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Polymyalgia Rheumatica Workup

  • Author: Ehab R Saad, MD, MA, FACP, FASN; Chief Editor: Herbert S Diamond, MD  more...
 
Updated: Aug 12, 2016
 

Approach Considerations

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[19] :

  • 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
  • Blood glucose
  • Serum creatinine
  • Liver function tests
  • Bone profile (including calcium and alkaline phosphatase)
  • Dipstick urinalysis

Additional studies to consider are as follows[19] :

  • Protein electrophoresis
  • Thyroid-stimulating hormone (TSH)
  • Creatine kinase
  • Vitamin D

If clinically indicated, tests such as the following may be considered to exclude alternative diagnoses[19] :

  • Antinuclear antibodies (ANA)
  • Anti–cytoplasmic neutrophil antibodies (ANCA)
  • Tuberculosis tests
  • Chest radiographs

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.[20] 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.[21]

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%).

Imaging studies

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.[22]

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.[23]

Symptomatic vasculitis in cranial and extracranial vessels is rare in PMR, but a study by Kermani et al demonstrated subclinical involvement in about one third of patients using ultrasonography and positron emission tomography (PET) scanning.[24] In a study of 18F-fluorodeoxyglucose (FDG)-PET/CT,  Wakura et al reported abnormal FDG accumulation at the entheses, suggesting that enthesitis may be a feature of PMR and that its presence can help differentiate.PMR from eldelry-onset rheumatoid arthritis.[25]

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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.

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Contributor Information and Disclosures
Author

Ehab R Saad, MD, MA, FACP, FASN Associate Professor, Department of Medicine, Medical College of Wisconsin

Ehab R Saad, MD, MA, FACP, FASN is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine, American Society of Nephrology, American Society of Transplantation, International Society for Peritoneal Dialysis, National Kidney Foundation

Disclosure: Nothing to disclose.

Coauthor(s)

Gloria Fioravanti, DO Clinical Assistant Professor, Program Director, Department of Internal Medicine, St 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, American Osteopathic Association

Disclosure: Nothing to disclose.

Allen Samuels, MD 

Allen Samuels, MD is a member of the following medical societies: American College of Rheumatology

Disclosure: Nothing to disclose.

Patricia J Papadopoulos, MD Staff Rheumatologist, MultiCare Rheumatology Specialists

Patricia J Papadopoulos, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, American College of Rheumatology

Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD Visiting Professor of Medicine, Division of Rheumatology, State University of New York Downstate Medical Center; 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, Phi Beta Kappa

Disclosure: Nothing to disclose.

Acknowledgements

The views expressed in this article are those of the authors and do not reflect the official policy of the Department of the Army, Department of Defense, or the US Government. Additionally, this publication does not imply the Federal or Department of Defense endorsement of any product.

Past Contributors

Michael S Beeson, MD, MBA, FACEP Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine and Pharmacy; Attending Faculty, Akron General Medical Center

Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Gino A Farina, MD, FACEP, FAAEM Associate Professor of Clinical Emergency Medicine, Albert Einstein College of Medicine; Program Director, Department of Emergency Medicine, Long Island Jewish Medical Center

Gino A Farina, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

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.

Kristine M Lohr, MD, MS Professor, Department of Internal Medicine, Center for the Advancement of Women's Health and Division of Rheumatology, Director, Rheumatology Training Program, University of Kentucky College of Medicine

Kristine M Lohr, MD, MS is a member of the following medical societies: American College of Physicians and American College of Rheumatology

Disclosure: Nothing to disclose.

Geofrey Nochimson, MD Consulting Staff, Department of Emergency Medicine, Sentara Careplex Hospital

Geofrey Nochimson, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Robert E O'Connor, MD, MPH Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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