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
QUESTIONS 1 of 4 1 2 3 4 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 103081 Type & Select Correct Answer 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 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (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? QID: 105037 Type & Select Correct Answer 1 Mononeuritis multiplex 4% (1/25) 2 Polymyalgia rheumatica 32% (8/25) 3 Drug-induced myopathy 56% (14/25) 4 Polymyositis 4% (1/25) 5 Dermatomyositis 0% (0/25) M 6 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic