AM Report Cat Hathaway 3/16/2010

 Proximal myalgia of the hip and shoulder girdles associated with morning stiffness (at least 1 hour)  Etiology is largely unknown  Associated with HLA-DR4  Associated with viral infection? ◦ viral infection resulting in monocyte activation  Some series show higher prevalence of antibodies to Adenovirus and RSV

 Elderly patients, >50 years of age ◦ Incidence 52.5/ ◦ Prevalence %  Females 2:1  White, european (highest rates in Northern Europe)  Some evidence of genetic susceptibility  50% Temporal arteritis patients will have PMR (15% of PMR patients will develop TA)

 Often previously healthy, >50  Bilateral proximal muscle pain and stiffness  ESR >40, CRP elevation  Prompt response to steroids  Low grade fevers, weight loss  Malaise, fatigue, depression  Difficulty getting out of bed, rising from sitting, performing ADLs  Rarely can have high spiking fevers

 Low grade temp  Can have LE swelling  Muscle strength is NORMAL  Pain specifically in shoulder and hip girdle despite lack of clinically significant swelling  Tenderness to palpation and diminished ROM in shoulders and hips  Can get a transient synovitis (usually knee, wrist, sternoclavicular joints)

 Rule out infectious/autoimmune process ◦ Endocarditis ◦ RA ◦ Lupus ◦ Systemic Infection ◦ Myositis  Low dose prednisone (10-15mg/d) for 2-4 weeks. Then can start trying to taper.  Vitamin D/Calcium  Steroid sparing agents (MTX, azathioprine)  NSAIDs

 Starting >10mg  fewer relapses, shorter treatment periods than compared to <10mg  Starting >15mg lead to higher cumulative doses and more steroid adverse affects  Tapering lead to more successful treatment, fewer relapses, when done slowly (1mg/mo)

 Overall, benign disease  Self limited and most resolve within 1-3 years, however patients experience significant decrease in quality of life  50-75% of patients can often be weaned off all steroids by 3 years ◦ If relapse, often occurs within 12 months of weaning steroids  Need to be monitored for TA

 Amyloidosis (inflammatory)  Fibromyalgia  Osteoarthritis  Shoulder disorders  Cervical spondylosis  Parkinson’s Disease  Multiple Myeloma

 ESR (typically >40, sometimes >100), CRP  ANA, RF, Blood cultures  CBC  CK  NORMAL!  Serum IL6 (not necessary, but will be elevated and often parallels disease course)  No imaging necessary but Xrays should not show erosive disease or osteopenia. ◦ MRI if done will often show bursitis and senovitis.  TA biopsy only done if you suspect TA

 Visual loss  Headache  Scalp tenderness  Jaw claudication  CVA  Aortic arch syndrome  Thoracic aorta aneurysm  Dissection

 Polymyalgia Rheumatica. Saad, Fioravanti, Samuels. Emedicine. Updated Aug 20, 2009  Arch Intern Med Nov 9;169(20): Treatment of PMR: a systematic review. Hernandez-Rodriguez.  Lancet Jul 19;372(9634): PMR and Temporal Arteritis. Salvarani et al.