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Reumatologia/Rheumatology
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3/2018
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Case report

A case report of polymyalgia rheumatica

Iryna Kniazkova
,
Larysa Shapovalova
,
Maryna Bogun

Reumatologia 2018; 56, 3: 190-193
Online publish date: 2018/06/30
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Introduction

The diagnostics of polymyalgia rheumatica (PMR) may be a difficult task, as a number of clinical and laboratory signs may also be observed in other pathologies, including other rheumatic diseases, infections (osteomyelitis, tuberculosis, bacterial endocarditis, etc.) and malignant neoplasms. In addition, the response to standard therapy may vary, and although a good response to the initial dose of glucocorticoids is expected, as many as 29–45% do not respond to therapy in the first 4 weeks of treatment.
We present a clinical case of polymyalgia rheum-atica.

Case report

A 62-year-old patient was admitted to the rheumatology department with the following complaints: temperature increase up to 38.6°C, joint and upper limb pain, movement restriction, general weakness, and sleep disturbances due to the severity of pain.
From the anamnesis of the disease it is known that the patient fell ill unexpectedly 2 weeks ago after stress. The patient was treated with diclofenac gel with an insignificant effect.
Data of objective examination on admission: the general condition of moderate severity was due to the joint status. Tenderness on palpation of shoulder joints and shoulder muscles was found; the patient could hardly lift her hands to the horizontal level, and could not move them behind her head.
Additionally, in physical examination the respiratory rate was 20/min. There were no abnormalities in the lungs or auscultation. The boundaries of relative cardiac dullness were not expanded, the heart showed rhythmic activity, weakened I tone at the top and heart rate 96 bpm, with blood pressure 140/90 mm Hg. There were no pathological features in the abdominal examination and also there were no abnormalities in passing urine or stool.
Laboratory tests revealed: erythrocytes 4.4 × 10ą²/l, hemoglobin 128 and 144 g/l, color index 0.87 and 0.9, leukocytes 7.8 × 109/l and 6.7 × 109/l, eosinophils 4%, basal cells 2%, segmented 54%, lymphocytes 36%, monocytes 4%, elevated ESR 50 and 30 mm/h, C-reactive protein 24 mg/l (normal range is up to 6), rheumatoid factor 2 IU/ml (normal range is up to 14), total protein 76 g/l, sialic acids 3.18 mmol/l (normal range is 1.8–2.7 mmol/l), glucose 3.8 mmol/l, aspartate aminotransferase 47 U/l, alanine aminotransferase 39 U/l, total cholesterol 5.2 mmol/l, urea 4.4 mmol/l, creatinine 0.064 mmol/l, creatine phosphokinase 113.0 U/l (normal range is 26–192), in urinalysis without significant abnormalities, anti-cyclic citrullinated peptide antibodies (ACPA) < 7 U/ml (normal range is up to 17.0), negative antibody results for anti-neutrophil cytoplasmic antibody (ANCA) screening (myeloperoxidase – MPO), proteinase-3 (PR-3), and also negative test for detection of basal membrane of the glomerular apparatus (GBM).
Electrocardiography (ECG) values: sinus rhythm is accelerated, heart rate – 104 per minute, hypertrophy of the left ventricle. In the dynamics of treatment – heart rate is 72 per minute.
In the radiological examination of the shoulders: no pathology was detected. Echocardiography revealed: initial signs of atherosclerotic aortocardiosclerosis, ejection fraction (EF) 62%. In the abdominal ultrasonography no pathological findings in the liver, gallbladder, pancreas, spleen, kidneys. The esophagogastroduodenoscopy with biopsy, colonoscopy and computed tomography of lungs also were performed with no abnormalities pointing to oncological diseases.
Taking into account complaints, analysis of the disease, and all results the final diagnosis of polymyalgia rheumatica was established with third stage activity, with joint and upper limb injuries, and functional insufficiency of stages II–III.
Treatment with methylprednisolone from 16 mg/day, pantoprazole, ossein-hydroxyapatite compound (Osteogenone) and diclofenac was introduced. On treatment, pain in muscles and joints decreased, but did not resolve, the range of movements increased and the activity of the inflammatory process in laboratory tests decreased. The patient was discharged in a satisfactory condition. It was recommended to visit a rheumatologist at the place of residence in 7–10 days after discharge from the hospital to undergo regular medical check-up and for further therapy correction.
Gradual reduction of the dosage of methylprednisolone by 1 mg in 7–10 days under control of clinical and laboratory indicators until complete withdrawal is recommended in a month.

Discussion

Although the described case does not differ from the classic PMR descriptions, it draws attention to several aspects when making a diagnosis of PMR.
Most doctors are familiar with the main characteristics of PMR pain in the proximal parts of limbs and morning stiffness, accompanied by a significant increase of acute phase parameters. However, the reference to clinical manifestations only may lead to diagnostic errors. Thus, proximal pain and morning stiffness are observed in many other diseases. A third of patients show systemic manifestations (fever, loss of appetite and weight loss) [1]. In addition, 15–30% of patients experience pain in the distal parts of the musculoskeletal system. What is important, the beginning may be sudden, as occurred in the described patient, while the long course and poor response to treatment may suggest other diagnoses.
It is known that giant cell arteritis is associated with polymyalgia rheumatica. It was established that 10–15% of patients with polymyalgia rheumatica will subsequently develop giant cell arteritis. In these conditions, polymyalgia rheumatica is revealed in 50% of patients with giant cell arteritis [1, 2]. In addition, a significant increase in laboratory parameters of inflammation may occur in other pathologies, in particular rheumatic diseases, malignancy and infections. Family history of PMR is very rare, but it is also described [3].
A number of clinicians from experience administer corticosteroids as a diagnostic test, and the results are used as the main differential sign of PMR. Such an approach may lead to misdiagnosis because administration of corticosteroids with pronounced anti-inflammatory properties may conceal the symptoms of many severe pathological conditions which include inflammatory and non-inflammatory rheumatic diseases, e.g. osteoarthritis, rheumatoid arthritis, and infections and malignant tumors, especially with long-term therapy and at high dosages.
It should be noted that pain and stiffness of the muscles of the shoulder girdle are observed in 70–95% of patients with PMR [4].
Classification criteria for identifying polymyalgia rheumatica as a nosological form are presented in Table I [5].
Clinical evidence suggests that in some cases, an initial diagnosis requires revision in future. The main pathological conditions with which a differential diagnosis of polymyalgia rheumatica should be made are presented in Table II.
It is important to exclude active infection, malignant neoplasms and other inflammatory diseases. We should particularly focus on the need to exclude acute or active infection, oncological pathology and other inflammatory diseases. In addition, symptoms similar to polymyalgia rheumatica may be found in the onset of rheumatoid arthritis. Anti-cyclic citrullinated peptide antibodies are the most diagnostically effective marker of rheumatoid arthritis [6], and are included in the European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) RA classification criteria and allow one to differentiate rheumatoid arthritis and PMR.

Conclusions

Polymyalgia rheumatica is not a rare disease. As the number of elderly people in the world continues to increase, the prevalence of this disease will still increase in the coming years. Upon suspicion of PMR, it is necessary to exclude other rheumatic diseases, infections (osteomyelitis, tuberculosis, bacterial endocarditis, etc.) and malignant neoplasms, especially in the group of patients at a very advanced age, with family history of cancer, with contact with infection or patients from endemic areas for specific infections.
Knowledge of the directions of diagnostic search is extremely important for the doctors of different specialties since early diagnosis of PMR and further proper management of patients allow one to significantly improve the patient’s prognosis.

The authors declare no conflict of interest.

References

1. Dasgupta B, Borg FA, Hassan N, et al. BSR and BHPR guidelines for the management of giant cell arteritis. Rheumatology (Oxford) 2010; 49: 1594-1597.
2. Bhaskar D. Concise guidance: diagnosis and management of polymyalgia rheumatica. Clin Med 2010; 10: 270-274.
3. Liozon E, Ouattara B, Rhaiem K, et al. Familial aggregation in giant cell arteritis and polymyalgia rheumatica: a comprehensive literature review including 4 new families. Clin Exp Rheumatol 2009; 27 (Suppl. 52): S89-94.
4. Muratore F, Pazzola G, Pipitone N, et al. Recent advances in the diagnosis and treatment of polymyalgia rheumatic. Exp Rev Clin Immunol 2016; 12: 1037-1045.
5. Macchioni P, Boiardi L, Catanoso M, et al. Performance of the new 2012 EULAR/ACR classification criteria for polymyalgia rheumatica: comparison with the previous criteria in a single-centre study. Ann Rheum Dis 2014; 73: 1190-1193.
6. Buttgereit F, Dejaco C, Matteson EL, et al. Polymyalgia Rheumatica and Giant Cell Arteritis: A Systematic Review. JAMA 2016; 315: 2442-2458.
Copyright: © 2018 Narodowy Instytut Geriatrii, Reumatologii i Rehabilitacji w Warszawie. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) License (http://creativecommons.org/licenses/by-nc-sa/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited and states its license.






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