Ultrasonography of the glenohumeral joints--a helpful instrument in differentiation in elderly onset rheumatoid arthritis and polymyalgia rheumatica.

In a prospective study, the glenohumeral joints of 51 patients (aged 60 or above) were examined, using ultrasonography. Twenty-two patients were suffering from characteristic polymyalgia rheumatica (PMR) symptoms. In contrast, 29 other patients initially had similar complaints, but were diagnosed as having elderly onset rheumatoid arthritis (EORA, rheumatoid factor negative) upon development of typical symptoms. Ultrasound examination revealed glenohumeral joint inflammation in 40.9% (9/22) of the patients with PMR and 65.5% (19/29) of the patients with EORA. A discrete symmetrical biceps tendon sheath effusion was found in only three patients and unilateral in six patients with PMR. In contrast, 12 patients with EORA presented a massive effusion of the biceps tendon sheath, in some cases combined with a bilateral subdeltoid bursitis, and an intraarticular (i.a.) effusion/synovitis. To summarize our results: an i.a. effusion/synovitis, subdeltoid bursitis and biceps tendon sheath effusion were more frequent in patients with EORA, with a predominate symmetry and signs for massive inflammation. The typical ultrasonographic result in patients with PMR was a unilateral inflammation of the glenohumeral joint with predominate discrete biceps tendon sheath effusion and, in comparison with the EORA group, with signs of a low grade inflammation. We conclude that the results of our prospective study might be helpful in the differentiation of PMR and a rheumatoid factor negative subgroup of EORA at the first time of manifestation where clinical overlaps can be observed. However, ultrasonography of the glenohumeral joints might be a good and helpful instrument of differentiation in both diseases.

[Retroperitoneal fibrosis]. / Retroperitonealfibrose.

A 53-year-old man without previous significant illness developed severe backache. Neither physiotherapy nor nonsteroidal anti-inflammatory drugs improved his condition so that he had been regularly taking pain-killing medication. 6 months later elevated retention values were detected and the patient was admitted to hospital. On admission the erythrocyte sedimentation rate (ESR) was markedly elevated in the presence of a normocytic anaemia, serum creatinine concentration of 3.71 mg/dl (blood urea of 112 mg/dl) and haematuria. Sonography demonstrated bilateral hydronephrosis, stage III, and a weekly echogenic para-aortic mass. Abdominal computed tomography showed a half-moon-shaped density anterior to the aorta. The middle segments of both ureters were displaced medially and the proximal parts dilated. Other causes (tumour, drug therapy, inflammation) having been largely excluded, idiopathic retroperitoneal fibrosis was diagnosed. The marked urinary obstruction necessitated the implantation of double-J-stents. Immunosuppressive treatment was started with daily 150 mg azathioprine and, initially, 50 mg prednisone. Within one week the serum creatinine concentration and ESR had fallen and the signs of urinary obstruction regressed.