1. Polymyalgia Rheumatica
Presentation
An elderly patient (more commonly female) complains of a week or two of
morning stiffness, which may interfere with her ability to rise from bed, but
improves during the day. She may ascribe her problem to muscle weakness
or joint pains, but physical examination discloses that symmetrical pain and
tenderness of neck, shoulder, and hip muscles are the actual source of any
"weakness." There may be some mild arthritis of several peripheral joints, but
the rest of the physical examination is negative.
What to do:
• Perform a complete history and physical examination, particularly of
the cervical and lumbar spines and nerve roots (strength, sensation,
and deep tendon reflexes in the distal limbs should be intact with
PMR). Confirm the diagnosis of PMR by palpating tender shoulder
muscles (perhaps also hips, and, less commonly, neck).
• Confirm the diagnosis by obtaining an erythrocyte sedimentation rate,
which should be in the 30-l00mm/hour range. (An especially high ESR,
over 100/hour suggests more severe autoimmune disease or
malignancy.)
• Mild and borderline cases may respond with nonsteroidal anti-
inflammatory medications (ibuprofen, naproxen). More severe cases
will respond to prednisone 20-60mg qd within a week or two, after
which the dose should be tapered. Failure to respond to corticosteroid
therapy suggests some other diagnosis.
• Explain the syndrome to the patient and arrange for followup.
What not to do:
• Do not miss temporal arteritis, a common component of the
polymyalgia rheumatica syndrome, and a clue to the existence of
ophthalmic and cerebral arteritis, which can have dire neurological
consequences. Palpate the temporal arteries for tenderness, swelling,
or induration, and ask about transient neurological signs.
• Do not postpone diagnosis or treatment of temporal arteritis pending
results of a temporal artery biopsy showing giant cell arteritis. The
lesion typically skips areas, making biopsy an insensitive diagnostic
procedure.

2. Discussion
Stiffness, pain, and weakness are common complaints in older patients, but
polymyalgia rheumatica may respond dramatically to treatment. Rheumatoid
arthritis produces morning stiffness, but is usually present in more peripheral
joints, and without muscle tenderness. Polymyositis is usually characterized
by increased serum muscle enzymes with a normal ESR, and may include a
skin rash (dermatomyositis). Often, a therapeutic trial of prednisone helps
make the diagnosis.