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DESCRIPTIONPolymyalgia 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? - PowerPoint PPT Presentation
Polymyalgia RheumaticaAM Report Cat Hathaway3/16/2010 Proximal myalgia of the hip and shoulder girdles associated with morning stiffness (at least 1 hour)Etiology is largely unknownAssociated with HLA-DR4Associated with viral infection? viral infection resulting in monocyte activationSome series show higher prevalence of antibodies to Adenovirus and RSVWhat is it?Elderly patients, >50 years of ageIncidence 52.5/100000Prevalence 0.5-0.7%Females 2:1White, 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)EpidemiologyOften previously healthy, >50Bilateral proximal muscle pain and stiffnessESR >40, CRP elevationPrompt response to steroidsLow grade fevers, weight lossMalaise, fatigue, depressionDifficulty getting out of bed, rising from sitting, performing ADLsRarely can have high spiking feversClinical PictureLow grade tempCan have LE swellingMuscle strength is NORMALPain specifically in shoulder and hip girdle despite lack of clinically significant swellingTenderness to palpation and diminished ROM in shoulders and hipsCan get a transient synovitis (usually knee, wrist, sternoclavicular joints)Exam findingsRule out infectious/autoimmune processEndocarditisRALupusSystemic InfectionMyositisLow dose prednisone (10-15mg/d) for 2-4 weeks. Then can start trying to taper.Vitamin D/CalciumSteroid sparing agents (MTX, azathioprine)NSAIDsTreatmentStarting >10mg fewer relapses, shorter treatment periods than compared to 15mg lead to higher cumulative doses and more steroid adverse affectsTapering lead to more successful treatment, fewer relapses, when done slowly (1mg/mo)Few points about steroid therapyOverall, benign diseaseSelf 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 yearsIf relapse, often occurs within 12 months of weaning steroidsNeed to be monitored for TAPrognosisAmyloidosis (inflammatory)FibromyalgiaOsteoarthritisShoulder disordersCervical spondylosisParkinsons DiseaseMultiple Myeloma
Other differentials to considerESR (typically >40, sometimes >100), CRPANA, RF, Blood culturesCBCCK 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
Tests to orderVisual lossHeadacheScalp tendernessJaw claudicationCVAAortic arch syndromeThoracic aorta aneurysmDissectionTemporal Arteritis
Polymyalgia Rheumatica. Saad, Fioravanti, Samuels. Emedicine. Updated Aug 20, 2009Arch 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.