Imaging of polymyalgia rheumatica: what the radiologist should know

Imaging of polymyalgia rheumatica: what the radiologist should know Poster No.: P-0117 Congress: ESSR 2016 Type: Educational Poster Authors: R. Leao, L. C. Zattar-Ramos, E. L. Bizetto, M. F. Correa, M. Bordalo-Rodrigues, D. T. Amaral, C. Obara Kurimori, P. V. P. Helito, R. Y. Fernandes, H. P. Costa; Sao Paulo/BR Keywords: Education, Diagnostic procedure, Ultrasound, PET-CT, MR, Musculoskeletal system, Musculoskeletal joint, Inflammation DOI: 10.1594/essr2016/P-0117 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 20

Learning objectives 1. 2. 3. 4. Illustrate the cases of Polymyalgia Rheumatica emphasizing the imaging findings that may contribute for its specific diagnosis Illustrate the clinical set and the main image patterns that should make the radiologist think of PMR Illustrate the main affected sites of this pathology Emphasize the differential diagnosis of PMR Page 2 of 20

Background Introduction and epidemiology Polymyalgia rheumatica (PMR) is an inflammatory disease that affects people over the age of 50. The peak incidence occurs between ages 70 and 80 people over 50 years. Women are affected two to three times more often than men. PMR cannot be considered a rare disease, with an annual incidence of 52.5 68.3/100,000. On the other hand, the lack of specific diagnostic lab tests and image findings often causes a delay in the diagnosis of PMR. There is a close relation to giant cell arteritis (it occurs in about 50 % of patients with it). Clinical Symptoms Main symptoms: aching and morning stiffness in the shoulders, hip girdle, neck, and torso Stiffness - morning stiffness, which lasts at least 30 minutes. Pain - Shoulder, hip and neck. Pain is worse with movement and may interfere with sleep. Synovitis and bursitis: causes the discomfort and stiffness. Swelling and tenosynovitis - hands, wrists, ankles, and feet. Tenosynovitis: can cause carpal tunnel syndrome (10%) Systemic signs and symptoms - including malaise, fatigue, depression, anorexia, weight loss, and low-grade fever. Laboratory 1. High VHS and C-reactive protein levels. 2. Serologic tests: All negative: antinuclear antibodies, rheumatoid factor, and cyclic citrullinated peptide antibodies Page 3 of 20

Imaging findings OR Procedure Details Imaging findings The main finding of PMR is: "non erosive synovitis with a predilection for extraarticular synovial structures" 1. Classical imaging findings: - Glenohumeral synovitis - Subacromial-subdeltoid bursitis - Biceps tenosynovitis - Trochanteric bursitis - Synovitis at the hips 2. Possible new imaging findings: (*) In our service, we've been seeing new possible findings that may rase the diagnosis specificity - Atypical miotendineous junction edema - Adhesive capsulitis - Predominance of peritendinitis over tendinopathies Page 4 of 20

Images for this section: Fig. 9: Clinical and radiological work-out. Page 5 of 20

Fig. 10: Edema of soft tissue between the fascia lata and greater trochanter (A), with thickening of the fascia lata. Peritendinitis of the origin of the iliotibial tract in the iliac tubercle (B). Edema in the miotendineous transition of the ischiotibial tendons (C) and in the distal insertion of sacrotuberosos ligaments (D). Page 6 of 20

Fig. 11: (A, B ) Pericapsular edema in the subcoracoid recess (A), and rotator interval (B), suggestive of a adhesive capsulitis (C, D, E) Interstitial edema in the myotendinous transition of the teres minor (C) and subscapularis (D) associated to a subacromial subdeltoid bursitis (E). Page 7 of 20

Fig. 12: Clinical and radiological work-out. Page 8 of 20

Fig. 13: Summarizing the clinical and radiological concept. Page 9 of 20

Fig. 14: Differential diagnosis for PMR. Page 10 of 20

Fig. 1: MRI images of the cervical column. (A, B) COR T1 C+ FS and (C, D) AX T1 C+ FS showing inflammatory post contrast soft tissues enhancement adjacent to the posterior arch of C1, with obliteration of the perirradicular foraminal fat. Page 11 of 20

Fig. 2: MRI images of the cervical column. (E, F, G) SAG T1 C+ FS showing inflammatory post contrast enhancement of the soft tissues adjacent to the posterior arch of C1, with obliteration of the perirradicular foraminal fat. Page 12 of 20

Fig. 3: MR images of the right shoulder. COR T2 FS (A) and axial (D) showing thickening of the capsular joint in the axillary recess, associated with diffuse pericapsular inflammatory edema. And MR images of the left shoulder. COR T2 FS (B) and axial (D) demonstrating tendinopathy of the long head of the biceps. It is associated with a liquid distension of its synovial sheath in the extrarticular portion (tenosynovitis), with inflammatory swelling of adjacent plans. Page 13 of 20

Fig. 4: PET- CT shows hypermetabolism in adjacent soft tissues posterior to C1 arch. The appearance corresponds to local inflammatory process. Page 14 of 20

Fig. 5: Clinical and radiological work-out. Page 15 of 20

Fig. 6: Edemas in the miotendineous transitions of the iliopsoas muscle bellies (A), retofemoral (B) and lateral vastus muscle (C). Page 16 of 20

Fig. 8: Edema in miotendineous transitions of rotator cuff, particularly the supraspinatus (A, B), infraspinatus (C) and subscapularis (D). Page 17 of 20

Fig. 7: Adhesive capsulitis signs on both hips with edema and thickening of the capsular plans (E) and capsular thickening and enhancement on post-contrast sequences (D). Page 18 of 20

Conclusion In PMR the small amounts of synovitis cannot be detected on physical examination Also, there is no diagnostic laboratory test, inflammatory markers are not specific and clinicians often turn to the corticosteroid response as a 'test of treatment' to establish the diagnosis. For those reasons, the knwoledge of imaging findings related to PMR is techniques specially important for the diagnosis, and although still not stablish in literature, there are some new findings that may contribute to the specific diagnosis of this entity. Page 19 of 20

References 1. 2. Dasgupta B, Cimmino MA, Maradit-Kremers H, et al. Provisional classification criteria for polymyalgia rheumatica: a european league against rheumatism / american college of rheumatology collaborative initiative. Ann Rheum Dis 2012; 71: 484-492 Ceccato F, Roverano, SG, Papasidero S, Barrionuevo A, Rillo OL, Paira SO. Peripheral musculoskeletal manifestations in polymyalgia rheumatica. J Clin Rheumatol 2006; 12: 167-171 Page 20 of 20