A 70-year-old man comes to the physician for pain and stiffness of his neck, shoulders, and hips for the last 3 months. His stiffness is worse in the morning and lasts 1-2 hours. He also complains of general malaise and a recent weight loss of 3.17 kg (7 lb). The patient has no headache, scalp tenderness, visual symptoms, or jaw claudication. Examination shows no overt synovitis at the joints, with normal passive range of motion. The arteries of the scalp, neck, and extremities are normal on palpation without any tenderness. Laboratory results are as follows: Which of the following is the most appropriate next step in management of this patient?

Question

A 70-year-old man comes to the physician for pain and stiffness of his neck, shoulders, and hips for the last 3 months.  His stiffness is worse in the morning and lasts 1-2 hours.  He also complains of general malaise and a recent weight loss of 3.17 kg (7 lb).  The patient has no headache, scalp tenderness, visual symptoms, or jaw claudication.  Examination shows no overt synovitis at the joints, with normal passive range of motion.  The arteries of the scalp, neck, and extremities are normal on palpation without any tenderness.  Laboratory results are as follows:  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0ba_f199_8f63_af1bb97c4b97_MD0005_00 This patient has characteristic features of polymyalgia rheumatica (PMR): Age >50 Subacute-to-chronic (>1 month) pain in the shoulder and hip girdles Morning stiffness lasting >1 hour Constitutional symptoms Elevated erythrocyte sedimentation rate (>40 mm/h) No other apparent explanation for symptoms The physical examination in PMR is frequently unremarkable, with patients indicating no focal tenderness or pain with active or passive range of motion. Signs of inflammation in the joints are absent. When asked to identify the location of their pain, patients typically indicate the soft tissues, not the joints. Low-dose glucocorticoids are the treatment of choice for PMR (eg, prednisone 10-20 mg daily). Rapid and thorough relief of symptoms is expected, and failure to improve rapidly on prednisone should call the diagnosis into question. PMR is frequently associated with giant cell arteritis (GCA), also known as temporal arteritis. Symptoms of GCA include headache, jaw claudication, vision loss, and tenderness over the temporal artery. If GCA is suspected, patients should be considered for an expedited temporal artery biopsy (Choice B) and receive significantly higher doses of glucocorticoids (eg, prednisone 40-60 mg or higher daily) (Choice C). (Choice A) Antinuclear antibody and rheumatoid factor are screening tests for systemic lupus erythematosus and rheumatoid arthritis, respectively, and are frequently positive in a number of other inflammatory and autoimmune conditions. These tests have poor specificity in the absence of characteristic symptoms (eg, malar rash, metacarpophalangeal synovitis) and would be unlikely to change management in this patient. (Choice E) Nonsteroidal anti-inflammatory drugs are occasionally useful in PMR, for mild breakthrough discomfort or minor relapse of symptoms while tapering glucocorticoids. However, they are much less effective than glucocorticoids for initial management and are not recommended. Educational objective: Polymyalgia rheumatica (PMR) affects patients age >50 and is characterized by elevated erythrocyte sedimentation rate and pain and stiffness in the neck, shoulders, and pelvic girdle. The treatment of choice for uncomplicated PMR is low-dose prednisone, which results in rapid relief of symptoms. References: Recognition and management of polymyalgia rheumatica and giant cell arteritis. (http://www.ncbi.nlm.nih.gov/pubmed/24364483)

A 70-Year-Old Man Comes to the Physician for Pain and Stiffness