaguera observed. gested that the nature of this condition and its J Valverde-García Conclusion—The spectrum of distal mus- clinical expression are broader than has often D Roig-Escofet on September 26, 2021 by guest. Protected copyright. culoskeletal manifestations of PMR in our been considered, and supporting the link 9 Department of CT and series is similar to that reported in other between TA and PMR. By contrast, Gran et al, MRI, Institut de populations. By contrast, distal musculo- in a recent prospective study conducted in Diagnòstic per la skeletal symptoms are uncommon in TA. Norway, noted the particular absence of Imatge, Hospital The almost complete absence of distal peripheral arthritis in this group of patients.10 Duran I Reynals, The occurrence of peripheral arthritis in PMR Ciudad Sanitaria y musculoskeletal manifestations in pa- Universitaria de tients with pure TA suggests diVerent and not in TA may reflect diVerent mecha- Bellvitge, Barcelona, mechanisms of disease in PMR and TA, nisms of disease. Spain supporting the view of two separate condi- In view of these contradictory observations, J A Narváez tions or one common disease in which we have reviewed the musculoskeletal manifes- host susceptibility influences the clinical tations in a well defined cohort of 163 patients Rheumatology Unit, with PMR and/or TA diagnosed over a 15 year Department of expression. Internal Medicine, (Ann Rheum Dis 2001;60:1060–1063) period in an eVort to provide an accurate clini- Delfos Medical Center, cal picture of the frequency and clinical Barcelona, Spain spectrum of these manifestations, and have J Narváez There is controversy as to whether polymyalgia compared our results with those reported in rheumatica (PMR) and temporal arteritis (TA) other major studies of this condition. Correspondence to: are expressions of the same disease or are two Dr F J Narváez Garcia, C/ Llobregat no 5, 3 1, diVerent, partly overlapping, diseases. PMR is Hospitalet de Llobregat, a common syndrome of the elderly character- Methods 08904 Barcelona, Spain ised by pain and stiVness involving the neck, We retrospectively analysed all patients with [email protected] shoulder and pelvic girdles, generally accompa- PMR and/or TA diagnosed from 1985 to 1999 Accepted 18 April 2001 nied by constitutional symptoms and a raised by the Department of Rheumatology of www.annrheumdis.com Musculoskeletal manifestations in polymyalgia rheumatica and temporal arteritis 1061 Ann Rheum Dis: first published as 10.1136/ard.60.11.1060 on 1 November 2001. Downloaded from Table 1 Joints involved during 20 episodes of peripheral isolated PMR. The mean (SD) age at time of arthritis in 90 patients with isolated polymyalgia diagnosis for all patients was 72 (8) years rheumatica (PMR) and during eight episodes of peripheral arthritis in 73 patients with temporal arteritis (TA) (range 51–89) and the mean duration of symp- toms prior to the diagnosis was 2.7 (2.6) Joint Isolated PMR TA months. The main clinical features and labora- Knee 11 (55%) 4 (50%) tory data of most of these patients have been 13 Wrist 7 (35%) 4 (50%) extensively reported elsewhere. Metacarpophalangeal 5 (25%) 2 (25%) Proximal interphalangeal 3 (20%) – PATIENTS WITH ISOLATED PMR Elbow 1 (5%) 2 (25%) Sternoclavicular 2 (10%) 2 (25%) Eighteen of the 90 patients (20%) with pure Ankle – 1 (12.5%) PMR developed clinically detectable periph- eral synovitis in whom crystal arthritis and Data are presented as number (%) of episodes. osteoarthritis were excluded. Table 1 lists the Bellvitge Hospital, Barcelona, Spain. The diag- joints involved. These patients presented non- nosis of PMR was based on the criteria deforming monoarthritis or oligoarthritis in- proposed by Chuang et al.11 Patients were con- volving mainly wrists and knees or, less sidered to have PMR if they met these criteria frequently, the sternoclavicular joints, elbows, and had a rapid and persistent response to or some metacarpophalangeal (MCP) or proxi- corticosteroid treatment. The presence of other mal interphalangeal (PIP) joints. None of them diseases that might explain the symptoms such developed defined polyarthritis during the as chronic infection, connective tissue diseases, study. All of the patients presented with or malignancy excluded the diagnosis of PMR. peripheral manifestations at the time of diagno- The diagnosis of TA was made according to the sis and only two of the 18 had a second episode 1990 ACR criteria.12 Patients were diagnosed of peripheral symptoms when PMR relapsed. as having TA if they had a positive artery biopsy None of these patients presented with periph- specimen or, in cases with a negative biopsy or eral manifestations while proximal symptoms no biopsy, if they fulfilled the remaining four of PMR were absent. criteria and had a prompt and persistent Synovitis was transient and mild, usually response to corticosteroid treatment. asymmetrical, and resolved completely after After diagnosis all selected patients under- corticosteroid therapy was started or the pred- went periodic examinations at the outpatient nisone dose was increased. Rheumatoid factor clinic until death or cessation of treatment and was negative in all cases. No erosive changes or permanent disease remission. All patients were juxta-articular osteoporosis were seen on plain examined by a rheumatologist. radiographs of aVected joints. Two patients Inpatient and outpatient charts of all pa- (2%) with synovitis of the wrists referred tients were reviewed comprehensively to obtain symptoms of acute carpal tunnel syndrome. clinical, laboratory, and disease evolution data Finally, only one of the 18 patients (1%) devel- according to a specifically designed protocol. oped distal symmetrical swelling of the upper The end point of patient follow up was the date limbs with pitting oedema over the dorsum of of the last clinic visit or the date of death. In all the hands and wrists concurrently with proxi- http://ard.bmj.com/ selected patients we recorded information on mal PMR symptoms. In this patient MRI the presence and type of musculoskeletal examination showed severe extensor tenosyno- manifestations, their relationship to the onset vitis with peritendinous oedema, without and course of the
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