Case Presentation

Lance C. Brunner M.D.Assistant Clinical ChiefDepartment of Family Medicine

Case Presentation

82 yo male with type II DM and multi-infarct dementia presents to the ER with a 3 week history of worsening ability to walk, difficulty getting out of bed, leg spasms, and just general deconditioning. Daughter states that patient also has had decreased appetite, low grade fevers, and worsening depression.

Case Presentation

PMHX Type II DM HTN Excessive alcohol

intake – none for the last year

Multi-infarct dementia

PSHX None

Allergies None

Meds ASA Prinzide Simvastatin

FHx DM CAD

SHX Widowed Lives with daughter

Case Presentation

PE Gen – crying,

complaining of bilateral hip, lower back, and thigh pain, moderate distress

99.2 104 16 148/66 Neck – supple CV – RRR Lungs – dry crackles

Abd – soft + bs Ext – TTP of

paraspinal lumbar region, bilateral thighs, bilateral shoulders, moderate pain with back flexion

Neck - +paraspinal tenderness. Supple

Case Presentation

L/S x-ray mild OA/DDD

UA negative WBC 10.0 with

normal diff Plt 520 HB 13.2 Chem 7 normal SGPT 35

Total CK 123 CT back negative CXR negative CT head negative EKG LVH no acute

changes Troponin I <0.1

Case Presentation

Neurology called for formal consult Patient diagnosed with diffuse

myalgias likely statin related with dehydration

Hydration and MS given in the ER DC statin Vicoden given F/U pcp….

Case Presentation

Next day symptoms come back with a vengeance

Now what?

Case Presentation

Upon further questioning, daughter describes patient with significant muscle stiffness of the shoulders and thighs and difficulty getting out of a chair. Leg spasms still persist at night….

Case Presentation

ESR 103

Polymyalgia Rheumatica

Aching and morning stiffness in the girdle Subacute or acute Generally symmetric Malaise, fatigue, anorexia, low grade fever, weight

loss 10% of patients with PMR have Temporal Arteritis

(TA) 50% of patients with TA have PMR

Polymyalgia Rheumatica

Physical Exam Decreased rom of shoulders and hips Normal strength Muscle tenderness often not a prominent

feature – tenderness usually due to bursal involvement

Age > 50, ESR >50, although sedimentation rate can be normal in up to 22% of patients

Elevated CRP (may be more sensitive) Elevated IL6 levels may be related to disease

activity in TA

Differential

Occult infection RA Hypothyroidism Endocarditis Fibromyalgia Polymyositis OA Malignancy and

paraneoplastic syndromes

Bursitis Tendinitis Vasculitis

Gottron’s signin polymyositis

Polymyalgia Rheumatica

Treatment Prednisone 10-20 mg a day (40mg-80 daily at

if temporal arteritis is present) with subsequent taper

Always be on the lookout for temporal arteritis (temporal artery tenderness, headache, jaw pain, visual loss, and evidence of non-cranial ischemia)

Relapse 25-50% MTX a consideration if patients at high risk of

glucocorticoid side effects