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Achy shoulders and a very high CRP

Achy shoulders and a very high CRP. Sarah Tansley Rheumatology, Clinical Fellow. Case discussion. A case of polymyalgic onset rheumatoid arthritis was discussed – details removed for confidentiality purposes. PMR diagnosis. Core Inclusion criteria Age > 50

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Achy shoulders and a very high CRP

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  1. Achy shoulders and a very high CRP Sarah Tansley Rheumatology, Clinical Fellow

  2. Case discussion A case of polymyalgic onset rheumatoid arthritis was discussed – details removed for confidentiality purposes.

  3. PMR diagnosis • Core Inclusion criteria • Age > 50 • Bilateral shoulder or pelvic girdle aching or both • Morning stiffness >45 minutes • Evidence of acute phase response • No active cancer, active infection or active GCA • No urgency to start steroids – can investigate first

  4. Factors which Increase the likelihood of a non-PMR diagnosis • Age <60 years • Chronic Onset • Lack of shoulder involvement • Lack of inflammatory stiffness • Normal or very high CRP • Peripheral arthritis • Systemic symptoms, weight loss, neurological signs • Incomplete or non-response to steroids 15mg Prednisolone should result in >70% improvement within 1 week and normalisation of inflammatory markers within 4 weeks

  5. Who to refer • BSR guidelines recommend specialist referral when • Age <60 • Chronic onset >2 months • Lack of shoulder involvement • Lack of inflammatory stiffness • Prominent systemic features; weight loss, night pain, neurological signs • Features of other rheumatic disease • Normal or extremely high acute phase response • Treatment dilemmas (inadequate response to steroids, inability to reduce steroids, contraindication to steroids etc)

  6. RA diagnosis • Aim for early diagnosis and treatment but lack of features of established disease can cause difficulty • Considerable variability in presenting symptoms and lab results • History • Polyarticular involvement –may be small number of joints initially • Morning stiffness (>30 minutes) suggests inflammatory joint pain • Chronicity • Examination • Joint tenderness MCP, MTP, wrists • RA nodules, not usually seen until later • Upper and lower extremity involvement

  7. Synovitis

  8. Rheumatoid Arthritis Investigations • No single diagnostic test • Serology • RF • Positive in 70-80% of patients with RA • May be negative, especially early • Also seen in other conditions eg Sjogrens Syndrome • Positive in 5-10% of healthy individuals • Anti- CCP Abs • As sensitive • Much more specific

  9. Rheumatoid Arthritis Investigations • Inflammatory markers • Non-specific • Useful for distinguishing inflammatory conditions from non-inflammatory • Full blood count • Anaemia of chronic disease, leucocytosis, thrombocytosis • Radiology • Erosions of cartilage and bone • Presence more useful diagnostically with increasing duration of disease

  10. Radiology

  11. ACR/EULAR classification criteria • Designed to classify patients as RA earlier for purpose of clinical trials – not diagnostic criteria • Still useful, several differences from 1987 criteria which aimed to classify people with established disease • Target population • At least 1 joint with definite synovitis/swelling • Synovitis not better explained by another disease • Score >6 classified as RA

  12. Polymyalgic onset RA • Bajocchi et al 2000 • LO-RA vs YO-RA • Polymyalgic symptoms more common in LO RA • Higher frequency of shoulder involvement in LO RA • Lopez-Hoyos et al 2004 • Anti-CCP Abs in differential diagnosis of RA vs PMR • 65% LO RA anti-CCP Ab +ve • No PMR patients anti-CCP Ab +ve • Polymyalgic onset RA 2/10 anti-CCP +ve

  13. Polymyalgic onset RA • Gran, Mykebust 1999 • Incidence and Characteristics of peripheral arthritis in PMR & TA • 231 patients prospectively studied 1987-1993 • All ?PMR/TA in Norwegian county referred to rheumatology before treatment • Followed throughout the disease course • 187 ‘pure’ PMR • 38.5% developed peripheral arthritis • 11 developed RA (4.8% 6 female and 5 male)

  14. Polymyalgic RA • Mean duration of PMR at RA diagnosis was 63.2 months • 5/8 patients had erosive x-ray changes • 6/11 patients had positive RF (all negative initially) • Mean CRP higher at diagnosis among those who developed arthritis (88.6 vs 59.7)

  15. Polymyalgic onset RA • Pease et al 2009 • Prospective study of 147 patients presenting with PMR & 142 patients with LO-RA • Reviewed accuracy of initial diagnosis • 23% PMR patients had peripheral synovitis • In contrast to seronegative LO-RA, PMR patients younger, myalgia more frequent, PIP/MCP/wrist arthritis less frequent • Combination of wrist + MCP and/or PIP highly suggestive of RA

  16. Polymyalgic onset RA • Pease et al 2005 • 349 patients with new onset LO-RA, PMR or TA >60 yrs • 9/171 initially diagnosed PMR changed to LO-RA • All 9 dependant on higher steroid dose than typically expected for their stage of disease • Initially synovitis suppressed by steroidsbut returned when dose lowered • Initial plasma viscosity higher in this group (mean of 2.0 vs 1.86) • Difficulty to distinguish may lead to delay in correct diagnosis (average 13 months)

  17. Summary • Several challenges in diagnosing RA, particularly early in the disease course • Variety of possible presentations • Polymyalgic symptoms are common in elderly onset RA • May lead to diagnostic delay • No single diagnostic test; clinical history and examination important

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