Fortnightly review: Polymyalgia rheumatica and temporal arteritis: diagnosis and management

Introduction

Polymyalgia rheumatica and temporal arteritis are regarded as clinical syndromes affecting elderly people. They may occur in the same patient, producing constitutional symptoms with increased acute phase reactants. Both syndromes respond rapidly to corticosteroids, and in both syndromes temporal artery biopsy may show arteritis with giant cells (biopsy proved giant cell arteritis). The syndromes are considered to be different manifestations of giant cell arteritis. Dixon et al obtained 10 positive temporal artery biopsy samples in 29 patients with polymyalgia rheumatica.2

The incidence of temporal arteritis, whether diagnosed clinically alone or confined to biopsy proved cases, varies geographically. The disease is almost always confined to white people, and the incidence is higher in Scandinavia and northern Europe (between 17 and 18 cases per 100 000 population aged over 50)1 3 4 than in middle France, Spain,4 and Israel.5

The incidence of polymyalgia rheumatica alone is more difficult to determine. Salvarini et al studied the incidence of polymyalgia rheumatica in northern Italy and found a figure of 12.7 cases/100 000 population aged over 50.6 By contrast, studies from Sweden and Denmark using the same definition of polymyalgia rheumatica obtained figures of 20.47 and 68.3/100 000.1

Clinical presentation

Giant cell arteritis rarely presents below the age of 50.8 It affects many arteries throughout the body, producing symptoms and signs which mimic many other medical and surgical conditions.

Jones has suggested a useful classification of the presenting symptoms of giant cell arteritis9:

1. Systemic–malaise, anorexia, fever, night sweats, weight loss, and depression

2. Myalgic–proximal, symmetrical muscle pain and stiffness of polymyalgia rheumatica

3. Arteritic–involvement of the artery may produce:

1. Pain, swelling, erythema, and tenderness over the affected artery

2. Partial occlusion resulting in “claudication-like” symptoms

3. Total occlusion resulting in ischaemia and necrosis of structures supplied by the …