Polymyalgia rheumatica (PMR) is a chronic musculoskeletal disorder that causes aching and stiffness about the upper arms, neck, lower back and thighs. It is a common cause of widespread aching and stiffness that affects adults over the age of 50, especially Caucasians. It may also occur with giant cell arteritis. Because PMR does not often cause swollen joints, it may be hard to recognize.
PMR is clinically diagnosed based on symptoms, but accurate diagnosis is difficult because the symptoms may occur in many other rheumatic diseases. Recent research suggests that ultrasonography used in shoulder joints could detect findings specific to PMR, such as biceps tenosynovitis and subdeltoid bursitis. While MRI may visualize bone and muscle lesions, its application in PMR has not been established, so this cross-sectional, follow-up study evaluated gadolinium-enhanced MRI findings in the shoulder of PMR patients to assess whether it could improve diagnostic accuracy and prognosis prediction.
“The diagnosis of PMR remains challenging. Bird’s Classification Criteria composed of the combination of clinical symptoms is highly sensitive to detect PMR but is low in specificity and requires careful diagnosis of exclusion,” says Kazuro Kamada, MD, a rheumatologist at Tomakomai City Hospital in Japan, and the study’s lead author. “The EULAR/ACR Provisional Classification Criteria using ultrasound findings improved specificity, but the sensitivity was not enough. So, we need a new diagnostic tool with high specificity and sensitivity for PMR.”
Participants in the study included 175 patients with bilateral shoulder pain who fulfilled the Bird classification criteria for PMR between June 2012 and June 2018 at Tomakomai City Hospital. Out of these, 137 patients received both gadolinium-enhanced MRI and ultrasonography on their shoulders. At least two rheumatologists diagnosed PMR in 58 of the patients, and independent radiologists evaluated their MRI and ultrasonography findings. Patients diagnosed with PMR were prescribed 20 mg/day of prednisone initially, and then this dose was tapered after remission. The researchers followed patients until June 2019 to determine any recurrences of PMR symptoms.
The MRI findings in the study’s patients included enhancement of joint capsule, rotator cuff tendon or biceps tendon, synovial hypertrophy, shoulder joint effusion, enhancement of glenohumeral joint, and/or focal or diffuse bone edema in the humerus heads. These findings showed that PMR patients had significantly frequent enhancement of joint capsule or rotator cuff tendon and focal bone edema in humerus heads. When the researchers used these three findings in combination to diagnose PMR, MRI had 76 percent sensitivity and 85 percent specificity, higher compared to ultrasonography findings, which had 50 percent sensitivity and 72 percent specificity. During follow-up, 24 or 44 percent of the patients had a recurrence of PMR. Patients with recurrent PMR were younger in age, had less enhancement of their rotator cuff tendon and more synovial hypertrophy findings on their MRI.
These findings lead the study’s authors to conclude that Gadolinium-enhanced MRI of the shoulder can play a useful clinical role in patients with PMR, contributing to diagnostic accuracy and prediction of recurrence in patients with this rheumatic disease.
“Rheumatologists will diagnose PMR with confidence using gadolinium-enhanced MRI with high sensitivity and specificity, which will lead to decreasing misdiagnosis of PMR,” says Dr. Kamada. “Moreover, rheumatologists can consider using disease-modifying anti-rheumatic drugs from the early stage for PMR patients if recurrences can be predicted by gadolinium-enhanced MRI. We are going to validate the results in a larger cohort next in order to optimize and standardize the gadolinium-enhanced MRI procedure for PMR to apply in real-world clinical practice.”
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Gadolinium-Enhanced Magnetic Resonance Imaging in Shoulders Contributes Accurate Diagnosis and Predicting Recurrence to Patients with Polymyalgia Rheumatica
Background/Purpose: Polymyalgia rheumatica (PMR) is a glucocorticoid-responsive muscle pain and stiffness, especially in the shoulders and hips. PMR is clinically diagnosed based on the symptoms, although accurate diagnosis is difficult because the symptoms can occur in many other rheumatologic and inflammatory conditions. Recently, it was reported that ultrasonography (US) in shoulders could detect the specific findings to PMR, such as biceps tenosynovitis and subdeltoid bursitis. Magnetic resonance imaging (MRI) also has an advantage of visualizing bone and muscle lesions; however, the application to PMR diagnosis has not been established yet. In this study, we evaluated gadlinium-enhanced MRI findings of the shoulder in patients with PMR. The purpose of this study is to assess whether gadlinium-enhanced MRI could improve diagnostic accuracy and prognosis prediction in patients with PMR.
Methods: This study included the consecutive patients who had bilateral shoulders pain and fulfilled the Bird classification criteria for PMR between June 2012 and June 2018 in Tomakomai City Hospital. Gadlinium-enhanced MRI and US in shoulders were performed in the all patients. We excluded patients declining participation in the study or having contraindications of gadlinium-enhanced MRI. PMR was diagnosed by at least two rheumatologists. MRI and US findings were evaluated by independent radiologists. 20 mg/day of prednisolone was initially administered to patients with PMR and was tapered after remission. They were followed-up until June 2019 about recurrences.
Results: 269 patients visited our hospital complaining of bilateral shoulders pain, and 175 of them fulfilled the Bird classification criteria for PMR. 137 patients received gadlinium-enhanced MRI and US examinations, and PMR was diagnosed in 58 patients. Enhancement of joint capsule (Fig. 1A), rotator cuff tendon (B) or biceps tendon (C), synovial hypertrophy (D), shoulder joint effusion (E), enhancement of glenohumeral joint (F) and/or focal (G) or diffuse (H) bone edema in humerus heads were found in the patients. Of these MRI findings, enhancement of joint capsule or rotator cuff tendon and focal bone edema in humerus heads were significantly frequent in the PMR patients. If the three findings on MRI were used in combination to diagnose PMR, the sensitivity and specificity were 76% and 85%, respectively, higher than 50% and 72% of US findings (Fig. 2). In the follow-up study, PMR recurred in 24 patients (44%). Patients with recurrent PMR had younger ages, less enhancement of rotator cuff tendon and more synovial hypertrophy findings on MRI (Fig. 3).
Conclusions: Gadolinium-enhanced MRI displayed capsulitis, rotator cuff tendonitis and focal osteitis in shoulders, relatively specific to patients with PMR. Besides, rotator cuff tendonitis and synovial hypertrophy on MRI were associated with recurrences of PMR. Our study suggested that gadolinium-enhanced MRI in shoulders could contribute accurate diagnosis and predicting recurrence to patients with PMR.
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