Challenges in the diagnosis of polymyalgia rheumatica and related giant cell arteritis

ABSTRACT

Introduction

Polymyalgia rheumatica (PMR) has emerged as a relatively common condition in Western countries. Although the diagnosis is relatively straightforward in people over 50 years of age who complain of sudden onset of pain and stiffness in the shoulder and hip girdles along with elevation of biomarkers of inflammation, manifestations of polymyalgia can also occur in the context of different conditions. For this reason, a complete history and examination is required, including looking for symptoms and signs suggestive of giant cell arteritis (GCA).

Areas covered

The review describes when and how to identify PMR, as well as when to suspect the presence of associated GCA or multiple conditions mimicking PMR.

Expert opinion

PMR does not have a specific diagnostic test. For this reason, a thorough clinical history searching for clinical data of GCA is needed. Moreover, the possibility of other diseases mimicking PMR should be considered, particularly when atypical presentation or unusual clinical data are present.

KEYWORDS:

• Polymyalgia rheumatica
• disease presentation
• diagnosis
• giant cell arteritis, mimics

Article highlights

• PMR is a relatively common condition in individuals older than 50 years from Western counties.

• Bilateral shoulder and hip girdle involvement along with elevation of acute-phase reactants (erythrocyte sedimentation rate [ESR] and C-reactive protein [CRP]) as well as negative findings for rheumatoid factor/anti-citrullinated protein antibodies are typical of this condition.

• In some cases, PMR may present with low or more rarely with normal values of ESR and/or CRP but at least with elevated levels of fibrinogen.

• PMR may be the presenting manifestation of giant cell arteritis (GCA). Therefore, thorough assessment to exclude GCA in patients presenting with PMR is needed.

• Different conditions, including rheumatic/autoimmune diseases could mimic PMR.

• Infections and solid and hematologic malignancies among other conditions have to be ruled out before treatment indicated for PMR or the atypical presentation may help us suspect that the condition is not a ”pure” PMR.

Declaration of interest

M González-Gay received grants/research support from Abbvie, MSD, and Roche, and had consultation fees/participation in company-sponsored speaker’s bureau from Amgen, Roche, Sanofi, and Lilly. S Castañeda had consultation fees/participation in company-sponsored speaker’s bureau from BMS, Roche and UCB. S Castañeda is assistant professor of the cátedra EPID-Future, funded by UAM-Roche, Universidad Autónoma de Madrid (UAM), Spain. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

Funding for this study were provided by the Instituto de Salud Carlos III (Spain) through grants PI22/01263 (PI: Dr. Miguel A. González-Gay) and PI21/01474 (PI: Santos Castañeda), co-funded by the European Union (FEDER Funds, European Regional Development Funds, “A way of making Europe”), and the Red de Investigación RICORS RD21/0002/0025(Spain) (PI: Miguel A. González-Gay).