Transcript Polymyalgia Rheumatica

AM Report
Cat Hathaway
3/16/2010
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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
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Some series show higher prevalence of
antibodies to Adenovirus and RSV
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Elderly patients, >50 years of age
◦ Incidence 52.5/100000
◦ Prevalence 0.5-0.7%
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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)
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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
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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)
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Rule out infectious/autoimmune process
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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
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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)
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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
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Need to be monitored for TA
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Amyloidosis (inflammatory)
Fibromyalgia
Osteoarthritis
Shoulder disorders
Cervical spondylosis
Parkinson’s Disease
Multiple Myeloma
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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.
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TA biopsy only done if you suspect TA
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Visual loss
Headache
Scalp tenderness
Jaw claudication
CVA
Aortic arch syndrome
Thoracic aorta aneurysm
Dissection
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Polymyalgia Rheumatica. Saad, Fioravanti,
Samuels. Emedicine. Updated Aug 20, 2009
Arch Intern Med. 2009 Nov 9;169(20):183950. Treatment of PMR: a systematic review.
Hernandez-Rodriguez.
Lancet. 2008 Jul 19;372(9634):234-45. PMR
and Temporal Arteritis. Salvarani et al.