Table 2 PMR diagnosis and differentials*
| Â | Diagnosis | Clinical features and relevant investigations |
|---|---|---|
Inflammatory rheumatic diseases | PMR | Age > 50 years, symmetrical shoulder and hip/thigh symptoms |
GCA | Cranial symptoms, arm/leg claudication, palpaption of temporal, radial and pedal pulses, vascular bruits, bilateral blood pressure, vascular US, CT, PET-CT, TAB | |
Polyarteritis nodosa / other vasculitis | Petechiae/purpura/skin ulcers, abdominal/lower extremity pain, foot drop, rapidly evolving hypertension, ANCA, urine analysis, relevant organ biopsy, CT, MRI, PET-CT, selective angiography | |
Elderly-onset RA | Peripheral symmetrical arthritis, RF and ACPA, erosive joint changes on X-rays, musculoskeletal US | |
Elderly-onset spondyloarthritis | Enthesitis, dactylitis, uveitis, inflammatory bowel disease, HLA-B27, sacroiliitis, X-rays, MRI | |
Crystal-induced arthritis (e.g. CPPD disease) | Acute arthritis, most often knees > upper limb, synovial fluid aspiration with polarized light microscopy, chondrocalcinosis / crowned dens visible on X-rays / CT | |
RS3PE syndrome | Pitting oedema of hands/feets | |
Inflammatory myopathy | Muscle weakness, high creatine kinase, myositis-specific antibodies | |
Elderly-onset SLE/ other connective tissue disorders | Multiorgan involvement Autoantibodies | |
Other inflammatory diseases | Septic arthritis | Arthrocentesis with synovial fluid analysis and microbiologic culture, US |
Infection/sepsis (e.g. bacterial endocarditis, osteomyelitis) | Fever, relevant history, relevant imaging and microbiologic cultures (blood, urine etc.) | |
Neoplasia (e.g. lymphoma, myeloma) | B-symptoms, weight loss, bone pain, monoclonal component | |
PMR-like syndrome secondary to immune checkpoint inhibitors (ICIs) [56] | Prior or current treatment with ICIs | |
Non-inflammatory conditions | Osteoarthritis, rotator cuff disorders, frozen shoulder | Mechanical pain, capsular restriction, X-rays, US, MRI |
Chronic pain syndromes (e.g. fibromyalgia) | Widespread pain, tender points, fatigue, long-lasting | |
Endocrine-, metabolic- and bone disorders | Thyroid stimulating hormone, bone profile (calcium, phosphate, ALP, vitamin D, parathyroid hormone) | |
Neurodegenerative (e.g. Parkinson’s disease) | Rigidity, tremor, shuffling gait, ataxia |