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Explore This IssueNovember 2018
Polymyalgia rheumatica (PMR) is an inflammatory rheumatic condition characterized by pain and morning stiffness at the neck, shoulders and hip girdle. It can be associated with giant cell arteritis (GCA); in fact, the two disorders may represent a continuum of the same disease process. This case describes a patient who initially refused treatment for PMR and eventually developed GCA, resulting in multiple complications and requiring four hospitalizations over a yearlong period.
A 79-year-old woman presented to her primary care physician’s office for an annual physical. She described a four-month history of widespread pain, proximal muscle weakness and morning stiffness, most prominent in the neck and shoulders. These symptoms made her work as a hairdresser extremely difficult. Labs showed a normal creatine kinase (CK) of 53 units/L (normal range: 26–192 units/L), an elevated erythrocyte sedimentation rate (ESR) of 58 mm/hr (normal range: <30 mm/hr) and an elevated C-reactive protein (CRP) of 14.2 mg/L (normal range: <10 mg/L). She was then referred to our rheumatology clinic for suspected PMR.
At her initial visit with us, she complained of weakness in her bilateral shoulders, thighs and calves, all worse in the morning and improved with activity. She was unable to lift her arms above her shoulders due to pain and stiffness, and had a difficult time getting up from a seated position. She denied fevers, chills, night sweats, anorexia, weight loss, rash, headaches, vision changes, jaw pain/claudication, scalp tenderness or joint swelling.
Her medical history was notable for breast cancer, which was now in remission, asthma, irritable bowel syndrome and hyperlipidemia with a history of statin intolerance. Medications included a fluticasone inhaler twice daily, an albuterol inhaler as needed, and calcium and vitamin D supplements.
She had no family history of autoimmune disease, PMR or vasculitis. Her social history was significant for three to four years of smoking in her 20s and occasional alcohol use. The physical exam was normal, except for limited active abduction of the shoulders.
The patient was advised to start 15 mg of prednisone daily for a suspected diagnosis of PMR, but she refused. She expressed apprehension of taking any prescription medications and was adamant she wanted to “control the inflammation with dietary changes.”
The patient was warned that approximately 15% of patients with PMR develop GCA, which could potentially lead to permanent blindness.1 She was instructed to call our office if she changed her mind regarding starting the prednisone. She was educated about symptoms suggestive of GCA, and was instructed to contact us if she developed any such new symptoms.