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.
