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Polymyalgia rheumatica and the american rheumatism association criteria for rheumatoid arthritis.

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arthritis
and
rheumatism
Official journal of t h e American Rheumatism Association Section of t h e Arthritis Foundation
CURRENT COMMENT
POLYMYALGIA RHEUMATICA AND THE
AMERICAN RHEUMATISM ASSOCIATION CRITERIA
FOR RHEUMATOID ARTHRITIS
LOUIS A . HEALEY
Rheumatologists, particularly those whose
practices include many older patients, recognize that it
is often difficult to differentiate polymyalgia rheumatics from the onset of rheumatoid arthritis. This similarity has prompted reports of rheumatoid arthritis
presenting (1) or masquerading (2) as polymyalgia
rheumatica. It has long been recognized that in patients over age 60, the presentation of rheumatoid
arthritis is often quite different from the same disease
in younger patients (3). Constitutional symptoms, pronounced morning stiffness, and a rapid sedimentation
rate may overshadow the joint manifestations, which
localize primarily in the shoulders and hips. In this
guise-the anarthritic rheumatoid syndrome described
similarities to polymyalgia rheuby Bagratuni (4)-the
matica are obvious. These are the considerations that
led Ehrlich to suggest that pol ymyalgia rheumatica and
rheumatoid arthritis may be essentially the same disease (5).
With the recognition that polymyalgia rheumatics may be a symmetric synovitis, it is easy to
understand the confusion. Evidence for synovitis has
now accumulated from radioactive scans (6), biopsies
(7), arthroscopy (8), and clinical findings. In a series of
246 patients with polymyalgia rheumatica followed at
the Mason Clinic over a period of 16 years, clinical
manifestations of synovitis were found in 77 (9). Knee
effusions and swelling of the wrists, often with carpal
tunnel syndrome, were encountered most frequently;
From the Mason Clinic. Seattle, Washington.
Address reprint requests to Louis A. Healey, MD, The
Mason Clinic, 1100 Ninth Avenue, PO Box 900, Seattle, WA 981 1 1 .
Submitted for publication April 18, 1983: accepted in revised form July 1 1 . 1983.
Arthritis and Rheumatism, Vol. 26, No. 12 (December 1983)
small joints of the hands and feet were rarely involved.
Carpal tunnel symptoms in polymyalgia rheumatica are assumed to be due to compression of the
median nerve by synovitis within the tunnel, as in
rheumatoid arthritis. Effusions in the knee joint were
detected in 37 patients and fluid was aspirated in 14.
Effusions could be sizable, with aspirates of 30-150 cc,
and were inflammatory, with counts ranging from
5,900 to 21,000 white cells/mm'. No crystals were
present and polymorphonuclear leukocytes predominated. Synovitis was not detectable clinically in the
shoulders or hips, but it is m y belief that synovial
inflammation is the explanation for the pronounced
stiffness in shoulder and pelvic girdles on first arising
in the morning, described by patients with polymyalgia
rheumatica.
The synovitis in our patients was relatively
mild, confined to several joints, likely to appear either
at the onset of disease or when the steroid dose was
rapidly tapered, readily controlled by steroid alone,
and did not cause joint deformity or erosive radiographic changes. Swelling usually responded rapidly
to steroid treatment (5-10 mg prednisone daily), but in
4 patients knee effusions recurred and persisted for 3
to 6 months before eventually subsiding.
It might be argued that these patients had what
has been reported as benign rheumatoid arthritis of the
aged (10). Indeed, they are similar to the 4 reported
patients with rheumatoid arthritis presenting as polymyalgia rheumatica (1,2). However, it is significant
that none of the 77 patients with synovitis had a
positive rheumatoid factor, developed joint damage,
or had radiographic evidence of erosions during the
followup period of 2 to 16 years (mean 6 years). In
1418
addition, 12 of them had biopsy-proven temporal arteritis.
Classification as rheumatoid arthritis. Patients
have been classified as having rheumatoid arthritis on
the basis of the well-known American Rheumatism
Association (ARA) criteria (1 I). Sixteen of our study
patients with polymyalgia and evident synovitis could
have been labeled as having definite rheumatoid arthritis since they had morning stiffness and bilateral
symmetric joint swelling (criteria 1 through 5) persisting for at least 6 weeks. The question as to whether
their disease should be called polymyalgia rheumatica
or benign seronegative rheumatoid arthritis is not
merely semantic. By whatever name, the course and
prognosis of such patients is very different from that of
patients with seropositive rheumatoid arthritis, who
may develop nodules, vasculitis, or joint damage despite corticosteroid treatment.
The ARA criteria for rheumatoid arthritis have
remained unchanged for 25 years. They have been of
great use but, in light of current knowledge, are
outdated. In essence, the first 5 criteria classify any
persistent inflammatory polyarthritis, if it is symmetric, as rheumatoid arthritis. Twenty-five years ago
they accurately reflected the state of taxonomic
knowledge, but do not do so now. Results of testing
for the HLA-DRw4 antigen suggest there is a real
difference between seropositive and seronegative
rheumatoid arthritis (12). Based on experience with
HLA-B27 testing, Calin and Marks have pointed out
that many patients formerly labeled as having “seronegative rheumatoid arthritis” actually have a different disease (13). The patients discussed here show that
there is yet another group, some with biopsy-proven
giant cell arteritis, whose synovitis clinically resembles rheumatoid arthritis.
In conclusion, it is tempting to recommend that
the criteria for rheumatoid arthritis should be revised.
However, on reflection it seems that attempts to
aggregate patients on the basis of similar characteristics may no longer be appropriate, and a different
system of classification would prove more useful.
Rather than further revise criteria for an inclusive classification, it seems more appropriate to devise
schemata that segregate patients into groups which
better reflect our current knowledge and clinical practice. Such a system could be similar to the one the
HEALEY
New York Heart Association has devised for defining
cardiac disease. For example, a patient might be
described by the following criteria: etiology (if
known), immunogenetic, serologic, anatomic or
pathologic, and physiologic status. This suggestion has
previously been made by Paty in discussing arteritis
(14), but it could be applied to other rheumatic diseases as well.
REFERENCES
I . Dirnant J: Rheumatoid arthritis in the elderly, presenting
as polyrnyalgia rheurnatica. J Am Geriatr SOC27:183185, 1979
2. Weinberger KA: Rheumatoid arthritis masquerading as
polymyalgia rheurnatica: report of two cases. J Am
Geriatr SOC28523-524, 1980
3. Ehrlich GE, Katz WA, Cohen SH: Rheumatoid arthritis
in the aged. Geriatrics 25:103-113, 1970
4. Bagratuni L: Prognosis in anarthritic rheumatoid syndrome. Br Med J 1:513-518. 1963
5. Ehrlich GE: Polymyalgia rheurnatica (editorial). JAMA
240:57-58, 1978
6. O’Duffy JD, Hunder GG, Wahner HW: A follow-up
study of polyrnyalgia rheurnatica: evidence of chronic
axial synovitis. J Rheurnatol 7:685-693, 1980
7. Gordon L, Rennie AM, Branwood AW: Polymyalgia
rheurnatica: biopsy studies. Ann Rheum Dis 23:447-454,
1964
8. Henderson DRF, Tribe CR, Dixon ASJ: Synovitis in
polymyalgia rheurnatica. Rheumatol Rehabil 11 1 :244250, 1975
9. Healey LA: Long-term follow-up of polyrnyalgia rheumatica: evidence for synovitis. Semin Arthritis Rheum
(in press)
10. Comgan AB, Robinson RG, Tereny TR, Dick-Smith JB,
Walters D: Benign rheumatoid arthritis of the aged. Br
Med J 1:444-446, 1974
11. Ropes MW, Bennett GA, Cobb S, Jacox R, Jessar RA:
1958 revision of diagnostic criteria for rheumatoid arthritis. Bull Rheum Dis 9: 175-176, 1958
12. Dobloug JH, F&re 0,Kiss E, Thorsby E: HLA antigens and rheumatoid arthritis: association between
HLA-DRw4 positivity and IgM rheumatoid factor production. Arthritis Rheum 23:309-313, 1980
13. Calin A, Marks SH: The case against seronegative
rheumatoid arthritis. Am J Med 70:992-994, 1981
14. Paty JG Jr: Declassification of arteritis (letter). Arthritis
Rheum 21:171, 1978
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associations, rheumatic, arthritis, american, criterias, polymyalgia, rheumatoid
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