1.09 Polymyalgia Rheumatica

agk’s Library of Common Simple Emergencies

Presentation

An elderly patient (more commonly female) complains of a week or two of morning stiffness, which may interfere with her ability to rise from bed, but improves during the day. She may ascribe her problem to muscle weakness or joint pains, but physical examination discloses that symmetrical pain and tenderness of neck, shoulder, and hip muscles are the actual source of any “weakness.” There may be some mild arthritis of several peripheral joints, but the rest of the physical examination is negative.

What to do:

• Perform a complete history and physical examination, particularly of the cervical and lumbar spines and nerve roots (strength, sensation, and deep tendon reflexes in the distal limbs should be intact with PMR). Confirm the diagnosis of PMR by palpating tender shoulder muscles (perhaps also hips, and, less commonly, neck).
• Confirm the diagnosis by obtaining an erythrocyte sedimentation rate, which should be in the 30-l00mm/hour range. (An especially high ESR, over 100/hour suggests more severe autoimmune disease or malignancy.)
• Mild and borderline cases may respond with nonsteroidal anti-inflammatory medications (ibuprofen, naproxen). More severe cases will respond to prednisone 20-60mg qd within a week or two, after which the dose should be tapered. Failure to respond to corticosteroid therapy suggests some other diagnosis.
• Explain the syndrome to the patient and arrange for followup.

What not to do:

• Do not miss temporal arteritis, a common component of the polymyalgia rheumatica syndrome, and a clue to the existence of ophthalmic and cerebral arteritis, which can have dire neurological consequences. Palpate the temporal arteries for tenderness, swelling, or induration, and ask about transient neurological signs.
• Do not postpone diagnosis or treatment of temporal arteritis pending results of a temporal artery biopsy showing giant cell arteritis. The lesion typically skips areas, making biopsy an insensitive diagnostic procedure.

Discussion

Stiffness, pain, and weakness are common complaints in older patients, but polymyalgia rheumatica may respond dramatically to treatment. Rheumatoid arthritis produces morning stiffness, but is usually present in more peripheral joints, and without muscle tenderness. Polymyositis is usually characterized by increased serum muscle enzymes with a normal ESR, and may include a skin rash (dermatomyositis). Often, a therapeutic trial of prednisone helps make the diagnosis.

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