|
Scand J Rheumatol. 2003;32(1):38-41. Related Articles, Links
Causes of death in polymyalgia rheumatica. A prospective longitudinal study of 315 cases and matched population controls.
Myklebust G, Wilsgaard T, Jacobsen BK, Gran JT.
Department of Rheumatology, Institute of Clinical Medicine, University of Tromso, Tromso, Norway. geirmund.myklebust@aassh.no
OBJECTIVE: To determine causes of death in patients with pure polymyalgia rheumatica (PMR) compared to matched population
controls. METHODS: In a population based study from 1987-1997, 315 patients were diagnosed with PMR. The patients were each
randomly assigned four population controls, totally 1,260 controls. The date and causes of death were identified from the
data files at Statistics Norway up to the end of 1997. RESULTS: A total of 65 cases (20.6%) with PMR died compared to 338
(26.8%) among the controls (mortality rate ratio (MRR) = 0.73, 95% CI 0.56-0.97, p = 0.03). No statistically significant difference
was found between patients and controls with regard to mortality from coronary heart disease or stroke (MRR=0.78, 95% CI 0.52-1.18),
cancer (MRR = 0.59, 95% CI 0.30-1.17), and other causes (MRR=0.75, 95% CI 0.48-1.17). CONCLUSION: The increased survival found
in patients with PMR could not be explained by reduction in any particular cause of death.
PMID: 12635944 [PubMed - indexed for MEDLINE]
Clin Exp Rheumatol. 2000 Jul-Aug;18(4 Suppl 20):S38-9. Related Articles, Links
Magnetic resonance imaging in the diagnosis of PMR.
Pavlica P, Barozzi L, Salvarani C, Cantini F, Olivieri I.
Servizio di Radiologia Albertoni, Policlinico S. Orsola-Malpighi, Bologna, Italy.
The cause of musculoskeletal symptoms in polymyalgia rheumatica (PMR) is not clearly defined because joint synovitis may
only partially explain the diffuse discomfort. MRI imaging of the shoulders, hip and extremities of patients with PMR has
been analyzed. MRI showed that subacromial and subdeltoid bursitis of the shoulders and iliopectineal bursitis and hip synovitis
are the predominant and most frequently observed lesions in active PMR. The inflammation of the bursae associated with glenohumeral
synovitis, bicipital tenosynovitis and hip synovitis may explain the diffuse discomfort and morning stiffness.
Publication Types:
Review
Review, Tutorial
PMID: 10948759 [PubMed - indexed for MEDLINE]
Clin Exp Rheumatol. 2000 Jul-Aug;18(4 Suppl 20):S4-5. Related Articles, Links
Classification/diagnostic criteria for GCA/PMR.
Hunder GG.
Department of Internal Medicine/Rheumatology, Mayo Clinic, Rochester, Minnesota 55901, USA.
Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are two common rheumatic diseases occurring in middle-aged
and older persons. Their cause is unknown and in neither is there a single specific diagnostic test. As a result a combination
of findings is needed for their diagnosis. The American College of Rheumatology has established criteria for the classification
of GCA using two methods. These criteria are best used in research studies involving patients with a diagnosis of vasculitis.
One method is based on the so-called traditional format. In this method the patient with vasculitis is classified as GCA if
he/she manifests any 3 among the list of 5 criteria selected. The second method, the tree format or recursive partitioning
method, starts with the clinical finding that best separates patients with GCA from others with vasculitis and then uses other
criteria successively to point to a final decision regarding the presence or absence of GCA. Diagnostic criteria for GCA have
not been formulated. Diagnostic criteria have been established for PMR by analysis of a series of patients, but in practice
most rheumatologists use criteria established informally by consensus.
Publication Types:
Review
Review, Tutorial
PMID: 10948747 [PubMed - indexed for MEDLINE]
J Rheumatol. 2000 Apr;27(4):953-7. Related Articles, Links
Comment in:
J Rheumatol. 2001 May;28(5):1197-8.
Lack of association between infection and onset of polymyalgia rheumatica.
Narvaez J, Clavaguera MT, Nolla-Sole JM, Valverde-Garcia J, Roig-Escofet D.
Department of Rheumatology, Hospital Principes de Espana, Ciudad Sanitaria y Universitaria de Bellvitge, Hospitalet de
Llobregat, Barcelona, Spain. jnarvaez@csub.scs.e
OBJECTIVE: The etiology of giant cell arteritis (GCA) is unknown, but its sudden onset and the wide variation in incidence
reported from various parts of the world suggest a genetic predisposition and/or the influence of environmental factors, such
as infectious agents or a seasonal effect. We analyzed the influence of season on GCA in our area over the period 1985-97,
as well as the possible association between infection and onset. METHODS: Retrospective study of 143 cases of GCA diagnosed
from 1985 to 1997. To evaluate seasonal variation in disease onset, the month of onset of the first symptoms related to GCA
was used to calculate season-specific incidence rates. Differences between season incidence rates were assessed by chi-square
test. To test for an association between infection and GCA onset, we considered only infections that occurred within 2 months
before the onset of disease. Because of the difficulty in determining whether an infection was present using only the clinical
and laboratory data recorded in patients' medical charts, we categorized the likelihood of patients having infection into
3 groups: no infection, probable infection, and definite infection. RESULTS: Between 1985 and 1997 (both years included),
a total of 143 patients (88 women, 55 men) were diagnosed with GCA. Of these, 85 had isolated polymyalgia rheumatica (PMR),
22 had temporal arteritis (TA) without PMR, and 36 had PMR associated with TA. The main clinical features in our population
were similar to those reported in other studies. We found no seasonal variation in disease onset during the 13 year period.
Moreover, only one (0.7%) of 143 patients was categorized as a probable infection, whereas definite infection was not observed
in any case. From these results, the hypothesis of an infectious cause for GCA seems highly improbable. CONCLUSION: We were
unable to observe a seasonal pattern or an association between infection and the onset of GCA.
PMID: 10782822 [PubMed - indexed for MEDLINE]
Rheum Dis Clin North Am. 1990 May;16(2):325-39. Related Articles, Links
Polymyalgia rheumatica.
Cohen MD, Ginsburg WW.
Division of Rheumatology and Internal Medicine, Mayo Clinic Jacksonville, Florida.
Polymyalgia rheumatica is a syndrome that occurs in the elderly and is characterized by pain and stiffness involving the
neck, the shoulder girdle, and the hip girdle. The aching should be present for greater than one month. Polymyalgia rheumatica
may be more common than reported. The etiology remains unknown. There is generally little found pathologically in this disease.
The physical examination is often not impressive. Synovitis may be a main contributing factor to many of the symptoms seen
in patients with polymyalgia rheumatica. Symptoms often do not correlate with physical findings. Polymyalgia rheumatica must
be differentiated from many conditions since the diagnosis remains entirely clinical. Osteoarthritis, flu syndromes, inflammatory
myopathies, fibromyalgia, and depression all have features that may mimic polymyalgia rheumatica. Malignancies and infections
may also be difficult to separate from polymyalgia rheumatica. Polymyalgia rheumatica may also be extremely difficult to differentiate
from seronegative rheumatoid arthritis in patients older than 50 years. Although some patients with polymyalgia rheumatica
have underlying giant cell arteritis, the majority apparently do not. The distinction between polymyalgia rheumatica and giant
cell arteritis cannot be made on the basis of laboratory studies and relies solely on clinical symptoms and physical findings.
Although nonsteroidal antiinflammatory medications may control symptoms in patients with mild disease, most patients with
polymyalgia rheumatica require low-dose corticosteroids. The tapering schedule for the corticosteroids is contingent upon
the response of symptoms and laboratory parameters. Polymyalgia rheumatica usually follows a benign course with almost complete
response to an adequate treatment program. Recently, there have been several studies suggesting that the course of polymyalgia
rheumatica may not be as short and simple as once proposed. Nevertheless, many patients may be completely weaned from corticosteroids.
Other agents have been used in this disease, but for the most part their use remains somewhat controversial. Patients must
be monitored carefully. Most patients do well, and treatment is effective.
PMID: 2189154 [PubMed - indexed for MEDLINE]
Autoimmun Rev. 2004 Jan;3(1):46-53. Related Articles, Links
Ann Rheum Dis. 2004 Jul;63(7):797-803. Related Articles, Links
Lack of radiological and clinical benefit over two years of low dose prednisolone for rheumatoid arthritis: results of
a randomised controlled trial.
Capell HA, Madhok R, Hunter JA, Porter D, Morrison E, Larkin J, Thomson EA, Hampson R, Poon FW.
Centre for Rheumatic Diseases, Glasgow Royal Infirmary, North Glasgow University NHS Trust, Castle St, Glasgow G40SF,
UK. Hilary.Capell@northglasgow.scot.nhs.uk
BACKGROUND: Evidence for disease modifying activity of low dose corticosteroid treatment in rheumatoid arthritis is contradictory.
Studies showing radiological benefit suggest that continued treatment is required to sustain the effect. OBJECTIVE: To evaluate
the effect of low dose oral prednisolone in early rheumatoid arthritis on disease activity over two years. DESIGN: Double
blind placebo controlled trial. METHODS: Patients with rheumatoid arthritis, duration <3 years (n = 167), were started
on a disease modifying antirheumatic drug (DMARD; sulphasalazine) and allocated by stratified randomisation to prednisolone
7 mg/day or placebo. Primary outcome measure was radiological damage, assessed by the modified Sharp method. Clinical benefit
was a secondary outcome. A proactive approach to identifying and treating corticosteroid adverse events was adopted. Patients
who discontinued sulphasalazine were offered an alternative DMARD. RESULTS: 90 of 257 patients eligible for the study refused
to participate (more women than men). Of those enrolled, 84% were seropositive for rheumatoid factor, median age 56 years,
median disease duration 12 months, female to male ratio 1.8:1. Prednisolone was given to 84 patients; of these 73% continued
prednisolone and 70% sulphasalazine at 2 years. Of the 83 patients on placebo, 80% continued placebo and 64% sulphasalazine
at 2 years. There were no significant differences in radiological score or clinical and laboratory measures at 0 and 2 years.
CONCLUSIONS: Low dose prednisolone conferred no radiological or clinical benefit on patients maintained on a DMARD over two
years. Low dose corticosteroids have no role in the routine management of rheumatoid arthritis treated with conventional disease
modifying drugs.
PMID: 15194574 [PubMed - in process]
Immunopathways in giant cell arteritis and polymyalgia rheumatica.
Weyand CM, Ma-Krupa W, Goronzy JJ.
Department of Immunology, Guggenheim 401, Mayo Clinic, Rochester, MN, USA. weyand.cornelia@may.edu
Giant cell arteritis (GCA), a vasculitis that targets medium- and large-size arteries, is ranked as a medical emergency
because of its potential to cause blindness and stroke. The typical lesions, granulomas in the vessel wall, are formed by
IFN-gamma-producing CD4+ T cells and macrophages. CD4+ T cells undergo in situ activation in the adventitia, where they interact
with indigenous dendritic cells. Tissue injury is mediated by several distinct sets of macrophages that are committed to diverse
effector functions. The dominant tissue injury in the media results from oxidative stress and leads to smooth muscle cell
apoptosis and nitration of endothelial cells. Macrophage-derived growth factors are instrumental in driving the response-to-injury
program of the artery that causes intimal hyperplasia and vessel occlusion. Clinical manifestations are those of tissue ischemia
or a syndrome of exuberant systemic inflammation. The vascular and the systemic components of GCA contribute differentially
to the disease, leading to distinct clinical phenotypes of this arteritis. Immunologically most interesting is polymyalgia
rheumatica, in which the systemic component is combined with aborted vasculitis, suggesting a role for artery-specific tolerance
mechanisms.
PMID: 14871649 [PubMed - in process]
Rheumatology (Oxford). 2004 Apr;43(4):486-90. Epub 2004 Jan 13. Related Articles, Links
Bone turnover in untreated polymyalgia rheumatica.
Barnes TC, Daroszewska A, Fraser WD, Bucknall RC.
Department of Rheumatology, Royal Liverpool University Hospital, Liverpool, UK. tbarnes@doctors.org.uk
BACKGROUND: Polymyalgia rheumatica (PMR) is a common condition in the elderly. A previous study demonstrated that it is
associated with an increase in bone resorption. This effect was ameliorated by steroids, implying that inflammation is the
cause of increased bone resorption and that this can be reduced by steroids. This is in keeping with accumulating evidence
that systemic inflammation is associated with bone resorption and bone loss. We studied bone formation and resorption markers
in 53 patients with PMR prior to any therapeutic intervention. METHODS: Bone resorption was measured by estimating urinary
free pyridinoline (fPYD) and deoxypyridinoline (fDPD). Bone formation was estimated by measuring serum concentrations of procollagen
type 1 N-terminal propeptide (P1NP). Disease activity was assessed using inflammatory markers (erythrocyte sedimentation rate
and C-reactive protein). Patients had a baseline dual-energy X-ray absorptiometer scan to assess bone mineral density. RESULTS:
Bone resorption markers were significantly increased and bone formation markers significantly decreased in PMR patients prior
to treatment, compared with a control population matched for gender and age. CONCLUSIONS: This implies that bone turnover
is uncoupled in PMR. This may lead to a decrease in skeletal mass in the long term due to the disease process alone. However,
no significant loss of bone mineral density was detected. It is possible that, due to the acute onset of PMR, increased bone
resorption is not present long enough to result in a detectable decrease in bone mineral density. The effects of steroid treatment
on bone metabolism and the subsequent long-term outcome need to be investigated.
PMID: 14722347 [PubMed - in process] Tidsskr Nor Laegeforen. 2003 Dec 4;123(23):3387. Related Articles, Links
[Treatment and diagnosis of polymyalgia rheumatica and temporal arteritis]
[Article in Norwegian]
Gran JT.
Revmatologisk avdeling, Rikshospitalet, 0027 Oslo. jan.tore.gran@rikshospitalet.no
BACKGROUND: Studies of polymyalgia rheumatica and temporal arteritis have shown that a low initial dose of oral corticosteroids
should be preferred. It is, however, uncertain whether or not the suggested recommendations have been implemented by practising
physicians. MATERIAL AND METHODS: Questionnaires were mailed to members of the Norwegian association for patients with polymyalgia
rheumatica or temporal arteritis. RESULTS: The average initial dose of prednisolone in polymyalgia rheumatica was 35 mg; 51
of 62 patients were given a starting dose exceeding 15 mg. INTERPRETATION: The recommended low initial dose of prednisolone
has still been not implemented by the majority of general practitioners and rheumatologists.
PMID: 14713975 [PubMed - indexed for MEDLINE]
J Rheumatol. 2004 Jan;31(1):120-4. Related Articles, Links
Fat suppression magnetic resonance imaging in shoulders of patients with polymyalgia rheumatica.
Cantini F, Salvarani C, Niccoli L, Nannini C, Boiardi L, Padula A, Olivieri I, Valentino M, Barozzi L.
2nd Divisione di Medicina, Unita Reumatologica, Ospedale di Prato, Bologna, Italy. fcantini@conmet.it
OBJECTIVE: To evaluate the sites of inflammatory process in the shoulders of patients with polymyalgia rheumatica (PMR)
using fat suppressed magnetic resonance imaging (MRI). METHODS: Six consecutive, untreated new patients with PMR were investigated.
Five patients with early rheumatoid arthritis (RA) and 4 patients with early psoriatic arthritis (PsA) with bilateral shoulder
symptoms served as a control group. Bilateral shoulder fat-suppressed MRI sequences were performed in all patients and controls.
We evaluated the presence of joint synovitis, bursitis, tenosynovitis, and bone and soft tissue edema. RESULTS: Bilateral
subacromial/subdeltoid bursitis was found in all patients with PMR, in 1/5 (20%) patients with RA (p < 0.05), and in none
with PsA (p < 0.02). Glenohumeral synovitis was present in all case and controls. Biceps tenosynovitis was observed in
4/6 (67%) patients with PMR, in 4/5 (80%) with RA (not significant, NS), and in all 4 patients with PsA (NS). No evidence
of bone edema adjacent to the joint capsule and entheseal insertions or in the soft tissues was present in either cases or
controls. CONCLUSION: The absence of extracapsular abnormalities in the early shoulder disease of PMR does not confirm the
hypothesis of a capsular-based disorder.
PMID: 14705230 [PubMed - indexed for MEDLINE] Curr Opin Rheumatol. 2004 Jan;16(1):25-30. Related Articles, Links
Giant cell arteritis: strategies in diagnosis and treatment.
Nordborg E, Nordborg C.
Institute of Rheumatology, Huddinge University Hospital, Stockholm, Sweden. elisabeth.norborg@hs.se
PURPOSE OF REVIEW: This review summarizes current diagnostic assessments and therapeutic strategies in giant cell arteritis.
Giant cell arteritis or temporal arteritis is a chronic vasculitis of large and medium-size vessels. Concurrent symptoms of
proximal muscular ache and morning stiffness, polymyalgia rheumatica, are commonly seen. Recent investigations support the
contention that polymyalgia rheumatica and temporal arteritis are two different expressions of the same underlying vasculitic
disorder. RECENT FINDINGS: The symptomatology of giant cell arteritis is quite varying. Recently a frequent occurrence of
audiovestibular manifestations was demonstrated, which should be actively searched for in the clinical investigation. Although
color Doppler ultrasound, MRI, and positron emission tomography have illustrated the widespread nature of giant cell arteritis,
none of these techniques may currently replace temporal artery biopsy. Biopsy of the superficial temporal artery is a safe
and simple procedure, and remains the gold standard for the diagnosis of giant cell arteritis. The importance of long biopsies
and meticulous histologic examination using sub-serial sectioning is emphasized. Numerous recent publications confirm the
low diagnostic yield of a second, contralateral biopsy. Corticosteroids remain the cornerstone in the treatment of giant cell
arteritis. Although steroid treatment promptly eliminates symptoms of systemic inflammation, its effect on inflammatory morphology
is delayed. Consequently, there is a need for new therapeutic strategies. The potential role of aspirin has recently been
implicated.
Publication Types:
Review
Review, Tutorial
PMID: 14673385 [PubMed - indexed for MEDLINE]
Drugs. 1987 Mar;33(3):280-7. Related Articles, Links
Polymyalgia rheumatica. Its correct diagnosis and treatment.
Hart FD.
Giant cell (temporal) arteritis was first described by Horton and colleagues in 1932, and polymyalgia rheumatica in 1957
by Barber who suggested this title for an entity resembling, but distinct from, rheumatoid arthritis of unknown aetiology
in the elderly. Arteritic features were sufficiently common in polymyalgia rheumatica to suggest an arteriopathy as a cause,
further evidence of this being the change from the clinical picture picture of polymyalgia rheumatica to giant cell arteritis
and vice versa in many patients such that the alternative title polymyalgia arteritica was suggested. The clinical picture
of polymyalgia rheumatica is that of an elderly patient, more often female than male, usually over 60 years of age, with painful
stiffness in the girdle joints and muscles of the shoulders and hips, but seldom with findings in peripheral or intermediate
joints. The painful stiffness in the shoulders, hips and thighs is worse in the early morning. An erythrocyte sedimentation
rate over 50mm in 1 hour is usual, and there is a rapid and dramatic response to small doses of corticosteroids (around 10mg
prednisolone daily). Arteritic and axial arthritic features have been noted by different authors in different ratios, the
disorder gradually abating naturally over periods varying from several months to 7 to 10 years. Deaths, when they occur in
this elderly group of patients, have usually been unrelated to the disease or its treatment, but osteoporotic vertebral crush
fractures are not uncommon. Partial or complete blindness may occur in patients with either giant cell arteritis or polymyalgia
rheumatica, often appearing rapidly after cessation of corticosteroid therapy or rapid reduction of dosage.(ABSTRACT TRUNCATED
AT 250 WORDS)
Publication Types:
Review
PMID: 3552598 [PubMed - indexed for MEDLINE]
Ann Rheum Dis. 1991 Sep;50(9):619-22. Related Articles, Links
Polymyalgia rheumatica and rheumatoid arthritis of the elderly: a clinical, laboratory, and scintigraphic comparison.
Hantzschel H, Bird HA, Seidel W, Kruger W, Neumann G, Schneider G, Wright V.
Division of Rheumatology, Karl-Marx-University, Leipzig, Germany.
Clinical, laboratory, and scintigraphic features of 16 patients with polymyalgia rheumatica and 23 patients matched for
age presenting with classical or definite rheumatoid arthritis (American Rheumatism Association 1958 criteria) of the elderly
were compared in order to define features that might distinguish between these two syndromes. The sensitivity of proposed
diagnostic criteria for polymyalgia rheumatica was always higher in the group with polymyalgia rheumatica, though only significantly
so for morning stiffness. A comparison of 27 different laboratory features showed few significant differences between the
diseases, though correlation between laboratory variables within each of the disease groups differed, perhaps suggesting a
fundamental pathogenetic difference between them. Scintigraphy of the shoulder joint proved of no value in differential diagnosis.
It was concluded that polymyalgia rheumatica and rheumatoid arthritis of the elderly are probably discrete clinical entities.
Bilateral upper arm tenderness, lack of positive rheumatoid factor, and a normal caeruloplasmin are the most valuable features
for distinguishing polymyalgia rheumatica from rheumatoid arthritis of the elderly.
PMID: 1929583 [PubMed - indexed for MEDLINE] Intern Med. 2002 Aug;41(8):657-60. Related Articles, Links
Comment in:
Intern Med. 2002 Aug;41(8):605.
Elderly onset rheumatoid arthritis complicated by polymyalgia rheumatica.
Iwadate H, Takeda I, Kanno T, Kasukawa R.
Division of Rheumatology, Ohta Nishinouchi Hospital, Koriyama.
We report herein the case of a 70-year-old patient with elderly onset rheumatoid arthritis associated with severe muscle
pain in shoulder and pelvic girdle. The patient revealed erosive polyarthritis with high titers of rheumatoid factor. Muscle
pain started one month after the onset of rheumatoid arthritis followed by muscle weakness and muscle atrophy. Synovial effusion
and edema in the soft tissue outside of the articular capsule in the knee joint were confirmed ultrasonographically. Administration
of prednisolone at 20 mg/day dramatically abolished the muscular manifestations. The coexistence of an early stage of elderly
onset rheumatoid arthritis and polymyalgia rheumatica was considered due to the presence of seropositive erosive arthritis
and severe muscle manifestations at the same time.
Publication Types:
Case Reports
PMID: 12211537 [PubMed - indexed for MEDLINE]
Rheumatology (Oxford). 2004 May;43(5):655-7. Epub 2004 Feb 17. Related Articles, Links
Clinical utility of anti-CCP antibodies in the differential diagnosis of elderly-onset rheumatoid arthritis and polymyalgia
rheumatica.
Lopez-Hoyos M, Ruiz de Alegria C, Blanco R, Crespo J, Pena M, Rodriguez-Valverde V, Martinez-Taboada VM.
Immunology Service, Hospital Universitario Marques de Valdecilla, Facultad de Medicina, Universidad de Cantabria, Santander,
Spain.
BACKGROUND: In a significant number of patients the differential diagnosis between elderly-onset rheumatoid arthritis
(EORA) and polymyalgia rheumatica (PMR) is very difficult because of the lack of specific serum markers. Anti-cyclic citrullinated
peptide antibodies (anti-CCP Abs) have recently been shown to be highly specific for rheumatoid arthritis (RA). This is the
first study addressing the utility of these antibodies in the differential diagnosis between EORA and PMR. METHODS: Serum
samples from 57 EORA patients and 49 PMR patients were studied for the presence of anti-CCP Abs and rheumatoid factor (RF).
As controls, samples from 41 RA patients (age at onset <60 yr) and 24 aged healthy subjects were analysed. RESULTS: Sixty-five
per cent of EORA patients had anti-CCP Abs, whereas none of the PMR patients or the aged healthy subjects was positive for
those antibodies. Ten of the EORA patients started with polymyalgic symptoms and two of them were positive for anti-CCP Abs.
Interestingly, there was a significant correlation between anti-CCP Abs and RF in EORA but not in young RA patients. CONCLUSIONS:
The presence of anti-CCP Abs in a patient with clinical symptoms of PMR must be interpreted as highly suggestive of EORA.
PMID: 14970400 [PubMed - in process]
Ann Rheum Dis. 2001 Nov;60(11):1021-4. Related Articles, Links
Presenting features of polymyalgia rheumatica (PMR) and rheumatoid arthritis with PMR-like onset: a prospective study.
Caporali R, Montecucco C, Epis O, Bobbio-Pallavicini F, Maio T, Cimmino MA.
Cattedra di Reumatologia, Universita di Pavia, Pavia, Italy. caporali@smatteo.pv.it
OBJECTIVE: To evaluate in a prospective study whether patients with polymyalgia rheumatica (PMR) and patients with rheumatoid
arthritis (RA) with PMR-like onset show distinctive clinical and laboratory features. METHODS: A cohort of 116 consecutive
patients with bilateral girdle pain for at least one month and raised erythrocyte sedimentation rate (ESR) was studied and
followed up for 12 months. Laboratory tests included determination of ESR, IgM rheumatoid factor, haemoglobin, white blood
cell count, platelet count, percentage of CD8 lymphocytes, serum aspartate aminotransferase, alanine aminotransferase, alkaline
phosphatase, and glutamyltransferase concentrations. RESULTS: At first examination, RA was diagnosed in 22/116 (19%) patients
and PMR in 94 (81%) patients. During the follow up period, 19 additional patients developed RA, and the diagnosis of PMR was
confirmed in 65 (56%) patients at the end of the study. Of the clinical and laboratory features, only the presence of peripheral
synovitis could differentiate patients who will develop RA from those with "true" PMR, but the positive predictive
value of this feature was poor. CONCLUSION: At present, there are no clinical or routine laboratory features allowing early
differentiation between PMR and RA with PMR-like onset.
PMID: 11602472 [PubMed - indexed for MEDLINE]
Ryumachi. 1997 Oct;37(5):696-701. Related Articles, Links
[A case of polymyalgia rheumatica with excessive increase of rheumatoid factor]
[Article in Japanese]
Hoshina H.
Department of Internal Medicine, Hoshina Hospital, Fukushima.
A 76 year-old woman suffered from muscle pain and stiffness of acute onset in her shoulder girdle and pelvic girdle, which
were followed by mild left temporal headache and transient arthralgia. Neither joint swelling nor sicca symptom was observed.
Laboratory data showed high ESR (128 mm/hr), positive CRP (12.9 mg/dl), increased fibrinogen (485 mg/dl) and high titer of
rheumatoid factor (RF) (RAHA x 640). Other autoantibodies examined were negative. Muscle enzymes and electromyogram were within
normal limits. Joint X ray didn't reveal the finding suggestive of RA. After the treatment with prednisolone (PSL) 15 mg/day,
clinical symptoms and laboratory data improved dramatically. Though she had excessive increase of RF (RAHA x 10240) during
therapy, no recurrence of articular symptoms were recognized. She continues to be well with PSL 5 mg/day after 1 year 5 months
from onset. As for polymyalgia rheumatica (PMR) followed by RA, the appearance or exacerbation of arthritis corresponding
to the elevation of RF occurred in all previously reported 17 cases. Recurrence of arthralgia corresponding to the elevation
of RF was not recognized in this case. In addition, Hunder et al reported that PMR with little or no observable joint swelling
after several weeks of symptoms is unlikely to develope RA. Therefore, it is speculated that this case in unlikely to develope
RA and assessment of arthritis corresponding to the elevation of RF is important to differentiate PMR and elderly-onset RA.
This case of PMR is the 5th case with excessive increase of RF in Japan.
Publication Types:
Case Reports
Review
Review of Reported Cases
PMID: 9396372 [PubMed - indexed for MEDLINE]
Am J Med. 1996 Feb 26;100(2A):16S-23S. Related Articles, Links
Selection and use of laboratory tests in the rheumatic diseases.
Barland P, Lipstein E.
Division of Rheumatology, Montefiore Medical Center, Bronx, New York 10467, USA.
Current clinical practice relies heavily on serologic testing for the prompt and accurate diagnosis of rheumatic diseases.
Serologic testing should be used to support the findings of the history and physical examination, and, in some cases, to monitor
disease activity. The inflammation of the rheumatoid arthritis (RA), polymyalgia rheumatica, and temporal arteritis can be
assessed by the erythrocyte sedimentation rate (ESR). The C-reactive protein (CRP, an acute-phase protein) test, which is
newer, correlates more closely than ESR with clinical and radiographic parameters of RA inflammation. The rheumatoid factor
test is nonspecific as a screen for RA, and some argue that it is also insensitive (accounting for the existence of "seronegative"
RA). High titers of rheumatoid factor are associated with progressive joint inflammation, erosions, and disability. Antinuclear
antibody (ANA) tests are likewise nonspecific, but ANA subtypes have proved to be very specific for subtypes of connective
tissue diseases. Examples are the presence of anti-DNA antibody in systemic lupus erythematosus; anti-centromere antibody
in the CREST syndrome of scleroderma; anti-histone antibody in drug-induced lupus; and anti-Ro antibody in neonatal lupus.
Anti-neutrophil cytoplasmic antibodies (ANCA) are a new group of auto-antibodies seen in Wegener's granulomatosis. Brief case
descriptions are presented to illustrate appropriate selection of these antibody tests as well as tests for antiphospholipid
antibodies and cryoglobulins.
PMID: 8604722 [PubMed - indexed for MEDLINE]
Practitioner. 1975 Dec;215(1290):763-6. Related Articles, Links
Visual complications of polymyalgia rheumatica (polymyalgia arteritica).
Hart FD.
Four case histories are reported in which patients with polymyalgia rheumatica (polymyalgia arteritic) developed evidence
of cranial arteritis (in one case two years and in one six months) following withdrawal of steroid therapy after apparent
cure. In three cases partial or complete loss of sight has resulted. Steroid therapy should not only be introduced rapidly
at appropriate dosage levels as soon as the diagnosis is made but should not be reduced or discontinued prematurely.
Publication Types:
Case Reports
PMID: 1223854 [PubMed - indexed for MEDLINE]
Clin Neurol Neurosurg. 2002 Jan;104(1):20-9. Related Articles, Links
Polymyalgia rheumatica (PMR): clinical, laboratory, and immunofluorescence studies in 13 patients.
Shintani S, Shiigai T, Matsui Y.
Department of Neurology, Toride Kyodo General Hospital, 2-1-1 Hongoh, Toride City, 302-0022, Ibaraki, Japan. dw4s-sntn@asahi-net.or.jp
Thirteen elderly patients with polymyalgia rheumatica (PMR) are presented. The clinical and laboratory findings suggest
that many progressive symptoms are due to the non-specific inflammatory changes in various organs of the body, especially
in muscles and joints. An immunofluorescence study of muscle biopsy specimens revealed IgG, IgA, and fibrinogen deposits in
the perifascicular area of the perimysium. This finding suggests that immune complexes play a role in the pathogenesis of
this condition and that the pathophysiology of PMR is an interstitial inflammatory process. We think that the inflammatory
findings affecting the interstitial tissue of muscles in the immunofluorescence study are relatively specific to PMR, and
will be affected by steroid treatment.
PMID: 11792472 [PubMed - indexed for MEDLINE]
Homeopathy. 2004 Jan;93(1):12-6. Related Articles, Links
Action of Causticum in inflammatory models.
Prado Neto Jde A, Perazzo FF, Cardoso LG, Bonamin LV, Carvalho JC.
Faculdade de Ciencias da Saude de Sao Paulo, Instituto Brasileiro de Estudos Homeopaticos, R. Bartolomeu de Gusmao, 86,
CEP 04111-020, S. Paulo, SP, Brazil.
The anti-inflammatory effect of Causticum was evaluated using acute and chronic inflammatory models in vivo. The administration
of concentrated Causticum solution into the hind paw of rats produced an inflammatory reaction with oedema formation within
the first hour, showing that Causticum acts as an oedematogenic agent. Carrageenin induced rat paw oedema was significantly
inhibited (P<0.05) in the group treated with Causticum 30cH solution compared to control. Groups treated with potentized
Causticum (6cH, 12cH, 30cH and 200cH), showed significant inhibition (P<0.05) of the inflammation pre-induced by carrageenin.
However pre-treatment with Causticum 30cH for 6 days (0.5 ml, daily) did not significantly inhibit granulation using an implantation
method.
PMID: 14960097 [PubMed - indexed for MEDLINE]
Am J Chin Med. 2003;31(5):809-15. Related Articles, Links
Retrospective survey on therapeutic efficacy of Qigong in Korea.
Lee MS, Hong SS, Lim HJ, Kim HJ, Woo WH, Moon SR.
Professional Graduate School of Oriental Medicine, Institute of Medical Science, Wonkwang University, Korea.
Qigong is a complementary intervention for preventing and curing disease, and protecting and improving health through
regulation of body and mind. Recently, we have been studying the psychoneuroimmunological effects of Qigong on the promotion
of health. However, there are not many studies on the therapeutic efficacy of Qigong on various symptoms in Korea, hence the
need to survey the clinical efficacy of Qigong. To evaluate the impact of Qigong in health care we categorized its effectiveness
on the basis of ten years of subjects' memoranda. Among the 768 subjects, the motivation for doing Qigong was mostly to attend
to health problems (81.5%), and males were more likely to use Qigong than females. The most improved symptoms were associated
with psychological and musculoskeletal problems. Furthermore 66.9% of subjects reported improvements of perceived physical
health and 40.3% of perceived psychological health. Other symptoms reduced by Qigong were pain (43.1%), fatigue (22.1%), and
insomnia (8.7%). Wound healing was also surveyed (n = 332), and 84% of respondents reported improvement in recovery time,
66.6% reported reduced inflammation after Qigong and 50.3% reported no scarring as compared to before. In addition, 59.9%
of respondents reported an increase in resistance to the common cold after four months of Qigong. The limitation of the study
is that it is a retrospective survey on the basis of trainees' experiences of Qigong. Although this may constitute a potential
bias, the study despite its limitations does provide precious empirical evidence of the effectiveness of Qigong.
PMID: 14696684 [PubMed - indexed for MEDLINE]
Mediators Inflamm. 2003 Apr;12(2):59-69. Related Articles, Links
Anti-inflammatory actions of acupuncture.
Zijlstra FJ, van den Berg-de Lange I, Huygen FJ, Klein J.
Department of Anesthesiology, Erasmus Medical Centre, Centre location, Rotterdam, The Netherlands. f.zijlstra@erasmusmc.nl
Acupuncture has a beneficial effect when treating many diseases and painful conditions, and therefore is thought to be
useful as a complementary therapy or to replace generally accepted pharmacological intervention. The attributive effect of
acupuncture has been investigated in inflammatory diseases, including asthma, rhinitis, inflammatory bowel disease, rheumatoid
arthritis, epicondylitis, complex regional pain syndrome type 1 and vasculitis. Large randomised trials demonstrating the
immediate and sustained effect of acupuncture are missing. Mechanisms underlying the ascribed immunosuppressive actions of
acupuncture are reviewed in this communication. The acupuncture-controlled release of neuropeptides from nerve endings and
subsequent vasodilative and anti-inflammatory effects through calcitonine gene-related peptide is hypothesised. The complex
interactions with substance P, the analgesic contribution of beta-endorphin and the balance between cell-specific pro-inflammatory
and anti-inflammatory cytokines tumour necrosis factor-alpha and interleukin-10 are discussed.
Publication Types:
Review
Review Literature
PMID: 12775355 [PubMed - indexed for MEDLINE]
J Rheumatol. 2003 Nov;30(11):2338-43. Related Articles, Links
Comment in:
J Rheumatol. 2003 Nov;30(11):2302-5.
Abnormal levels of serum dehydroepiandrosterone, estrone, and estradiol in men with rheumatoid arthritis: high correlation
between serum estradiol and current degree of inflammation.
Tengstrand B, Carlstrom K, Fellander-Tsai L, Hafstrom I.
Department of Rheumatology, R92, Huddinge University Hospital, 141 86 Stockholm, Sweden. birgitta.tengstrand@hs.se
OBJECTIVE: Men with rheumatoid arthritis (RA) have a higher than normal frequency of low testosterone levels, but not
much is known about other sex hormones. We investigated serum levels of estradiol, estrone, and the adrenal androgen dehydroepiandrosterone
(DHEAS) in men with RA and evaluated the association of various disease variables with these sex hormones. METHODS: Inflammatory
activity, measured as disease activity score including 28 joints (Disease Activity Score 28), and degree of disability, measured
with the Health Assessment Questionnaire, were estimated in 101 men with RA. Presence of erosions, rheumatoid factor (RF),
smoking habits, and body mass index were recorded. DHEAS (not measured in patients taking glucocorticoids), estradiol, and
estrone were measured in patients and in healthy controls. RESULTS: DHEAS and estrone concentrations were lower and estradiol
was higher in patients compared with healthy controls. DHEAS differed between RF positive and RF negative patients. Estrone
did not correlate with any disease variable, whereas estradiol correlated strongly and positively with all measured indices
of inflammation. CONCLUSION: Men with RA had aberrations in all sex hormones analyzed, although only estradiol consistently
correlated with inflammation. The high levels of estradiol may have positive implications for bone health. The low levels
of estrone and DHEAS may depend on a shift in the adrenal steroidogenesis towards the glucocorticoid pathway, whereas increased
conversion of estrone to estradiol seemed to be the cause of the high estradiol levels.
PMID: 14677174 [PubMed - indexed for MEDLINE]
Ann N Y Acad Sci. 2002 Jun;966:131-42. Related Articles, Links
Androgens and estrogens modulate the immune and inflammatory responses in rheumatoid arthritis.
Cutolo M, Seriolo B, Villaggio B, Pizzorni C, Craviotto C, Sulli A.
Laboratory and Division of Rheumatology, Department of Internal Medicine and Medical Specialities, University of Genova,
Genova, Italy. mcutolo@unige.it
Generally, androgens exert suppressive effects on both humoral and cellular immune responses and seem to represent natural
anti-inflammatory hormones; in contrast, estrogens exert immunoenhancing activities, at least on humoral immune response.
Low levels of gonadal androgens (testosterone/dihydrotestosterone) and adrenal androgens (dehydroepiandrosterone and its sulfate),
as well as lower androgen/estrogen ratios, have been detected in body fluids (that is, blood, synovial fluid, smears, salivary)
of both male and female rheumatoid arthritis patients, supporting the possibility of a pathogenic role for the decreased levels
of the immune-suppressive androgens. Several physiological, pathological, and therapeutic conditions may change the sex hormone
milieu and/or peripheral conversion, including the menstrual cycle, pregnancy, the postpartum period, menopause, chronic stress,
and inflammatory cytokines, as well as use of corticosteroids, oral contraceptives, and steroid hormonal replacements, inducing
altered androgen/estrogen ratios and related effects. Therefore, sex hormone balance is still a crucial factor in the regulation
of immune and inflammatory responses, and the therapeutical modulation of this balance should represent part of advanced biological
treatments for rheumatoid arthritis and other autoimmune rheumatic diseases.
Publication Types:
Review
Review, Tutorial
PMID: 12114267 [PubMed - indexed for MEDLINE]
Ann N Y Acad Sci. 2002 Jun;966:13-9. Related Articles, Links
Neuroimmunoendocrinology of the rheumatic diseases: past, present, and future.
Wilder RL.
Department of Clinical Development, MedImmune, Inc., Gaithersburg, Maryland 20878, USA. wilderr@medimmune.com
Adaptation to stressful stimuli, maintenance of homeostasis, and ultimately, survival require bidirectional feedback communication
among components of the stress response and immune and endocrine systems. Substantial progress has been made in delineating
molecular, cellular, and systemic physiologic mechanisms underlying this communication, particularly mechanisms that target
the immune system. For example, our understanding of the immunomodulatory activities of numerous neuroendocrine mediators,
such as cortisol, estrogen, testosterone, DHEA, catecholamines, corticotropin-releasing hormone, and adenosine, has advanced
substantially. Substantial progress has also been made in defining how abnormalities involving these factors may contribute
to the initiation, progression, and severity of autoimmune rheumatic diseases, particularly rheumatoid arthritis (RA) and
systemic lupus erythematosus (SLE). For RA, the available data support the view that inflammatory and immune system inhibitory
mechanisms, involving the hypothalamic-pituitary-adrenal (HPA) axis and sympathetic nervous system are deficient. Age, gender,
and reproductive status acting, in part, through gonadal hormonal effects on disease susceptibility genes also appear likely
to modulate the inhibitory stress response systems and immune function. Animal model data also have provided direct evidence
that many autoimmune disease regulatory genes are gender influenced. For SLE, a growing body of recent data indicates that
estrogens and androgens exert contrasting effects on B-lymphocytes (i.e., estrogens enhance and testosterone suppresses autoantibody
production). These observations provide potential new insights into SLE pathogenesis and gender differences in prevalence.
Continued investigation will refine our understanding of these observations and will uncover even more extensive interactions
of the nervous, immune, and endocrine systems. Moreover, it is highly likely that improved understanding of these interactions
will translate into improved therapy for the rheumatic diseases.
Publication Types:
Review
Review, Tutorial
PMID: 12114254 [PubMed - indexed for MEDLINE]
Arthritis Res. 2001;3(6):362-7. Epub 2001 Sep 12. Related Articles, Links
High frequency of association of rheumatic/autoimmune diseases and untreated male hypogonadism with severe testicular
dysfunction.
Jimenez-Balderas FJ, Tapia-Serrano R, Fonseca ME, Arellano J, Beltran A, Yanez P, Camargo-Coronel A, Fraga A.
Departmento de Reumatologia, Hospital de Especialidades, Centro Medico Nacional SXXI IMSS Mexico, DF, Mexico. fjjimenez19@yahoo.com
Our goal in the present work was to determine whether male patients with untreated hypogonadism have an increased risk
of developing rheumatic/autoimmune disease (RAD), and, if so, whether there is a relation to the type of hypogonadism. We
carried out neuroendocrine, genetic, and rheumatologic investigations in 13 such patients and 10 healthy male 46,XY normogonadic
control subjects. Age and body mass index were similar in the two groups. Nine of the 13 patients had hypergonadotropic hypogonadism
(five of whom had Klinefelter's syndrome [karyotype 47,XXY]) and 4 of the 13 had hypogonadotropic hypogonadism (46,XY). Of
these last four, two had Kallmann's syndrome and two had idiopathic cryptorchidism.Eight (61%) of the 13 patients studied
had RADs unrelated to the etiology of their hypogonadism. Of these, four had ankylosing spondylitis and histocompatibility
B27 antigen, two had systemic lupus erythematosus (in one case associated with antiphospholipids), one had juvenile rheumatoid
arthritis, and one had juvenile dermatomyositis. In comparison with the low frequencies of RADs in the general population
(about 0.83%, including systemic lupus erythematosus, 0.03%; dermatomyositis, 0.04%; juvenile rheumatoid arthritis, 0.03%;
ankylosing spondylitis, 0.01%; rheumatoid arthritis, 0.62%; and other RAD, 0.1%), there were surprisingly high frequencies
of such disorders in this small group of patients with untreated hypogonadism (P < 0.001) and very low serum testosterone
levels (P = 0.0005). The presence of RADs in these patients was independent of the etiology of their hypogonadism and was
associated with marked gonadal failure with very low testosterone levels.
PMID: 11714390 [PubMed - indexed for MEDLINE]
Rheumatology (Oxford). 2002 Mar;41(3):285-9. Related Articles, Links
Bioavailable testosterone in men with rheumatoid arthritis-high frequency of hypogonadism.
Tengstrand B, Carlstrom K, Hafstrom I.
Department of Rheumatology, Karolinska Institutet at Huddinge University Hospital, 141 86 Stockholm, Sweden.
OBJECTIVES: To study bioavailable testosterone (T) in men with rheumatoid arthritis (RA) by determining non-sex hormone-binding
globulin (SHBG)-bound T (NST) under standardized conditions and to investigate if NST is related to disease variables. METHODS:
Basal serum concentrations of total T, SHBG and luteinizing hormone (LH) were measured in 104 men with RA, and the levels
of NST as well as the quotient T/SHBG were calculated. The data were compared with those of 99 age-matched healthy men. The
results were analysed separately for the age groups 30-49, 50-59 and 60-69 yr. RESULTS: The RA men had lower NST levels than
the healthy men in all age groups. T levels and the T/SHBG ratio were lower only in the age group 50-59 yr. SHBG did not differ
significantly. LH was significantly lower in the patients than in the controls. Thirty-three of the 104 patients were considered
to have hypogonadism compared with seven of the 99 healthy men. The only clinical variable apart from age that had a significant
impact on NST was the Stanford Health Assessment Questionnaire (HAQ). CONCLUSION: Men with RA had lower levels of bioavailable
T and a large proportion were considered hypogonadal. The low levels of LH suggested a central origin of the relative hypoandrogenicity.
PMID: 11934965 [PubMed - indexed for MEDLINE]
Altern Med Rev. 2001 Jun;6(3):314-8. Related Articles, Links
DHEA. Monograph.
[No authors listed]
Dehydroepiandrosterone (DHEA) is a steroid hormone secreted primarily by the adrenal glands and to a lesser extent by
the brain, skin, testes, and ovaries. It is the most abundant circulating steroid in humans and can be converted into other
hormones, including estrogen and testosterone. It has been characterized as a pleiotropic "buffer hormone," with
receptor sites in the liver, kidney, and testes, and has a key role in a wide range of physiological responses. Circulating
levels of DHEA decline with age and a relationship has been suggested between lower DHEA levels and heart disease, cancer,
diabetes, obesity, chronic fatigue syndrome, AIDS, and Alzheimer's disease. Other research suggests that autoimmune diseases
such as systemic lupus erythematosus (SLE), rheumatoid arthritis, and multiple sclerosis might be associated with declining
DHEA levels.
PMID: 11410076 [PubMed - indexed for MEDLINE]
Z Rheumatol. 2000;59 Suppl 2:II/108-18. Related Articles, Links
Replacement therapy with DHEA plus corticosteroids in patients with chronic inflammatory diseases--substitutes of adrenal
and sex hormones.
Straub RH, Scholmerich J, Zietz B.
Laboratory of Neuroendocrinoimmunology, Department of Internal Medicine I, University Hospital, Franz-Josef-Strauss-Allee
11, D-93042 Regensburg, Germany. Rainer.Straub@klinik.uni-regensburg.de
A dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis was found in animal models of chronic inflammatory diseases,
and the defect was located in more central portions of the HPA axis. This defect of neuroendocrine regulatory mechanisms contributes
to the onset of the model disease. Since these first observations in animal models were made, evidence has accumulated that
the possible defect in the HPA axis in humans is more distal to the hypothalamus or pituitary gland: In chronic inflammatory
diseases, such as rheumatoid arthritis, an alteration of the HPA stress response results in inappropriately low cortisol secretion
in relation to adrenocorticotropic hormone (ACTH) secretion. Furthermore, it has recently been shown that the serum levels
of another adrenal hormone, dehydroepiandrosterone (DHEA), were significantly lower after ACTH stimulation in patients with
rheumatoid arthritis without prior corticosteroids than in healthy controls. These studies clearly indicate that chronic inflammation
alters, particularly, the adrenal response. However, at this point, the reason for the specific alteration of adrenal function
in relation to pituitary function remains to be determined. Since one of the down-regulated adrenal hormones, DHEA, is an
inhibitor of cytokines due to an inhibition of nuclear factor-kappa B (NF-kappa B) activation, low levels of this hormone
may be deleterious in chronic inflammatory diseases. We have recently demonstrated that DHEA is a potent inhibitor of IL-6,
which confirmed an earlier study in mice. Since IL-6 is an important factor for B lymphocyte differentiation, the missing
down-regulation of this cytokine, and others such as TNF, may be a significant risk factor in rheumatic diseases. Since in
these patients, administration of prednisolone or the chronic inflammatory process itself alters adrenal function, endogenous
adrenal hormones in relation to proinflammatory cytokines change. Furthermore, these mechanisms may also lead to shifts in
steroidogenesis which have been demonstrated in chronic inflammatory diseases. It was repeatedly demonstrated that the serum
level of the sulphated form of DHEA (DHEAS) was significantly lower in patients with chronic inflammatory diseases. Since
DHEAS is the pool for peripheral sex steroids, such as testosterone and 17 beta-estradiol, lack of this hormone leads to a
significant sex hormone deficiency in the periphery. This overview will demonstrate mechanisms why DHEAS is reduced in chronic
inflammatory diseases. The importance of DHEAS deficiency will be demonstrated with respect to osteoporosis. As a consequence,
we suggest a combined therapy with corticosteroids plus DHEA in chronic inflammatory diseases.
Publication Types:
Review
Review, Tutorial
PMID: 11155790 [PubMed - indexed for MEDLINE]
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