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Polymyalgia Rheumatica. AM Report Cat Hathaway 3/16/2010. What is it?. Proximal myalgia of the hip and shoulder girdles associated with morning stiffness (at least 1 hour) Etiology is largely unknown Associated with HLA-DR4 Associated with viral infection?

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polymyalgia rheumatica

PolymyalgiaRheumatica

AM Report

Cat Hathaway

3/16/2010

what is it
What is it?
  • Proximal myalgia of the hip and shoulder girdles associated with morning stiffness (at least 1 hour)
  • Etiology is largely unknown
  • Associated with HLA-DR4
  • Associated with viral infection?
    • viral infection resulting in monocyte activation
  • Some series show higher prevalence of antibodies to Adenovirus and RSV
epidemiology
Epidemiology
  • Elderly patients, >50 years of age
    • Incidence 52.5/100000
    • Prevalence 0.5-0.7%
  • Females 2:1
  • White, european (highest rates in Northern Europe)
  • Some evidence of genetic susceptibility
  • 50% Temporal arteritis patients will have PMR (15% of PMR patients will develop TA)
clinical picture
Clinical Picture
  • Often previously healthy, >50
  • Bilateral proximal muscle pain and stiffness
  • ESR >40, CRP elevation
  • Prompt response to steroids
  • Low grade fevers, weight loss
  • Malaise, fatigue, depression
  • Difficulty getting out of bed, rising from sitting, performing ADLs
  • Rarely can have high spiking fevers
exam findings
Exam findings
  • Low grade temp
  • Can have LE swelling
  • Muscle strength is NORMAL
  • Pain specifically in shoulder and hip girdle despite lack of clinically significant swelling
  • Tenderness to palpation and diminished ROM in shoulders and hips
  • Can get a transient synovitis (usually knee, wrist, sternoclavicular joints)
treatment
Treatment
  • Rule out infectious/autoimmune process
    • Endocarditis
    • RA
    • Lupus
    • Systemic Infection
    • Myositis
  • Low dose prednisone (10-15mg/d) for 2-4 weeks. Then can start trying to taper.
  • Vitamin D/Calcium
  • Steroid sparing agents (MTX, azathioprine)
  • NSAIDs
few points about steroid therapy
Few points about steroid therapy
  • Starting >10mg  fewer relapses, shorter treatment periods than compared to <10mg
  • Starting >15mg lead to higher cumulative doses and more steroid adverse affects
  • Tapering lead to more successful treatment, fewer relapses, when done slowly (1mg/mo)
prognosis
Prognosis
  • Overall, benign disease
  • Self limited and most resolve within 1-3 years, however patients experience significant decrease in quality of life
  • 50-75% of patients can often be weaned off all steroids by 3 years
    • If relapse, often occurs within 12 months of weaning steroids
  • Need to be monitored for TA
other differentials to consider
Other differentials to consider
  • Amyloidosis (inflammatory)
  • Fibromyalgia
  • Osteoarthritis
  • Shoulder disorders
  • Cervical spondylosis
  • Parkinson’s Disease
  • Multiple Myeloma
tests to order
Tests to order
  • ESR (typically >40, sometimes >100), CRP
  • ANA, RF, Blood cultures
  • CBC
  • CK  NORMAL!
  • Serum IL6 (not necessary, but will be elevated and often parallels disease course)
  • No imaging necessary but Xrays should not show erosive disease or osteopenia.
    • MRI if done will often show bursitis and senovitis.
  • TA biopsy only done if you suspect TA
temporal arteritis
Temporal Arteritis
  • Visual loss
  • Headache
  • Scalp tenderness
  • Jaw claudication
  • CVA
  • Aortic arch syndrome
  • Thoracic aorta aneurysm
  • Dissection
bibliography
Bibliography
  • PolymyalgiaRheumatica. Saad, Fioravanti, Samuels. Emedicine. Updated Aug 20, 2009
  • Arch Intern Med. 2009 Nov 9;169(20):1839-50. Treatment of PMR: a systematic review. Hernandez-Rodriguez.
  • Lancet. 2008 Jul 19;372(9634):234-45. PMR and Temporal Arteritis. Salvarani et al.