1. Polymyalgia Rheumatica (PMR) Temporal Arteritis (TA)

2. Diagnostic Criteria- PMR (healey 1984) 1.Age> 50 yrs 2.Pain corresponding to proximal muscles of the limbs. 2 out of 3 regions: neck, shoulder & pelvic girdle. Symptoms> 1 month 3.Morning stiffness> 1 hr 4.Elevated ESR (>40 mm/hr) 5.Rapid response to low dose of steroids

3. Diagnostic Criteria- TA (ACR 1990) 1.Age> 50 years 2.Recent localized headache 3.Temporal artery abnormality 4.Elevated ESR 5.Temporal biopsy positive for vasculitis * Diagnosis ≥ 3

4. Epidemiology Central+north of Europe, north America Mainly Caucasian Women>men X2-3 Older age 90%> 60 years Annual prevalence: TA: 6.7/10 5 PMR: 53/10 5

5. Etiology Genetic tendency (familial+ethnic). HLA-DR 4 Infectious agent? (Clusters of cases+annual variation) Immune response involving 2 processes: a.An immune response with presence of active mononuclear cells in peripheral blood (IL-6) +systemic symptoms. b.Granulomatotic inflammation with involvement of CMI against Ag in the inner elastic membrane or near

6. Pathology 1.Lymphocytic infiltration (CD4) near the elastica 2.Thickening of the intima without prominent infiltration 3.Massive infiltration: lymphocytes+macrophages+giant cells+granulomas 4.Necrosis of the arterial wall 5.Thrombosis of blood vessels in inflamed areas 6.Recanalization

10. Arteries Involved: - Superficial temporal, Vertebral, Posterior Ciliary, Ophtalmic - Central retinal, Carotid, Subclavian, Brachial, Aorta,

11. Clinical Features The onset usually insidious I. Constitutional symptoms II. TA III. PMR

12. I. Constitutional Symptoms 1.Fatigue, depression 2.Anorexia, weight loss (50%, 6 Kg) 3.Fever (50%) 15% of cases with FUO age>65 yrs TA

13. II. Temporal Areteritis 1.Headache- often localized to temples or occiput (2/3). On physical exam: Nodular, thickened, tender vessel +absent or weak pulse 2.Ophthalmic manifestation: 20-50%. a. Diplopia b. Ptosis c. Visual loss: 6-10%. Usually sudden, painless and permanent. Fundus: Anterior>Posterior ischemic optic neuropathy

15. II. Temporal Areteritis 3. Neurological manifestation: 30% a. Peripheral neuropathy b. Involvement of carotid or vertebrobasilar TIA, CVA 4. Jaw claudication 5. Sore throat 6. Hoarseness

16. II. Temporal Areteritis 7. Occlusion of large as: 10-15%. a. Claudication of the hands. On exam: Bruits + weak pulses b. Raynaud phenomenon c. Aneurysm, dissection of thoracic aorta- late

17. III. Polymyalgia Rheumatica 1.Arthralgia/myalgia. Usually starts in neck, shoulder +pelvic girdle Symetrical Infrequent distal involvement On exam: muscle strength usually unimpaired 2. Morning stiffness 3. Night pains 4. Tenderness of periarticular structures: capsule,bursa, tendon 5. +Mild & transient synovitis usually knees, wrists, SCJ

18. Relationship between PMR & TA 1.Similar Age & sex & ethnic distribution 2.In both + systemic features 3.10-15% of PMR have positive temporal biopsies 4.Good response to steroids 5.40-60% of TA patients +PMR 6.20-40% of TA patients PMR is the presenting symptoms * PMR may precede, coincide with or follow TA

19. Investigations 1.ESR 2.Anemia-normocytic, mild to moderate 3.ILFT- 30%, ALP (70%) 4.RF, ANA- negative 5.Doppler of temporal as 6.CT, MRI if involvement of large as is suspected 7.Temporal biopsy

20. Differential Diagnosis 1.Malignancy a. Solid tumors b. Hematological malignancy: MM, Leukemia, Lymphoma 2. Joint diseases a. OA, especially +cervical involvement b. RA c. Collagen vascular diseases

21. Differential Diagnosis 3. Muscles diseases a. Polymyositis b. Myopathy 4. Chronic infections a. SBE b. osteomyelitis 5. Hypothyroidism 6. Parkinson disease 7. Functional

22. Treatment 1.Steroids a. Initial dose PMR: 10-20 mg of prednisone per day TA: 40-60 mg per day +Eye involvement: Pulse IV methylprednisolone 1 gr X 3 ds b. Gradual decease of steroids dose 2. Steroid sparing agents: Methotrexate