eMedicine Specialties > Rheumatology > Vasculitis

Polymyalgia Rheumatica: Differential Diagnoses & Workup

Author: Ehab R Saad, MD, FACP, FASN, MA, Assistant Professor, Department of Medicine, Medical College of Wisconsin
Coauthor(s): Gloria Fioravanti, DO, Program Director, Clinical Assistant Professor, Department of Internal Medicine, Saint Luke's Hospital of Bethlehem, Temple University School of Medicine; Allen Samuels, MD, Consulting Staff, Department of Internal Medicine, Division of Rheumatology, St Luke's Hospital, Lehigh Valley Hospital, Pocono Medical Center
Contributor Information and Disclosures

Updated: Aug 20, 2009

Differential Diagnoses

Amyloidosis, AA (Inflammatory)
Multiple Myeloma
Depression
Osteoarthritis
Fibromyalgia
Polymyositis
Giant Cell Arteritis
Rheumatoid Arthritis
Hypothyroidism

Other Problems to Be Considered

Acute or chronic infection
Endocarditis
Malignancy
Parkinson disease
RS3PE
Shoulder disorders, including shoulder synovitis, rotator cuff tendinitis, and subdeltoid bursitis
Cervical spondylosis

Workup

Laboratory Studies

  • Erythrocyte sedimentation rate
    • ESR is the most sensitive diagnostic study for polymyalgia rheumatica, although it is not specific.
    • The ESR is frequently elevated and greater than 40 mm/h, but the rate can exceed 100 mm/h.
    • In 20% of patients, the ESR is mildly elevated or, occasionally, normal, which may occur in patients with limited disease activity. In these cases, diagnosis is based on rapid positive response to low-dose oral corticosteroids (10-15 mg/d).
  • C-reactive protein
    • The C-reactive protein level is often elevated and may parallel the ESR.
    • Longitudinal studies suggest that it may be a more sensitive test than ESR for the diagnosis of polymyalgia rheumatica.4
  • CBC count with differential
    • CBC count reveals mild normocytic, normochromic anemia.
    • The WBC count may be normal or mildly elevated. Platelet counts are often increased.
  • Other laboratory tests
    • Liver function tests reveal normal transaminase enzyme levels, the alkaline phosphatase may be mildly increased. Serum albumin levels may be slightly decreased.
    • The creatine kinase level is normal and helps differentiate the disease from polymyositis and other primary myopathic disorders.
    • Antinuclear antibodies and rheumatoid factor levels are usually normal.
    • Serum IL-6 levels are elevated and often closely parallel inflammatory activity of the disease.

Imaging Studies

  • Radiography: Radiographs of the painful joints rarely show abnormalities such as osteopenia, joint space narrowing, or erosions.
  • MRI
    • MRI is not necessary for diagnosis.
    • MRI of the shoulder reveals subacromial and subdeltoid bursitis and glenohumeral joint synovitis in the vast majority of patients.5
    • MRI of the hands and feet demonstrates inflammation of the tendon sheaths in many patients.
    • T2-weighted MRI of the shoulders may reveal subdeltoid, subacromial, ad bicipital tenosynovitis. These findings have led many investigators to believe that nonerosive synovitis and tenosynovitis are responsible for many symptoms of polymyalgia rheumatica.
  • Bursa ultrasonography6
    • This study may reveal an effusion within the shoulder bursae.
    • The ultrasonography findings and those of MRI usually correlate well.
    • Ultrasonography is very operator-dependent and may be useful when the diagnosis is uncertain.

Procedures

  • Occasionally, synovitis with effusions may be observed. In these cases, synovial fluid analysis reveals signs of mild inflammation, including poor mucin clotting. WBC counts are usually 1000-20,000 cells/µL, with 40-50% polymorphonuclear leukocytes.
  • Temporal artery biopsy
    • Temporal artery biopsy (TAB) has a very low yield in patients with isolated polymyalgia rheumatica and is therefore usually unnecessary in patients with polymyalgia rheumatica without symptoms of giant cell arteritis.
    • TAB is not indicated in patients with mild symptoms of polymyalgia rheumatica that is of recent onset or in patients who have remained stable over a long period (1 y or longer without current or previous clinical evidence of arteritis).
    • Patients should be monitored for symptoms or signs of arteritis after treatment initiation because low-dose corticosteroids do not prevent progression of polymyalgia rheumatica to giant cell arteritis. If clinical signs of vasculitis develop, TAB should be performed.
    • TAB may also be warranted in patients with polymyalgia rheumatica who are receiving low-dose corticosteroids if the clinical response is incomplete or if the ESR remains elevated or rises despite symptom resolution on corticosteroid therapy. Low-dose corticosteroids do not appear to affect biopsy yield.

Histologic Findings

  • Synovitis is histologically mild and is characterized by a predominance of macrophages and CD4+ helper cells.

More on Polymyalgia Rheumatica

Overview: Polymyalgia Rheumatica
Differential Diagnoses & Workup: Polymyalgia Rheumatica
Treatment & Medication: Polymyalgia Rheumatica
Follow-up: Polymyalgia Rheumatica
References
Further Reading
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Keywords

polymyalgia rheumatica, PMR, giant cell arteritis, GCA, collagen diseases, muscle pain, morning stiffness, HLA-DR4, interleukin-2, IL-2, interleukin-6, IL-6, remitting seronegative symmetrical synovitis with pitting edema, RS3PE, carpal tunnel syndrome, malaise, fatigue, depression, nonerosive synovitis, tenosynovitis, bursitis, proximal myalgia of the hip, shoulder girdles, HLA-DR4 haplotype

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Contributor Information and Disclosures

Author

Ehab R Saad, MD, FACP, FASN, MA, Assistant Professor, Department of Medicine, Medical College of Wisconsin
Ehab R Saad, MD, FACP, FASN, MA is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine, American Geriatrics Society, American Society of Nephrology, and National Kidney Foundation
Disclosure: Nothing to disclose.

Coauthor(s)

Gloria Fioravanti, DO, Program Director, Clinical Assistant Professor, Department of Internal Medicine, Saint Luke's Hospital of Bethlehem, Temple University School of Medicine
Gloria Fioravanti, DO is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine and American Osteopathic Association
Disclosure: Nothing to disclose.

Allen Samuels, MD, Consulting Staff, Department of Internal Medicine, Division of Rheumatology, St Luke's Hospital, Lehigh Valley Hospital, Pocono Medical Center
Allen Samuels, MD is a member of the following medical societies: American College of Rheumatology
Disclosure: Nothing to disclose.

Medical Editor

Kristine M Lohr, MD, MS, Program Director, Professor, Department of Internal Medicine, Division of Rheumatology and Women's Health, University of Kentucky School of Medicine
Kristine M Lohr, MD, MS is a member of the following medical societies: American College of Physicians, American College of Rheumatology, and American Medical Women's Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Elliot Goldberg, MD, Dean of the Western Pennsylvania Clinical Campus, Professor, Department of Medicine, Temple University School of Medicine
Elliot Goldberg, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, and American College of Rheumatology
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD, Professor of Medicine, Temple University School of Medicine; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital
Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, and Phi Beta Kappa
Disclosure: medifocus Honoraria Review panel membership; health dialogs Honoraria Consulting; West Penn Allegheny Health System None Board membership

 
 
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