42. Polymyalgia

• Constitutional symptoms: fever, weight loss, night sweats

• Fatigue and malaise

• Depressed mood

• Symptoms of anemia

• Musculoskeletal symptoms: primarily affects shoulders, neck, and pelvic girdle

  • New onset, symmetric pain that is worse at night

  • Morning stiffness (> 45 min)

  • Muscular atrophy and weakness: not directly caused by PMR but resulting from reduced activity due to pain and stiffness

  • Muscular pain and stiffness → limitation of activity → muscular wasting → muscular weakness

symptoms of giant cell arteritis (if both diseases are present)

• ↑ ESR, specifically > 50 mm/h

• ↑ CRP

• Leukocytosis

• Normochromic anemia

• Normal creatine kinase, negative rheumatoid factors, and no autoantibodies

• Bursitis on ultrasound of affected joints

• Giant cell arteritis

  • Both diseases often coexist and share common findings (e.g., elevated ESR, B symptoms)

  • May develop during the course of PMR (patients should be routinely evaluated for symptoms of GCA)

• Rheumatoid arthritis: positive rheumatoid factor and/or anti-CCP antibodies

• Polymyositis and dermatomyositis: ↑ serum creatine kinase (normal in PMR)

• Fibromyalgia: normal laboratory values

• Low-dose oral glucocorticoids (alternatively IM glucocorticoids) [8]

  • Usually rapid symptomatic relief (2–4 weeks)

  • If symptoms improve: slowly taper and eventually stop glucocorticoids

  • No improvement after 2 weeks or relapse: increase dose

• Unknown

• Possible contributing factors are:

  • Genetic predisposition (e.g., human leukocyte antigen HLA-DR4)

  • Association with giant cell arteritis (GCA): Approx. 10% of individuals with polymyalgia rheumatica also have GCA. [4]

• Sex: ♀ > ♂ (3:1) [1]

• Most common inflammatory rheumatic disease in the elderly (second most common overall)

• Age of onset: >70 years (rarely seen in patients < 50 years) [2]

• More common in individuals of Northern European descent [3]

• Nonspecific symptoms: gastroenteritis, fever, nausea, sore throat, myalgia, and headaches for 1–3 days

• Complete recovery without complications or transition to poliomyelitis with CNS involvement

Nonparalytic poliomyelitis: aseptic meningitic form

• Begins several days following abortive poliomyelitis (often temporary, symptom-free interval)

• Fever, neck stiffness, headache, vomiting, muscle pain

• Neck muscle weakness (head drop sign: head falls back when placed in a supine position)

• No paresis

Paralytic poliomyelitis

• Occurs 2–3 days following the meningitic form after a brief symptom-free interval

• Fever, malaise, headache, nausea

• Severe back, neck, and muscle pain

• Asymmetric flaccid paralysis worsens over hours to days

  • Most commonly affects the leg muscles, although the arms, abdomen, trunk, thorax, and eyes may be affected

  • Paralysis is usually more severe in proximal muscles than in distal muscles.

  • Ascending paralysis with diaphragmatic involvement → respiratory failure

  • Bulbar form with brain stem involvement (rare): damage to the cerebral or autonomic nerve centers (cranial nerves and respiratory center) → central respiratory paralysis

• Diminished deep tendon reflexes

• Muscle atrophy

• Hypotonia

• Fasciculations