Endgames Case Review

Polymyalgia rheumatica in primary care: managing diagnostic uncertainty

BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5199 (Published 07 October 2015) Cite this as: BMJ 2015;351:h5199
  1. Rammya Mathew, academic clinical fellow in general practice1,
  2. Ahmed Rashid, academic clinical fellow in general practice2
  1. 1Department of Primary Care and Population Health, University College London, London, UK
  2. 2Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
  1. Correspondence to: R Mathew rammya.mathew{at}nhs.net

A 78 year old white woman presented with a six week history of bilateral shoulder stiffness and pain. Stiffness was the main symptom—it was so severe that she could not dress herself or brush her hair. She also had constitutional features including anorexia, weight loss, and profound lethargy. She was a smoker with a 30 pack year history. Initial blood tests showed markedly raised inflammatory markers, with an erythrocyte sedimentation rate of 98 mm in the first hour (reference range 0-12) and C reactive protein of 933 nmol/L (0-47.6). A diagnosis of polymyalgia rheumatica was considered.

Questions

  • 1. What other differential diagnoses need to be considered?

  • 2. Which further investigations should be arranged?

  • 3. How would you manage diagnostic uncertainty?

  • 4. If polymyalgia rheumatica is confirmed, what advice is needed?

  • 5. When would you refer a patient with suspected polymyalgia rheumatica to secondary care, and how often do patients need to be reviewed?

Answers

1. What other differential diagnoses need to be considered?

Short answer

Given her symptoms, risk factors, and raised inflammatory markers, underlying cancer must be excluded. Other differential diagnoses include inflammatory polyarthropathy, vasculitis, and drug induced or autoimmune myositis.

Discussion

Several conditions can mimic polymyalgia rheumatica (table).

View this table:

Polymyalgia rheumatica mimics

Because of the patient’s smoking history, the presence of constitutional features, and the reported weight loss, it is essential to rule out underlying cancer. Pain in the shoulders could be secondary to myeloma, bony metastases, or secondary hypercalcaemia. Given her age and demographic, important primary cancers to consider are lung and breast cancer.

Polymyalgic syndrome also overlaps with other inflammatory disorders including late onset rheumatoid arthritis, which tends to present symmetrically, with pain and swelling in the small joints of the hands and feet, and less commonly in the larger joints.1 Seronegative arthropathy is also a possibility, but it usually affects younger patients.2 A late onset variant …

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