Differentiating Polymyalgia rheumatica from other diseases: Difference between revisions

Latest revision as of 21:23, 29 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Elsaiey, MBBCH [2]

Overview

Polymyalgia rheumatica (PMR) must be differentiated from other conditions such as late onset rheumatoid arthritis, polymyositis, dermatomyositis, fibromyalgia, and remitting seronegative symmetrical synovitis with pitting edema.

Differentiating Polymyalgia Rheumatica from other Diseases

Polymyalgia rheumatica (PMR) must be differentiated from other conditions such as late onset rheumatoid arthritis, polymyositis, dermatomyositis, fibromyalgia, and remitting seronegative symmetrical synovitis with pitting edema.^[1]^[2]^[3]^[4]

Differentiating polymyalgia rheumatica on the basis of fatigue and chronic pain

Disease	Differentiating signs and symptoms	Diagnostic findings
Polymyalgia rheumatica	Older at onset Generalized stiffness	Elevated ESR or CRP Response to corticosteroids
Fibromyalgia	Symptoms have been present at a similar level for at least 3 months. Chronic musculoskeletal pain with multiple tender points Stiffness, numbness, and fatigue Headaches Sleep disorder	All lab tests are normal
Rheumatoid arthritis	Multiple joint swelling Morning stiffness Rheumatoid nodules	Positive RF or anti-cyclic citrullinated protein (CCP) antibody Elevated ESR or CRP
SLE	Maculopapular rash Multi-system involvement	Positive anti-Smith antibodies
Chronic fatigue syndrome	Fatigue plus 4 of the following symptoms: Short-term memory loss Sore throat Tender lymph nodes in the neck or armpit Muscle pain Joint pain without swelling or redness Headaches Insomnia Malaise	Diagnosis of exclusions Symptoms must present for more than 6 months
Spondyloarthritis	Axial skeletal pain and stiffness Restricted spinal motion	Elevated ESR or CRP Negative RF Bamboo spine on x-ray
Osteoarthritis	Localized joint pain Restricted to affect joints Older at onset	Degenerative joint changes on x-ray
Hypothyroidism	Systemic symptoms such as weight gain, constipation, dry skin Muscular aching Prominent fatigue	Elevated TSH Low free T4
Polymyositis and dermatomyositis	Pelvic and shoulder girdle muscle weakness Rash	Muscle biopsy confirms the diagnosis Elevated CPK enzyme
Neuropathy	Numbness and tingling Paresthesia	Abnormal EMG

Differentiating polymyalgia rheumatica from other causes of inflammatory myopathy

Organ system	Disease	Symptoms												History	Physical Examination	Diagnosis
Organ system	Disease	Age of onset	Muscle weakness	Fever	Myalgia	Contractures	Gait abnormality	Neuropathy	Atrophy	Stiffness	Myoglobinuria	Other features	Laboratory Findings	History	Physical Examination	Creatine Kinase	Muscle Biopsy	Electromyogram
Inflammatory/ Rheumatologic	Polymyalgia Rheumatica^[5]	50s	Diffuse	+	+	−	−	−	−	+	−	Weight loss	History of joints stiffness, worse in the morning	Restricted shoulder motion	↑↑ ESR ↑↑ CRP	Normal	Normal	Normal
	Dermatomyositis^[6]	40s−50s Can affect children	Proximal	+	+	−	−	−	−	+	−	Rash Dyspnea Weight loss Cough	Viral infections Cancer	Heliotrope rash on face and hands Telangiectasia Erythema Mechanic's hands Gottron's sign ( violaceous scaly eruption )	↑↑ ESR ↑↑ CRP	↑↑	Perimysial mononuclear infiltrate	Myopathic
	Polymyositis^[7]	> 18 years	Proximal	+	+	−	−	−	−	+	−	Similar to dermatomyositis without mucous and skin involvement	N/A	N/A	↑↑ ESR ↑↑ CRP	↑↑	Endomysial mononuclear infiltrate Patchy necrosis	Myopathic
	Inclusion body myositis^[8]	50s	Proximal & distal	−	−	−	−	−	−	−	−	Dysphagia Asymmetric weakness	Retrovirus (most common)	N/A	Antibodies to cytoplasmic 5'−nucleotidase	↑↑	Inflammatory cells Invading muscle cells Vacuolar degeneration Inclusions or plaques	Neurogenic
	Fibromyalgia^[9]	40−50s	Generalized	−	−	−	−	+	−	−	−	Anxiety or depression features Fatigue Sleep disturbance Numbness Muscle spasms	History of depression	Tenderness in the soft tissue anatomical location	Normal	Normal	Normal	Normal
Organ system	Disease	Age of onset	Muscle weakness	Fever	Myalgia	Contractures	Gait abnormality	Neuropathy	Atrophy	Stiffness	Myoglobinuria	Other features	History	Physical Examination	Laboratory Findings	Creatine Kinase	Muscle Biopsy	Electromyogram

References

↑ Pease CT, Haugeberg G, Montague B; et al. (2009). "Polymyalgia rheumatica can be distinguished from late onset rheumatoid arthritis at baseline: results of a 5-yr prospective study". Rheumatology (Oxford). 48 (2): 123–7. doi:10.1093/rheumatology/ken343. PMID 18980958. Unknown parameter |month= ignored (help)
↑ Pease CT, Haugeberg G, Morgan AW, Montague B, Hensor EM, Bhakta BB (2005). "Diagnosing late onset rheumatoid arthritis, polymyalgia rheumatica, and temporal arteritis in patients presenting with polymyalgic symptoms. A prospective longterm evaluation". J. Rheumatol. 32 (6): 1043–6. PMID 15940765. Unknown parameter |month= ignored (help)
↑ Sørensen CD, Hansen LH, Hørslev-Petersen K (2010). "[Myositis as differential diagnosis in polymyalgia rheumatica]". Ugeskr. Laeg. (in Danish). 172 (42): 2899–900. PMID 21040663. Unknown parameter |month= ignored (help)
↑ Hopkinson ND, Shawe DJ, Gumpel JM (1991). "Polymyositis, not polymyalgia rheumatica". Ann. Rheum. Dis. 50 (5): 321–2. PMC 1004419. PMID 2042988. Unknown parameter |month= ignored (help)
↑ Myklebust G, Gran JT (1996). "A prospective study of 287 patients with polymyalgia rheumatica and temporal arteritis: clinical and laboratory manifestations at onset of disease and at the time of diagnosis". Br J Rheumatol. 35 (11): 1161–8. PMID 8948307.
↑ Dalakas MC (1991). "Polymyositis, dermatomyositis and inclusion-body myositis". N Engl J Med. 325 (21): 1487–98. doi:10.1056/NEJM199111213252107. PMID 1658649.
↑ Dalakas MC (1991). "Polymyositis, dermatomyositis and inclusion-body myositis". N Engl J Med. 325 (21): 1487–98. doi:10.1056/NEJM199111213252107. PMID 1658649.
↑ Dalakas MC (1991). "Polymyositis, dermatomyositis and inclusion-body myositis". N Engl J Med. 325 (21): 1487–98. doi:10.1056/NEJM199111213252107. PMID 1658649.
↑ Ohara N, Katada S, Yamada T, Mezaki N, Suzuki H, Suzuki A, Hanyu O, Yoneoka Y, Kawachi I, Shimohata T, Kakita A, Nishizawa M, Sone H (2016). "Fibromyalgia in a Patient with Cushing's Disease Accompanied by Central Hypothyroidism". Intern. Med. 55 (21): 3185–3190. doi:10.2169/internalmedicine.55.5926. PMC 5140872. PMID 27803417.

[pmid18980958-1] Pease CT, Haugeberg G, Montague B; et al. (2009). "Polymyalgia rheumatica can be distinguished from late onset rheumatoid arthritis at baseline: results of a 5-yr prospective study". Rheumatology (Oxford). 48 (2): 123–7. doi:10.1093/rheumatology/ken343. PMID 18980958. Unknown parameter |month= ignored (help)

[pmid15940765-2] Pease CT, Haugeberg G, Morgan AW, Montague B, Hensor EM, Bhakta BB (2005). "Diagnosing late onset rheumatoid arthritis, polymyalgia rheumatica, and temporal arteritis in patients presenting with polymyalgic symptoms. A prospective longterm evaluation". J. Rheumatol. 32 (6): 1043–6. PMID 15940765. Unknown parameter |month= ignored (help)

[pmid21040663-3] Sørensen CD, Hansen LH, Hørslev-Petersen K (2010). "[Myositis as differential diagnosis in polymyalgia rheumatica]". Ugeskr. Laeg. (in Danish). 172 (42): 2899–900. PMID 21040663. Unknown parameter |month= ignored (help)

[pmid2042988-4] Hopkinson ND, Shawe DJ, Gumpel JM (1991). "Polymyositis, not polymyalgia rheumatica". Ann. Rheum. Dis. 50 (5): 321–2. PMC 1004419. PMID 2042988. Unknown parameter |month= ignored (help)

[pmid8948307-5] Myklebust G, Gran JT (1996). "A prospective study of 287 patients with polymyalgia rheumatica and temporal arteritis: clinical and laboratory manifestations at onset of disease and at the time of diagnosis". Br J Rheumatol. 35 (11): 1161–8. PMID 8948307.

[pmid1658649-6] Dalakas MC (1991). "Polymyositis, dermatomyositis and inclusion-body myositis". N Engl J Med. 325 (21): 1487–98. doi:10.1056/NEJM199111213252107. PMID 1658649.

[pmid16586492-7] Dalakas MC (1991). "Polymyositis, dermatomyositis and inclusion-body myositis". N Engl J Med. 325 (21): 1487–98. doi:10.1056/NEJM199111213252107. PMID 1658649.

[pmid16586493-8] Dalakas MC (1991). "Polymyositis, dermatomyositis and inclusion-body myositis". N Engl J Med. 325 (21): 1487–98. doi:10.1056/NEJM199111213252107. PMID 1658649.

[pmid27803417-9] Ohara N, Katada S, Yamada T, Mezaki N, Suzuki H, Suzuki A, Hanyu O, Yoneoka Y, Kawachi I, Shimohata T, Kakita A, Nishizawa M, Sone H (2016). "Fibromyalgia in a Patient with Cushing's Disease Accompanied by Central Hypothyroidism". Intern. Med. 55 (21): 3185–3190. doi:10.2169/internalmedicine.55.5926. PMC 5140872. PMID 27803417.

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@@ Line 1: / Line 1: @@
 __NOTOC__
-{{Polymyalgia rheumatica}}
+[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Polymyalgia_rheumatica]]
 {{CMG}}; {{AE}} {{AEL}}
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 ==Differentiating Polymyalgia Rheumatica from other Diseases==
-PMR must be differentiated from the following conditions:
+Polymyalgia rheumatica (PMR) must be differentiated from other conditions such as late onset [[rheumatoid arthritis]], [[polymyositis]], [[dermatomyositis]], [[fibromyalgia]], and [[remitting seronegative symmetrical synovitis with pitting edema]].<ref name="pmid18980958">{{cite journal |author=Pease CT, Haugeberg G, Montague B, ''et al.'' |title=Polymyalgia rheumatica can be distinguished from late onset rheumatoid arthritis at baseline: results of a 5-yr prospective study |journal=Rheumatology (Oxford) |volume=48 |issue=2 |pages=123–7 |year=2009 |month=February |pmid=18980958 |doi=10.1093/rheumatology/ken343 |url=}}</ref><ref name="pmid15940765">{{cite journal |author=Pease CT, Haugeberg G, Morgan AW, Montague B, Hensor EM, Bhakta BB |title=Diagnosing late onset rheumatoid arthritis, polymyalgia rheumatica, and temporal arteritis in patients presenting with polymyalgic symptoms. A prospective longterm evaluation |journal=J. Rheumatol. |volume=32 |issue=6 |pages=1043–6 |year=2005 |month=June |pmid=15940765 |doi= |url=}}</ref><ref name="pmid21040663">{{cite journal |author=Sørensen CD, Hansen LH, Hørslev-Petersen K |title=[Myositis as differential diagnosis in polymyalgia rheumatica] |language=Danish |journal=Ugeskr. Laeg. |volume=172 |issue=42 |pages=2899–900 |year=2010 |month=October |pmid=21040663 |doi= |url=}}</ref><ref name="pmid2042988">{{cite journal |author=Hopkinson ND, Shawe DJ, Gumpel JM |title=Polymyositis, not polymyalgia rheumatica |journal=Ann. Rheum. Dis. |volume=50 |issue=5 |pages=321–2 |year=1991 |month=May |pmid=2042988 |pmc=1004419 |doi= |url=}}</ref>
-* [[Rheumatoid arthritis]]: PMR and late onset [[rheumatoid arthritis]] (RA) can initially present with similar clinical features like [[synovitis]].  These patients are treated initially as PMR with [[glucocorticoids]].  RA treatment is started when there is no improvement or when it evolves into characteristic RA or when there is a persistently raised plasma viscosity.<ref name="pmid18980958">{{cite journal |author=Pease CT, Haugeberg G, Montague B, ''et al.'' |title=Polymyalgia rheumatica can be distinguished from late onset rheumatoid arthritis at baseline: results of a 5-yr prospective study |journal=Rheumatology (Oxford) |volume=48 |issue=2 |pages=123–7 |year=2009 |month=February |pmid=18980958 |doi=10.1093/rheumatology/ken343 |url=}}</ref> <ref name="pmid15940765">{{cite journal |author=Pease CT, Haugeberg G, Morgan AW, Montague B, Hensor EM, Bhakta BB |title=Diagnosing late onset rheumatoid arthritis, polymyalgia rheumatica, and temporal arteritis in patients presenting with polymyalgic symptoms. A prospective longterm evaluation |journal=J. Rheumatol. |volume=32 |issue=6 |pages=1043–6 |year=2005 |month=June |pmid=15940765 |doi= |url=}}</ref>
-* [[Polymyositis]] and [[dermatomyositis]]: Patients with [[dermatomyositis]] or [[polymyositis]] present with tenderness and weakness of proximal muscles, while PMR patients present with pain and stiffness. This differentiation between these entities may be difficult in elderly patients. Proper history, complete physical examination, [[ESR]], [[creatine kinase]] levels and [[muscle biopsy]] help in establishing the proper diagnosis.<ref name="pmid21040663">{{cite journal |author=Sørensen CD, Hansen LH, Hørslev-Petersen K |title=[Myositis as differential diagnosis in polymyalgia rheumatica] |language=Danish |journal=Ugeskr. Laeg. |volume=172 |issue=42 |pages=2899–900 |year=2010 |month=October |pmid=21040663 |doi= |url=}}</ref> <ref name="pmid2042988">{{cite journal |author=Hopkinson ND, Shawe DJ, Gumpel JM |title=Polymyositis, not polymyalgia rheumatica |journal=Ann. Rheum. Dis. |volume=50 |issue=5 |pages=321–2 |year=1991 |month=May |pmid=2042988 |pmc=1004419 |doi= |url=}}</ref>
-* [[Malignancy]] (such as [[myeloma]]): Patients with [[malignancy]] sometimes present with PMR like symptoms and have  poor response to [[steroid]] therapy.<ref name="pmid3774196">{{cite journal |author=Manganelli P, Borghi L, Coruzzi P, Novarini A, Ambanelli U |title=[Paraneoplastic polymyalgia rheumatica. Case contribution] |language=Italian |journal=Minerva Med. |volume=77 |issue=38 |pages=1739–41 |year=1986 |month=October |pmid=3774196 |doi= |url=}}</ref> This is in fact paraneoplastic syndrome presenting as PMR.<ref name="pmid19562970">{{cite journal |author=Kwiatkowska B, Filipowicz-Sosnowska A |title=[Polymyalgia rheumatica mimicking neoplastic disease--significant problem in elderly patients] |language=Polish |journal=Pol. Arch. Med. Wewn. |volume=118 Suppl |issue= |pages=47–9 |year=2008 |pmid=19562970 |doi= |url=}}</ref>
-*[[Fibromyalgia]]: [[Fibromyalgia]] occurs in age groups 20-50 years.  Patients have characteristic tender points. Unlike PMR, the active phase proteins and [[ESR]] are normal.
-*[[Hyperparathyroidism]]: [[Hyperparathyroidism]] presents with proximal stiffness and bone pain with elevated [[parathyroid hormone]] levels and often raised [[calcium]] levels without elevation of [[ESR]] levels.
-* Chronic infection ([[subacute bacterial endocarditis]] ([[SBE]])): Rheumatologic symptoms seen in [[infective endocarditis]] can present as a clinical picture suggestive of [[polymyalgia rheumatica]] hindering the correct diagnosis.<ref name="pmid16859595">{{cite journal |author=Auzary C, Le Thi Huong D, Delarbre X, ''et al.'' |title=Subacute bacterial endocarditis presenting as polymyalgia rheumatica or giant cell arteritis |journal=Clin. Exp. Rheumatol. |volume=24 |issue=2 Suppl 41 |pages=S38–40 |year=2006 |pmid=16859595 |doi= |url=}}</ref>
-* [[Hypothyroidism]]: Patients with hypothyroidism muscle and joint pain and weakness similar to [[PMR]]. Delayed relaxation of deep tendon reflexes is seen in [[hypothyroidism]] with elevated [[TSH]] levels and low [[T4]] levels.
-*[[Remitting seronegative symmetrical synovitis with pitting edema]] ([[RS3PE]]): [[RS3PE]] presents with symmetrical [[synovitis]] and [[pitting edema]], usually in patients over 50 years of age and lack [[rheumatoid factor]]. Unlike PMR, the symptoms commonly manifest distally.
 ===Differentiating polymyalgia rheumatica on the basis of fatigue and chronic pain===
 {|
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 === Differentiating polymyalgia rheumatica from other causes of inflammatory myopathy ===
-[[Dexamethasone suppression test|<nowiki/>]]
 {|
 ! rowspan="2" style="background:#4479BA; color: #FFFFFF;" align="center" + |Organ system
@@ Line 137: / Line 119: @@
 ! style="background:#4479BA; color: #FFFFFF;" align="center" + |Fever
 ! style="background:#4479BA; color: #FFFFFF;" align="center" + |Myalgia
-! style="background:#4479BA; color: #FFFFFF;" align="center" + |'''Contractures'''
+! style="background:#4479BA; color: #FFFFFF;" align="center" + |Contractures
 ! style="background:#4479BA; color: #FFFFFF;" align="center" + |Gait abnormality
 ! style="background:#4479BA; color: #FFFFFF;" align="center" + |Neuropathy
@@ Line 149: / Line 131: @@
 ! style="background:#4479BA; color: #FFFFFF;" align="center" + |Electromyogram
 |-
-| rowspan="5" |Inflammatory/ Rheumatologic
+! rowspan="5" style="background:#DCDCDC;" align="center" + |Inflammatory/ Rheumatologic
 ! style="background:#DCDCDC;" align="center" + |[[Polymyalgia rheumatica|Polymyalgia Rheumatica]]<ref name="pmid8948307">{{cite journal| author=Myklebust G, Gran JT| title=A prospective study of 287 patients with polymyalgia rheumatica and temporal arteritis: clinical and laboratory manifestations at onset of disease and at the time of diagnosis. | journal=Br J Rheumatol | year= 1996 | volume= 35 | issue= 11 | pages= 1161-8 | pmid=8948307 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8948307  }}</ref>
 | style="background:#F5F5F5;" align="center" + |50s
@@ Line 174: / Line 156: @@
 | style="background:#F5F5F5;" align="left" + |
 * Normal
-|
+| style="background:#F5F5F5;" align="left" + |
+* Normal
 |-
 ! style="background:#DCDCDC;" align="center" + |[[Dermatomyositis]]<ref name="pmid1658649">{{cite journal| author=Dalakas MC| title=Polymyositis, dermatomyositis and inclusion-body myositis. | journal=N Engl J Med | year= 1991 | volume= 325 | issue= 21 | pages= 1487-98 | pmid=1658649 | doi=10.1056/NEJM199111213252107 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1658649  }}</ref>
@@ Line 321: / Line 304: @@
 ==References==
 {{reflist|2}}
-{{WH}}
-{{WS}}
+[[Category:Medicine]]
-[[Category:Disease]]
 [[Category:Rheumatology]]
+[[Category:Up-To-Date]]

Differentiating Polymyalgia rheumatica from other diseases: Difference between revisions

Latest revision as of 21:23, 29 July 2020

Overview

Differentiating Polymyalgia Rheumatica from other Diseases

Differentiating polymyalgia rheumatica on the basis of fatigue and chronic pain

Differentiating polymyalgia rheumatica from other causes of inflammatory myopathy

References

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