Gadolinium-enhanced shoulder MRI helps predict polymyalgia rheumatica recurrence

Gadolinium-enhanced magnetic resonance imaging (MRI) of the shoulders of patients with polymyalgia rheumatica (PMR) may improve diagnosis accuracy and recurrence prediction, according to research presented at the 2019 annual meeting of the American College of Rheumatology (ACR/ARP) held in November in Atlanta. Gadolinium MRI scans displayed the capsulitis, rotator cuff tendinitis, and focal osteitis that are relatively specific to polymyalgia rheumatica, according to physicians from Tomakomai City Hospital in Tomakomai, Japan.¹

A chronic musculoskeletal disorder that may also occur with giant cell arteritis, PMR causes upper arm, neck, lower back, and thigh achiness and stiffness. The condition can be difficult to diagnose because it doesn’t often cause swollen joints, and its symptoms can occur in many other rheumatologic and inflammatory conditions.

Lead author and rheumatologist Kazuro Kamada, MD, sought to assess whether contrast-enhanced MRI could improve diagnostic accuracy and prognosis because the examination’s application had not yet been established for the condition, which recent research suggests can be diagnosed with ultrasonography of the shoulder.

The study focused on 137 patients with bilateral shoulder pain and who fulfilled the Bird classification criteria for PMR. The patients underwent ultrasound and a gadolinium MRI during a six-year period at Tomakomai City Hospital.² Fifty-eight cases of PMR were identified, and patients were followed until June 2019.

MRI findings included enhancement of the joint capsule, rotator cuff tendon, or biceps tendon, synovial hypertrophy, shoulder joint effusion, enhancement of the glenohumeral joint, and/or focal or diffuse bone edema in the humerus heads. Of these, PMR patients had significantly frequent enhancement of the joint capsule or rotator cuff tendon, and focal bone edema in the humerus heads. When these findings were combined to diagnose PMR, MRI had 76% sensitivity and 85% specificity compared to 50% sensitivity and 72% specificity for ultrasound.

Twenty-four patients had a recurrence of PMR. In addition to being younger overall than the other patients, these patients’ MRIs had less enhancement of their rotator cuff tendon, and more synovial hypertrophy findings.

“Rheumatologists will diagnose PMR with confidence using gadolinium-enhanced MRI with high sensitivity and specificity, which will lead to decreasing misdiagnosis of PMR,” wrote Dr. Kamada. “Moreover, rheumatologists can consider using disease-modifying antirheumatic drugs from the early stage for PMR patients if recurrences can be predicted by gadolinium-enhanced MRI. We are going to validate the results in a larger cohort next in order to optimize and standardize the gadolinium-enhanced MRI procedure for PMR to apply in real-world clinical practice.”

REFERENCES

1. Kamada K, Nakamura H, Tarumi M, et al. Gadolinium-enhanced magnetic resonance imaging in shoulders contributes accurate diagnosis and predicting recurrence to patients with polymyalgia rheumatica. Arthritis Rheumatol. 2019; 71 (suppl 10). https://acrabstracts.org/abstract/gadolinium-enhanced-magnetic-resonance-imaging-in-shoulders-contributes-accurate-diagnosis-and-predicting-recurrence-to-patients-with-polymyalgia-rheumatica/. Accessed November 13, 2019.
2. Bird HA, Essenlinckx W, Dixon AS, et al. An evaluation of criteria for polymyalgia rheumatica. Ann Rheum Dis.1979;38(5):434-9. doi.10.1136/ard.38.5.434.