Polymyalgia Rheumatica (PMR) Giant Cell Arteritis (GCA) Temporal Arteritis (TA) Flashcards
Polymyalgia Rheumatica (PMR) characteristics
Systemic inflammatory disorder
Symmetric, proximal muscle pain and stiffness
Symptom relief with prednisone
Epidemiology
Mean age--73 Annual incidence--13 to 113 per 100,000 Caucasian >> African American,Hispanic Women >> Men Think of onset of symptoms over the age of 50
Symptoms of PMR
95%--symmetric shoulder girdle pain 70%--neck and pelvic pain Upper arm and thigh pain Subacute Morning >> Evening Weight loss Fever Malaise Difficulty standing Difficulty grooming
Physical Exam
Joint ROM –normal Muscle strength –normal Soft tissue swelling -knees, wrists, and MCP joints Lower extremity edema Carpel tunnel syndrome
Diagnosis of PMR
No specific laboratory tests for PMR
***90%–ESR >40 mm/hr
CBC-leukocytosis, thrombocytosis, anemia.
Other lab abnormalities:
Alkaline phosphatase
C-reactive protein
Elevated CK is not seen in PMR- (because it is not muscle in nature)
No serological tests specific for the diagnosis of PMR
That is RA ANA etc
Ddx for PMR
Rheumatic conditions myositis rheumatoid arthritis bursitis fibromyalgia osteoarthritis of shoulers impingement of shoulders Drug toxicity (statins metabolic myopathy) Hypothyroidism Malignancies
Treatment for PMR
Corticosteroids (CS) -treatment of choice
Prednisone 15 to 20 mg per day 10mg
Relief within days -if symptoms do not promptly improve -consider another diagnosis
Normalization of ESR/CRP will occur over weeks following symptom improvement
Corticosteroid Treatment
Continue initial prednisone dose for 4 weeks
Taper to the lowest effective dose
Duration of therapy: 1-2 years
Relapses requiring increase in CS are common
Relapses should be based on clinical symptoms and not a rise in ESR/CRP alone
Adverse events of Corticosteroid treatment
Infection Glaucoma Cataracts Hypertension Diabetes Osteoporosis Skin atrophy Easy bruisability
How to monitor for GCA
Asking about GCA symptoms at follow-up visits
At clinic visits monitor examination for: - unequal blood pressures between extremities - bruits - new murmurs of aortic insufficiency
GCA/TA Characteristics
Inflammatory disease of large-and medium-sized vessels
Most commonly affected vessels:
extracranial branches of carotid arteries
primary branch arteries of aorta (any branch)
GCA histopathology
Granulomatous inflammation Multinucleated giant cells Inflammation causes luminal narrowing Visual loss Strokes
GCA epidemiology
Most common systemic vasculitis in humans
18 of 100,000 people
Mean age–74
Symptoms of GCA
Headache Jaw claudication PMR Fever Constitutional Amarosus fugax Irreversible blindness
Non specific symptoms of GCA
Cough
Throat pain
Tongue pain
Aortic branch vessel involvement
Arm or leg claudication
Complications associated with GCA
Stroke
Aneurysm formation
Visual complications
Visual loss –30%
Physical Exam for GCA
Abnormal temporal artery
Asymmetric blood pressures
Bruits
Murmur of aortic insufficiency
Diagnosis of GCA
Clinical features supported by laboratory values Erythrocyte sedimentation rate C-reactive protein– always high Thrombocytosis Elevated alkaline phosphatase No serological test specific for GCA Temporal artery biopsy --gold standard Imaging to look for large vessel involvement
Main treatment of GCA
Prednisone--treatment of choice Improves symptoms Prevents blindness Therapy should not be withheld to pursue biopsy Initial dose: Prednisone 40-60 mg per day
ASA for GCA
Daily, oral aspirin
81 mg per day
Reduce risk of stroke and blindness
No increased risk of gastrointestinal complications
Aspirin should be given to all patients with GCA who do not have contraindications.
Outcomes of GCA
Mortality risk from the late development of aortic aneurysms
-Dissection or rupture
Patients with GCA have 17x higher frequency of thoracic aortic aneurysm
Annual monitoring for aneurysm development
At clinic visits monitor examination for:
- murmur of aortic insufficiency - bruits - unequal blood pressures between extremities
