Polymyalgia rheumatica PMR occurs in the elderly and is characterized by pain and stiffness in the proximal muscles (scapularis and pelvic girdle muscles) 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 increasing incidence with age, and few people suffer from it before the age of 50. There are two to three times more women than men. There are family clusters. The disease can be seen in the same patient with giant cell arteritis (GCA), 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 before the onset of the general condition is good, can suddenly onset, morning wake up shoulder and back or generalized pain, discomfort, low fever, weakness and other symptoms; can also be insidious onset, lasting several weeks or months, and more accompanied by weight loss. (2) Typical symptoms: stiffness and pain in the neck, shoulder and hip muscles, either unilaterally or bilaterally, or limited to one 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. (1) Mild to moderate orthochromic anemia may be present. (2) Blood sedimentation is significantly increased (≥50mm/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 normal limits. (4) Electromyography and muscle biopsy have no basis for inflammatory myopathy. (5) Antinuclear and other autoantibodies and rheumatoid factor are usually negative. (6) There may be a small amount of synovial cavity 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 be considered rheumatic polymyalgia after excluding other diseases such as tumor. 1. Diagnostic criteria: The 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. 2. Differential diagnosis: (1) Giant cell arteritis (GCA): rheumatic polymyalgia is closely related to giant cell arteritis, and the following conditions should be noted in rheumatic polymyalgia, except for the combination of giant cell arteritis: poor response to low-dose glucocorticoid therapy; temporal artery anger, enhanced or weakened fluctuations and tenderness; accompanied by scalp pain, headache or visual abnormalities, etc., all need further temporal artery ultrasound, angiography or temporal artery biopsy, angiography or temporal artery biopsy, etc. (2) Rheumatoid arthritis: persistent symmetrical small arthritis is the main manifestation, often with positive rheumatoid factor. In contrast, rheumatic polymyalgia may have joint swelling, but no persistent small joint synovitis, no destructive joint lesions and no rheumatoid nodules, usually rheumatoid factor negative. (3) polymyositis: myasthenia is more prominent in this disease, with myasthenia, elevated serum myosin activity, electromyography shows myogenic damage, muscle biopsy for myositis, while patients with rheumatic polymyositis have normal myosin, electromyography and muscle biopsy, and myalgia is more than myasthenia. (4) fibromyalgia syndrome: the syndrome has fixed sensitive pressure points for somatic pain, such as the attachment point of the occipital region of the cervical muscle, the middle of the superior border of the trapezius muscle, the beginning of the supraspinatus muscle, the near medial border above the scapular spine, the lateral upper border of the junction of the second rib and cartilage, 2 cm below the lateral epicondyle of the humerus, the fold of the gluteus muscle in the outer upper quadrant of the hip, 2 cm after the greater trochanter There were 18 pressure points, including 9 in the medial goose bursa area of the knee joint. There was also sleep disturbance, tension headache, irritable enteritis, irritable cystitis, normal blood sedimentation, negative rheumatoid factor; poor response to glucocorticoid therapy. (5) Exclude other diseases: such as tuberculosis and other infectious diseases; exclude multiple myeloma and lymphoma or other tumors; and pay attention to differentiate with other rheumatic diseases such as dry syndrome and systemic vasculitis. Treatment plan and principles】 1. General treatment: make good explanation, relieve worries, follow medical advice, rational use of drugs, and prevent recurrence of disease. Perform appropriate limb exercises to prevent muscle atrophy. 2, drug treatment: (1) non-steroidal anti-inflammatory drugs: for the first or less severe cases can be tried non-steroidal anti-inflammatory drugs, such as anti-inflammatory pain, diclofenac, etc.. About 10-20% of rheumatic polymyalgia patients can control the symptoms with NSAIDs alone. However, it is difficult to prevent the occurrence of complications. See rheumatoid arthritis for medication attention routine. (2) Glucocorticoids: Prednisone 10~15mg/day orally is preferred in general cases. If the diagnosis is correct, the symptoms should improve significantly within a week and the blood sedimentation should start to decrease. For those with 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, cataract, osteoporosis), and it is very important to give corresponding treatment in time. (3) Immunosuppressants: For those who have contraindications to the use of glucocorticoids, or have poor results, or have difficulty in reducing the dose, or have serious adverse reactions, the immunosuppressant methotrexate 7.5~15mg/week or other immunosuppressants such as azathioprine, cyclophosphamide, etc. can be used in combination. The prognosis of PMR is good if it does not develop into GCA.