Rheumatology

Polymyalgia Rheumatica (PMR) and Temporal/Giant Cell/Cranial Arteritis (GCA)

Definition

• Subacute, immune system mediated inflammation of the articular and periarticular regions of the shoulder and pelvic girdle
• Occurring in patients 50-60 years of age or older
• Generally with absent or minimal evidence of joint inflammation (PMR)
• Occasionally complicated by arteritis affecting predominantly the medium sized and large vessels of the brachiocephalic circulation (GCA)

History – PMR

• What is the patient’s age?  Does it fall into the range expected for patients with PMR or GCA?
• Does the patient report stiffness, pain, weakness or limited ROM in the typical PMR distribution including the neck, shoulder girdle, proximal upper extremity, lumbosacral, pelvic girdle and proximal lower extremity regions largely sparing the areas distal to the elbows and distal to the knees?
• When did the symptoms begin or when was diagnosis first made?
• Are these symptoms worse at night or on arising in the morning (morning stiffness), and improved with activity?
• How many minutes or hours of activity does it take in the morning to relieve the worst of the stiffness and pain?
• Has there been any evidence of fever and weight loss?
• Any symptoms or signs of GCA (see below)?
• Has the patient been evaluated by rheumatologist and given any other diagnoses?  Results?
• Specifically, any previous history of fibromyalgia, cervical or lumbar spine disorders, shoulder or hip disorders that could mimic symptoms of PMR?
• Any previous history of other systemic disorders that could mimic PMR including other collagen vascular disorders, infections or malignancies?
• Has the ESR been checked?  What was the numerical value?
• What was the response to NSAIDS, oral or parenteral corticosteroids or other medications?
• What dose of corticosteroid was used and what was the minimum effective dose?
• How quickly and to what extent did symptoms improve after initiation of corticosteroid treatment?

History – CGA

• New onset of headache? Head pain? Scalp tenderness to brushing, combing or washing hair? Temporal artery swelling?
• Any pain in the jaw or teeth or difficulty chewing or talking due to tiredness, aching or pain in the jaw region (jaw claudication)?
• Diplopia or amaurosis fugax sumptoms?
• Chronic headaches, chornic TMG disorder, chornic visual problems or vascular disorders?
• Cough or dysphagia?
• Symptoms of vascular claudication symptoms of the arms or legs?
• When did symptoms begin or when was the diagnosis first made?
• Any symptoms of PMR (see above)?
• Ever been evaluated by rheumatologist and given any other diagnoses? Results?
• Has the ESR been checked?  What was it?
• Have corticosteroids been used?  Before or after temporal artery biopsy?
• How long was the patient on corticosteroids before the temporal artery biopsy was performed?
• What dose of corticosteroid was used and what was the minimum effective dose?
• How quickly and to what extend did symptoms improve after initiation of corticosteroid treatment?
• Have immune suppressing agents (eg., MTX, azathioprine) been used?

Exam

• Completely examine the spine and all peripheral joints noting range of motion, discomfort, evidence of synovitis.  Include the TMJ!
• Perform vascular examination including palpation of temporal artery pulses (beginning just above the TMJ), and carotid and radial artery pulses at minimum.  Auscultate for carotid, subclavian, or brachial artery bruits and cardiac murmurs.
• Note evidence of petechaie, purpura, nailfold infarcts, mononeuritis, etc.
• Note evidence of other systemic diseases that might mimic PMR or GCA especially infections, cancers an other collagen vascular disorders