Fibromyalgia; PMR; Giant Cell Arthritis Flashcards
Define fibromyalgia
Chronic widespread pain associated with mechanical hypersensitivity
Describe the clinical presentation of fibromyalgia [6]
- chronic pain: at multiple site, sometimes ‘pain all over’
- lethargy
- cognitive impairment: ‘fibro fog’
- sleep disturbance, headaches, dizziness are common
-
allodynia, a type of neuropathic pain, making
them extremely sensitive to touch - headaches
- numbness/tingling sensations
Describe how you dx fibromyalgia [3]
Clinical:
- presence of chronic (>3 months), widespread body pain and associated symptoms such as fatigue and sleep disturbance
Bloods:
- Should have normal ESR; ANA: RF: thyroid; anti-CCP, vitamin D, ferritin
If a patient is tender in at least 11 of 18 points it makes a diagnosis of fibromyalgia more likely
What are risk factors for fibromyalgia? [5]
- FH
- Hx of rheumatoid conditions
- Female; 20-60
- stressful events
- sleep problems
Describe how you manage fibromyalgia
Education; graded excerise programme
Psychological support
- CBT
Aerobic exercise - strong evidence
Analgesia
- amitriptyline; duloxetine; pregabalin
Describe conversation might have with a patient about how to manage their fibromyalgia [2]
- FM is a chronic illness, akin to that of diabetes mellitus and congestive heart failure, selfmanagement of day-to-day symptoms is key and has been associated with decreased pain,
depression, catastrophic thinking, and improved quality of life -
Identify specific goals regarding health status and quality of life, that is encouraging exercise
and sleep hygiene.
Define polymyalgia rheumatica [1]
Which condition does PMR have a strong association with? [1]
Polymyalgia rheumatica (PMR) is an inflammatory condition that causes pain and stiffness in the shoulder and pelvic girdles. It rarely occurs in those under 50 years of age and is more common in women (3:1 female to male ratio).
. There is a strong association with giant cell arteritis, and the two conditions often occur together.
Describe the clinical features of PMR [+]
Patients may have a relatively rapid onset of symptoms over days to weeks:
Stiffness and pain in the
* Shoulders, potentially radiating to the upper arm and elbow
* Pelvic girdle (around the hips), potentially radiating to the thighs
* Neck
Systemic symptoms (40-50%).
* Includes low grade fever
* fatigue
* anorexia
* weight loss
* depression.
Peripheral oligoarticular arthritis (50%).
The characteristic features of the pain and stiffness are:
* Worse in the morning
* Worse after rest or inactivity
* Interfere with sleep
* Take at least 45 minutes to ease in the morning
* Somewhat improve with activity
If the patient is younger than [], an alternative explanation should be sought as PMR is very rare in this age group.
If the patient is younger than 50, an alternative explanation for the above symptoms should be sought as PMR is very rare in this age group.
RA presents similiarly in the early stages of the disease to PMR.
What specifically should you look for give a ddx? [2]
Rheumatoid arthritis can have an initial phase that presents similarly to PMR and so the presence of synovitis or clinical features suggestive of rheumatoid arthritis should prompt consideration of this as a potential diagnosis and referral to secondary care for confirmation.
RA patients also do not respond well to corticosteroids, unlike PMR
RA antibodies (anti-CCP; RF)
How would you investigate for PMR?
Baseline blood tests
- Elevated ESR/CRP
- Normal other blood tests
All these would be normal
Which type of bursitis is associated with PMR? [1]
subacromial bursitis is associated with PMR.
What are the key clinical features of GCA? [4]
unilateral headache
jaw claudication
visual disturbance
tender or thickened temporal artery on palpation
How do you distinguish PMR and fibromyalgia? [2]
Differences:
- The pain of fibromyalgia tends to be more widespread and would not have the prolonged stiffness that is associated with PMR
- Inflammatory markers would also be normal.
Describe the treatment regime for PMR
Oral corticosteroids 15mg prednisolone daily, initially and gradually weaned off them with dose adjustments typically being every 4-8 weeks and reviews (telephone or face to face) scheduled for one week after each dose adjustment.
Treatment with steroids typically lasts 1-2 years. NICE suggest the following reducing regime of prednisolone:
* 15mg until the symptoms are fully controlled, then
* 12.5mg for 3 weeks, then
* 10mg for 4-6 weeks, then
* Reducing by 1mg every 4-8 weeks
In secondary care, patients may be considered for DMARD treatment as 2nd line therapy (e.g. methotrexate) or tocilizumab as 3rd line.
NB: Patients with PMR have a dramatic improvement in symptoms (at least 70%) within one week. Inflammatory markers return to normal within one month. A poor response to steroids suggests an alternative diagnosis.
PMR
Describe the presentation of temporal arteritis [5]
Unilateral headache is the primary presenting feature, typically severe and around the temple and forehead. It may be associated with:
* Scalp tenderness (e.g., noticed when brushing the hair)
* Jaw claudication
* Blurred or double vision
* Loss of vision if untreated
Anterior ischemic optic neuropathy accounts for the majority of ocular complications
Lethargy, depression, low-grade fever, anorexia, night sweats
NB patients are typically > 60; rapid onset (< 1month)
Describe investigations would conduct for CGA
raised inflammatory markers
temporal artery biopsy
- skip lesions may be present
- multinucleated giant cells present
Duplex ultrasound
- showing the hypoechoic “halo” sign and stenosis of the temporal artery
