Widespread pain and fatigue

Question 1

What are the differentials for widespread pain and fatigue?

Answer 1

Endocrine
o	Addison’s disease
o	Hyperparathyroidism
o	Hypothyroid myopathy
o	Vitamin D deficiency 

Infection
o Hepatitis C
o HIV

Rheumatology
o	RA
o	SLE
o	Polymyalgia rheumatica
o	Fibromyalgia 

Malignancy
o Lymphoma

Question 2

What is fibromyalgia?

Answer 2

Chronic widespread pain
• >3 months
• Found on both sides of the body
• Above and below the waist and along the axial spine

Question 3

What are the other features of fibromyalgia?

Answer 3

• Lethargy
• Difficulty sleeping
• Cognitive impairment

Question 4

What are the risk factors for fibromyalgia?

Answer 4

• Low household income
• Lack of further education
• Female sex
• Family Hx
• Trauma
• RA

Question 5

How do you diagnose fibromyalgia?

Answer 5

• Widespread Pain Index (WPI) and Symptom Severity Score (SSS)
  o WPI ≥7 and SSS ≥5 OR WPI 4-6 and SSS ≥9
• Generalised pain: pain in 4/5 regions
• Symptom’s present ≥3 months

Question 6

What other investigations would you do and why?

Answer 6

TSH
- Hypothyroidism

12-hydroxy vitamin D
- Low

Vitamin B12
- Low

Iron studies
- Low

Magnesium
- Low

ESR/CRP

• Normal
• Raised in inflammatory arthritis

CK
- Raised in myositis or statin-induced myopathy

Question 7

How do you manage fibromyalgia?

Answer 7

• Nonpharmacological`; Exercise, CBT, acupuncture, hydrotherapy
• Screen for anxiety and depression
• Pharmacological : Duloxetine, pregabalin, tramadol, low dose amitriptyline