A 70-year-old man comes to the office due to pain and stiffness of his neck, shoulders, and hip region for the last 3 months. His stiffness is worse in the morning and lasts 1-2 hours. He also has had 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 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 office due to pain and stiffness of his neck, shoulders, and hip region for the last 3 months.  His stiffness is worse in the morning and lasts 1-2 hours.  He also has had 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 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: 11ec25c8_d514_cda5_bc81_8bd2ecb47712_MD0003_00 This patient has the following 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 (eg, malaise, weight loss) Elevated erythrocyte sedimentation rate >40 mm/h No other apparent explanation for symptoms Despite the musculoskeletal manifestations of PMR, the physical examination is frequently unremarkable with patients having 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 and 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, or tenderness over the temporal artery, none of which are present in this patient. If GCA is suspected, patients should be considered for an expedited temporal artery biopsy (Choice C) and receive significantly higher doses of glucocorticoids (eg, prednisone 40-60 mg or higher daily). (Choice A) Antinuclear antibody (ANA) is a screening test for systemic lupus erythematosus but is frequently positive in a number of other inflammatory and autoimmune conditions. ANA levels 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 B) Fibromyalgia most commonly presents in young to middle-aged women with widespread pain, fatigue, and cognitive/mood disturbances. Patients have point muscle tenderness in areas such as the mid trapezius, lateral epicondyle, costochondral junction in the chest, and greater trochanter. Regular aerobic exercise and good sleep hygiene are recommended for fibromyalgia. However, constitutional symptoms (eg, weight loss) or elevated erythrocyte sedimentation rate are not present in fibromyalgia. (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 pain and stiffness in the neck, shoulders, and pelvic girdle, along with an elevated erythrocyte sedimentation rate. 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 Office Due to Pain