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Case report
Point of care ultrasound for the diagnosis of polymyalgia rheumatica in chronic seronegative polyarthritis: A case report
Ultrasonografía point of care para el diagnóstico de polimialgia reumática en poliartritis crónica seronegativa: un reporte de caso
Otto Barnaby Guillén Lópeza,b,
Corresponding author
otto.guillen.l@upch.pe

Corresponding author.
a Departamento de Clínicas Médicas, Faculty of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
b Servicio de Medicina Interna, Hospital Nacional Arzobispo Loayza, Lima, Peru
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of the patients diagnosed with this disease may have distal manifestations such as peripheral arthritis and swollen hands&#44; which can lead us to confuse the diagnosis with late-onset rheumatoid arthritis &#40;RA&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Nevertheless&#44; it has been established that both are separate entities&#44; despite the fact that they share phenotypic similarity at the beginning&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">For this reason&#44; new criteria to diagnose PMR in a more specific way were established in 2012&#44; including&#44; in addition to the mentioned classic clinical and laboratory criteria&#44; some abnormal ultrasound &#40;US&#41; findings on the shoulders and hips&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">On the other hand&#44; the US Point of Care &#40;POC US&#41; is defined as a US study conducted by the physician in charge of the patient&#44; usually as an adjunct to the physical examination&#44; to identify the presence or absence of a limited number of specific findings&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Thus&#44; it can be used in an elderly patient with a clinical picture of polyarticular inflammation without a precise diagnosis&#44; looking for the presence of bursitis in the shoulders and trochanters to identify a case of PMR&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The indexed bibliography does not report PMR cases in Peru&#46; Consequently&#44; our objective is to report a case of polymyalgia rheumatica associated with seronegative polyarthritis that was diagnosed using the POC US&#44; in order to identify some of the current criteria for the diagnosis of this disease&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case presentation</span><p id="par0030" class="elsevierStylePara elsevierViewall">A 65-year-old woman admitted due to a clinical picture that had started 6 months before with pain in the temporomandibular joint and the jaw&#44; bilateral&#44; with an intensity of 7&#47;10&#44; that impeded mastication&#44; associated with pain of the same intensity&#44; in addition to bilateral stiffness in the occipital region&#44; posterior neck&#44; trapezius muscles and shoulders&#44; which prevented her from moving and lifting the shoulders and turning the neck&#46; In addition&#44; she presented pain in the right hip &#40;gluteal and trochanteric region&#41; that increased when she was sitting for more than 20&#160;min and prevented her from walking&#46; These pains were persistent&#44; with no variation between day and night&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Five months before her admission&#44; she had an increase in volume in the metacarpophalangeal joints of both hands&#44; related to pain of intensity 7&#47;10&#44; without associated erythema&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Four months before her admission&#44; these symptoms increased to an intensity of 8&#47;10&#44; with an increase in local temperature and edema of all the fingers of both hands and wrists associated with a non-quantified sensation of thermal rise for 15 days&#44; which resolved spontaneously&#46; This was associated with stiffness of all the involved joints&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Two months prior to her admission&#44; bilateral pain in the neck&#44; shoulder girdle&#44; hands and wrists persisted&#44; and erythematous spots were added in the dorsal aspect of all the proximal interphalangeal &#40;PIP&#41; and metacarpophalangeal &#40;MCP&#41; joints of both hands&#46; In addition&#44; she had stiffness in all these joints throughout the whole day&#44; predominantly in the morning&#44; which lasted for several hours and improved moderately as the day passed due to movement&#44; but did not disappear completely&#46; This stiffness was more intense in the hands&#44; to the point that she could not clench her fist or grasp things&#46; She also experienced Raynaud&#39;s phenomenon in the hands and was unable to stand up without help due to additional similar involvement of both knees&#46; It was not possible for her to close her hands to hold things&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The patient received 10&#160;mg of prednisone during a month&#44; without improvement in her condition&#44; because her treating doctor thought at this time that it was an &#8220;activity of a rheumatoid arthritis&#8221;&#46; Throughout the course of the disease&#44; the polyarticular pain ranged between 7&#47;10 and 10&#47;10&#44; predominantly in the morning&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">One month before admission&#44; bilateral pain and increase in volume of the ankles and toes were added&#46; At this time&#44; the intensity of the polyarticular pain was 10&#47;10&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Ten days before admission&#44; due to the pain and stiffness described&#44; she could no longer get out of bed&#44; it was not possible to separate her arms from her body and she depended on others to wash&#44; eat&#44; bathe&#44; go to the bathroom or write&#46; During the entire time of the disease&#44; she presented hyporexia and lost 12&#160;kg in total&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">She had no previous headache&#44; visual disturbances&#44; jaw claudication&#44; pain or swelling in temporal regions&#44; cutaneous lesions on the face&#44; malar rash&#44; photosensitivity&#44; foamy urine&#44; or cardiorespiratory symptoms at the time of admission&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">She has the antecedent of having suffered from inflammatory joint disease of the shoulders&#44; back and hands 35 years ago&#44; which at this time was diagnosed as &#8220;seronegative rheumatoid arthritis&#8221; and treated with prednisone 10&#160;mg&#47;day&#44; conditional to the symptoms &#40;last episode 3 years ago&#41;&#46; Likewise&#44; she had had osteoarthrosis of the hands 10 years ago&#59; arterial hypertension 5 years ago&#44; treated with losartan&#59; fibromyalgia and depression 5 years before&#44; treated with pregabalin&#44; NSAIDs&#44; sertraline and alprazolam&#59; dry eye syndrome 5 years before&#44; treated with artificial tears&#59; and &#171;fatty liver&#187; 3 years ago&#46; There was no history of previous diabetes mellitus&#44; thyroid disease&#44; cerebrovascular or neuromuscular disease&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In the physical examination on admission she had a blood pressure of 130&#47;60&#160;mmHg&#44; a hearth rate of 72 beats per minute&#44; respiratory rate &#40;RR&#41; of 24 breaths per minute&#44; temperature of 37&#46;6&#160;&#176;C and oxygen saturation of 95&#37; with ambient oxygen&#46; She had mild conjunctival pallor&#44; but without scleral icterus&#46; The temporal arteries were not painful and they did not appear increased in caliber or consistency&#46; Erythematous spots were found in the skin of the dorsal area of the PIP and MCP joints of both hands &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; She did not have malar rash or lesions in the face and the trunk&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">In the articular examination&#44; she had increased volume of all the joints of the hands&#44; both wrists&#44; shoulders&#44; elbows&#44; knees&#44; ankles and joints of both feet&#44; with a bilateral positive squeeze test in the hands and feet&#46; She had mild synovitis in the PIP and MCP joints in both hands &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#44; left&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The examination was painful on muscle palpation of both deltoids&#44; while the active abduction of the shoulders was minimal due to severe pain&#46; In addition&#44; she presented increased volume and pain on palpation and digitopressure of the subtrochanteric area in both thighs&#46; The muscle mass was greatly decreased in the thighs&#44; shoulders&#44; arms and forearms&#44; but the muscle tone was normal&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The abdominal&#44; neurological&#44; pulmonary and cardiac examination was normal&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In the laboratory tests she presented erythrocyte sedimentation rate &#40;ESR&#41; of 65&#160;mm&#47;h and C reactive protein of 9&#46;7&#160;mg&#47;dl &#40;NV&#58; 0&#8211;0&#46;5&#41;&#46; The immunological markers showed negative anti-extractable nuclear antigen &#40;ENA profile&#41;&#44; anti-cyclic citrullinated peptide &#40;anti-CCP&#41;&#44; antinuclear &#40;ANA&#41; antibodies and rheumatoid factor&#46; In the laboratory tests she had Hb in 10&#160;g&#47;dL&#44; with normal corpuscular constants&#44; in addition to normal counts of leukocytes and platelets&#46; In the biochemical tests&#44; the glucose&#44; creatinine&#44; DHL&#44; TGO&#44; total CPK&#44; serum calcium&#44; albumin and globulin were within normal ranges&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The electromyography only showed signs of bilateral carpal tunnel syndrome without myopathic involvement&#46; A magnetic resonance imaging &#40;MRI&#41; of the hands was also performed&#44; in which adequate regular and symmetric metacarpophalangeal and proximal interphalangeal joint spaces were evidenced&#44; without synovial thickening or joint erosions in proximal interphalangeal&#44; metacarpophalangeal&#44; carpometacarpal and midcarpal joints&#44; although a slight increase in volume of periarticular structures was observed&#44; especially in the second and third metacarpophalangeal joints &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">POC US studies of the shoulders&#44; wrists and hands were performed with a Samsung&#174; SonoAceR3 ultrasound equipment&#44; with a high frequency linear transducer to establish the diagnosis&#44; and subdeltoid bursitis was evidenced in both shoulders &#40;greater in the left than in the right&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#44; left&#41;&#44; as well as tenosynovitis in the left biceps tendon &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41; and bilateral trochanteric bursitis with synovitis of the hip &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#44; right&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">With these findings&#44; the diagnosis of PMR was confirmed and treatment was started with 20&#160;mg of oral prednisone&#44; but there was no improvement on the first day&#44; so the dose of this drug was increased to 30&#160;mg&#46; As a result&#44; the pain intensity decreased at 24&#160;h from 8&#47;10 to 5&#47;10&#46; Likewise&#44; the periarticular inflammation in the hands&#44; wrists and ankles decreased&#44; and the patient was able to sit up by herself at the second day of treatment with 30&#160;mg of prednisone&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The patient was discharged on the fifth day of use of prednisone 30&#160;mg per day&#44; walking on her own&#44; eating by herself and very satisfied with having improving substantially and with the global pain intensity in 4&#8211;5&#47;10&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Treatment with 20&#160;mg of methotrexate weekly associated with oral folic acid daily was also started&#44; according with the 2015 EULAR&#47;ACR guidelines&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> because the patient had previously been a user of corticosteroids and she had several relapses in the last year&#44; especially the last episode which was disabling&#44; and also because she had a high risk of adverse effects from the corticosteroids&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The patient was reevaluated after 2 weeks of treatment with methotrexate weekly and prednisone 30&#160;mg&#47;day&#44; and she was already walking alone&#44; raised her arms above her shoulders and could flex her fingers better &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#44; right&#41;&#46; In addition&#44; she reported a pain intensity of 3&#8211;4&#47;10 &#40;and some days she reported no pain&#41;&#44; but that allowed her to fend for herself&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">An ultrasound control was performed&#44; in which a considerable decrease in the subdeltoid &#40;from 7&#46;8&#160;mm to 5&#46;5&#160;mm&#41; and trochanteric bursitis &#40;from 11&#46;9&#160;mm to 2&#46;2&#160;mm&#41; was evidenced &#40;<a class="elsevierStyleCrossRefs" href="#fig0020">Figs&#46; 4 and 5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0135" class="elsevierStylePara elsevierViewall">The reported case describes an older adult patient with multiple pathological antecedents who presented with a chronic clinical picture of osteomyoarticular pain&#46; This picture had started in the shoulder girdle&#44; the neck&#44; and the hips&#44; and then it became generalized to the hands&#44; knees&#44; and ankles&#44; without improvement with low doses of prednisone&#44; NSAIDs&#44; and pregabalin&#46; Since in this case there were previous episodes of osteoarticular pain for more than 30 years&#44; the patient was previously diagnosed as seronegative RA and she partially improved with low doses of corticosteroids until this last episode&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Even though a clinical picture of PMR in older adults can be confused not only with RA&#44; but also with other rheumatologic pathologies &#40;arthritis due to crystals&#44; vasculitis&#44; among others&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> the patient had negative RF&#44; anti-CCP&#44; ANA and ANCA&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Despite the fact that PMR is frequently associated with giant cell arteritis&#44;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a> this patient did not have clinical symptoms of giant cell arteritis&#46; Thus&#44; since she presented non-specific rheumatological symptoms&#44; including arthritis and synovitis&#44; she was cataloged as seronegative RA &#40;although the arthritis was non-erosive&#41; and received low doses of corticosteroids without finding improvement in the clinical picture&#46; This led her to a functional disability&#44; to the point of making her completely dependent to perform some activity&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">In Latin America&#44; cases of PMR have been reported only in Colombia&#44; and patients very frequently report pain or stiffness in the shoulder girdle &#40;99&#37;&#41; and in the pelvic girdle &#40;90&#37;&#41;&#44; with predominance in the female gender &#40;80&#37;&#41;&#44; cervical pain &#40;49&#37;&#41;&#44; fatigue &#40;36&#37;&#41;&#44; weight loss &#40;21&#37;&#41;&#44; arthritis &#40;21&#37;&#41; and fever &#40;16&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> The reported patient presented all these characteristics&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Due to the multiple clinical criteria for the diagnosis of PMR&#44; in 2012 the EULAR&#47;ACR agreed to include criteria of ultrasonography images in order be able to establish a diagnosis of this disease with a sensitivity and specificity of more than 90&#37;&#46; These criteria are unilateral or bilateral subdeltoid bursitis&#44; bicipital tenosynovitis or trochanteric bursitis&#44; either unilateral or bilateral&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;10</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Moreover&#44; US is being increasingly used as an extension of the physical examination for the initial evaluation of many musculoskeletal inflammatory diseases&#44; since it is portable&#44; non-invasive&#44; does not involve radiation&#44; and it is inexpensive&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Then&#44; when we performed the POC US studies in the patient looking for these abnormalities&#44; we found bilateral involvement of the three anatomical structures described&#44; and according to the 2012 criteria&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> the patient had a score of more than five points with US&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">With this&#44; we classified the patient as PMR and agreed with her to start therapy with prednisone at a dose higher than the recommended of 15&#160;mg&#44; since she was already receiving this drug at doses between 10 and 20&#160;mg for about 6 months &#40;due to a misdiagnosis of seronegative RA&#41; and she did not improve&#46; In this way the patient fulfilled a criterion of definition of a patient resistant to glucocorticoids&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> With the increase to 30&#160;mg of prednisone&#44; the expected clinical response was obtained in 48&#160;h&#44; as described above&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Findings of certain characteristics of patients with PMR resistant to glucocorticoids&#44; such as female gender&#44; C-reactive protein value higher than 8&#160;mg&#47;dl&#44; ESR higher than 80&#160;mm&#47;h&#44; greater pain intensity at admission by visual analogue scale &#40;between 7 and 10&#41;&#44; morning stiffness for more than 2&#160;h and presence of peripheral arthritis are described&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Our patient had all these characteristics&#44; except the ESR value&#46; For this reason&#44; therapy with methotrexate was added&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">On the other hand&#44; a comparative MRI of the hands was performed to the patient before she was admitted to hospitalization&#44; without observing articular changes suggestive of RA&#44; such as bone edema&#44; synovitis or bone erosions&#44; which are reported in between 80 and 100&#37; of the cases of rheumatoid arthritis&#44; even in early RA of less than 3 months of evolution&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">Although there are studies that suggest some findings in the MRI of the hands that are more frequent in patients with PMR than in healthy controls&#44; such as tenosynovitis of the common extensor of the fingers without significant synovitis&#44;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> the tendon of this muscle could not be visualized in the incidence of the MRI image of the reported patient&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">After discharge&#44; we reevaluated the patient 14 days after the initiation of the therapy with prednisone and methotrexate&#44; and when we conducted another POC US study we evidenced a decrease in the echographic extension of the bursitis&#44; both subdeltoid and trochanteric&#46; This was consistent with the improvement in the pain and in the general clinical picture with the immunosuppressive treatment&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">This is in agreement with previous studies that also suggest that US can be used as a useful tool for monitoring the response to treatment in PMR&#44; either with corticosteroids&#44; or with anti-TNF&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Even&#44; a decrease in shoulder bursitis is reported&#44; from in 61&#37; of the patients before treatment&#44; to 36&#37; after 12 weeks of treatment with tocilizumab&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">For this reason&#44; we consider that the MRI&#44; despite detecting findings characteristic of PMR&#59; has higher costs and technical difficulties compared with a POC US study at the bedside of the patient&#44; which can find the same results that are observed in the MRI&#58; trochanteric and subdeltoid bursitis and bicipital synovitis&#44; as established by the current classification criteria for PMR&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In addition&#44; an US equipment can be available immediately and&#44; when it is used by trained personnel&#44; it can report these findings more quickly than a MRI&#44; at the same moment of the clinical evaluation of the patient&#44; either in hospitalization&#44; or even in some doctor&#8217;s offices&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">We can conclude&#44; then&#44; that PMR can present in an older adult patient associated with non-erosive symmetric polyarthritis&#44; without presenting giant cell arteritis with elevated inflammatory markers&#44; and that it can be differentiated from RA by having negative RF and anti-CCP&#44; and findings in the US POC of bicipital tendinitis and shoulder and trochanteric bursitis&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">In the case of women over 50 years of age with chronic polyarticular pain of inflammatory type&#44; that makes us suspect late onset RA&#44; but who have negative markers for this pathology&#44; we should investigate whether a possible PMR is present&#46; For this reason we recommend to carry out POC US studies in patients over 50 years of age with chronic osteomyoarticular pain&#44; to be able to differentiate between the true synovial and articular involvement and the bursae and tendon involvement&#44; especially when the greatest pain commitment is in the pelvic and shoulder girdle&#46; Even&#44; the POC US can be used for monitoring the response to pharmacological management&#44; which goes hand in hand with the clinical response&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflict of interest</span><p id="par0210" class="elsevierStylePara elsevierViewall">The author declares that he has no conflict of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Polymyalgia Rheumatica is one of the most frequent inflammatory musculoskeletal disorders in adults over 50 years of age that can present with polyarthritis&#46; The case is presented of a 65-year-old woman with chronic disabling severe polyarticular pain associated with polyarthritis&#46; It was initially diagnosed as seronegative rheumatoid arthritis&#44; in which bilateral sub-deltoid and trochanteric bursitis was demonstrated by ultrasound&#44; along with bicipital tenosynovitis&#44; all features of <span class="elsevierStyleItalic">polymyalgia rheumatica</span>&#46; A good clinical and ultrasound response to corticosteroid treatment is also described&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">La polimialgia reum&#225;tica es una de las patolog&#237;as inflamatorias musculoesquel&#233;ticas m&#225;s frecuentes en adultos mayores de 50 a&#241;os que pueden presentarse con poliartritis&#46; Se presenta el caso de una mujer de 65 a&#241;os con cuadro cr&#243;nico de dolor poliarticular severo incapacitante&#44; asociado a poliartritis&#44; diagnosticada inicialmente como artritis reumatoide seronegativa&#44; en quien se demostr&#243;&#44; mediante ultrasonido&#44; bursitis subdeltoidea y trocant&#233;rica bilaterales&#44; as&#237; como tenosinovitis bicipital&#44; todas caracter&#237;sticas de polimialgia reum&#225;tica&#46; Se describe tambi&#233;n una buena respuesta cl&#237;nica y ultrasonogr&#225;fica al tratamiento con corticoides&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Guill&#233;n L&#243;pez OB&#46; Ultrasonograf&#237;a point of care para el diagn&#243;stico de polimialgia reum&#225;tica en poliartritis cr&#243;nica seronegativa&#58; un reporte de caso&#46; Rev Colomb Reumatol&#46; 2022&#59;29&#58;68&#8211;73&#46;</p>"
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