Scand J Rheumatol 2002;31:103 –6

CASE REPORT

Renal cell carcinoma mimicking polymyalgia rheumatica

Clues for a correct diagnosis

Laura Niccoli1, Carlo Salvarani2, Giovanna Baroncelli1, Angela Padula3, Ignazio Olivieri3, and Fabrizio Cantini1

12nd Divisione di Medicina, Unita Reumatologica, Ospedale di Prato, 2Divisione di Reumatologia, Arcispedale S. Maria Nuova, Reggio Emilia,3Divisione di Reumatologia, Ospedale S. Carlo, Potenza, Italy

Proximal musculoskeletal symptoms mimicking the clinical picture of polymyalgia rheumatica may herald the onset of solid malignancies.We report on three patients presenting with polymyalgia-like symptoms, who had renal cell carcinoma. The review of the literature andour cases suggest that the absence of prolonged morning stiVness, the atypical clinical � ndings, the ineYcacy of corticosteroids, and theabsence of shoulder sonographic pathologic � ndings may help to facilitate the proper diagnosis.

Key words: paraneoplastic polymyalgia rheumatica, polymyalgia rheumatica, morning stiVness, shoulder ultrasonography,renal cell carcinoma

Solid and hematologic malignancies may be associ- but palpation of muscles of the thighs and calveswas felt painful by the patient. Cranial symptomsated with proximal musculoskeletal symptoms mim-

icking the clinical picture of polymyalgia rheumatica and signs suggesting temporal arteritis were absent.The physical � ndings were otherwise normal. Body(PMR) (1). In view of its variety of nonmetastatic

clinical manifestations, renal cell carcinoma (RCC) temperature was 37.8°C.Blood tests showed erythrocyte sedimentation ratehas been called ‘‘ the internist tumor’’ (2). PMR-like

manifestations heralding RCC have been described (ESR) 88 mm/hour, C-reactive protein (CRP)10.3 mg/dl (normal: < 0,5), hemoglobin 9 g/dl, within several reports (1,3–5).

We describe three additional patients with RCC other routine assays normal, including alkalinephosphatase, serum protein electrophoresis, andpresenting with clinical features suggesting PMR.

The clinical and articular imaging � ndings diVerent- urine analysis. Thyroid function was normal and ser-ology for rheumatoid factor, � uorescent antinucleariating paraneoplasti c PMR from ‘‘pure’’ PMR are

discussed. antibodies, brucellosis, tumor markers were negative.Also 3 consecutive blood cultures were negative.

Case descriptionsTreatment with diclofenac 150mg/day gave good control ofthe symptomsPatient 1. An 85-year old woman was admitted with

a 3-month history of aching in shoulder and pelvicChest radiograph, two-dimensional echo-color

girdles associated with low grade fever, anorexia, anddoppler echocardiography, and whole body scinti-

weight loss (6 Kgs). The shoulder pain was localizedgraphy did not result in pathological � ndings.

in the gleno-humeral joint area bilaterally and associ-Shoulder ultrasonography showed no in� ammat-

ated with myalgias of the whole upper limbs. Pelvicory involvement of the articular and extraarticular

pain radiated down toward the lower limbs until thesynovial structures.

calves and exacerbated with movement. Aching wasAbdominal ultrasonography and computed tomo-

also present at rest at night. Morning stiVness wasgraphy disclosed a 6.5 cm renal mass of the lower

absent.pole of the left kidney (Fig. 1A, 1B).

The physical examination revealed tenderness ofA left nephrectomy was performed and histological

glenohumeral and acromioclavicular joints withoutexamination revealed a clear cell carcinoma. The

limitation of motion. Hip movements were unaltered,musculoskeletal symptoms subsided over 2 weeks andthe patient is still well after a 9-month follow-up

Fabrizio Cantini, 2nd Divisione di Medicina, Unita period.Reumatologica, Ospedale Misericordia e Dolce di Prato, Piazza Patient 2. A 79 year-old female was hospitalizedOspedale, 1 IT-59100 Prato, Italy. E-mail: fcantini@conmet.it

after a 2-month history of shoulder and pelvic girdlespain with associated fever (38.5 °C) and weight lossReceived 31 October 2001

Accepted 28 February 2002 (5 Kg). There was signi� cant night pain, but no

103© 2002 Taylor & Francis on license from Scandinavian Rheumatology Research Foundation

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Two-dimensional echo-color doppler echocardio-graphy and whole body scintigraphy were negative.However, abdominal ultrasonography and computedtomography showed a solid mass of 6.8 cm ofdiameter involving the right kidney.

The patient underwent surgical resection and histo-logical examination revealed a clear cell carcinoma.

Articular symptoms completely resolved 10 dayafter the intervention. Twenty months later, thepatient was in complete remission without therapy.

Patient 3. A 78-year old, previously healthy manwas admitted because of a 2-month history of fatigue,anorexia, low grade fever, and musculoskeletal dis-comfort aVecting the neck and shoulders associatedwith elevated acute-phase reactants. Pain was presentin nocturnal hours but articular morning stiVness wasabsent. Physical examination did not disclose anypathologic � ndings. Signs and symptoms suggestinggiant cell arteritis were absent.

Intermittent fever with a maximum value of 38°Cwas recorded. Blood cultures taken during fever peaksresulted negative.

ESR was 56 mm/hour and CRP 4.0 mg/dl, withnormality of other routinary blood examinationsThyroid hormones were within the normal range andserology for rheumatoid factor, � uorescent anti-nuclear antibodies, brucellosis, tumor markers werenegative. The patient was given diclofenac 150 mg/day with remission of pain.

Chest radiograph and two-dimensional echo-colordoppler echocardiography did not show pathological� ndings.

Shoulder ultrasonography � ndings were normal.Abdominal ultrasonography and computed tomo-

graphy disclosed a 4 cm mass of the superior pole of

a

b

Fig. 1A, 1B. Patient 1. Computed tomography of the abdomen. the right kidney. In absence of evidence of metastaticLeft kidney. Solid mass of 6.5 of diameter with extracapsular disease the patient underwent surgical resection ofdiVusion (arrows). Histologic � ndings were consistent with a the right kidney. Histological � ndings were consistentdiagnosis of renal cell carcinoma.

with a diagnosis of renal cell carcinoma. Musculo-skeletal pain resolved over a few days after theintervention.morning stiVness. Neither limitation of motion nor

peripheral synovitis were detected at inspection.Cranial signs/symptoms of temporal arteritis were

Discussionabsent. ESR was 130 mm/h, CRP 19.20 mg/dl, withother routine assays normal. Fluorescent antinuclear The combination of persistent pain of at least one

month duration associated with pronounced morningantibodies, rheumatoid factor, and monoclonal com-ponents were absent. Tumor markers and thyroid stiVness in the neck, shoulder, and pelvic girdles in

presence of elevated acute-phase reactants highlyhormones were not raised and serology for brucellosiswas negative. Chest radiograph was negative. suggests a diagnosis of PMR (6). Prolonged proximal

morning stiVness is usually a predominant feature ofA diagnosis of polymyalgia rheumatica was madeand the patient was treated with methylprednisolone PMR and it has been included in all sets of diagnostic

criteria for PMR (6). Physical � ndings in the shoulder16 mg/day. After two weeks the dosage was increasedto 24 mg/daily for absence of response. Articular of PMR patients usually reveal pain exacerbated by

active and passive movements, often associated withsymptoms improved slightly and two months later,because of the lack of any response, the patient was bilateral painful arc sign (7, 8).

The three patients with RCC described in thisagain hospitalized.

104

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RCC mimicking PMR

Tabl

eI.

Clin

ical

feat

ures

and

atyp

ical

findi

ngs

inal

lrep

orte

dca

ses

with

RCC

mim

ickin

gPM

R.

Case

1Ca

se2

Case

3Ca

se4

Case

5Ca

se6

Case

7Ca

se8

(Ref

.3)

(Ref

.4)

(Ref

.1)

(Ref

.1)

(Ref

.5)

(Pre

sent

repo

rt)(P

rese

ntre

port)

(Pre

sent

repo

rt)

Age

(yea

rs)

6770

n.a.

*n.

a.*

6985

7979

Sex

mal

efe

mal

efe

mal

em

ale

fem

ale

fem

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fem

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stem

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and

wei

ghtl

oss

anor

exia

asth

enia

asth

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abse

ntfe

ver,

anor

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,fe

ver,

wei

ghtl

oss

feve

rsy

mpt

oms

wei

ghtl

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Prox

imal

achi

ng(s

houl

der

pres

ent

pres

ent

pres

ent

pres

ent

pres

ent

pres

ent

pres

ent

pres

ent

and/

orpe

lvic

gird

le)

Mor

ning

stiff

ness

pres

ent

pres

ent

pres

ent

pres

ent

pres

ent

abse

ntab

sent

abse

nt>

30m

inut

esES

R(m

m/ h

our)

130

85no

tava

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eno

tava

ilabl

e42

8813

056

CRP

(mg/

dl)

nota

vaila

ble

2.9

nota

vaila

ble

nota

vaila

ble

nota

vaila

ble

10.3

19.2

4.0

Tend

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itatio

nsl

ight

abse

ntab

sent

abse

ntpr

esen

tpr

esen

tab

sent

abse

ntof

mot

ion

ofsh

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ers

and/

orhi

psBu

rsiti

sat

US

orM

RIsc

ans

nota

vaila

ble

nota

vaila

ble

nota

vaila

ble

nota

vaila

ble

nota

vaila

ble

abse

ntno

tava

ilabl

eab

sent

Resp

onse

toco

rtico

ster

oids

abse

ntpa

rtial

abse

ntab

sent

slig

htCS

notg

iven

abse

ntCS

notg

iven

Atyp

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left

flank

and

test

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abdo

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alm

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ain

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ofCS

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105

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paper had proximal musculoskeletal discomfort, asso- the normality of shoulder sonographic � ndingsshould alert the clinician for a diagnosis other thanciated with elevated acute-phase reactants. However,PMR.the absence of prolonged morning stiVness and of

remarkable limitation of motion of the shouldersrepresented clinical manifestations somehow atypical Referencesfor PMR. Moreover, the distal pain in patient 1 and

1. Gonzalez-Gay MA, Garcia-Porrua C, Salvarani C, Olivieri I,the ineYcacy of corticosteroids in patient 2 raised theHunder GG. The spectrum of conditions mimicking polymyal-

suspicion of a diVerent disease. gia rheumatica in Northwestern Spain. J Rheumatol 2000;27:It has long been recognized that PMR-like 2179–84.

2. Cronin RE, Kachny WD, Miller PR, Stables DP, Gabow PA,symptoms may occur in patients with infections,Ostroy PR, et al. Renal cell carcinoma: unusual systemicneoplasms, or other rheumatic conditions (9).manifestations. Medicine 1976;55:291 –311.Paraneoplastic manifestations are present in up to 3. Sidhom OA, Basalaev M, Sigal LH. Renal cell carcinoma

20% of the patients with RCC (10–12). Among these, presenting as polymyalgia rheumatica. Arch Intern Med1993;153:2043 –5.musculoskeletal manifestations resembling those of

4. Hopkinson N, Myint AA, Benjamin S. Polymyalgia and lowPMR have been described in several reports (1,3–5).back pain: a common cause not to be missed. Ann RheumA careful reading of the case descriptions showsDis 1999;58:462 –4.

that the clinical features are somewhat atypical to 5. Gonzalez-Gay MA, Garcia-Porrua C, Salvarani C, Olivieri I,those of pure PMR. As shown in Table I, all patients Hunder GG. Polymyalgia manifestations in diVerent condi-

tions mimicking polymyalgia reumatica. Clin Exp Rheumatolpresented atypical clinical features such as the distri-2000;18:755 –9.bution of pain, the absence of morning stiVness,

6. Salvarani C, Macchioni P, Boiardi L. Polymyalgia rheumatica.and of tenderness and limitation of motion of the Lancet 1997; 350: 43–7.shoulders. Moreover, the lack of response to corti- 7. Hunder GG. Gian cell arteritis and polymyalgia rheumatica.

In: Ruddy S, Harris ED, Sledge CB, editors. Kelley’s Testbookcosteroids strongly suggested a diVerent diagnosis.of Rheumatology. 6th Edition. Philadelphia, WB SaundersIn addition, our report suggests another feature2001:1155–64.which may be useful for a correct diagnostic 8. Hazleman B. Polymyalgia rheumatica and giant cell arteritis.

approach. Recently, magnetic resonance imaging and In: Klippel JH, Dieppe PA, editors. Rheumatology. 2nd Ed.London: Mosby; 1998:7.21.1 –8.ultrasonography studies evidenced that subacromial/

9. Gonzalez-Gay MA, Garcia-Porrua C, Salvarani C, Hundersubdeltoid bursitis in association with joint synovitisGG. Diagnostic approach in a patient presenting with polymy-and biceps tenosynovitis represents the imagingalgia rheumatica. Clin Exp Rheumatol 1999;17:276 –8.

hallmark of PMR (13–15). 10. Gold PJ, Fefer A, Thompson JA. Paraneoplastic manifesta-There are no data on the articular imaging � ndings tions of renal cell carcinoma. Semin Urol Oncol

1996;14:216 –22.of paraneoplastic PMR. However, in our patient 111. Papac RJ, Poo-Hwu WJ. Renal cell carcinoma: a paradigm ofand 3, shoulder ultrasonography did not disclose any

lanthanic disease. Am J Clin Oncol 1999;22:223 –31.synovial in� ammatory involvement. Therefore, the 12. Stummvold GR, Aringer M, Machold KP, Smolen JS,absence of articular and extraarticular synovitis may Raderer M. Cancer polyarthritis resembling RA as a � rst sign

of hidden neoplasms. Scand J Rheumatol 2001;30:40 –4.explain the diVerent clinical picture and physical13. Salvarani C, Cantini F, Olivieri I, Barozzi L, Macchioni L,� ndings with respect to pure PMR.

Niccoli L, et al. Proximal bursitis in active polymyalgiaIn conclusion, our cases oVered the opportunity to rheumatica. Ann Intern Med 1997;127:27 –31.

assess the clinical and radiological diVerences between 14. Salvarani C, Cantini F, Olivieri I, Hunder GG. Polymyalgiareumatica: a disorder of extraarticular synovial structures?PMR and paraneoplastic PMR. In evaluating anJ Rheumatol 1999;26:517 –21.elderly patient with proximal musculoskeletal pain

15. Cantini F, Salvarani C, Olivieri I, Niccoli L, Padula A,associated with elevated acute-phase reactants, theMacchioni L, et al. Shoulder ultrasonography in the diagnosis

absence of morning stiVness, the atypical distribution of polymyalgia rheumatica: a case-control study. J Rheumatol2001;28;1049 –55.of pain, the unresponsiveness to corticosteroids, and

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