Polymyalgia Rheumatica

AM Report Cat Hathaway

3/16/2010

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

What is it?

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)

Epidemiology

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

Clinical Picture

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)

Exam findings

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

Treatment

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)

Few points about steroid therapy

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

Prognosis

Amyloidosis (inflammatory) Fibromyalgia Osteoarthritis Shoulder disorders Cervical spondylosis Parkinson’s Disease Multiple Myeloma

Other differentials to consider

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

Tests to order

Visual loss Headache Scalp tenderness Jaw claudication CVA Aortic arch syndrome Thoracic aorta aneurysm Dissection

Temporal Arteritis

Polymyalgia Rheumatica. 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.

Bibliography