Polymyalgia Rheumatica: Biopsy Studies.

Polymyalgia rheumatica is a clinical syndrome affecting middle-aged and elderly persons and is characterized by periarthritic and muscular pain and stiffness particularly in the shoulder and hip girdles. Systemic symptoms are present, the erythrocyte sedimentation rate (E.S.R.) is greatly elevated, and the Waaler-Rose test is almost invariably negative. Suppression of symptoms with corticosteroid therapy is striking. The disease appears to run a benign course and in cases not treated with corticosteroids muscular and periarthritic pains disappear spontaneously and completely in 2 to 4 years (Gordon, 1960). The cause of the syndrome is not known. Some recent authors have suggested that the myalgia is a manifestation of giant cell arteritis. The myalgia and the less common arthralgia sometimes associated with giant cell arteritis certainly may resemble polymyalgia rheumatica and diagnosis may be difficult in the early stages. Significant differences, however, exist. Giant cell arteritis is now regarded as a widespread arterial disease which may spare, at least for a time, the commonly involved temporal, occipital, and retinal arteries. Rheumatic symptoms may precede, accompany, or follow the phase of temporal artery involvement and present as pain in the muscles of the limb girdles and trunk and as arthralgia of the larger joints. As in polymyalgia rheumatica, the disease occurs in the elderly, the erythrocyte sedimentation rate is considerably elevated, and the symptoms rapidly respond to corticosteroid therapy. In polymyalgia rheumatica, however, the pain in the shoulder and hip girdles is overshadowed by the stiffness of the shoulders with gross limitation of movement in the average case. Stiffness of the shoulder joints is not a prominent feature of giant cell arteritis. Severe pain and tenderness in the muscles of the limb girdles and trunk may occur in giant cell arteritis and, in cases of long duration, these symptoms are associated with weakness and wasting of muscles, the latter being out of all proportion to the clinical and radiological involvement of the joints (Russell, 1959). Such wasting and weakness do not occur in polymyalgia rheumatica. In reviewing 175 cases oftemporal arteritis from the Mayo Clinic, Hollenhorst, Brown, Wagener, and Shick (1960) described diffuse aching in the muscles of the extremities, neck, and shoulders. Limitation of movement of the shoulder joints was not a feature, though extreme tenderness of the neck muscles often prevented the patient from bending or turning the head. In some of the case histories of giant cell arteritis detailed by Paulley and Hughes (1960) severe widespread rheumatic pains were noted. Stiffness occurred in some but it is not clear how severe was this symptom. Kogstad (1963) described twenty cases of "polymyalgia rheumatica", six of which had temporal arteritis confirmed by biopsy. Muscle pains were frequently located in the neck and shoulder regions, but there is no mention of any limitation of movements of the shoulder joints. Alestig and Barr (1963) considered that polymyalgia rheumatica was due to an arteritis. They found changes of giant cell arteritis on biopsy of a temporal artery in seven patients with rheumatic symptoms none of whom had good clinical evidence of temporal arteritis. Stiffness is mentioned in only three cases and, in the case described as typical, the rheumatic symptoms are noted as pain, paraesthesiae, and weakness of the legs-symptoms which can hardly be accepted as those of polymyalgia rheumatica. Furthermore, evidence of giant cell arteritis has not been encountered in any of the recent descriptions of polymyalgia rheumatica (Barber, 1957; Gordon, 1960; Boyle and Beatty,