Polymyalgia Rhuematic and Its Differential Diagnosis.

A 75-year-old woman presents with rather severe shoulder and hip pain that has been progressively worse over the last 3 months. She complains of morning stiffness and low-grade fevers, malaise, and weight loss. She has no headache or visual disturbance, and electromyogram (EMG) study of her
lower extremities was normal. Her labs reveal a normocytic–normochromic anemia and her erythrocyte sedimentation rate (ESR) was found to be 60mm/h.
Appropriate management at this time includes
A) Referral for a temporal artery biopsy
B) Initiation of prednisone
C) Initiation of an NSAID
D) Referral to physical therapy
E) Referral to orthopaedics for consideration of joint replacement

Answer And Discussion: The answer is B. (Initiation of prednisone)

Polymyalgia Rhuematic: The true prevalence, etiology, and pathogenesis of polymyalgia rheumatica (PMR) are not entirely known. In some, the condition is a manifestation of underlying temporal arteritis. Although most
patients are not at significant risk for the complications of temporal arteritis, they should be warned of the possibility and should immediately report such symptoms as headache, visual disturbance, and jaw muscle pain on chewing.
PMR usually occurs in patients older than 60 years, and the female:male ratio is 2:1. Onset may be acute or subacute. PMR is characterized by severe pain and stiffness of the neck and shoulders and
hips; morning stiffness; stiffness after inactivity; and systemic complaints, such as malaise, fever, depression, and weight loss.

There is no selective muscle weakness or evidence of muscle disease on EMG or biopsy.
Normochromic–normocytic anemia may be present. In most patients, the ESR is dramatically elevated, often >100 mm/h, usually >50 mm/h. C reactive protein levels are usually elevated (>0.7 mg/dL) and may be a more sensitive marker of disease activity in certain patients than is ESR.

Differential Diagnosis: PMR is distinguished from rheumatoid arthritis (RA) by the usual absence of small joint synovitis (although some joint swelling may be present), erosive or destructive disease, rheumatoid factor, or rheumatoid nodules.
PMR is differentiated from polymyositis by usually normal muscle enzymes, EMG, and muscle biopsy, as well as by the prominence of pain over weakness.
Hypothyroidism can present as myalgia, with abnormal thyroid function tests and elevated creatine kinase (CK).
PMR is differentiated from myeloma by the absence of monoclonal gammopathy and from fibromyalgia by the systemic features and elevated ESR. PMR usually responds dramatically to prednisone initiated at doses of at least 15