Daily Archive 27.09.2019

Temporal arteritis and polymyalgia rheumatica

Temporal arteritis (giant cell arteritis, Horton’s disease ) – a disease of the elderly and senile, more common in women, characterized by damage to the aorta and arteries of the head and neck. Rheumatic polymyalgia is a disease of people of the same age and gender, characterized by pain and stiffness in the proximal parts of the muscles of the shoulder and pelvic girdle in combination with fever, weight loss. Both diseases are often found in the same patient, and therefore their common origin is not excluded, the role of a viral infection, including hepatitis B virus, is possible. Temporal arteritis is characterized by granulomatous inflammatory infiltrates with lymphocytes and giant multinucleated vessels in the vessels extending from the aortic arch; more often the temporal arteries are affected. Gradually, a thickening of the inner membrane develops with a narrowing of the lumen of the vessels and parietal thrombosis. The most common symptom is a burning throbbing headache. The temporal arteries are painful and swollen, the skin above them is hyperemic. Subsequently, the temporal arteries condense, become crimped. The most serious complications are eye damage, 20% of patients develop vision loss due to ischemia of the optic nerves. Intermittent pain in the masticatory muscles, sometimes in the muscles of the tongue and the muscles involved in swallowing, can be observed . In 10-15% of patients, large arteries are affected, ischemic pains in the upper or lower extremities, noises or a decreased pulse on the vessels of the neck or limbs, sometimes aortic rupture are noted. More rare symptoms are cough, depression, psychosis, hemiparesis, peripheral neuropathy , acute hearing loss, cerebrovascular accident, myocardial infarction. Most patients have a fever, sometimes of an unclear origin. Almost all patients note a sharp weakness, weight loss, anorexia. Half of the patients have signs of rheumatic polymyalgia – pain and stiffness in the muscles of the shoulder and pelvic girdle, neck. Often there is moderate normochromic anemia, thrombocytosis. The white blood cell count is usually normal. A significant increase in ESR is characteristic. In 1/3 of patients, moderate liver dysfunction is detected. The diagnosis of temporal arteritis should be discussed in any patient older than 50 years who has a headache, transient or sudden loss of vision, pain and stiffness in the muscles, prolonged fever, anemia, and an increase in ESR. The diagnosis is confirmed by biopsy of the temporal artery. Differentiate temporal arteritis with periarteritis nodosa, which can affect the temporal arteries, nonspecific aortoarteritis , RA, vasculitis , migraine, trigeminal neuralgia, intracranial pathological processes, including tumors. After diagnosis, glucocorticoids should be prescribed immediately (prednisone at a dose of 45-60 mg per day). After a marked improvement in clinical and laboratory signs, the dose can be slowly reduced (2.5-5 mg every 2-4 weeks ). Long-term maintenance therapy is indicated, however, in most patients, glucocorticoids can subsequently be canceled. The prognosis is usually favorable , the disease does not affect life expectancy. The main serious complication is blindness. The prognosis worsens with damage to large vessels and aorta. The main clinical sign of rheumatic polymyalgia is pain in the muscles of the shoulder and pelvic girdle. Morning stiffness, as well as stiffness after a period of immobility, restriction of movements in the cervical spine, shoulder and hip joints are characteristic . Patients hardly get out of bed, dress, comb their hair, rise and go down the stairs; the gait becomes minced. Muscle strength usually does not decrease, although atrophy from inaction (due to pain ) can develop . With a careful examination of the joints, the detection of synovitis is possible . Pain in the proximal joints, tendons, and joint bags may be noted. Unpleasant sensations may appear first on one side, but soon become bilateral, common symptoms are characteristic – weakness, moderate fever, weight loss. Some patients have signs of temporal arteritis, primarily a headache, which may be the first sign of the disease. ESR is sharply increased, sometimes up to 60-80 mm / h. Mild normochromic anemia may be detected . Increased levels of fibrinogen, C-reactive protein. Polymyalgia rheumatica should be considered when there are severe bilateral pains in the muscles of the neck, shoulder and pelvic girdle, accompanied by a significant increase in ESR in patients over the age of 50 years. The disease should be differentiated with systemic vasculitis , dermatomyositis, RA, paraneo -plastic syndrome.