Should all patients with polymyalgia rheumatica have a vascular ultrasound assessment?

There is a growing appreciation that both giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are closely interrelated conditions that have significant overlap in aetiology, clinical characteristics and treatment regimens. Subclinical GCA in PMR is becoming increasingly recognised, and there is evolving evidence that this may be a more aggressive disease phenotype than PMR. Ultrasound (US) lends itself well as a screening tool for GCA in PMR; it is inexpensive, non-invasive, widely available, lacks ionising radiation, may be performed at the bedside and is recommended by EULAR as a first-line investigation for suspected GCA. There is insufficient evidence to currently recommend that all patients with PMR should have a US assessment for vascular involvement. However, as clinical and laboratory parameters alone do not accurately diagnose patients with subclinical GCA, we suggest that vascular US will be increasingly performed by rheumatologists in practice to identify these patients with PMR, preferably as part of larger prospective outcome studies.

Real-world outcomes of a dedicated fast-track polymyalgia rheumatica clinic.

OBJECTIVES: To examine the clinical impact of a fast-track PMR clinic to enable early diagnosis and treatment, and to define both patient and disease characteristics in newly diagnosed PMR. METHODS: Primary care physicians were invited to refer patients with new PMR to our fast-track clinic. Referral criteria included new onset shoulder or pelvic girdle pain and/or stiffness with elevated inflammatory markers in patients over 50 years. All patients were seen within 72 h of referral. Patients with a rheumatology diagnosis of PMR had an ultrasound (US) of their temporal and axillary arteries. RESULTS: 172 patients were referred from primary care over 12 months. 39% of patients referred with suspected PMR had an alternative diagnosis for which PMR regimen glucocorticoids was inappropriate. 55% of the non-PMR diagnoses were other inflammatory rheumatological conditions requiring follow-up. Only 20% of patients referred from primary care already on glucocorticoids were commenced on bone protection. PMR patients were co-morbid with a mean of 2.5 other conditions. 75% of PMR patients experienced a glucocorticoid-related adverse event in the first 12 months of treatment. 16% of patients with new PMR had ultrasound features of subclinical giant cell arteritis. CONCLUSION: The commencement of glucocorticoid therapy should be deferred until after specialist evaluation to enable an accurate clinical diagnosis. A delay in treatment can only realistically be avoided if GPs have access to a Fast-track PMR clinic. We believe that rheumatologists should consider establishing fast-track PMR clinics and this study provides a strong case for and a template to support this practice innovation.

Evolution of ultrasound in giant cell arteritis.

Ultrasound (US) is being increasingly used to diagnose Giant Cell Arteritis (GCA). The traditional diagnostic Gold Standard has been temporal artery biopsy (TAB), but this is expensive, invasive, has a false-negative rate as high as 60% and has little impact on clinical decision-making. A non-compressible halo with a thickened intima-media complex (IMC) is the sonographic hallmark of GCA. The superficial temporal arteries (STA) and axillary arteries (AA) are the most consistently inflamed arteries sonographically and imaging protocols for evaluating suspected GCA should include at least these two arterial territories. Studies evaluating temporal artery ultrasound (TAUS) have varied considerably in size and methodology with results showing wide discrepancies in sensitivity (9-100%), specificity (66-100%), positive predictive value (36-100%) and negative predictive value (33-100%). Bilateral halos increase sensitivity as does the incorporation of pre-test probability, while prior corticosteroid use decreases sensitivity. Quantifying sonographic vasculitis using Halo Counts and Halo Scores can predict disease extent/severity, risk of specific complications and likelihood of treatment response. Regression of the Halo sign has been observed from as little as 2 days to as late as 7 months after initiation of immunosuppressive treatment and occurs at different rates in STAs than AAs. US is more sensitive than TAB and has comparable sensitivity to MRI and PET/CT. It is time-efficient, cost-effective and allows for the implementation of fast-track GCA clinics which substantially mitigate the risk of irreversible blindness. Algorithms incorporating combinations of imaging modalities can achieve a 100% sensitivity and specificity for a diagnosis of GCA. US should be a standard first line investigation in routine clinical care of patients with suspected GCA with TAB reserved only for those having had a normal US in the context of a high pre-test probability.

Sarcoidosis manifesting during treatment with secukinumab for psoriatic arthritis.

Sarcoidosis is a multisystem inflammatory disorder of uncertain aetiology. There are numerous case reports of sarcoidosis occurring during treatment with biological immunotherapies. Here, we describe the case of a 52-year-old woman with psoriatic arthritis who developed multisystem sarcoidosis while being treated with secukinumab (anti-interleukin-17A) therapy which, to our knowledge, is the first such case. We discuss existing literature and hypothesise that IL-17 blockade may precipitate the development of granulomatous disease.