Review Question - QID 103011

This patient's presentation is consistent with polymyositis given her proximal muscle weakness and elevated CRP/aldolase. The first-line treatment of inflammatory myositis is high-dose glucocorticoids (such as prednisone).

Polymyositis is a systemic and inflammatory disease that is characterized by proximal muscle pain and weakness. More advanced disease is associated with shortness of breath and difficulty swallowing with involvement of the pharyngeal and/or esophageal musculature. Initial laboratory tests can include an ESR, CRP, and aldolase. EMG is abnormal in almost all patients with polymyositis. Muscle biopsy provides more definitive diagnosis and shows inflammation as well as muscle cell necrosis and regeneration. Management is first with corticosteroids followed by immunosuppressants and other agents (IVIG and monocolonal antibodies) as second-line agents as appropriate.

Incorrect Answers:
Answer 1: Intravenous immunoglobulin is indicated for steroid-resistant cases. First-line therapy should include steroids. It offers rapid control of symptoms and may be indicated for severe cases where the patient has dysphagia and cannot protect her airway (which is not occurring at this presentation).

Answer 2: Methotrexate has limited data supporting its use in polymyositis in steroid-refractory cases. This DMARD may be indicated in rheumatoid arthritis which presents in middle-aged women with symmetric/proximal joint pain that is worse in the morning.

Answer 3: Naproxen may reduce pain/stiffness; however, it will not treat the patient's underlying inflammatory condition and weakness. This may be indicated in the management of painful conditions such as polymyalgia rheumatica.

Answer 5: Neostigmine/pyridostigmine are indicated in the treatment of myasthenia gravis which presents with muscle weakness/diplopia that is worse at the end of the day/after exertion. These medications are acetylcholinesterase inhibitors.

Bullet Summary:
Initial treatment of polymyositis is steroids.