A 76-year-old woman comes to the office due to malaise accompanied by diffuse, achy pain. The pain began 6 weeks ago and is most pronounced around her shoulder and pelvic girdle muscles. The patient has no headache, visual symptoms, fever, rash, muscle weakness, or urinary symptoms. She has a history of hypertension, hypercholesterolemia, and osteoporosis. The patient's medications include enalapril, simvastatin, alendronate, and hydrochlorothiazide. Family history is unremarkable. She does not use tobacco or alcohol. Physical examination shows mild tenderness in the muscles of the pelvic girdle. The rest of the physical examination is unrevealing. Routine laboratory studies, including serum creatine kinase levels, are normal. What is the best next step in management of this patient?

Question

A 76-year-old woman comes to the office due to malaise accompanied by diffuse, achy pain.  The pain began 6 weeks ago and is most pronounced around her shoulder and pelvic girdle muscles.  The patient has no headache, visual symptoms, fever, rash, muscle weakness, or urinary symptoms.  She has a history of hypertension, hypercholesterolemia, and osteoporosis.  The patient's medications include enalapril, simvastatin, alendronate, and hydrochlorothiazide.  Family history is unremarkable.  She does not use tobacco or alcohol.  Physical examination shows mild tenderness in the muscles of the pelvic girdle.  The rest of the physical examination is unrevealing.  Routine laboratory studies, including serum creatine kinase levels, are normal.  What is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0ba_5557_8f63_af3fa66f1095_MD0005_00 This patient-age >50 with subacute onset of muscle pain most prominent in the shoulders and pelvic girdle and a normal creatine kinase (CK) level-has characteristic features of polymyalgia rheumatica (PMR). Although the term "polymyalgia" implies a myopathic process, PMR is an inflammatory disorder of the proximal joints, bursae, and tendons. The muscle itself is unaffected, and therefore strength and CK levels remain normal. Pain in the soft tissue is referred from nearby joint structures, and tenderness (if present) is typically mild. Active range of motion may be limited due to pain or stiffness, but passive range of motion is usually normal. Although there are no specific tests for PMR, acute-phase inflammatory markers (eg, erythrocyte sedimentation rate [ESR], C-reactive protein) are very sensitive and, when elevated in a patient with classic symptoms, are considered adequate indications to initiate treatment. Low-dose glucocorticoids (eg, prednisone 20 mg daily) are the treatment of choice. Rapid relief of symptoms is expected; therefore, failure to improve rapidly with glucocorticoid therapy should call the diagnosis into question. (Choice A) Statin myopathy is characterized by an elevated CK level and normal ESR, in contrast to the elevated ESR and normal CPK in PMR. Statins may occasionally cause a mild myopathy with normal CPK; therefore, if the ESR is normal, discontinuation of the statin may be considered. (Choice C) Inflammatory myopathies (eg, polymyositis) usually present with significant weakness and have characteristic abnormalities on muscle biopsy. However, CK is frequently elevated in these conditions. Muscle biopsy is not useful in the diagnosis of PMR. (Choice D) Nonsteroidal anti-inflammatory drugs may be used for benign muscle pain but are much less effective than glucocorticoids in PMR and are not recommended for initial management. (Choice E) PMR is frequently associated with giant cell arteritis (GCA), which causes headache, jaw claudication, vision loss, and tenderness over the temporal artery. To prevent vision loss, high-dose glucocorticoids (eg, prednisone ≥60 mg daily) should be started immediately in patients in whom there is a concern for GCA. However, in patients with symptoms of uncomplicated PMR, treatment should be deferred until after obtaining inflammatory markers because glucocorticoids can rapidly normalize these laboratory abnormalities, which can muddy the diagnosis. Educational objective: Polymyalgia rheumatica affects patients age >50 and is characterized by pain and stiffness in the neck, shoulders, and pelvic girdle and elevated inflammatory markers (eg, erythrocyte sedimentation rate, C-reactive protein). Low-dose glucocorticoids are the treatment of choice. References: Polymyalgia rheumatica and giant cell arteritis. (http://www.ncbi.nlm.nih.gov/pubmed/17111894) Recognition and management of polymyalgia rheumatica and giant cell arteritis. (http://www.ncbi.nlm.nih.gov/pubmed/24364483)

A 76-Year-Old Woman Comes to the Office Due to Malaise