Swollen joints and peripheral arthritis are signs of malignancy in polymyalgia rheumatica

Absence of Long-Lasting Morning Stiffness at the Time of Diagnosis as Paraneoplastic Warning in Patients with Polymyalgia Rheumatica (PMR): Data from Italian Single-Center Study

BACKGROUND

There is little literature on the paraneoplastic value of the absence of long-lasting morning stiffness (MS) at the time of diagnosis of polymyalgia rheumatica (PMR). We investigated whether and to what extent this finding was related to the probability of diagnosing a neoplasia.

PATIENTS AND METHODS

This was an observational, retrospective, single-center cohort study. We enrolled all patients consecutively referred to our rheumatologic outpatient clinic between January 2015 and December 2020, who could be classified as PMR according to 2012 EULAR/ACR criteria. In particular, we assessed all patients scoring a minimum of five points with a combination of clinical and ultrasound (US) criteria. The exclusion criteria were as follows: (a) follow-up duration <two years; (b) malignancy prior to PMR; (c) first-degree familiarity of malignancy; (d) incomplete data; and (e) diagnostic change during follow-up in different rheumatologic diseases.

RESULTS

143 patients (108 women; median age: 71.5 years) were enrolled, and 35 of them did not have long-standing MS at the time of PMR diagnosis. In 10 patients (6.9%), a neoplasia was diagnosed in the first 6 months of follow-ups; among these, 7 did not have long-lasting MS. Among the remaining 133 PMR patients without subsequent malignancy, 28 did not have long-lasting MS. The odds of cancer were 0.114 (C.I. 95% 0.028, 0.471). Long-lasting MS was inversely associated with the development of neoplasias. In all eight PMR patients diagnosed with solid cancers during follow-ups, the removal of the neoplastic mass led to a fast disappearance of clinical, ultrasound and laboratory findings, thus supporting the diagnosis of paraneoplastic PMR. Finally, a positive response to glucocorticoids (GCs) was present in 100% of the 28 PMR patients without long-lasting MS at the time of diagnosis and without neoplasia during their follow-ups. On the contrary, a positive response to GCs was present in 71% of PMR patients without long-lasting MS and neoplasias during follow-up. Among the variables we assessed, a positive response to GCs was the only one that was statistically significant (p < 0.0001). These data suggested that an inadequate response to GCs in PMR patients without long-lasting MS at the time of diagnosis should strengthen investigations to rule out neoplasias.

CONCLUSIONS

The absence of long-standing MS at the time of diagnosis can be a paraneoplastic warning in patients classified as PMR. A thorough investigation is therefore needed in this subset of patients to rule out neoplasia, before diagnosing an idiopathic PMR and starting treatment with GCs.

Clinical analysis of gender and pre-existing diabetes mellitus in patients with polymyalgia rheumatica: A retrospective study in a Japanese population

OBJECTIVE

This study clarifies the involvement of gender and pre-existing diabetes mellitus (DM) in the clinical characteristics of polymyalgia rheumatica (PMR).

METHODS

The clinical records of patients diagnosed with PMR in our department between January 2011 and June 2021, especially in terms of gender and DM were retrospectively analysed.

RESULTS

We identified 89 patients with the median age of 75.37 cases were men and 52 cases were women. Pre-existing DM was found in 21 patients (23.6%). Male PMR patients exhibited a higher complication rate of pre-existing DM and C-reactive protein (CRP) levels at diagnosis (p = .04 and p < .01, respectively) than female patients, and men were more common in the patient group with pre-existing DM (p = .04). The CRP levels of male PMR patients without pre-existing DM were higher than female PMR patients without pre-existing DM.

CONCLUSION

Male PMR patients might have a varying pathophysiology from female patients in terms of high inflammation levels accompanied by a high prevalence rate of pre-existing DM and need a gender-specific approach.

Fast track clinic for early diagnosis of polymyalgia rheumatica: Impact on symptom duration and prednisolone initiation

OBJECTIVES

To evaluate the efficacy of a fast track clinic (FTC) for patients suspected of polymyalgia rheumatica (PMR) regarding symptom duration, prednisolone initiation before rheumatological assessment, number of hospital contacts before diagnosis, and cancer diagnosis.

METHODS

It is a retrospective cohort study with a one year follow-up period. Patients referred to the FTC (1st August 2016 to 25th June 2019) were compared to a historical cohort of PMR patients (1st August 2014 to 1st August 2016). Referral criteria are: age over 50, symptoms of PMR but not cranial GCA, and increased C-reactive protein. Data were obtained from patient journals.

RESULTS

Ninety-seven PMR patients in the historical cohort and 113 FTC patients, of whom 83 patients had PMR, were included. The median (interquartile range) number of days from symptom onset until PMR diagnosis were 53 (31-83) days in the FTC versus 80 (58-132) days in the historical cohort (P<0.001). Prednisolone was prescribed before rheumatological assessment to 11% in the FTC versus 42% in the historical cohort (P<0.001). Patients in the FTC had significantly fewer contacts with the hospital before the diagnosis compared with the historical cohort. Four patients in the FTC were diagnosed with a cancer, all of which were found by imaging.

CONCLUSION

The FTC reduced the time from symptom onset until diagnosis, lowered prednisolone initiation before rheumatological assessment, and resulted in fewer hospital visits. The frequency of cancers was low in patients suspected of PMR and cancers were discovered by imaging.