Polymyalgia rheumatica

Question 1

What is Polymyalgia rheumatica?

Answer 1

Polymyalgia rheumatica is a chronic, systemic rheumatic inflammatory disease characterized by aching and morning stiffness in the neck, shoulder, and pelvic girdle in people older than 50 years of age.

Question 2

What are the signs and symptoms of polymyalgia rheumatica?

Answer 2

Pain and stiffness (moderate to severe) in the neck, shoulders, upper arms, thighs, and hips, which inhibits activity, especially in the morning/after sleeping

Raised CPR

Fatigue

Malaise

Question 3

A 79 year old woman has 4 weeks of malaise, and pain in the arms and legs, with morning stiffness of 3 hours, and difficulty washing and dressing. She cannot lift her arms above her head due to pain, but there is no objective muscle weakness. She has Heberden’s nodes, but otherwise joint examination is normal. Her CRP is 67 mg/L (<5).

Which is the most likely diagnosis to explain her symptoms?

Answer 3

Patient is elderly with a short history and raised CRP. No muscle weakness so not polymyositis. No waddling gait so not osteomalacia. Also morning stiffess that takes hours to go away is more suggestive of an inflammatory cause –> polymyalgia rheumatica

Question 4

What causes polymyalgia rheumatica?

Answer 4

The pain and stiffness result from the activity of inflammatory cells and proteins that are normally a part of the body’s disease-fighting immune system, and the inflammatory activity seems to be concentrated in tissues surrounding the affected joints

Question 5

What is the clinical presentation of someone with polymyalgia rheumatica?

Answer 5

Limitation in shoulder motion, or swelling of the joints in the wrists or hands, are noted by the doctor, morning stiffness, malaise

Elevated erythrocyte sedimentation rate
Elevated CPR

Question 6

How would you manage polymyalgia rheumatica?

Answer 6

Prednisolone 15mg daily

Reduce the dose of prednisolone slowly when symptoms are fully controlled

Question 7

What are risk factors for polymyalgia rheumatica?

Answer 7

Older age
Female gender
Northern European ancestry
Infection

Question 8

What are the complications following polymyalgia rheumatica?

Answer 8

Giant cell arteritis (GCA) and its complications

Complications of long-term corticosteroid treatment

Question 9

What are the adverse effects of longterm corticosteroid treatment?

Answer 9

Cardiovascular — hypertension.

Cerebrovascular — benign intracranial hypertension.

Endocrine — adrenal suppression, diabetes mellitus (new onset or worsening of blood glucose control in existing diabetes mellitus), Cushing’s syndrome (this is usually reversible on withdrawal of treatment).

Gastrointestinal — peptic ulceration with perforation and haemorrhage, dyspepsia, abdominal distension, and oesophageal ulceration

Immunological — immunosuppression, increased susceptibility to infection

Metabolic — hyperglycaemia, protein catabolism, dyslipidaemia, weight gain, sodium retention, fluid retention, potassium loss, calcium loss.
Musculoskeletal — osteoporosis, avascular necrosis of bone, tendinopathies