Rheumatology Advance Access originally published online on April 4, 2008
Rheumatology 2008 47(6):926-927; doi:10.1093/rheumatology/ken098
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LETTERS TO THE EDITOR |
Is FDG-PET useful in the evaluation of steroid-resistant PMR patients?
Clinica Reumatologica, Dipartimento di Medicina Interna, Università di Genova, Italy
Correspondence to: M. A. Cimmino, Clinica Reumatologica, Dipartimento di Medicina Interna e Specialità Mediche, Viale Benedetto XV, 6, 16132 Genova, Italy. E-mail: cimmino{at}unige.it
SIR, Blockmans et al. [1] showed that 31% of the patients with newly-diagnosed polymyalgia rheumatica (PMR) have moderate PET signs of vasculitis, especially of the subclavian arteries. Not surprisingly, more prominent vasculitic changes were found in 74% of the patients with GCA [2]. We have performed PET in steroid-resistant PMR patients with the aim of ascertaining whether undetected vasculitic changes could explain steroid resistance. Diagnosing large-vessel vasculitis should be relevant in this setting, because patients may need increased doses of steroids and the addition of immunosoppressive drugs, as in case of concomitant GCA [3]. Steroid resistance was defined as the impossibility to withdraw prednisolone treatment before 2 yrs and to taper its dosage to <7.5 mg daily without exacerbations [4]. This was the cause of referral to our unit in the eight consecutive PMR patients considered for this study (female/male 4/4, median age 73 yrs, mean disease duration 69.4 ± 61.4 months, mean cumulative steroid dosage 18.2 ± 11.8 g). All the patients gave their informed written consent to publish their data. Of them, five showed headache or temporal tenderness, suggesting the possible coexistence of GCA, diagnosis of which was confirmed by biopsy in only one patient.
Three of these eight patients (37.5%) showed large-vessel vasculitis on a PET scan (Fig. 1). The only patient with biopsy-proven GCA was negative on PET scan.
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A 73-yr-old woman complained of fever, fatigue and pain in the cervical spine and girdles, with a systemic inflammatory laboratory response, which responded promptly to 25 mg prednisolone a day, but recurred when steroid was tapered. The attending physician suspected GCA, although biopsy was not performed and clinical presentation was not convincing. After 2 yrs, a PET revealed aortitis with a total vascular score (TVS) of 7 [1, 2]. The patient was treated with MTX 15 mg/week and prednisolone 12.5 and 18.75 mg on alternate days with improvement of both symptoms and laboratory findings.
A 76-yr-old female inpatient showed girdle pain, weight loss, and temporal pain associated with raised ESR and CRP, in May 2003. A temporal artery biopsy was negative but, based on clinical findings, she was treated with prednisolone 50 mg daily with rapid tapering. Symptoms recurred when prednisolone dosage reached 10 mg daily. A PET scan, performed in October 2007, showed increased vascular uptake of all regions with a TVS of 17 (Fig. 1). She has recently added 15 mg of weekly MTX with an improvement of subjective findings.
A 77-yr-old woman complained of girdle pain, high-grade fever, weight loss and elevation of the indexes of inflammation. The diagnosis of PMR associated with GCA was suspected because of local loss of pulse and slight tenderness. She was treated with methylprednisolone (16 mg daily for 6 months). After initial improvement, symptoms recurred when corticosteroid was tapered. PET showed an increased uptake of the thoracic aorta spreading to the abdominal tract, together with the initial part of the supra-aortic branches. Her TVS was 7. These findings were confirmed by MRI. The patient was treated with MTX (10 mg/week) and prednisolone (12.5 mg daily) with improvement.
In our small group of steroid-resistant PMR patients, three showed increased vascular uptake of the large arteries. This observation is in keeping with the frequency of arterial lesions exhibited by untreated PMR patients at diagnosis. Only women had increased vascular uptake. Patients with positive PET had higher CRP (146 ± 82 vs 44 ± 11 mg/dl, P = 0.03) and ESR (103 ± 11 vs 65 ± 18 mm/h, P = 0.07). Large arteries vasculitis could not explain persistence of PMR in most of our patients. These anecdotal observations are insufficient to support the view that vasculitis is a complication of pure PMR, or that the correct initial diagnosis in the concerned patients was GCA or idiopathic aortitis. We, however, feel that PET may play a role in the follow-up evaluation of steroid-resistant polymyalgic patients with GCA symptoms. This subset should be relatively small because only 30% of PMR patients experience persistent disease course in spite of corticosteroid treatment [5].
From another viewpoint, fluorodeoxyglucose (FDG) uptake was present in spite of the long-term and still ongoing steroid treatment, a finding supporting the opinion that low-dosage steroids usually administered in PMR are ineffective in large-vessel vasculitis. We wonder, however, if some uptake could have also been present in the other patients, if they were untreated. In conclusion, PET could be a useful adjunct in the evaluation of patients with steroid-resistant PMR, especially if they show persistently high inflammation indices.
Disclosure statement: The authors have declared no conflicts of interest.
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 Top References |
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- Blockmans D, De Ceuninck L, Vanderschueren S, Knockaert D, Mortelmans L, Bobbaers H. Repetitive 18-fluorodeoxyglucose positron emission tomography in isolated polymyalgia rheumatica: a prospective study in 35 patients. Rheumatology (2007) 46:672–7.
[Abstract/Free Full Text] - Blockmans D, De Ceuninck L, Vanderschueren S, Knockaert D, Mortelmans L, Bobbaers H. Repetitive 18-fluorodeoxyglucose positron emission tomography in giant cell arteritis: a prospective study in 35 patients. Arthritis Rheum (2006) 55:131–7.[CrossRef][Web of Science][Medline]
- Mahr AD, Jover JA, Spiera RF, et al. Adjunctive methotrexate for treatment of giant cell arteritis: an individual patient data meta-analysis. Arthritis Rheum (2007) 56:2789–97.[CrossRef][Web of Science][Medline]
- Salvarani C, Cantini F, Niccoli L, et al. Treatment of refractory polymyalgia rheumatica with infliximab: a pilot study. J Rheumatol (2003) 30:760–3.
[Abstract/Free Full Text] - Salvarani C, Cantini F, Boiardi L, Hunder GG. Polymyalgia rheumatica and giant-cell arteritis. N Engl J Med (2002) 347:261–71.
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