Polymyalgia rheumatica differential diagnosis
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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 and fibromylagia.
Differentiating Polymyalgia rheumatica from other Diseases
- Rheumatoid arthritis: PMR and late onset rheumatoid arthritis can initially present with similar clinical 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 characteristic RA or when there is a persistently raised plasma viscosity.[1] [2]
- 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.[3] [4]
- Malignancy (myeloma, others): 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 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.
- Hyperparathyroidism: Hyperparathyroidism presents with proximal stiffness and bone pain with elevated parathyroid hormone levels and often calcium levels without elevation of ESR levels.
- Chronic infection (subacute bacterial endocarditis (SBE)): Rheumatologic symptoms seen in infective endocarditis can present a clinical picture suggesting polymyalgia rheumatica hindering the correct diagnosis.[7]
- 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.
- 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.
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) - ↑ 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) - ↑ 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.
- ↑ 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.