Updated: 5/1/2018

Polymyalgia Rheumatica

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Snapshot
  • A 60-year-old woman presents to her physician's office for headache and muscle weakness. She reports that she usually never has headaches but recently started experiencing headaches in the morning about 2 weeks ago. She also reports feeling very weak and tired in the mornings and cannot even raise her arms to brush her hair. Physical exam shows that she has normal strength and normal range of movement. She is sent for further laboratory workup for inflammatory disease.
Introduction
  • Clinical definition
    • chronic and inflammatory rheumatic disease characterized by muscle pain and stiffness
  • Epidemiology
    • demographics
      • female > male
      • > 50 years of age
    • risk factors
      • winter months
      • viral infections
  • Pathogenesis
    • pathogenesis is unclear but may be triggered by environmental factors such as winter or viral infections and inflammatory cytokines play a key role
  • Associated conditions
    • giant cell arteritis (in ~20% of patients)
  • Prognosis
    • ~50% of patients experience relapse
Presentation
  • Symptoms
    • muscle pain and stiffness in the neck, shoulders, or pelvis for > 2 weeks
      • stiffness is more prominent in the morning
      • difficulty rising out of chair or lifting arms above head
    • constitutional symptoms
      • fatigue
      • low-grade fevers
      • weight loss
    • headache may indicate giant cell arteritis
  • Physical exam
    • normal muscle strength
    • reduced active and passive range of movement
    • joint swelling may be appreciated
Imaging
  • Ultrasound of shoulder
    • indication
      • to assess for bursitis in patients with bilateral shoulder aching and stiffness
        • > 90% sensitivity and specificity for diagnosis of polymyalgia rheumatica
    • findings
      • bursitis
Studies
  • Labs
    • ↑ inflammatory markers
      • erythrocyte sedimentation rate
      • C-reactive protein
    • normal creatine kinase
    • autoantibodies typically absent
  • Making the diagnosis
    • based on clinical presentation and laboratory studies
Differential
  • Rheumatoid arthritis
  • Adhesive capsulitis
  • Fibromylagia
  • Corticosteroid-induced myopathy
    • proximal muscle weakness with normal erythrocyte sedimentation rate and creatine kinase
      • may present in polymyalgia rheumatica patient being treated with chronic steroids
Treatment
  • Management approach
    • if patients do not rapidly respond to low-dose corticosteroids, consider an alternative diagnosis
    • nonsteroidal anti-inflammatory drugs usually do not have any effect
  • Medical
    • systemic low-dose corticosteroids  
      • indication
        • initial therapy for patients with polymyalgia rheumatica
          • low-dose steroid response is usually rapid
          • consider supplementing with calcium and vitamin D for prevention of osteoporosis
    • methotrexate
      • indications
        • added to treatment regimen for patients on prolonged therapy and with inadequate response to steroids
        • used in patients in whom steroids are contraindicated
Complications
  • Blindness caused by giant cell arteritis
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(M3.RH.16.58) A 59-year-old male with history of hypertension presents to your clinic for achy, stiff joints for the last several months. He states that he feels stiff in the morning, particularly in his shoulders, neck, and hips. Occasionally, the aches travel to his elbows and knees. His review of systems is positive for low-grade fever, tiredness and decreased appetite. On physical exam, there is decreased active and passive movements of his shoulders and hips secondary to pain without any obvious deformities or joint swelling. His laboratory tests are notable for an ESR of 52 mm/hr (normal for males: 0-22 mm/hr). What is the best treatment in management? Tested Concept

QID: 103081
1

Nonsteroidal antiinflammatory agent

17%

(2/12)

2

Hyaluronic acid

0%

(0/12)

3

Bisphosphonate

0%

(0/12)

4

Methotrexate

8%

(1/12)

5

Corticosteroid

67%

(8/12)

M 11 C

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(M2.RH.15.37) A 67-year-old female presents to her primary care physician complaining of headaches in her left temple and scalp area, neck stiffness, occasional blurred vision, and pain in her jaw when chewing. The appropriate medical therapy is initiated, and a subsequent biopsy of the temporal artery reveals arteritis. Five months later, the patient returns to her physician with a complaint of weakness, leading to difficulty climbing stairs, rising from a chair, and combing her hair. The patient states that this weakness has worsened gradually over the last 2 months. She reports that her headaches, jaw pain, and visual disturbances have resolved. Physical examination is significant for 4/5 strength for both hip flexion/extension as well as shoulder flexion/extension/abduction. Initial laboratory work-up reveals ESR and creatine kinase levels within normal limits. Which of the following is the most likely diagnosis in this patient's current presentation? Tested Concept

QID: 105037
1

Mononeuritis multiplex

0%

(0/23)

2

Polymyalgia rheumatica

35%

(8/23)

3

Drug-induced myopathy

57%

(13/23)

4

Polymyositis

4%

(1/23)

5

Dermatomyositis

0%

(0/23)

M 6 E

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Evidence (5)
Topic COMMENTS (6)
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