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Updated: Dec 28 2021

Polymyalgia Rheumatica

Images rheumatica.jpg
  • 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)
  • 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
  • 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
    • Making the diagnosis
      • based on clinical presentation and laboratory studies
  • 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
  • Prognosis
    • ~50% of patients experience relapse
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