POLYMYALGIA RHEUMATICA - Boston Foot



POLYMYALGIA RHEUMATICA

Dr. Vivek Rajagopal MD, MRCP

Consultant Rheumatologist

West Suffolk Hospital, Bury St Edmunds, UK

Polymyalgia Rheumatica (PMR) is an inflammatory condition of unknown cause, characterised by aching and morning stiffness in the neck, shoulder and pelvic girdle.

Epidemiology

This is the most common cause of new inflammatory disease in elderly people.

The average age of onset is just over 70. It is hardly ever seen in patients younger than 50 years. It is 2 to 3 times more common in females. Prevalence varies between populations with Scandinavians having the highest rate, black and Asians the lowest rate.

Annual incidence in the UK – 84/ 100,000.

Symptoms

Onset – Usually rapid, but may be insidious.

Muscle pain – Presenting feature in 70- 90%. Occurs in the shoulder and described as an aching, worse in the morning and can radiate towards the elbow. It can start in one shoulder and become bilateral. Upper thigh and neck pain is seen in two thirds of people and the pain interferes with sleep.

Stiffness – Morning stiffness of more than 45 minutes is typical. Patients often need assistance to get out of bed. The stiffness can recur after a period of rest.

Systemic symptoms – such as low grade fever, night sweats, fatigue, anorexia, weight loss and depression occur in up to 40% of people.

Headache, scalp tenderness and visual disturbances – indicate the presence of giant cell arteritis (GCA) which can accompany PMR in 10 – 20%. (Conversely, up to 50% of patients with GCA can have symptoms of PMR).

Signs

Very few clinical signs are seen. Bilateral upper arm tenderness is sometimes present. Shoulder abduction may be limited due to pain.

Muscle strength – usually unaffected, but testing can be difficult due to pain.

Peripheral musculoskeletal signs such as oedema of upper limbs and carpal tunnel syndrome may be seen in 50%.

Diagnosis

Diagnosis is based on typical history and physical features. Usually accompanied by blood abnormalities which include a raised ESR, CRP and normocytic normochromic anaemia. There are no diagnostic tests. Several diagnostic criteria have been proposed mainly for research purposes to ensure uniformity within trials. They have also been used for clinical purposes.

Differential Diagnosis

1, Degenerative disorders- e.g.; cervical and lumbar spondylitis, Osteoarthritis of the shoulder, rotator cuff disorders, bilateral adhesive capsulitis.

2, Endocrine disorders – Thyroid and Parathyroid disease.

3, Infection – Osteomyelitis, Viral infection, TB.

4, Inflammatory disorders – RA (can begin with a polymyalgic onset)

Remitting Seronegative Symmetric Synovitis with peripheral oedema – A rare disorder that tends to respond to steroids. Can be associated with malignancy.

Polymyositis / Dermatomyositis – Muscle weakness is a prominent feature, while pain is usually mild to moderate.

5, Malignancy – Haematological disorders or bony metastasis.

6, Drugs – Myalgia and myositis due to statins.

7, Miscellaneous – fibromyalgia, other chronic pain syndromes.

Investigations

As previously mentioned, there are no diagnostic tests for PMR. The following may help support a diagnosis.

• ESR – Typically, will be higher than 40. Can be normal at presentation in up to 20%.

• CRP – Typically elevated.

• Normochromic normocytic anaemia

Mild abnormalities in liver function tests are common. Alkaline phosphatase can be raised in a third with PMR.

Consider tests to exclude other conditions.

Diagnostic Criteria- PMR can be diagnosed with a sensitivity of 92%, specificity 80% if 3 or more of the following are present.

• Bilateral shoulder pain or stiffness

• Onset of illness < 2 weeks

• Initial ESR. 40mm/hr

• 65 years of age or more

• Depression and weight loss

• Bilateral tenderness in upper arms

Consider referral to Rheumatologist if:

• Atypical features such as normal inflammatory markers, younger age

• Lack of typical response to steroids

• Dependence on prednisolone

• Features of Giant Cell Arteritis

Treatment

PMR responds well to low dose prednisolone. A starting dose of 15mg usually causes dramatic improvement within 48 hrs. Usually patients need 12 to 18 months of prednisolone to prevent relapse. The dose can be tapered down by 2.5 mg every 3 weeks until 10mg and then reduced by 1mg/month.

Ensure Osteoporosis prophylaxis for patients over 65 as per local/national guidelines.

Review patient in a week. If there is a poor response, consider referral to a specialist.

Prognosis

PMR tends to respond well to treatment and the majority of patients can be in drug free remission within 1-2 years. Up to 20% of patients may remain steroid dependent and should be managed in specialist clinics.

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