Polymyalgia Rheumatica and Giant cell Arteritis Flashcards

1
Q

what % of Polymyalgia rheumatica patients develop giant cell arteritis and vice versa

A

PMR to GCA = 15-30%

GCA to PMR = 50%

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2
Q

whats the pathology for polymyagia rheumatica

A

Mild, non-erosive synovial and periarticular inflammation of proximal joints
In some patients sub-clinical arterial inflammation is evident
This leads to Intense muscle pain and stiffness of joints
Shoulder and pelvic girdle most commonly affected

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3
Q

whats the pathology for Giant cell/temporal arteritis

A

Inflammatory infiltrative accumulates in medium and large arteries
Results in granulomatous vasculitis
Vessel wall injury, luminal occlusion and vascular stenosis
Leading to ischaemia

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4
Q

what are the diagnostic criteria for PMR

A

> 50

> 2 weeks

Bilateral shoulder or pelvic girdle aching, or both
Purely pelvic girdle involvement is much less likely

Morning stiffness duration of >45 mins

Evidence of an acute phase response (fever, W/L)

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5
Q

if polymalgia rheumatica is diagnosed what must be assessed immediately afterwards

A

GCA/temporal arteritis

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6
Q

what are some differntials for proximal girdle pain

A
Multiple myeloma 
Rheumatoid arthritis 
Late onset spondyloarthritis 
CTD:SLE 
Polyarticular calcium pyrophosphate deposition disease 
Muscle disease 
Cervical spondylosis 
Leukaemia 
Hypothyroidism 
Fibromyalgia 
Paraneoplastic syndrome 
MSK issues  
Osteomalacia 
Infections – bacterial endocarditis 
Parkinsons 
Osteomyelitis
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7
Q

what investigations are typically done in polymyalgia rheumatica

A
Bloods 
ESR (raised) 
CRP (raised)  
FBC (normochromic/normocytic anaemia)  
Platelets (may be raised)  
Rheumatoid factor, ANA, anti-CCP negative 

Scans
US/MRI

Peri-articular inflammation
X-ray
Good to do as a screen to check for chest malignancies/Tb which can cause a similar presentation as outlined earlier

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8
Q

what is polymyalgic onset of rheumatoid

A

RA presents as PMR atypically instead of the normal fashion

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9
Q

what is a rule of thumb when someone is admitted with a pyrexia of an unknown cause

A

1/3 will have malignancy, 1/3 sepsis, 1/3 autoimmune disease

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10
Q

how do you manage polymyalgia rheumatica

A

prednisolone - 15mg for 2 weeks then reduce by 1mg for 4-6 weeks when weaning off to get to maintenance dose of 5-7mg/day for 6 months. reduce the maintenance by 1mg every 6-8 weeks + attempt withdrawal by 18 months - 2 years of treatment

supplement with PPI + bisphosphonate + Vit D + Calcium

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11
Q

what are side effects of treatment for polymyalgia rheumatica (side effects of steroids)

A
Weight gain 
Skin atrophy 
Oedema 
Increased IOP  
Cataracts 
GI distrubance  
Diabetes 
Osteoporosis
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12
Q

when should you consider specialist referral for polymyalgia rheumatica

A
<60 
Chronic onset 
Lack of shoulder involvement  
Lack of inflammatory stiffness 
RED FLAGS  
Suspect other rheumatology condition 
Poor response  
Need for prolonged steroids  
Contra-indications to steroid use
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13
Q

what is the average treatment length for polymyalgia rheumatica

A

3 years

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14
Q

what are clinical features of giant cell arteritis/temporal arteritis

A

Abrupt onset new Headache

Tenderness in scalp - Can be a 9/10 on pain scale

Altered vision (15%) 
Pain 
Visual blurring 
Transient loss of vision 
Visual hallucinations 
Diplopia 
Blurring (from optic neuritis)  
Amarurosis figax  
15% of patients have optic nerve ischaemia

Jaw/tongue claudication (50%)

Nodular swellings

Poor pulsation

Weight loss, fever, malaise

Rarer ones 
Scalp necrosis 
Cranial nerve palsy  
Limb claudication  
Systemic s+s
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15
Q

what are complications for giant cell arteritis/temporal arteritis

A

blindness

Stroke

Inflammatory aortitis - may develop AAA

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16
Q

how should you investigate ?temporal Arteritis

A

History + examination
PALPATE TEMPORAL ARTERIES
Think about possibility
50% of biopsies with patients who have the disease come back negative so clinical assessment is vital

Blood tests  
ESR/CRP (raised) 
Platelets (raised)  
WBCC (raised)  
Anaemia  
Liver enzymes (alk Phos elevated in 1/3)  

Biopsy
Gold standard diagnostic tool (despite false negatives
Useful if in doubt or if no improvement
Not undertaken routinely
Beware false negatives, skip lesions/lab process
Preferably taken within 1 week of starting steroids – but don’t delay steroids to wait for biopsy
Large chunk (1 inch) taken because of skip lesions – disease appears in different areas

17
Q

why is a large chunk taken in temporal arteritis

A

skip lesions commonly occur

18
Q

what is the treatment for temporal arteritis

A

Acute
60mg prednisolone stat
IV if there is visual involvement (2 days of 500mg methyprednisolone)

Maintenance
without visual symptoms - 20-40mg prednisolone daily for 8 weeks, reduce by 5mg every 3-4 weeks, at 10mg/day treat as PMR

with visual symptoms - 40-80mg daily for 8 week, reduce t 20mg daily over next 4 weeks. then treat as without visual symptoms