Rheumatic polymyalgia
Rheumatic polymyalgia occurs in the elderly and is characterized by pain and stiffness in the proximal muscles (scapular girdle, pelvic girdle) and cervical muscles, with a significant increase in blood sedimentation and non-specific systemic symptoms. The etiology of the disease is unknown. It is generally a benign process and is closely related to age, with an increasing incidence with age, and few people suffer from it before the age of 50. It is 2-3 times more common in women than in men. There are family clusters. The disease can be seen in the same patient with giant cell arteritis, suggesting a close relationship between the two, but the exact relationship between the two is not well understood. PMR is not uncommon in China.
Clinical manifestations
1.Symptoms and signs
(1) General symptoms are in good condition before the onset of the disease, but it can start suddenly and wake up in the morning with shoulder and back or generalized pain, discomfort, low fever, weakness and other symptoms; it can also start insidiously and last for several weeks or months, and is mostly accompanied by weight loss.
(2) Typical symptoms are stiffness and pain in the neck, shoulder and hip muscles, which can be unilateral or bilateral, or limited to a certain muscle group. In severe cases, the person cannot get up, the upper limb lifting is limited, the lower limb cannot be lifted, cannot squat, and has difficulty going up and down stairs. Unlike polymyositis, these symptoms are not due to muscle weakness, but rather to muscle pain. Some lesions may also involve the tendon attachments of the limb girdle, and some may also show pain and edema in the wrist and interphalangeal joints, or even transient synovitis of the sternoclavicular, shoulder, knee or hip joints.
2.Auxiliary examination.
(1) Mild to moderate orthochromic anemia may be present.
(2) Blood sedimentation is significantly increased (≥50 mm/hr Weiss method); C-reactive protein is increased and is consistent with disease activity.
(3) Liver enzymes may be mildly elevated, but serum myosin, which reflects transverse muscle inflammation, is mostly within the normal range.
(4) Electromyography and muscle biopsy have no basis for inflammatory myopathy.
(5) Antinuclear antibodies and other autoantibodies and rheumatoid factor are usually negative.
(6) There may be a small amount of synovial fluid in the shoulder, knee or hip joint, which is a non-specific inflammatory reaction.
Diagnostic points
Elderly people with unexplained fever, increased blood sedimentation and unexplained moderate anemia with difficulty in raising arms, dressing, squatting and standing should consider rheumatic polymyalgia after excluding other diseases such as tumor.
1.Diagnostic criteria.
Diagnosis can be made based on the following 6 clinical features.
(1) Age of onset ≥ 50 years.
(2) Muscle stiffness and pain in the neck, scapula and pelvis, at least two places, with morning stiffness, lasting for four weeks or more.
(3) Blood sedimentation ≥50 mm/hr (Weil’s method).
(4) Negative for antinuclear antibody and rheumatoid factor.
(5) Excellent response to low-dose glucocorticoid (prednisone 10-15mg/day) therapy.
(6) Secondary polymyalgia should be excluded.
Treatment plan and principles
1. General treatment: make good explanation, relieve worries, follow medical advice, use drugs reasonably and prevent recurrence of the disease. Carry out appropriate limb exercises to prevent muscle atrophy.
2.Drug treatment.
(1) non-steroidal anti-inflammatory drugs can be tried for the first or mild cases, such as anti-inflammatory pain, diclofenac, etc. About 10-20% of patients with rheumatic polymyalgia can control their symptoms with NSAIDs alone. However, it is difficult to prevent the occurrence of complications. Medication attention routine see rheumatoid arthritis.
(2) Glucocorticoids are preferred in general cases Prednisone 10-15mg/day, orally. If the diagnosis is correct, the symptoms should improve significantly within a week and the blood sedimentation should start to decrease. For those with more severe disease, fever, myalgia and obvious activity limitation, prednisone 15-30mg/day can be used. As the symptoms improve and the blood sedimentation approaches normal, then gradually reduce the dosage and maintain the dosage 5-10mg/day, and the maintenance time should not be less than 6-12 months. Reducing the dose too early, too fast or stopping the drug too early can lead to rekindling or relapse. Most patients can stop using hormones within 2 years, and a few patients need to maintain small amounts for many years.
It must be noted that the long-term use of glucocorticosteroids in the elderly should pay special attention to their adverse effects and complications (such as hypertension, diabetes mellitus, cataracts, osteoporosis), and it is very important to provide appropriate treatment in a timely manner.
(3) Immunosuppressants For those who have contraindications to the use of glucocorticosteroids, or have poor results, or have difficulty in reducing the dose, or have serious adverse effects, the immunosuppressants methotrexate 7.5-15 mg/week or other immunosuppressants such as azathioprine and cyclophosphamide can be used in combination.
Prognosis
PMR can be rapidly controlled, remitted or cured with appropriate treatment; it can also be prolonged or recurrent; and serious conditions such as muscle wasting atrophy or shoulder capsular contracture can occur in the later stages of the disease.