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 52.5/100000 ◦ Prevalence 0.5-0.7% 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. 2009 Nov 9;169(20):183950. Treatment of PMR: a systematic review. Hernandez-Rodriguez. Lancet. 2008 Jul 19;372(9634):234-45. PMR and Temporal Arteritis. Salvarani et al.