Case Presentation

1
Case Presentation

• Lance C. Brunner M.D.
• Assistant Clinical Chief
• Department of Family Medicine

2
Case Presentation

• 82 yo male with type II DM and multi-infarct
  dementia presents to the ER with a 3 week history
  of worsening ability to walk, difficulty getting
  out of bed, leg spasms, and just general
  deconditioning. Daughter states that patient
  also has had decreased appetite, low grade
  fevers, and worsening depression.

3
Case Presentation

• PMHX
• Type II DM
• HTN
• Excessive alcohol intake none for the last year
• Multi-infarct dementia
• PSHX
• None
• Allergies
• None

• Meds
• ASA
• Prinzide
• Simvastatin
• FHx
• DM
• CAD
• SHX
• Widowed
• Lives with daughter

4
Case Presentation

• PE
• Gen crying, complaining of bilateral hip, lower
  back, and thigh pain, moderate distress
• 99.2 104 16 148/66
• Neck supple
• CV RRR
• Lungs dry crackles

• Abd soft bs
• Ext TTP of paraspinal lumbar region, bilateral
  thighs, bilateral shoulders, moderate pain with
  back flexion
• Neck - paraspinal tenderness. Supple

5
Case Presentation

• L/S x-ray mild OA/DDD
• UA negative
• WBC 10.0 with normal diff
• Plt 520
• HB 13.2
• Chem 7 normal
• SGPT 35

• Total CK 123
• CT back negative
• CXR negative
• CT head negative
• EKG LVH no acute changes
• Troponin I lt0.1

6
Case Presentation

• Neurology called for formal consult
• Patient diagnosed with diffuse myalgias likely
  statin related with dehydration
• Hydration and MS given in the ER
• DC statin
• Vicoden given
• F/U pcp.

7
Case Presentation

• Next day symptoms come back with a vengeance
• Now what?

8
Case Presentation

• Upon further questioning, daughter describes
  patient with significant muscle stiffness of the
  shoulders and thighs and difficulty getting out
  of a chair. Leg spasms still persist at night.

9
Case Presentation

• ESR 103

10
Polymyalgia Rheumatica

• Aching and morning stiffness in the girdle
• Subacute or acute
• Generally symmetric
• Malaise, fatigue, anorexia, low grade fever,
  weight loss
• 10 of patients with PMR have Temporal Arteritis
  (TA)
• 50 of patients with TA have PMR

11
Polymyalgia Rheumatica

• Physical Exam
• Decreased rom of shoulders and hips
• Normal strength
• Muscle tenderness often not a prominent feature
  tenderness usually due to bursal involvement
• Age gt 50, ESR gt50, although sedimentation rate
  can be normal in up to 22 of patients
• Elevated CRP (may be more sensitive)
• Elevated IL6 levels may be related to disease
  activity in TA

12
Differential

• Occult infection
• RA
• Hypothyroidism
• Endocarditis
• Fibromyalgia
• Polymyositis
• OA
• Malignancy and paraneoplastic syndromes

• Bursitis
• Tendinitis
• Vasculitis

Gottrons sign in polymyositis
13
Polymyalgia Rheumatica

• Treatment
• Prednisone 10-20 mg a day (40mg-80 daily at if
  temporal arteritis is present) with subsequent
  taper
• Always be on the lookout for temporal arteritis
  (temporal artery tenderness, headache, jaw pain,
  visual loss, and evidence of non-cranial
  ischemia)
• Relapse 25-50
• MTX a consideration if patients at high risk of
  glucocorticoid side effects