Zdenek Rehak, Andrea Sprlakova-Pukova, Zbynek Bortlicek, Zdenek Fojtik, Tomas Kazda, Marek Joukal, Renata Koukalova, Jiri Vasina, Jana Eremiasova and Petr Nemec
Polymyalgiarheumatica (PMR) is the most common inflammatory rheumatic disease in patients older than 50 years, with a higher incidence in women. PMR shares many pathogenetic and epidemiological features with giant cell arteritis (GCA) 1 , and 50% of patients with GCA also develop PMR symptomatology. 2 The typical symptoms of PMR are bilateral aching of the shoulder girdle, neck and hip girdle, and morning stiffness lasting for 30 minutes or more. These symptoms are probably related to inflammation of the subacromial, subdeltoid and
1. Salvarani C, Gabriel SE, O’Fallon WM, Hunder GG. Epidemiology of polymyalgiarheumatica in Olmsted County, Minnesota, 1970-1971, Arthritis Rheum 1995; 38:369
2. Crowson CS, Matteson EL, Myasoedova E, et al. The lifetime risk of adult-onset rheumatoid arthritis and other inflammatory autoimmune rheumatic diseases. Arthris Rheum 2011;63:633
3. Liozon E, Ouattara B, Rhaiem K, et al. Familial aggregation in giant cell arteritis and polymyalgia rheumatic: a comprehensive literature review including 4 new families. Clin Exp Rheumatol
Mile Bosilkovski, Marija Dimzova, Marija Cvetkova, Kostadin Poposki, Katerina Spasovska and Ivan Vidinic
Introduction. The study aimed to compare the etiologic spectrum of diseases causing fever of unknown origin (FUO) and methods for definitive diagnosis in a tertiary care hospital in the Republic of North Macedonia during two different time periods.
Patients and methods. There were analysed retrospectively the causes for FUO and final diagnostic approaches in 185 patients with classic FUO that were treated at the University Hospital for Infectious Diseases in Skopje during two time periods. Seventy nine patients were treated during 1991 to 1995 and 106 patients during 2011 to 2015.
Results. When comparing these two periods, infections were present in 46.8% and 29.2% (p = 0.014), non-infective inflammatory disorders in 22.8% and 25.5% (p = 0.674), neoplasms in 10.1% and 13.2% (p = 0.522), miscellaneous in 8.9% and 12.3% (p = 0.461) and undiagnosed cases in 11.4% and 19.8% (p = 0.124), respectively. The most common causes for FUO during the first period were abscesses (8.9%), tuberculosis and systemic lupus erythematosus (7.6% each), whereas in the second period the commonest causes were adult onset Still disease and solid organ neoplasm (7.6% each), polymyalgia rheumatica, abscesses and visceral leishmaniasis (5.7% each). The newer imaging techniques and clinical course evaluation had superior diagnostic significance during the second period.
Conclusion. A changing pattern of diseases causing FUO during the examined periods was evident. Infections continue to be the most common cause but with decreasing incidence when compared to 20 years ago. Even nowadays clinical evaluation and follow-up still remain the vital diagnostic tools in determining the etiology of FUO.
The erythrocyte sedimentation rate (ESR) remains one of the most widely used laboratory tests. Its clinical usefulness and interpretation are in the monitoring of inflammatory diseases, in particular rheumatoid arthritis, temporal arteritis and polymyalgia rheumatica. At present, the reference method for measuring the ESR proposed by the International Committee for Standardization in Haematology (ICSH) utilizes EDTA-anticoagulated-undiluted blood to perform the test using the method described by Westergren in 1921. Current interest in the methodology focuses on the development of an automated closed system that allows the determination of the sedimentation rate with selected working methods, using a single sample for more than one haematological test, improving the bio-hazardous aspects of the testing procedures. As a consequence, standardization becomes necessary. ESR results should be reliable, despite the increased number of different methods and testing variables. Control materials and External Quality Assurance Schemes are now available, and should be used. In conclusion, innovative techniques may improve the appropriateness and usefulness of ESR in clinical practice, but in addition, they need to guarantee the traceability of results in comparison to the reference method in order to ensure comparability of results among different clinical laboratories.
syndrome as an initial manifestation of crystalline deposition disease . Intern Med. 2015; 54 (18):2405-8.
7. MATSUMURA M, HARA S. Images in clinical medicine. Crowned dens syndrome. N Engl J Med. 2012; 367 (23):e34.
8. AOUBA A, VUILLEMIN-BODAGHI V, MUTSCHLER C, DE BANDT M. Crowned dens syndrome misdiagnosed as polymyalgiarheumatica, giant cell arteritis, meningitis or spondylitis: an analysis of eight cases. Rheumatology (Oxford) 2004; 43 : 1508-12.
9. NAGASAKI H, DOI H. Crowned dens syndrome mimicking meningitis: Report of two cases. Neurology
in disease monitoring. It could detect active disease in those with normal C-reactive protein, which was common in IgG4-RD. The disappearance of FDG uptake correlated with treatment response [ 19 ].
PET is sensitive in detecting synovitis and bursitis at shoulders and hips [ 20 ]. Yamashita et al. found that uptakes at ischial tuberosities, greater trochanters, and lumbar spinous process were commonly seen in polymyalgiarheumatica (PMR). Positive results at two of these three sites would be even more specific than uptakes
Heba Assal, Ashraf Elsherbiny, Ahmed Alsayed, Mohamed Maaboud, Hesham alShabrawi and Enas Rasheed
Wiseman P, Stewart K, Rai GS. Hypothyroidism in polymyalgiarheumatica and giant cell arteritis. BMJ. 1989;298(6674):647-648. doi:10.1136/bmj.298.6674.647 PMID:2496792
Carter JN, Eastmen CJ, Corcoran JM, Lazarus L. Inhibition of conversion of thyroxin to triiodothyronine in patients with severe chronic illness. Clin Endocrinol (Oxf). 1976;5(6):587-594. doi:10.1111/j.1365-2265.1976.tb03861.x PMID:1009671
Hesch RD (Ed): The low T3 syndrome. In proceedings of the serono symposia, 40. Academic Press: New York, 1981:I
Loredana Hanzu-Pazara, Alina Martinescu and Maria Suta
. & Hajeer, A.H. (2002). Influence of human leukocyte antigen-DRB1 on the susceptibility and severity of rheumatoid arthritis. Semin Arthritis Rheum. 31, 355-360
7. Reviron, D., Foutrier, C., Guist, S., Mercier, P. & Roudier, J. (2001). DRB1 alleles in polymyalgiarheumatica and rheumatoid arthritis in southern France. Eur J Immunogenet. 28, 83-87
8. Saruhan-Direskeneli, G., SG IR (1998). Shared epitope ‘‘Homozygosity’’ is strongly associated with RA patients in Turkey. Br J Rheumatol. 37, 1126-1128
9. Delgado-Vega, A
This is the first paper in the occasional series which aims to aid and facilitate internists and colleagues who have little or no experience in writing and submitting manuscripts for publication.
Case reports have a very low level of evidence, but they do have a place in medical publications. Polymyalgiarheumatica (PMR) was first established as a distinct disease in 1966 following the publication of a case report on 11 patients. [ Davison S, Spiera H, Plotz CM “Polymyalgiarheumatica”. Arthritis and Rheumatism. 9 (1): 18–23.]
What is a case report?