Musculoskeletal manifestations in polymyalgia rheumatica and temporal arteritis. (Concise Reports).

Abstract

Objective--To evaluate the incidence and characteristics of musculoskeletal manifestations in polymyalgia rheumatica (PMR) and temporal arteritis (TA).

Methods--The records of 163 cases of PMR or TA diagnosed over a 15 year period in one area of Spain were reviewed for the presence and type of musculoskeletal manifestations.

Results--Of 163 patients, 90 had isolated PMR and 73 had TA. Eighteen of the 90 patients (20%) with isolated PMR developed distal peripheral arthritis either at diagnosis or during the course of the disease. When it occurred, synovitis was mild, monoarticular or pauci-articular, asymmetrical, transient, and not destructive. Other distal manifestations observed in these patients were carpal tunnel syndrome and distal extremity swelling with pitting oedema. In all cases these manifestations occurred in conjunction with active PMR. As expected, PMR was the most frequent musculoskeletal manifestation in patients with TA, occurring in 56% of cases. On the contrary, only 11% of patients with TA developed peripheral arthritis. An important finding was that peripheral arthritis in these patients appears to be linked only temporally to the presence of simultaneous PMR and is not observed in its absence. Distal extremity swelling or defined polyarthritis were not observed.

Conclusion--The spectrum of distal musculoskeletal manifestations of PMR in our series is similar to that reported in other populations. By contrast, distal musculoskeletal symptoms are uncommon in TA. The almost complete absence of distal musculoskeletal manifestations in patients with pure TA suggests different mechanisms of disease in PMR and TA, supporting the view of two separate conditions or one common disease in which host susceptibility influences the clinical expression.

(Ann Rheum Dis 2001;60:1060-1063)

There is controversy as to whether polymyalgia rheumatica (PMR) and temporal arteritis (TA) are expressions of the same disease or are two different, partly overlapping, diseases. PMR is a common syndrome of the elderly characterised by pain and stiffness involving the neck, shoulder and pelvic girdles, generally accompanied by constitutional symptoms and a raised erythrocyte sedimentation rate. The cause of musculoskeletal pain in PMR is not completely understood, but inflammation in proximal joints and periarticular structures is a likely basis for much of the discomfort since, to date, there is little evidence to suggest that the musculoskeletal symptoms are related to underlying vasculitis. Evidence of proximal articular and periarticular synovitis has been demonstrated by scanning, MRI, arthroscopy, and synovial biopsy. (1-3) Moreover, an increasing number of reports have underlined the presence of peripheral synovitis and other distal musculoskeletal manifestations in PMR, suggesting that the spectrum of musculoskeletal involvement in this entity is not completely defined and is broader than has often been thought previously. (4-8) The clinical predominance of proximal symptoms in PMR has probably overshadowed the less well characterised and more variable distal musculoskeletal manifestations. (4)

TA is a vasculitis of large and medium sized vessels with a predisposition to the cranial arteries in patients older than 50 years. Although cranial and ocular symptoms are the most prominent manifestations in TA, musculoskeletal findings, especially those of PMR, are also common. However, controversy exists over the presence of distal musculoskeletal manifestations in TA and two recent studies have produced conflicting results. Salvarini et al, in a population based study at the Mayo Clinic, …