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==Overview==
==Overview==
== 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]].
* [[Rheumatoid arthritis]] - Polymyalgia rheumatica and late onset rheumatoid arthritis can initially present with similar clincal features like synovitis. These patients are treated initially as PMR with gluococorticoids. RA treatment is started when there is no improvement or when it evolves into charecteristic 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 prominently. This differentiation may be difficult in elderly patients. Proper history,complete physical examination, ESR,creatine kinase levels and muscle biopsy help in establishing 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>
== Differentiating Polymyalgia Rheumatica from other Diseases ==
PMR must be differentiated from the following conditions:
* [[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>


* Malignancy ([[myeloma]], others) - 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>
* [[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>


*[[Fibromyalgia]] - [[Fibromyalgia]] is commonly presented in age groups 20-50 years and patients have characteristic tender points. The active phase protiens and [[ESR]] are normal unlike [[PMR]].
* [[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>


*[[Hyperparathyroidism]] - [[Hyperparathyroidism]] presents with proximal stiffness and bone pain with elevated [[parathyroid hormone]] levels and often [[calcium]] levels without elevation of [[ESR]] levels.
*[[Fibromyalgia]]: [[Fibromyalgia]] occurs in age groups 20-50 years.  Patients have characteristic tender points. Unlike PMR, the active phase proteins and [[ESR]] are normal.


* Chronic infection ([[subacute bacterial endocarditis]] ([[SBE]])) - Rheumatologic symptoms seen in [[infective endocarditis]] can present a clinical picture suggesting [[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>
*[[Hyperparathyroidism]]: [[Hyperparathyroidism]] presents with proximal stiffness and bone pain with elevated [[parathyroid hormone]] levels and often raised [[calcium]] levels without elevation of [[ESR]] levels.


* [[Hypothyroidism]] - These patients have signs like 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.
* 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>
*[[Remitting seronegative symmetrical synovitis with pitting edema]] - [[RS3PE]] presents with symmetrical [[synovitis]] and [[pitting edema]],usually in patients over 50 years of age and lack [[rheumatoid factor]]. The symptoms are commonly manifested distally unlike [[PMR]].
 
* [[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.


==References==
==References==

Latest revision as of 12:23, 2 June 2014

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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

PMR must be differentiated from the following conditions:

  • 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.[1] [2]
  • Malignancy (such as myeloma): Patients with malignancy sometimes present with PMR like symptoms and have poor response to steroid therapy.[5] This is in fact paraneoplastic syndrome presenting as PMR.[6]
  • Fibromyalgia: Fibromyalgia occurs in age groups 20-50 years. Patients have characteristic tender points. Unlike PMR, the active phase proteins and ESR are normal.
  • 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.

References

  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)
  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)
  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)
  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)
  5. Manganelli P, Borghi L, Coruzzi P, Novarini A, Ambanelli U (1986). "[Paraneoplastic polymyalgia rheumatica. Case contribution]". Minerva Med. (in Italian). 77 (38): 1739–41. PMID 3774196. Unknown parameter |month= ignored (help)
  6. Kwiatkowska B, Filipowicz-Sosnowska A (2008). "[Polymyalgia rheumatica mimicking neoplastic disease--significant problem in elderly patients]". Pol. Arch. Med. Wewn. (in Polish). 118 Suppl: 47–9. PMID 19562970.
  7. Auzary C, Le Thi Huong D, Delarbre X; et al. (2006). "Subacute bacterial endocarditis presenting as polymyalgia rheumatica or giant cell arteritis". Clin. Exp. Rheumatol. 24 (2 Suppl 41): S38–40. PMID 16859595.

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