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Polymyalgia Rheumatica — SCE Rheumatology MCQ

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HardMusculoskeletal ImagingPolymyalgia RheumaticaSCE Rheumatology

A 56-year-old glucocorticoid-naive woman has a 6-week history of bilateral shoulder and hip-girdle pain, morning stiffness lasting 90 minutes and constitutional symptoms. C-reactive protein is 68 mg/L, creatine kinase is normal, and rheumatoid factor and anti-CCP antibodies are negative. FDG-PET/CT shows symmetrical uptake at the subacromial-subdeltoid, trochanteric and ischiogluteal bursae, with additional uptake in the lumbar interspinous bursae. There is no focal tumour, sacroiliac uptake, peripheral small-joint uptake or abnormal arterial-wall uptake. Which interpretation is most likely?

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Correct answer: C — Polymyalgia rheumatica without PET evidence of large-vessel vasculitis

The symmetrical, multilocular pattern of periarticular and bursal FDG uptake at the shoulder and pelvic girdles, particularly when accompanied by interspinous bursal uptake, is characteristic of active polymyalgia rheumatica. The absence of abnormal arterial-wall uptake means that this scan provides no PET evidence of concurrent large-vessel GCA, although a negative PET scan does not exclude cranial GCA if clinically suspected. Elderly-onset rheumatoid arthritis more typically produces prominent synovial uptake, including peripheral joints. Late-onset spondyloarthritis would be supported by sacroiliac or characteristic entheseal involvement rather than this predominantly bursal pattern. Metastatic disease would usually produce focal or anatomically irregular lesions rather than symmetrical uptake at recognised PMR sites.

Reference: van der Geest KSM et al. Diagnostic value of [18F]FDG-PET/CT in polymyalgia rheumatica: a systematic review and meta-analysis. European Journal of Nuclear Medicine and Molecular Imaging. 2021;48:1876-1889. https://pubmed.ncbi.nlm.nih.gov/33372248/