SUMMARY
Polymyalgia rheumatica (PMR) is a chronic, inflammatory disorder of unknown cause clinically characterized by pain and prolonged morning stiffness affecting the shoulders and often the pelvic girdle and neck. Imaging has substantially contributed to defining PMR as a disease mainly involving extra-articular structures. This review article analyses the role of the different imaging techniques in the diagnosis and follow-up of patients with PMR with particular emphasis on the role of ultrasound, PET/CT and MRI.
Key words: Rheumatology; Polymyalgia rheumatica; Imaging; Ultrasound; MRI; PET-CT.
Reumatismo, 2018; 70 (1): 51-58
n INTRODUCTION
P
olymyalgia rheumatica (PMR) is a chronic, inflammatory disorder of un- known cause. It is almost never seen in people aged 50 years or younger. Clinical- ly, the disorder is characterized by pain and prolonged morning stiffness affecting the shoulders and often the pelvic girdle and neck. Symptoms are usually symmetric.Inflammatory markers are mostly raised, and patients typically experience a swift response to glucocorticoids (1).
n IMAGING FINDINGS IN POLYMYALGIA RHEUMATICA In PMR, both joints and periarticular tis- sues can be involved. Arthritis is typically non-erosive and promptly responds to ther- apy (2), while on imaging the subacromial- subdeltoid (SAD) and trochanteric bursae appear often inflamed (1) (Figure 1). De- spite the name of polymyalgia (pain in nu- merous muscles), the muscles have a nor- mal appearance on imaging (3).
Routine radiographs of inflamed joints do not show abnormalities in patients with PMR (3). Scintigraphy has gone out of fash- ion with the advent of imaging techniques that provide better spatial resolution, such as ultrasonography (US) and magnetic res-
onance imaging (MRI), but has high sensi- tivity in PMR patients not treated with glu- cocorticoids (4). 18F-Fluorodeoxyglucose positron emission tomography (PET) is not routinely used to image patients with PMR, but is indicated if large-vessel vasculitis is suspected. In addition, PET can also reveal inflammatory changes in articular and peri- articular structures (3).
Imaging has substantially contributed to defining PMR as a disease mainly involv- ing extra-articular structures. In fact, while mild synovitis is a known feature of PMR, it was noted that it can only partially ex- plain the diffuse and severe discomfort of the proximal limb extremities experienced by PMR patients (5). A pivotal study by Salvarani et al. published back in 1997 clarified that the main source of pain and stiffness in PMR with shoulder symptoms was SAD bursitis (6). Using MRI, the au- thors investigated the shoulders of thirteen patients with PMR and of nine control pa- tients with elderly onset rheumatoid arthri- tis as well as of ten age-matched unaffected controls. The main finding of this study was that SAD bursitis was present in 100%
of PMR patients compared with only 22%
of control patients, while the frequencies of joint synovitis and biceps tenosynovitis did not significantly differ between case and control patients.
Corresponding author:
Niccolò Possemato Rheumatology Unit, Arcispedale Santa Maria Nuova Viale Risorgimento, 80 42123 Reggio Emilia, Italy E-mail: niccolo.possemato@asmn.re.it
Imaging in polymyalgia rheumatica
N. Possemato, C. Salvarani, N. Pipitone
Rheumatology Unit, Department of Internal Medicine, Azienda Ospedaliera ASMN, Istituto di Ricovero e Cura a Carattere Scientifico, Reggio Emilia, Italy
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onance imaging (MRI), but has high sensi
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onance imaging (MRI), but has high sensi tivity in PMR patients not treated with glu
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tivity in PMR patients not treated with glu
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prolonged morning stiffness affecting the
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prolonged morning stiffness affecting the shoulders and often the pelvic girdle and
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shoulders and often the pelvic girdle and neck. Symptoms are usually symmetric.
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neck. Symptoms are usually symmetric.
ers are mostly raised,
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ers are mostly raised, and patients typically experience a swift
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and patients typically experience a swift response to glucocorticoids (1).
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response to glucocorticoids (1).
IMAGING FINDINGS IN
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IMAGING FINDINGS IN
POLYMYALGIA RHEUMATICA
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POLYMYALGIA RHEUMATICA
cocorticoids (4).
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cocorticoids (4). 18
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18
positron emission tomography (PET) is not
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positron emission tomography (PET) is not routinely used to image patients with PMR,
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routinely used to image patients with PMR, but is indicated if large-vessel vasculitis is
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but is indicated if large-vessel vasculitis is suspected. In addition, PET can also reveal
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suspected. In addition, PET can also reveal in
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infl
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flammatory changes in articular and peri
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ammatory changes in articular and peri articular structures (3).
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articular structures (3).
Imaging has substantially contributed to
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Imaging has substantially contributed to
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onance imaging (MRI), but has high sensi
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onance imaging (MRI), but has high sensi tivity in PMR patients not treated with glu
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tivity in PMR patients not treated with glu
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Patients with PMR may also present with neck and, less commonly, with lower back pain, but the source of spinal pain has long not been recognized. Using PET, Block- mans et al. (7) had observed increased FGD accumulation at the level of the spi- nous processes in about one-half of PMR patients, but owing to the relatively low spatial resolution of PET the exact ana- tomical structures involved could not be identified. Two subsequent studies spe- cifically looked at cervical (8) and lumbar (9) spine changes in patients with active PMR. Using MRI, Salvarani et al. were able to identify interspinous bursitis as the typical alteration of PMR patients.
In the first study, twelve untreated PMR patients were compared with thirteen controls including patients with fibromy- algia, cervical osteoarthritis, ankylosing spondylitis and psoriatic spondylitis (8).
In all patients with PMR, MRI showed the presence of fluid in the cervical inter- spinous bursae at C5-C7 level consistent with bursitis, while bursitis was noted in only 46% of control patients. Moderate to
severe bursitis occurred significantly more frequently in PMR (83%) than in control (31%) patients. Similarly, MRI evidence of lumbar interspinous bursitis was de- tected in a subsequent study in 90% of 10 PMR patients, but in only 46% of a control group consisting of seven patients with spondyloarthropathy, two patients with spinal spondylosis and two patients with rheumatoid arthritis who had back pain (9). On the basis of these findings, it was proposed that PMR should be consid- ered a disorder of extra-articular synovial structures (5, 10) and that joint synovitis might be secondary to shedding of pro- inflammatory molecules of extrasynovial membranes (10). From a nosological point of view, it was thus suggested that PMR might share a prevalent extra-articular sy- novial involvement with other conditions such as RS3PE (remitting seronegative symmetrical synovitis with pitting edema) and probably a subset of elderly onset rheumatoid arthritis, with important im- plications for the classification of arthritis in the elderly population (5).
Currently, US has gained a pivotal role in the assessment of PMR due to its capacity to visualize both joints and periarticular tis- sues, its low cost and widespread availabil- ity. Importantly, US in PMR has excellent reliability, with very high intra-observer (0.96) and inter-observer (0.99) intraclass correlation coefficients (11).
The most frequent US abnormalities are usually detected at shoulder level and are represented by SAD bursitis and long head of biceps tendon tenosynovitis (12). Ac- cording to a recent review, SAD bursitis is found in about 70-100% of patients with PMR, while the prevalence of long head of biceps tendon tenosynovitis hovers around 45-100% (13). In this context, Rozin et al.
described the two tram tracks sign, a spe- cific US sign of active PMR. In some PMR patients, the two layers of the deltoid fascia and the two leaflets of the subdeltoid bursa, when viewed anteriorly with the shoulder extended, abducted and internally rotated, are seen as parallel hypoechogenic layers.
This sign has been seen to resolve after treatment with glucocorticoids. Just how Figure 1 - Distension of the subacromial-deltoid bursa in a patient with PMR.
In the second figure from top, the main anatomical structures are highlighted (the bursa in yellow, the supraspinatus tendon in grey and the bone and bursal margins in white).
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Patients with PMR may also present with
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Patients with PMR may also present with neck and, less commonly, with lower back
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neck and, less commonly, with lower back pain, but the source of spinal pain has long
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pain, but the source of spinal pain has long not been recognized. Using PET, Block
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not been recognized. Using PET, Block mans et al. (7) had observed increased
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mans et al. (7) had observed increased FGD accumulation at the level of the spi
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FGD accumulation at the level of the spi nous processes in about one-half of PMR
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nous processes in about one-half of PMR patients, but owing to the relatively low
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patients, but owing to the relatively low spatial resolution of PET the exact ana
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spatial resolution of PET the exact ana tomical structures involved could not be
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tomical structures involved could not be - Distension of the subacromial-deltoid bursa in a patient with PMR.
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- Distension of the subacromial-deltoid bursa in a patient with PMR.
In the second figure from top, the main anatomical structures are highlighted
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In the second figure from top, the main anatomical structures are highlighted (the bursa in yellow, the supraspinatus tendon in grey and the bone and bursal
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(the bursa in yellow, the supraspinatus tendon in grey and the bone and bursal
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of view, it was thus suggested that PMR
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of view, it was thus suggested that PMR might share a prevalent extra-articular sy
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might share a prevalent extra-articular sy novial involvement with other conditionsuse
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structures (5, 10) and that joint synovitis
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might share a prevalent extra-articular sy
Imaging in polymyalgia rheumatica
prevalent this sign is in PMR is as yet un- known (14).
At hip level, extra-articular involvement is the most relevant finding with the evidence of trochanteric bursitis that is present in a significantly higher number of cases with PMR than in controls (15). Other findings that have been reported are glenohumeral or hip joint effusions or tenosynovitis (15-18).
Joint effusion can be also detected in the hips, knees, and wrists with prevalence rates of 40%, 38%, and 18%, respectively (19). Synovitis of hand and wrist are pos- sible findings, but less helpful in differen- tiating PMR from other inflammatory con- ditions such as rheumatoid arthritis (RA).
Joint involvement at feet level (metatarso- phalangeal joints) is rare and should sug- gest another diagnosis.
MRI can also depict periarticular struc- tures very well. In a study, MRI of the shoulders showed bilateral SAD bursitis in all PMR patients and biceps tenosynovitis in 67%; glenohumeral synovitis was also detected in all patients (20). Similarly, at hip level using MRI, Cantini et al. dem- onstrated trochanteric bursitis in 100%
and hip synovitis in 85% of PMR patients (15). US had the same sensitivity as MRI for the detection of trochanteric bursitis, whereas US findings of hip synovitis were present only in 45% of patients. A preva- lent extra-articular pattern has also been demonstrated in the hands of patients with PMR using MRI. Cimmino et al. report- ed tenosynovitis in 67% of 15 PMR pa- tients versus 30% of unaffected controls;
extensor tenosynovitis was seen in 53%
and flexor tenosynovitis in 60% of PMR patients, although only the rate of exten- sor tenosynovitis was significantly higher than in controls (21). In contrast, signs of synovitis were comparable in PMR pa- tients and controls. Likewise, in patients with florid, PMR-associated RS3PE (re- mitting seronegative symmetrical synovi- tis with pitting edema), the most common MRI findings are extensor tenosynovitis, followed in decreasing order by hand joint arthritis and flexor tenosynovitis (22).
A periarticular pattern of PMR has recent- ly been highlighted in a study by Mackie et
al. (23). In this study, 22 patients with PMR and 16 with RA underwent whole-body, multiple-joint, 3T MRI. The authors iden- tified a pattern of symmetrical extracapsu- lar inflammation at the level of the greater trochanter, acetabulum, ischial tuberosity and/or symphysis pubis in 64% of PMR.
This pattern was associated with higher pre-treatment interleukin-6 and C-reactive protein levels and a complete response to glucocorticoids, as well as with better post- treatment fatigue and function. However, patients presenting with such a pattern were more likely to require glucocorticoid treatment for >1 year.
PET is also a valuable tool in identifying inflammatory changes in PMR as well as in disclosing subclinical large vessel vasculi- tis (Figure 2). In PMR, the increased FDG uptake is mainly related to bursitis (peri-
Figure 2 - PET/CT image in a patient with PMR - associated vasculitis. The FDG uptake pattern at the level of the periarticular structures of the shoul- ders, hips (bursitis) and humeral head (synovitis) is consistent with PMR. In this patient, PET/CT also shows an associated large vessel vasculitis (in- creased vascular FDG uptake at the thoracic aorta, subclavian arteries and axillary arteries, score 2 according to Meller J et al. Eur J Nucl Med Mol Imaging, 2003).
fig 2
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and hip synovitis in 85% of PMR patients
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and hip synovitis in 85% of PMR patients (15). US had the same sensitivity as MRI
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(15). US had the same sensitivity as MRI for the detection of trochanteric bursitis,
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for the detection of trochanteric bursitis, whereas US findings of hip synovitis were
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whereas US findings of hip synovitis were present only in 45% of patients. A preva
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present only in 45% of patients. A preva lent extra-articular pattern has also been
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lent extra-articular pattern has also been demonstrated in the hands of patients with
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demonstrated in the hands of patients with
PMR using MRI. Cimmino et al. report
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PMR using MRI. Cimmino et al. report
ed tenosynovitis in 67% of 15 PMR pa
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ed tenosynovitis in 67% of 15 PMR pa
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ge vessel vasculi
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ge vessel vasculi tis (Figure 2). In PMR, the increased FDG tis (Figure 2). In PMR, the increased FDG
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uptake is mainly related to bursitis (peri
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were more likely to require glucocorticoid
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were more likely to require glucocorticoid PET is also a valuable tool in identifying PET is also a valuable tool in identifying
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ammatory changes in PMR as well as in
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ammatory changes in PMR as well as in ge vessel vasculi
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ge vessel vasculi tis (Figure 2). In PMR, the increased FDG
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tis (Figure 2). In PMR, the increased FDG
articular accumulation pattern) (24). In one of the first papers based on PET pub- lished by Blockmans et al., high 18F-FDG uptake was detected in shoulders in 33/35 (94%) patients and in hips in 31/35 (89%) patients as well as in the spinous process of the vertebrae in 51% (7). PET can allow assessment of deep bursae, not easily vis- ible with US, such as ischial tuberosities, lumbar spinous processes and greater tro- chanters. Positive results at this level seems to be highly sensitive (85.7%) and specific (88.2%) for the diagnosis of PMR, accord- ing to Yamashita et al. (25).
Rehak et al. recently described various pat- terns of PET findings in 67 patients who fulfilled Healey’s criteria for PMR (26).
The authors found articular involvement in proximal joints in 88.1% of patients (86.6% shoulders, 70.1% hips and 46.3%
sternoclavicular joints). Vascular involve- ment was seen in 40.3% of patients. Ex- tra-articular involvement was present in ischiogluteal bursae in 52.2% of patients, around the symphysis and ventral to pubic bones in 7.5% of patients, in spinous inter- spaces of cervical vertebrae in 19.4% of patients and in lumbar vertebrae in 56.7%
of patients.
Imaging studies are particularly useful in securing diagnosis of PMR when the in- flammatory markers are normal. Cantini et al. demonstrated that MRI and US in PMR patients with normal or high erythrocyte sedimentation rate reveal similar inflam- matory shoulder lesions (27).
PET is especially helpful in disclosing vascular involvement associated with PMR, since it can visualize almost all arteries including the deeper vessels.
Blockmans et al. showed that about one- third of 35 patients with isolated PMR had increased vascular FDG uptake (pre- dominantly in the subclavian arteries) (28). However, uptake intensity was less marked than in giant cell arteritis, with only 2/35 (6%) patients showing intense vascular uptake. Moosig et al. (29) de- scribed increased FDG vascular uptake in 12 out of 13 PMR patients in the aorta and its major branches, but in another study, only 2/14 (14%) untreated patients with
PMR had increased FDG vascular uptake (25). Importantly, PMR patients without clinical evidence of arteritis but with im- aging signs of giant cell arteritis do not appear prone to developing vascular isch- emic complications.
n ROLE OF IMAGING IN THE CLASSIFICATION CRITERIA OF POLYMYALGIA RHEUMATICA A gold standard diagnostic test for PMR is lacking. Moreover, PMR can be mim- icked by numerous other conditions, many of which may also respond in some degree to glucocorticoids. Various classification criteria have been proposed for diagnos- ing PMR, including those by Chuang (30), Healey (31) and Bird (32). However, none of these criteria have been validated or been widely accepted. Therefore, new clas- sification criteria have been developed un- der the aegis of the American College of Rheumatology and of European League Against Rheumatism (33).
In patients aged 50 years or older present- ing with bilateral shoulder aching and raised inflammatory markers, these criteria had 68% sensitivity and 78% specificity for PMR. US was not mandatory, but when ultrasonography findings consistent with PMR were included, sensitivity remained virtually unchanged at 66%, whereas specificity increased to 81%. US findings deemed consistent with PMR included at least one shoulder with subdeltoid bursitis and/or biceps tenosynovitis and/or gleno- humeral synovitis (either posterior or ax- illary) and at least one hip with synovitis and/or trochanteric bursitis. Macchioni et al. recently demonstrated the increased specificity of the clinical criteria if inte- grated with ultrasonography (34). Patients with PMR were compared to those with other joint inflammatory disorders includ- ing rheumatoid arthritis (RA). Adding ul- trasonography, specificity increased from 81.5% to 91.3% in total cases and from 79.7% to 89.9% in RA. These findings suggest that ultrasonography examination is helpful in increasing the specificity of a clinical diagnosis of PMR.
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sternoclavicular joints). Vascular involve
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sternoclavicular joints). Vascular involve ment was seen in 40.3% of patients. Ex
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ment was seen in 40.3% of patients. Ex-
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- tra-articular involvement was present in
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tra-articular involvement was present in ischiogluteal bursae in 52.2% of patients,
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ischiogluteal bursae in 52.2% of patients, around the symphysis and ventral to pubic
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around the symphysis and ventral to pubic bones in 7.5% of patients, in spinous inter
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bones in 7.5% of patients, in spinous inter spaces of cervical vertebrae in 19.4% of
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spaces of cervical vertebrae in 19.4% of patients and in lumbar vertebrae in 56.7%
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patients and in lumbar vertebrae in 56.7%
Imaging studies are particularly useful in
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Imaging studies are particularly useful in securing diagnosis of PMR when the in
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securing diagnosis of PMR when the in ammatory mark
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ammatory markers are normal. Cantini et
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ers are normal. Cantini et al. demonstrated that MRI and US in PMR
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al. demonstrated that MRI and US in PMR patients with normal or high erythrocyte
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patients with normal or high erythrocyte sedimentation rate reveal similar in
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sedimentation rate reveal similar in matory shoulder lesions (27).
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matory shoulder lesions (27).
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ing PMR, including those by Chuang (30),
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ing PMR, including those by Chuang (30), Healey (31) and Bird (32). However, none
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Healey (31) and Bird (32). However, none
Imaging in polymyalgia rheumatica
n ROLE OF IMAGING IN THE DIFFERENTIAL DIAGNOSIS OF POLYMYALGIA RHEUMATICA Current published data suggest a possible role for imaging in differentiating PMR from other rheumatic conditions that may present with a polymyalgic onset. Falsetti et al. in 2011 demonstrated an improve- ment of diagnostic sensitivity for PMR when US assessment was used. The authors suggested a predictive model of US evalua- tion to classify PMR patients, including the presence of SAD bursitis, low frequency of wrist, metacarpophalangeal and metatar- sophalangeal effusion/synovitis, low fre- quency of Achilles enthesitis, low frequen- cy of knee menisci chondrocalcinosis, and tendinous calcaneal calcifications, and low hypervascularization at power-Doppler US analysis in the wrist (13, 18).
In another study, Falsetti et al. compared US findings in patients with PMR versus those with RA or spondyloarthropathies (SpA) (35). They found that enthesitis was more frequent in SpA, while synovitis of the elbow, knee, and wrist was significant- ly more common in patients with RA and SpA patients compared with those with PMR. At shoulder level, a study that com- pared PMR with RA and psoriatic arthritis (PsA) patients found that bilateral SAD bursitis was universal (100%) in patients with PMR, whereas only 20% of patients of RA patients and no PsA patients had such findings (20). In contrast, no signifi- cant difference was detected in the distri- bution of biceps tenosynovitis among the study groups. Another study that looked at shoulder US findings in patients with PMR and RA confirmed that SAD bursi- tis was more specific to PMR (36). In this study, bilateral SAD bursitis was revealed in 37% of PMR patients, but only in 3%
of patients with RA, while bilateral biceps tenosynovitis was present in 30% of PMR patients versus none of the RA controls. A semiquantitative scoring system for evalu- ating periarticular shoulder US inflamma- tory signs has recently been proposed by Suzuki et al. (37). Using a four-point scale scoring the hyperemia of the suprascapu-
laris tendon, the authors demonstrated that inflammation in PMR was predominantly localized to the periarticular tissue com- pared with elderly-onset RA. The scoring showed good intra- and inter-observer reli- ability.
MRI is also an excellent imaging technique for PMR, due to its capacity to visualize in- flamed tissues at joint and bursae level, and has proved useful for the purpose of dif- ferential diagnosis. In 2001, McGonagle et al. published an MRI study comparing the anatomical sites of inflammatory changes in the shoulders of 14 patients with early PMR and 14 with RA using fat suppres- sion MRI (38). The authors described a common involvement of synovial joints in PMR and RA and a slightly higher fre- quency of bursitis in PMR patients. Inter- estingly, they also described the presence of inflammatory changes in the soft tissues, defined as extracapsular changes.
In 2007, the same group published an in- teresting paper evaluating the relation- ship between synovial and extracapsular inflammation in PMR and early RA us- ing contrast-enhanced and fat suppression MRI (39). The results confirmed a much greater degree of gadolinium enhancement in the extracapsular tissues in the PMR pa- tients. A surprising finding was that MRI- determined erosion and bone edema were equally common in both groups, while it has been recognized that PMR synovitis is usually non-erosive at standard X-ray eval- uation (22). This finding may be related to the capacity of MRI to detect even small erosions, which can be found even in nor- mal subjects (21).
Approximately 16-21% of patients with PMR have giant cell arteritis (1). Imaging methods can aid in detecting those PMR patients that have an associated vasculitis.
US can be a valuable tool for a correct di- agnosis of these patients, especially when superficial arteries are involved, with a sensitivity ranging from 55% to 100%
and specificity ranging from 78% to 100%
(40). In large vessel vasculitis, the inflam- matory infiltrate of the vessel wall results in the loss of the normal echostructure of the intima-media complex. The major so-
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ammatory
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ammatory changes in the soft tissues,
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changes in the soft tissues, defined as extracapsular changes.
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defined as extracapsular changes.
In 2007, the same group published an in
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In 2007, the same group published an in teresting paper evaluating the relation
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teresting paper evaluating the relation ship between synovial and extracapsular
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ship between synovial and extracapsular
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ly more common in patients with RA and
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ly more common in patients with RA and SpA patients compared with those with
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SpA patients compared with those with PMR. At shoulder level, a study that com
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PMR. At shoulder level, a study that com-
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- pared PMR with RA and psoriatic arthritis
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pared PMR with RA and psoriatic arthritis (PsA) patients found that bilateral SAD
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(PsA) patients found that bilateral SAD bursitis was universal (100%) in patients
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bursitis was universal (100%) in patients with PMR, whereas only 20% of patients
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with PMR, whereas only 20% of patients
of RA patients and no PsA patients had
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of RA patients and no PsA patients had
such findings (20). In contrast, no signifi
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such findings (20). In contrast, no signifi fl
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flammation in PMR and early RA us
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ammation in PMR and early RA us ing contrast-enhanced and fat suppression
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ing contrast-enhanced and fat suppression MRI (39). The results confirmed a much
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MRI (39). The results confirmed a much greater degree of gadolinium enhancement
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greater degree of gadolinium enhancement in the extracapsular tissues in the PMR pa
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in the extracapsular tissues in the PMR pa
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in PMR and RA and a slightly higher fre
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in PMR and RA and a slightly higher fre quency of bursitis in PMR patients. Inter
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quency of bursitis in PMR patients. Inter
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estingly, they also described the presence
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estingly, they also described the presence changes in the soft tissues,
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changes in the soft tissues, defined as extracapsular changes.
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defined as extracapsular changes.
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in the shoulders of 14 patients with early
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in the shoulders of 14 patients with early at suppres
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at suppres-
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- sion MRI (38). The authors described a sion MRI (38). The authors described a
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common involvement of synovial joints
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common involvement of synovial joints in PMR and RA and a slightly higher fre
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in PMR and RA and a slightly higher fre quency of bursitis in PMR patients. Inter
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quency of bursitis in PMR patients. Inter
nographic signs are the thickening of the arterial wall with disappearance of the tri- laminar structure of the intima-media com- plex, the presence of a perivascular halo, and the presence of stenoses or vascular dilatations (Figure 3) (41, 42).
PET, too, can be used to detect an under- lying large-vessel vasculitis as well as to depict the pattern of involvement of periar- ticular structures in PMR. In terms of dif- ferential diagnosis, PET has been suggest- ed as useful in differentiating PMR from elderly onset RA, with important implica- tions in terms of prognosis and treatment.
Yamashita et al. compared FDG accumula- tion sites at PET between 27 patients with PMR and 10 with elderly onset RA. In PMR, abnormal accumulation at the ischi- al tuberosity, vertebral spinous processes, and iliopectineal bursa was significantly higher compared with RA, while shoul- der involvement had a similar prevalence (25). Similarly, Wakura et al. suggested that an abnormal FDG accumulation at the entheses of the girdle such as enthesis of the pectineus muscle, and enthesis of the rectus femoris muscle might assist in dif- ferentiating PMR from EORA (43).
n ROLE OF IMAGING IN ASSESSING TREATMENT RESPONSE IN POLYMYALGIA RHEUMATICA
There is limited evidence on the role of imaging in monitoring patients with PMR.
In a prospective study containing 53 pa- tients evaluated clinically, serologically and by US before and after (at 4 weeks and at 12 weeks) glucocorticoid therapy, clinical, laboratory and ultrasonography decreased in parallel over time (11). US inflammatory findings showed similar or better sensitivity to change than clinical and laboratory markers of PMR activ- ity (11). However, in another prospective study on 57 newly diagnosed patients with PMR, while glucocorticoids significantly reduced the frequency and the severity of SAD bursitis, long head biceps teno- synovitis, and glenohumeral synovitis, a sizeable 59% of 44 patients in clinical remission or in low disease activity had persistent inflammatory lesions at follow- up US (24). No association was found be- tween the persistence of US inflammatory changes and the risk of relapses or recur- rences, although a positive power-Doppler signal at diagnosis was significantly asso- ciated with the subsequent occurrence of relapses or recurrences. Similarly, FDG uptake at PET (in the shoulders, hips, and spinous processes) was shown to decrease following the institution of glucocorti- coids therapy; however, basal FDG uptake did not predict the risk of relapses over time (28).
Recently, Palard-Novello et al. suggested a role for PET in assessing the efficacy of tocilizumab in the treatment of PMR (44).
Patients enrolled in a multicentric clinical trial underwent PET at baseline, after the first infusion of tocilizumab (week 2) and after the last infusion (week 12). Eighteen patients could be evaluated. At week 0, high FDG uptake was found at the shoul- der (89% of patients) and pelvic (94% of patients) girdle as well as in the cervical spinous processes (56% of patients). After the first infusion, SUV max significantly decreased and decreased further by week 12, although in a lesion-based analysis no significant decrease was observed in the shoulders and cervical spinous processes.
Further studies are required to fully elu- cidate the role of imaging in gauging re- sponse to treatment and monitoring PMR patients over time.
Figure 3 - Vasculitis of the axillary arteries in a patient with PMR. Note both in the transversal (left) and in the longitudinal view (right) the concentric thicken- ing of the intima-media complex of the axillary artery at the humeral head level.
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and the presence of stenoses or vascular
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and the presence of stenoses or vascular PET, too, can be used to detect an under
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PET, too, can be used to detect an under-
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- lying large-vessel vasculitis as well as to
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lying large-vessel vasculitis as well as to depict the pattern of involvement of periar
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depict the pattern of involvement of periar ticular structures in PMR. In terms of dif
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ticular structures in PMR. In terms of dif ferential diagnosis, PET has been suggest
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ferential diagnosis, PET has been suggest ed as useful in differentiating PMR from
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ed as useful in differentiating PMR from elderly onset RA, with important implica
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elderly onset RA, with important implica tions in terms of prognosis and treatment.
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tions in terms of prognosis and treatment.
Yamashita et al. compared FDG accumula
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Yamashita et al. compared FDG accumula tion sites at PET between 27 patients with
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tion sites at PET between 27 patients with PMR and 10 with elderly onset RA. In
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PMR and 10 with elderly onset RA. In PMR, abnormal accumulation at the ischi
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PMR, abnormal accumulation at the ischi al tuberosity, vertebral spinous processes,
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al tuberosity, vertebral spinous processes, and iliopectineal bursa was significantly
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and iliopectineal bursa was significantly
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and the presence of stenoses or vascular
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and the presence of stenoses or vascular
persistent in
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persistent in
up US (24). No association was found be
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up US (24). No association was found be tween the persistence of US inuse
tween the persistence of US inchanges and the risk of relapses or recur
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changes and the risk of relapses or recur rences, although a positive power-Doppleruse
rences, although a positive power-Doppleronly
of SAD bursitis, long head biceps teno
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of SAD bursitis, long head biceps teno synovitis, and glenohumeral synovitis,
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synovitis, and glenohumeral synovitis, a sizeable 59% of 44 patients in clinical a sizeable 59% of 44 patients in clinical
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remission or in low disease activity had
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remission or in low disease activity had persistent in
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persistent infl
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flup US (24). No association was found be
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up US (24). No association was found be
Imaging in polymyalgia rheumatica
n FUTURE PROSPECTS
Imaging appears to increase the specificity of a clinical diagnosis of PMR, and to dis- criminate better between PMR and its mim- ickers at an early stage. Therefore, imaging can conceivably play an important role in selecting PMR patients for clinical trials with greater accuracy. As suggested by Butt- gereit et al. (45), imaging including MRI could help to identify a fairly homogeneous subset of patients with PMR with potential value for defining eligibility for early clini- cal trials of targeted therapies. In addition, imaging could also complement clinical and laboratory assessments of patients over time, including response to therapy.
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