Available online 28 November 2023

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Polymyalgia rheumatica (PMR) is an inflammatory disorder usually diagnosed in patients older than 50 years of age. It is characterized by sudden onset pain and prolonged morning stiffness in the scapular and/or pelvic girdle, sometimes debilitating and accompanied by constitutional symptoms such as weight loss. In approximately 20% of the cases, it is linked to giant cell arteritis (GCAV) representing a disease continuum. The diagnosis is mainly clinical and noninvasive imaging such as ultrasound of joints may be helpful. In atypical PMR cases, whole body imaging using [18F]FDG-PET/CT may be useful. First, to confirm or rule out the diagnosis of PMR, secondly, to assess the coexistence of a GCA, and thirdly to establish the differential diagnosis with other types of arthritides encountered in this age group, such as elderly-onset rheumatoid arthritis, spondyloarthropathies, crystal-induced arthropathies or the rare remittent seronegative symmetrical synovitis with pitting edema. Relatively typical patterns of [18F]FDG-PET/CT are well known, based on the clinical distribution of the disease (eg, scapular and pelvic girdle, interspinous bursae, sterno-costoclavicular joints, entheses), especially the hypermetabolism at the interspinous lumbar bursae that has shown the best post-test likelihood ratio in a meta-analysis. This article focuses on the differential diagnosis and on the visual and semi-quantitative tools that can be used to guide to the correct diagnosis of PMR as an add-on to the clinical picture. Further, we briefly discuss the options that can improve molecular imaging in the future for inflammatory rheumatisms in elderly.

Section snippetsPolymyalgia Rheumatica: Definition

Polymyalgia rheumatica (PMR) is an inflammatory rheumatism of unknown origin, affecting people >50 years, with an onset peak at 75 years.2,3 It is the second most common inflammatory rheumatic disorder of the elderly after rheumatoid arthritis (RA) with a lifetime risk of around 2%.4,5 PMR is a complete and complex disease targeting different structures: joints, tendons, tendon sheath, entheses, articular bursae, and muscles.6, 7, 8, 9, 10 The clinical presentation is most usually stereotypic,

PET-CT in PMR: Relevance, Interpretation, and Limitations

PET/CT using [18F]fluoro-2-deoxy-D-glucose ([18F]FDG-PET/CT) has become a widely available tool in standard practice in high-income countries and has reached an industrial maturity that favors its use for a wide variety of inflammatory disorders. A recent survey from the EULAR task force documented the current training, implementation, and role of modern musculoskeletal imaging techniques, including [18F]FDG-PET, among rheumatologists in Europe.15 Interestingly, the access to PET/CT varied

Differential Diagnosis

In routine practice, clinical features and laboratory work-up, sometimes with the inclusion of ultrasound should suffice to establish the diagnosis of a typical PMR patient. However, as stated before, the clinical presentation can be atypical and overlap exists with other PMR-mimicking inflammatory rheumatisms, making the diagnosis challenging (Fig. 4).

Perspectives and Future Work

From this review, it is clear that [18F]FDG-PET/CT can be an add-on to the diagnosis of PMR. However, it has not been accepted yet as a criterion to establish the diagnosis, as stated by international consensus reports such as the EULAR and ACR ones. Large, multicentric, international studies may be needed to determine in which clinical situations the role of [18F]FDG-PET/CT may be essential, to avoid on the one hand overconsumption and on the other hand, missing essential diagnoses that may

Declaration of Competing Interest

The authors have no conflicts of interest with this paper.

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