Polymyalgia Rheumatica and Giant Cell Arteritis

Slides:



Advertisements
Similar presentations
Anterior ischemic optic neuropathy (AION) Most common over 50 years Painless monocular over hours to days Visual acuity Visual field APD.
Advertisements

Polymalgia Rheumatica
Carpal Tunnel Syndrome Presented By NathaëlF Hyppolite RIII MF.
Headaches The Migraine headache is unilateral pain (affecting one half of the head) and pulsating in nature, lasting from 4 to 72 hours; symptoms include.
Case Presentation Lance C. Brunner M.D. Assistant Clinical Chief Department of Family Medicine.
Lyme disease. Borrelia Borrelia burgdorferi sensu stricto Borrelia garinii Borrelia afzelii.
Lananh Nguyen, M.D. Division of Neuropathology University of Pittsburgh Medical Center 72-year-old male with fever of unknown origin.
Polymyalgia Rheumatica (PMR) Temporal Arteritis (TA)
Headache Catriona Gribbin.
VISUAL LOSS IN THE ELDERLY
Achy shoulders and a very high CRP Sarah Tansley Rheumatology, Clinical Fellow.
History of PMR 1888 First described as senile rheumatic gout (Bruce) 1936Secondary fibrositis 1945Periarthrosis humeroscapular 1946Peri-extra-articular.
2008. Diagnostic criteria  At least 10 episodes fulfilling following criteria  Headache lasting 30 mins to 7 days  Has 2 at least 2 of the following.
AM Report Cat Hathaway 3/16/2010.  Proximal myalgia of the hip and shoulder girdles associated with morning stiffness (at least 1 hour)  Etiology is.
5) Migraine Throbbing pain lasting hours - 3 days Sensitivity to stimuli: light and sound, sometimes smells Nausea Aggravated by physical activity (prefers.
Kawasaki Disease Danielle Hann ST2 GPVTS Kawasaki Disease 80% cases aged 6/12 to 5 years Acute inflammatory vasculitis of medium sized arteries.
The Child With Joint Pain Diagnostic Clues
Vasculitis and connective tissue disease – just a taster!! The common and the rare!!
Fibromyalgia. Fibromyalgia What do you know about fibromyalgia? What do you know about fibromyalgia? Who gets it? Who gets it? What is the cause? What.
PMR & GCA Janet Pope Professor of Medicine Division of Rheumatology University of Western Ontario Polymyalgia Rheumatica (PMR) Giant-Cell Arteritis (GCA)
Objectives What is a vasculitis Know the more common and relevant vasulitides. Understand how to investigate and manage these conditions. Case scenario.
 70yo woman presents with sudden onset loss of vision in her right eye half hour ago  No improvement since  No previous ophthalmic history  What are.
Dr. amal Alkhotani Frcpc neurology, epilepsy
Imaging in headache patients “Incidentalomas” Giles Elrington Barts & The London
Vasculitis Hisham Alkhalidi.
Diagnosis and management of primary headache
Rheumatoid Arthritis Anila Malik GPVTS. Aims To cover the following: What is RA? Diagnostic criteria and clinical features Rheumatoid Factor Investigations.
Rheumatoid Arthritis(RA)
Giant cell arteritis and Polymyalgia rheumatica
Headache Dr. Mansour Al Moallem.
GIANT CELL ARTERITIS (Temporal or Cranial Arteritis)
Polymyalgia Rheumatica A micro-teach of BSR & BHPR guidelines
FIBROMYALGIA Rheumatology Module Anna Mae Smith, MPAS, PA-C.
Assessment Approach Dr. Hunt. Areas of Assessment Basic Medical record Urgent Symptom Disease Symptom-based condition.
Teaching NeuroImages Neurology Resident and Fellow Section © 2013 American Academy of Neurology.
Giant Cell Arteritis Julie Story July 27, Overview Typical case presentation Differential diagnosis Confirming the diagnosis Associated symptoms.
Sagittal FLAIR images - Stable nonenhancing hyperintensities within the pericallosal white matter and bilateral centrum semiovale, consistent with known.
Takayasu’s Disease Arteritis affecting primarily the aorta and its main branches –Leads to segmental stenosis, occlusion, dilatation, and aneurysm formation.
Inflammatory Illnesses. Aims Appreciate the impact of inflammatory illnesses on patients’ lives Know how to identify and manage common inflammatory disorders.
Vasculitides constitute a spectrum of diseases characterized by inflammation & necrosis of blood vessels with resulting ischemia of those tissues.
Polymyalgia Rheumatica By: Tiffany Zumbahlen And Sedona Hilt.
Polymyglia Rheumatica Abbie & Kayla. What PMR is: o Polymyalgia Rheumatica (or PMR) is a syndrome that involves having intense pain in your muscles. Especially.
Aortitis Infectious Noninfectious -takayasu disease
Case Discussion Dr. Raid Jastania. What is the outcome of inflammation?
POLYMYALGIA RHEUMATICA
OPTIC NEUROPATHIES 1. Clinical features 2. Special investigations
Rheumatoid Arthritis.
THE ROLE OF PLATELET COUNT IN DECISION-MAKING FOR SUSPECTED GIANT CELL ARTERITIS CS Bouchard, MD, AZ Ahmad, MD, WC Park, MD, B Hayek, MD, S Blatt, MS4.
Rheumatoid Arthritis Dr Chandini Rao Consultant Rheumatologist.
TULSA BONE & JOINT ANTOINE (TONY) JABBOUR, MD ORTHOPAEDIC SPORTS MEDICINE SURGEON KNEE AND SHOULDER SUBSPECIALTY CHAPTER 20 PAIN SYNDROMES CHAPTER 21 NERVE.
Chikungunya Retinitis
Dr. Zahoor 1. What is Vasculitis?  It is inflammatory disorder of blood vessels which causes endothelial damage.  Vasculitis is histological term describing.
جامعة الكوفه مركز تطوير التدريس والتدريب الجامعي Tention Headache اعداد د. محمد راضي رديف بورد طب جمله عصبيه كلية الطب – جامعة الكوفه 2015 م.
Dr. M.Sofi MD; FRCP (London); FRCPEdin; FRCSEdin.
POLYMYALGIA & GIANT CELL ARTERITIS
Acute Painless Loss of Vision
Polymyalgia Rheumatica & Giant-cell Arteritis
Normal TA. intima media adventitia Bluish curly line is internal elastic lamina.
POLYMYALGIA RHEUMATICA & GIANT CELL ARTERITIS
POLYMYALGIA RHEUMATICA & GIANT CELL ARTERITIS
POLYMYALGIA RHEUMATICA & GIANT CELL ARTERITIS
Headache Dr shinisha paul.
Dr Mohamad Shehadeh Agha MD MRCP(UK)
POLYMYALGIA RHEUMATICA
Overview of GCA. Giant Cell Arteritis: Timely Diagnosis and Emerging Treatment Strategies.
PMG Patient Information Evening
Giant Cell Arteritis and Polymyalgia Rheumatica Definition
L Alvarez 2018 Adjuncts to Steroid Treatment
Algorithm based on the 2015 European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) recommendations for the management of polymyalgia.
Important notes by the doctor
Presentation transcript:

Polymyalgia Rheumatica and Giant Cell Arteritis

Definition of Fibromyalga “Chronic and widespread pain located at 11 or more of 18 tender points”-ACR definition No specific diagnostic test and no cure.

Clinical manifestations Chronic and persistent pain with varying manifestations Diffuse musculoskeletal pain, stiffness and fatigue Joints not swollen painful or red Sensation such as tingling, numbness, burning, crawling are often described Pain is aggravated by change in weather, stress, fatigue, lack of sleep et cetera et cetera

Epidemiology 2% of all US citizens affected: 5.5 million Most common cause of generalized pain in women ages 20 to 50 Prevalence increases with age: 2% ages 20 to 35, with 8% at age 70 Females 10 times more common than males

                                   .                                    Source: “The Manual Tender Point Survey”, D. Sinclair, T. Starz, D. Turk Univ. of Pittsburgh, School of Medicine

Tender points Usually described with a number of kilos of pressure In reality no real guidelines 11 of 18 tender points Fraught with controversy

: Comorbid conditions Irritable bowel syndrome Chronic fatigue syndrome Migraine headache syndrome Sleep disorder Altered cognitive function TM problems

Differential diagnosis Polymyalgia rheumatica Dermato or polymyositis Hypothyroidism Rheumatoid arthritis Lyme disease Toxic myopathies secondary to statin exposure or fibric acid

Definitions Polymyalgia Rheumatica (PMR) – Inflammatory condition of unknown etiology. Giant Cell Arteritis (GCA) – Vasculitis of medium or large arteries of unknown cause They often occur together so are suspected to have the same underlying pathophysiology.

PMR Diagnosis is difficult and uncertain as the symptoms are non-specific. As such incidence is hard to predict. Shoulder and/or pelvic girdle pain with early morning stiffness forms the polymyalgic syndrome. There is no diagnostic test and is in many ways a diagnosis of exclusion.

Bird Criteria (3 or more) Bilateral shoulder pain or stiffness Onset of illness less than 2 weeks Initial ESR >40 Morning stiffness >1hr Age 65 or older Depression and/or weight loss Bilateral tenderness in upper arms

PMR Take care not to miss other causes of the symptoms PMR less likely to be the cause if: incomplete response to steroids, muscular weakness, prominent peripheral joint symptoms, lack of morning stiffness, unilateral symptoms. ESR/CRP are usually raised, normochromic normocytic anaemia is common, LFT’s esp AlkP may be abnormal.

PMR It’s complications are debility due to pain. 20% will develop GCA Response to steroid is rapid though some patients are hard to wean off steroids.

GCA 3 times more common in females Also known as temporal arteritis Affects cranial branches of arteries from arch of aorta and branches of ophthalmic artery. Associated with critical ischaemia : stroke blindness. These can occur very early in the disease.

GCA Rare if <50y old Unilateral headache most often in temporal region. Scalp tenderness classically noticed while brushing hair. Pain on chewing – claudication of muscles of mastication Fever, weight loss, fatigue, anorexia.

GCA Double vision or amaurosis fugax (transient painless loss of monocular vision of variable duration) Can have reduced visual acuity and/or visual field defects. Fundoscopy – oedema/pallor of optic disc small retinal haemorrhages may also be seen

GCA Include general CV examination – check BP both arms as aortic dissection can occur. Check peripheral pulses and listen for carotid bruits. The American College Of Rheumatology (ACR) is a helpful diagnostic criteria.

ACR Criteria for GCA (three or more needed) Age 50 or greater New type of headache Clinically abnormal temporal artery (thickened, tender or nodular decreased pulsation) ESR 50 or > Abnormal artery biopsy – necrotizing arteritis with mononuclear infiltrate or granulomatous infiltrate usually with multinucleated giant cells!

GCA Inflammatory markers are not always raised do not withhold treatment if strong clinical suspicion. As PMR normochromic normocytic anaemia is common as are abnormal LFT’s Use of temporal artery biopsy is debated - + confirms GCA but negative does not exclude due to skip lesions

GCA Large artery complications common Aortic aneurysm or dissection occurs in 18%!!! Patients with GCA have a higher risk of stroke/MI/CHF. A variety of neurological complications can also ensue Early adequate dose steroids prevent most complications.

GIANT CELL ARTERITIS Presentation Headache Scalp tenderness Thickened temporal arteries Jaw claudication Acute visual loss Weight loss, anorexia, fever, night sweats, malaise & depression

GIANT CELL ARTERITIS Temporal Artery Biopsy Arteries have skip lesions ultrasound/Doppler may help identify involved areas If positive, confirms diagnosis – helpful in management of future disease If negative, doesn’t exclude diagnosis, but need to think about an alternative diagnosis

Management of PMR and GCA Follows pattern of induction, maintenance and reduction of treatment. Most evidence for steroid dose is observational Oral prednisolone is the most common treatment used.

Management of PMR and GCA PMR no signs GCA Prednisolone 10-20mg od (after baseline investigations) 70% improve in 1/52 Inflammatory markers improve in 3-4/52 2) GCA without visual disturbance 40-60mg prednisolone od R/V at 48hrs sooner if visual disturbance

Management of PMR and GCA 3) GCA with visual disturbance - Medical emergency 60mg prednisolone urgent admission to ophthalmologists

Maintenance PMR and GCA continue dose steroid for up to 4 weeks then can be decreased every 2-4weeks 5mg a time in GCA and 2.5mg in PMR. When on 10mg decrease every 4-6weeks by 1mg When on 7mg maintain at this for 12months before reducing further. Steroids should only be stopped if proximal pain and morning stiffness have resolved. Helpful to monitor CRP/ESR during above Can relapse requiring step up in steroid again

Who and when to Refer? GCA any with visual symptoms even if on treatment should be referred on that day to ophthalmology. Other patients with GCA – routine referral to rheumatology or general medicine for shared care. PMR can be managed in GP setting Consider secondary care referral if doubt as to diagnosis, poor response to treatment or adverse effects with steroid treatment.

Considerations Don’t forget long term risks of steroid treatment especially if used for 12-24+months Frequent BP and bloods should be offered Osteoporos is important consideration Encourage increased activity

Summary PMR – pain+stiffness proximal muscles GCA vasculitis – headaches/scalp tenderness GCA vasculitis – headaches/scalp tenderness GCA can cause irreversible blindness ESR + CRP are commonly raised in GCA +PMR Dramatic response to corticosteroids in both Relapse common during steroid reduction Patients require long term steroids thus use osteoporosis prophylaxis as per local guidelines.