Polymyalgia Rheumatica Workup
- Author: Ehab R Saad, MD, MA, FACP, FASN; Chief Editor: Herbert S Diamond, MD more...
Joint guidelines from the European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR) recommend performing the following laboratory studies in all patients with polymyalgia rheumatica (PMR), both to help to exclude mimicking conditions and to establish a baseline for monitoring therapy :
Rheumatoid factor and/or anti-cyclic citrullinated peptide antibodies (anti-CCP)
C-reactive protein (CRP) and/or erythrocyte sedimentation rate (ESR)
Complete blood cell count (CBC) with differential
Liver function tests
Bone profile (including calcium and alkaline phosphatase)
Additional studies to consider are as follows :
Thyroid-stimulating hormone (TSH)
If clinically indicated, tests such as the following may be considered to exclude alternative diagnoses :
Antinuclear antibodies (ANA)
Anti–cytoplasmic neutrophil antibodies (ANCA)
The ESR is a sensitive diagnostic study for PMR, but it is not specific. The ESR is frequently greater than 40 mm/hr, but it can exceed 100 mm/hr.The ESR is mildly elevated in 7-20% of patients. Occasionally, the ESR is normal; this may occur in patients with limited disease activity. In these cases, the diagnosis is based on rapid positive response to low-dose oral corticosteroids (10-15 mg/day).
The CRP level is often elevated and may parallel the ESR. Longitudinal studies suggest that CRP may be a more sensitive test than ESR for the diagnosis of PMR
The CBC reveals mild normocytic, normochromic anemia in most patients. The white blood cell count may be normal or mildly elevated. Platelet counts are often increased, reflecting systemic inflammation.
Liver function tests reveal normal transaminase enzyme levels. Alkaline phosphatase may be mildly increased in approximately one third of patients. The serum albumin level may be slightly decreased.
The creatine kinase level is normal; this finding helps differentiate PMR from polymyositis and other primary myopathic disorders.
Antinuclear antibodies, complements , rheumatoid factor, and anti-CCP levels are usually normal. Serum interleukin-6 (IL-6) level is elevated and often closely parallel the inflammatory activity of the disease; however, the test is not readily available in most laboratories.
In a study of serum markers related to immune cells that may be involved in PMR and giant cell arteritis (GCA), serum B-cell activating factor (BAFF) and IL-6 were most strongly associated with disease activity in both GCA and PMR patients. The study population comprised 24 newly diagnosed, untreated GCA/PMR patients; 14 corticosteroid-treated GCA/PMR patients in remission; and 13 controls.
In patients who have synovitis with effusions, synovial fluid analysis reveals signs of mild inflammation, including poor mucin clotting. Synovial fluid WBC counts range between 1,300-11,000 cells/µL (median 6,000 cells/µL), with 34% polymorphonuclear leukocytes (range 12-78%).
Radiographs reveal either normal joints or evidence of osteoarthritis. Evidence of erosive arthritis should prompt evaluation for other disorders such as rheumatoid arthritis or crystalline arthritis. Magnetic resonance imaging (MRI) is not necessary for diagnosis, but MRI of the shoulder reveals subacromial, subdeltoid bursitis and glenohumeral joint synovitis in the vast majority of patients. MRI of the hands and feet demonstrates inflammation of the tendon sheaths in many patients.
In a Japanese study, MRI of the shoulder showed a significantly thicker supraspinatus tendon and more frequent severe rotator cuff tendinopathy in patients with PMR than in patients with rheumatoid arthritis or control. In both shoulder and hip joint MRIs, effusion around the joints was greater in PMR patients, and periarticular soft tissue edema was significantly more frequent.
Ultrasonography is operator-dependent but may be useful when the diagnosis is uncertain. Bursa ultrasonography may reveal an effusion within the shoulder bursae. The ultrasonography findings and those of MRI usually correlate well.
Symptomatic vasculitis in cranial and extracranial vessels is rare in polymyalgia rheumatica, but a study by Kermani et al demonstrated subclinical involvement in about one third of patients using ultrasonography and positron emission tomography (PET) scanning.
Temporal Artery Biopsy
Temporal artery biopsy (TAB) has a very low yield in patients with isolated polymyalgia rheumatica (PMR) and is therefore usually unnecessary in patients with PMR who do not have symptoms of giant cell arteritis (GCA). TAB is not indicated in patients with mild symptoms of PMR that is of recent onset or in patients who have remained stable over a long period (1 year or longer without current or previous clinical evidence of arteritis).
Patients should be monitored for symptoms or signs of GCA after treatment initiation because low-dose corticosteroids do not prevent progression of PMR to GCA. TAB should be considered if clinical signs of vasculitis develop, if clinical response is incomplete with low doses of prednisone (≤20 mg/d), and/or if the ESR or CRP remains elevated or rises despite symptom resolution on corticosteroid therapy. Low-dose corticosteroids do not appear to affect biopsy yield.
Gonzalez-Gay MA, Barros S, Lopez-Diaz MJ, Garcia-Porrua C, Sanchez-Andrade A, Llorca J. Giant cell arteritis: disease patterns of clinical presentation in a series of 240 patients. Medicine (Baltimore). 2005 Sep. 84(5):269-76. [Medline].
Gonzalez-Gay MA, Vazquez-Rodriguez TR, Lopez-Diaz MJ, Miranda-Filloy JA, Gonzalez-Juanatey C, Martin J, et al. Epidemiology of giant cell arteritis and polymyalgia rheumatica. Arthritis Rheum. 2009 Oct 15. 61(10):1454-61. [Medline].
Ghosh P, Borg FA, Dasgupta B. Current understanding and management of giant cell arteritis and polymyalgia rheumatica. Expert Rev Clin Immunol. 2010 Nov. 6(6):913-28. [Medline].
Caylor TL, Perkins A. Recognition and management of polymyalgia rheumatica and giant cell arteritis. Am Fam Physician. 2013 Nov 15. 88(10):676-84. [Medline].
Salvarani C, Cantini F, Hunder GG. Polymyalgia rheumatica and giant-cell arteritis. Lancet. 2008 Jul 19. 372(9634):234-45. [Medline].
Martinez-Taboada VM, Alvarez L, RuizSoto M, Marin-Vidalled MJ, Lopez-Hoyos M. Giant cell arteritis and polymyalgia rheumatica: role of cytokines in the pathogenesis and implications for treatment. Cytokine. 2008 Nov. 44(2):207-20. [Medline].
Gonzalez-Gay MA, Garcia-Porrua C, Miranda-Filloy JA, Martin J. Giant cell arteritis and polymyalgia rheumatica: pathophysiology and management. Drugs Aging. 2006. 23(8):627-49. [Medline].
Wilke WS. The role of imaging in polymyalgia rheumatica/giant cell arteritis. Skeletal Radiol. 2008 Sep. 37(9):779-83. [Medline].
Blockmans D. PET in vasculitis. Ann N Y Acad Sci. 2011 Jun. 1228:64-70. [Medline].
Salvarani C, Cantini F, Boiardi L, Hunder GG. Polymyalgia rheumatica and giant-cell arteritis. N Engl J Med. 2002 Jul 25. 347(4):261-71. [Medline].
Healey LA. Long-term follow-up of polymyalgia rheumatica: evidence for synovitis. Semin Arthritis Rheum. 1984 May. 13(4):322-8. [Medline].
Macchioni P, Boiardi L, Catanoso M, Pazzola G, Salvarani C. Performance of the new 2012 EULAR/ACR classification criteria for polymyalgia rheumatica: comparison with the previous criteria in a single-centre study. Ann Rheum Dis. 2013 Dec 2. [Medline].
Dasgupta B, Cimmino MA, Maradit-Kremers H, Schmidt WA, Schirmer M, Salvarani C, et al. 2012 provisional classification criteria for polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Ann Rheum Dis. 2012 Apr. 71(4):484-92. [Medline].
Salvarani C, Cantini F, Macchioni P, Olivieri I, Niccoli L, Padula A, et al. Distal musculoskeletal manifestations in polymyalgia rheumatica: a prospective followup study. Arthritis Rheum. 1998 Jul. 41(7):1221-6. [Medline].
[Guideline] Dejaco C, Singh YP, Perel P, et al. 2015 Recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Ann Rheum Dis. 2015 Oct. 74 (10):1799-807. [Medline]. [Full Text].
Cantini F, Salvarani C, Olivieri I, et al. Erythrocyte sedimentation rate and C-reactive protein in the evaluation of disease activity and severity in polymyalgia rheumatica: a prospective follow-up study. Semin Arthritis Rheum. 2000 Aug. 30(1):17-24. [Medline].
van der Geest KS, Abdulahad WH, Rutgers A, Horst G, Bijzet J, Arends S, et al. Serum markers associated with disease activity in giant cell arteritis and polymyalgia rheumatica. Rheumatology (Oxford). 2015 Aug. 54 (8):1397-402. [Medline].
Ochi J, Nozaki T, Okada M, Suyama Y, Kishimoto M, Akaike G, et al. MRI findings of the shoulder and hip joint in patients with polymyalgia rheumatica. Mod Rheumatol. 2015 Sep. 25 (5):761-7. [Medline].
Matteson EL, Maradit-Kremers H, Cimmino MA, Schmidt WA, Schirmer M, Salvarani C, et al. Patient-reported Outcomes in Polymyalgia Rheumatica. J Rheumatol. 2012 Apr. 39(4):795-803. [Medline].
Hernández-Rodríguez J, Cid MC, López-Soto A, Espigol-Frigolé G, Bosch X. Treatment of polymyalgia rheumatica: a systematic review. Arch Intern Med. 2009 Nov 9. 169(20):1839-50. [Medline].
Dejaco C, Duftner C, Cimmino MA, et al. Definition of remission and relapse in polymyalgia rheumatica: data from a literature search compared with a Delphi-based expert consensus. Ann Rheum Dis. 2011 Mar. 70(3):447-53. [Medline]. [Full Text].
Leeb BF, Bird HA, Nesher G, et al. EULAR response criteria for polymyalgia rheumatica: results of an initiative of the European Collaborating Polymyalgia Rheumatica Group (subcommittee of ESCISIT). Ann Rheum Dis. 2003 Dec. 62(12):1189-94. [Medline]. [Full Text].
Gabriel SE, Sunku J, Salvarani C, O'Fallon WM, Hunder GG. Adverse outcomes of antiinflammatory therapy among patients with polymyalgia rheumatica. Arthritis Rheum. 1997 Oct. 40(10):1873-8. [Medline].
van der Veen MJ, Dinant HJ, van Booma-Frankfort C, van Albada-Kuipers GA, Bijlsma JW. Can methotrexate be used as a steroid sparing agent in the treatment of polymyalgia rheumatica and giant cell arteritis?. Ann Rheum Dis. 1996 Apr. 55(4):218-23. [Medline]. [Full Text].
Caporali R, Cimmino MA, Ferraccioli G, Gerli R, Klersy C, Salvarani C, et al. Prednisone plus methotrexate for polymyalgia rheumatica: a randomized, double-blind, placebo-controlled trial. Ann Intern Med. 2004 Oct 5. 141(7):493-500. [Medline].
Ferraccioli G, Salaffi F, De Vita S, Casatta L, Bartoli E. Methotrexate in polymyalgia rheumatica: preliminary results of an open, randomized study. J Rheumatol. 1996 Apr. 23(4):624-8. [Medline].
Salvarani C, Macchioni P, Manzini C, et al. Infliximab plus prednisone or placebo plus prednisone for the initial treatment of polymyalgia rheumatica: a randomized trial. Ann Intern Med. 2007 May 1. 146(9):631-9. [Medline].
González-Gay MA, García-Porrúa C, Vázquez-Caruncho M, Dababneh A, Hajeer A, Ollier WE. The spectrum of polymyalgia rheumatica in northwestern Spain: incidence and analysis of variables associated with relapse in a 10 year study. J Rheumatol. 1999 Jun. 26(6):1326-32. [Medline].