ACR Convergence

An official publication of the ACR and the ARP serving rheumatologists and rheumatolgy professionals

Letters: Don’t Forget Lyme Disease When Considering Polymyalgia Rheumatica

Alfred Miller, MD and William P. Docken, MD  |  Issue: July 2013  |  

Dr. Docken states [in “A Tale of Two Inflammations,” March 2013], “The rapid onset of symptoms suggests the possibility of an exposure, particularly to an infectious agent, but the search for evidence of such a pathogen in PMR [polymyalgia rheumatica] has been, to date, unrevealing.”

In fact, numerous reports indicate Lyme disease may present the identical clinical picture as PMR.1,2 Steroid treatment is contraindicated in Lyme disease.3 Furthermore, giant cell arteritis has also been reported in Lyme disease.4,5

In view of consequences of an incorrect diagnosis and subsequent treatment, it is imperative to rule out Lyme disease when considering a diagnosis of PMR and or giant cell arteritis.

Alfred Miller, MD
San Antonio, Texas

Dr. Docken Weighs In

My article did not cover the differential diagnosis of either PMR or GCA. PMR is, of course, a clinical diagnosis, with no definitive diagnostic test. Thus, when this diagnosis is under consideration, atypical features must be carefully watched for (e.g., fever, rash, asymmetrically distributed musculoskeletal symptoms and signs, etc.). I personally have never seen a polymyalgic presentation of Lyme disease. Lyme disease is on the diagnostic list in a patient from an endemic area presenting with fever and headache, but I do not routinely screen for Lyme antibody in all patients with suspected GCA.

William P. Docken, MD
Senior Physician
Brigham and Women’s Hospital
Assistant Professor of Medicine
Harvard Medical School
Boston

References

  1. Paparone PW. Polymyalgia rheumatica or Lyme disease? How to avoid misdiagnosis in older patients. Postgrad Med. 1995;97:161-164, 167-170.
  2. Schwartzberg M, Weber CA, Musico J. Lyme borreliosis presenting as a polymyalgia rheumatica-like syndrome. Br J Rheumatol. 1995;34:392-393.
  3. Muslmani M, Gilson M, Sudre A, Juvin R, Gaudin P. Lyme disease with hepatitis and cortico­steroids: a case report. Rev Med Interne. 2012;33:339-342.
  4. Träisk F, Andersson M, Svenungsson E. Three cases of neuroborreliosis misdiagnosed as giant cell arteritis. Scand J Rheumatol. 2012;41:158-160.
  5. Pizzarello LD, MacDonald AB, Semlear R, DiLeo F, Berger B. Temporal arteritis associated with Borrelia infection. A case report. J Clin Neuroophthalmol. 1989;9:3-6.