The support of the ultrasonography of the shoulder in the diagnosis of polymyalgia rheumatica with normal erythrocyte sedimentation rate

Abstract

The Polymyalgia Rheumatica (PMR) is a cronic inflammatory syndrome that affects the elderly population and whose diagnosis is mainly based on clinical criteria taking little advantage of the latest innovatory methods of diagnostic imaging, for instance ultrasonography. Although it is generally characterised by increasing of inflammation values as well as pain and stiffness on the shoulder and pelvic girdles, there is a significant percentage of patients with PMR whose erythrocyte sedimentation rate (ESR) is normal; in this case to make a diagnosis is difficult. The purpose of our study is to demonstrate how useful ultrasound investigations on the shoulders joints could be in order to make a diagnosis of PMR, especially for those patients with atypical normal ESR. Our case control study included 23 patients with atypical PMR and 88 patients with standard symptomatic PMR; both groups underwent shoulder ultrasound scans before receiving steroid therapy. As it has been previously shown, the ultrasound method is able to detect distinctive aspects in the joints and tissues of the patients with PMR; so that we could find that 90% of the patients with PMR of both groups suffered from bilateral subdeltoid bursitis. This disorder is seldom found in healthy people and consequently its presence could be considered a useful diagnostic test/check for/of PMR independently from ESR values

Musculoskeletal ultrasound in the evaluation of Polymyalgia Rheumatica

“…Moreover, the studies conducted by Zaccaria et al and Jimenez et al in 2009 identified the absence of significant differences in the US pattern in patients with normal or high erythrocyte sedimentation rate (ESR). In addition, even in the presence of a parallel decrease in the findings, the authors did not find significant correlation between changes of clinical, laboratory and US parameters during the follow-up period [20,26].…”

“…However, the prevalence of SAD bursitis resulted higher compared to LBT tenosynovitis in the majority of the studies, suggesting this lesion as the inflammatory hallmark in PMR [13,[18][19][20]22,25,26]. Moreover, as reported in Table I, a frequent US finding was the identification of bilateral involvement both at shoulder and hip level [19,21,[25][26][27].…”

“…Three studies analyzed the correlations between US inflammatory findings and laboratory data [19,20,26]. No significant correlations between disease activity biomarkers and US findings were identified by Macchioni et al: in particular, at the evaluation performed at 24 weeks follow-up, 59.1% of patients in clinical remission or with low disease activity (Leeb's DAS < 7) showed persistent inflammatory lesions at the US evaluation [19].…”

“…As shown in table I, most of them were cross-sectional studies, were performed in Southern European countries (above all Italy) and described the main inflammatory US lesions at disease onset or during relapse. Except for the study of Zaccaria et al, they were conducted in small groups of PMR patients [12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28]. In terms of clinical assessment, when patients were investigated for the presence of symptoms, shoulder pain was the most frequent complain.…”

“…An extensive polyarticular US examination was performed in two studies which were focused on the comparison between PMR and Rheumatoid arthritis (RA) [21][22]. Concerning the scoring system used for grading the severity of inflammatory lesions, in the majority of studies exclusively a binary assessment was applied [12,13,19,[22][23][24]; in a few of them a semiquantitative 0 to 3 score was used [18,25,26], and finally, in two cases both scoring methods were applied [21][22][23][24][25][26][27].…”