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Polymyalgia Rheumatica and Giant-Cell Arteritis

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Polymyalgia Rheumatica and Giant-Cell Arteritis MEDICAL PROGRESS Review Article Medical Progress EPIDEMIOLOGY AND DIAGNOSTIC CRITERIA Polymyalgia rheumatica is a common illness in cer- POLYMYALGIA RHEUMATICA tain populations, with a prevalence of 1 case for every 133 people over the age of 50 years.8 Giant-cell ar- AND IANT ELL RTERITIS G -C A teritis is less frequent than polymyalgia rheumatica. In Olmsted County, Minnesota, the average annual inci- CARLO SALVARANI, M.D., FABRIZIO CANTINI, M.D., dence was 17.8 cases per 100,000 persons 50 years of LUIGI BOIARDI, M.D., PH.D., AND GENE G. HUNDER, M.D. age and older.9 However, autopsy studies suggest that giant-cell arteritis may be more common than is clin- ically apparent.10 Women are affected twice as often OLYMYALGIA rheumatica and giant-cell ar- as men. teritis are closely related conditions that affect The incidence of polymyalgia rheumatica and giant- persons of middle age and older and frequent- cell arteritis increases after the age of 50 years and P peaks between 70 and 80 years of age. Population sur- ly occur together. Many authorities consider them to veys show higher frequencies of polymyalgia rheumat- be different phases of the same disease. Polymyalgia 8,9,11-15 rheumatica is an inflammatory condition of unknown ica and giant-cell arteritis at higher latitudes. The cause characterized by aching and morning stiffness incidence of polymyalgia rheumatica appears to have in the cervical region and shoulder and pelvic girdles. been relatively stable in recent years; in contrast, the It usually responds rapidly to low doses of corticoster- incidence of giant-cell arteritis appears to have in- creased. In addition, there is evidence of periodic oids and has a favorable prognosis. 9 The first description of polymyalgia rheumatica was clustering of cases of giant-cell arteritis. The mortality provided by Bruce in 1888, who called this condition rate in patients with polymyalgia rheumatica and gi- “senile rheumatic gout,” thus emphasizing its occur- ant-cell arteritis is similar to that expected in general rence in the elderly.1 In 1957, Barber proposed the populations of similar age and sex, although thoracic 2 aortic aneurysms and dissection of the aorta are im- use of the term “polymyalgia rheumatica.” In 1963, 16 Bagratuni outlined the nonerosive articular nature of portant late complications of giant-cell arteritis. polymyalgia rheumatica,3 and in the 1990s, diffuse The current diagnostic criteria for polymyalgia rheumatica were empirically formulated by Chuang swelling of the hands and edema were reported in 17 18 some patients.4 et al. and Healey (Table 1). The two sets of criteria Giant-cell arteritis is a chronic vasculitis of large and medium-sized vessels. Although it may be widespread, symptomatic vessel inflammation usually involves the cranial branches of the arteries originating from the TABLE 1. TWO SETS OF DIAGNOSTIC CRITERIA FOR POLYMYALGIA RHEUMATICA.* aortic arch. The first clinical description of giant-cell 5 arteritis was presented by Hutchinson in 1890. How- Criteria of Chuang et al.,17 1982 ever, it was not reported again until the 1930s, when Age of 50 years or older 6 Bilateral aching and stiffness for one month or more and Horton and colleagues described the histologic ap- involving two of the following areas: neck or torso, pearance of granulomatous arteritis of the temporal shoulders or proximal regions of the arms, and hips or vessels. The relation between polymyalgia rheumatica proximal aspects of the thighs Erythrocyte sedimentation rate greater than 40 mm/hour and giant-cell arteritis was not widely accepted until Exclusion of all other diagnoses except giant-cell arteritis more than 20 years later, and Paulley and Hughes were Criteria of Healey,18 1984 among the first to recognize the association.7 Pain persisting for at least one month and involving two of the following areas: neck, shoulders, and pelvic girdle Morning stiffness lasting more than one hour Rapid response to prednisone («20 mg/day) Absence of other diseases capable of causing the musculo- From the Rheumatology Service, Arcispedale S. Maria Nuova, Reggio skeletal symptoms Emilia, Italy (C.S., L.B.); the Unit of Rheumatology, Division of Medicine, Age of more than 50 years Ospedale di Prato, Prato, Italy (F.C.); and the Mayo Clinic, Rochester, Minn. Erythrocyte sedimentation rate greater than 40 mm/hour (G.G.H.). Address reprint requests to Dr. Salvarani at the Servizio di Reuma- tologia, Arcispedale S. Maria Nuova, Viale Umberto I N50, 42100 Reggio *For each set of criteria, all the findings must be present Emilia, Italy, or at [email protected]. for polymyalgia rheumatica to be diagnosed. N Engl J Med, Vol. 347, No. 4 · July 25, 2002 · www.nejm.org · 261 The New England Journal of Medicine Downloaded from nejm.org at UNIV OF PENN LIBRARY on November 11, 2016. For personal use only. No other uses without permission. Copyright © 2002 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine are similar, the only difference being the inclusion in Patients with polymyalgia rheumatica who do not the Healey criteria of responsiveness to corticosteroids. have symptoms of claudication or abnormalities of Criteria for the classification of giant-cell arteritis were temporal arteries on examination have a very high formulated by the American College of Rheumatology probability of having normal findings on biopsy.23 in 1990 (Table 2).19 These criteria were designed for Consequently, we perform temporal-artery biopsy use in investigative studies to help distinguish giant-cell only in patients with polymyalgia rheumatica who arteritis from other types of vasculitis; they are not use- present with cranial symptoms or signs. ful for making the diagnosis in individual patients.20 Temporal-artery biopsy is recommended in all pa- PATHOGENESIS tients who are suspected of having giant-cell arteritis. Polymyalgia rheumatica and giant-cell arteritis are The inflammatory involvement of affected arteries is probably polygenic diseases in which multiple envi- often intermittent rather than continuous. If the tem- ronmental and genetic factors influence susceptibility poral artery is clearly abnormal on physical examina- and severity. The increased incidence at higher lati- tion, only a small specimen needs to be removed for tudes and in Scandinavian countries and U.S. commu- histopathological review. When extracranial arteries nities with a strong Scandinavian ethnic background are normal on palpation and giant-cell arteritis is sus- and the occasional familial cases support the evidence pected, it is important to obtain a biopsy of a longer suggesting environmental and genetic causes.8,9,11-15 segment of temporal artery (3 to 5 cm) and consider A viral cause has been suspected but not confirmed performing a contralateral biopsy if the results of the in polymyalgia rheumatica and giant-cell arteritis. An first biopsy are normal. We used this approach and increased prevalence of antibodies against parainflu- found that only 10 percent of patients had negative enza virus type 1 was reported in patients with poly- findings on biopsy.21 When possible, temporal-artery myalgia rheumatica and giant-cell arteritis.24 A close biopsy should be performed before treatment is initi- temporal relation between the observed incidence ated; however, examination of temporal-artery–biopsy peaks of polymyalgia rheumatica and giant-cell arteri- specimens may reveal evidence of arteritis after more tis and epidemics of Mycoplasma pneumoniae, parvo- than two weeks of corticosteroid therapy.22 virus B19, and Chlamydia pneumoniae infections has Population-based studies of polymyalgia rheumat- been found.14 However, other studies were unable to ica have demonstrated the presence of biopsy-proved find any association between infection and the onset giant-cell arteritis in 16 to 21 percent of patients.8,11 of polymyalgia rheumatica and giant-cell arteritis.25 Conversely, symptoms of polymyalgia rheumatica have The epidemiologic evidence that there is a similar cy- been observed in 40 to 60 percent of patients with clic fluctuation (every six to seven years) in the inci- giant-cell arteritis in clinical series.9 Polymyalgia rheu- dence of giant-cell arteritis and parvovirus B19 infec- matica may thus begin before, at the same time as, or tion suggests that this virus has a role.9 A significant after giant-cell arteritis. association between histologic evidence of giant-cell TABLE 2. TRADITIONAL CRITERIA FOR THE CLASSIFICATION OF GIANT-CELL (TEMPORAL) ARTERITIS.* CRITERION DEFINITION Age at onset of disease »50 yr Development of symptoms or findings beginning at the age of 50 or older New headache New onset of or new type of localized pain in the head Temporal-artery abnormality Tenderness of temporal artery to palpation or de- creased pulsation, unrelated to arteriosclerosis of cervical arteries Elevated erythrocyte sedimentation rate Erythrocyte sedimentation rate »50 mm per hour ac- cording to the Westergren method Abnormal findings on biopsy of Artery-biopsy specimen shows vasculitis characterized temporal artery by a predominance of mononuclear-cell infiltrates or granulomatous inflammation, usually with multinu- cleated giant cells *The criteria were formulated in 1990 by the American College of Rheumatology.19 For the pur- poses of classification, a patient with vasculitis is said to have giant-cell (temporal) arteritis if at least three of these five criteria are met. The presence of three or more criteria yields a sensitivity
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