1. Case Presentation Lance C. Brunner M.D. Assistant Clinical Chief Department of Family Medicine

2. Case Presentation  82 yo male with type II DM and multi-infarct dementia presents to the ER with a 3 week history of worsening ability to walk, difficulty getting out of bed, leg spasms, and just general deconditioning. Daughter states that patient also has had decreased appetite, low grade fevers, and worsening depression.

3. Case Presentation  PMHX Type II DM HTN Excessive alcohol intake – none for the last year Multi-infarct dementia  PSHX None  Allergies None  Meds ASA Prinzide Simvastatin  FHx DM CAD  SHX Widowed Lives with daughter

4. Case Presentation  PE Gen – crying, complaining of bilateral hip, lower back, and thigh pain, moderate distress 99.2 104 16 148/66 Neck – supple CV – RRR Lungs – dry crackles Abd – soft + bs Ext – TTP of paraspinal lumbar region, bilateral thighs, bilateral shoulders, moderate pain with back flexion Neck - +paraspinal tenderness. Supple

5. Case Presentation  L/S x-ray mild OA/DDD  UA negative  WBC 10.0 with normal diff  Plt 520  HB 13.2  Chem 7 normal  SGPT 35  Total CK 123  CT back negative  CXR negative  CT head negative  EKG LVH no acute changes  Troponin I <0.1

6. Case Presentation  Neurology called for formal consult  Patient diagnosed with diffuse myalgias likely statin related with dehydration  Hydration and MS given in the ER  DC statin  Vicoden given  F/U pcp….

7. Case Presentation  Next day symptoms come back with a vengeance  Now what?

8. Case Presentation  Upon further questioning, daughter describes patient with significant muscle stiffness of the shoulders and thighs and difficulty getting out of a chair. Leg spasms still persist at night….

9. Case Presentation  ESR 103

10. Polymyalgia Rheumatica  Aching and morning stiffness in the girdle  Subacute or acute  Generally symmetric  Malaise, fatigue, anorexia, low grade fever, weight loss  10% of patients with PMR have Temporal Arteritis (TA)  50% of patients with TA have PMR

11. Polymyalgia Rheumatica  Physical Exam Decreased rom of shoulders and hips Normal strength Muscle tenderness often not a prominent feature – tenderness usually due to bursal involvement Age > 50, ESR >50, although sedimentation rate can be normal in up to 22% of patients Elevated CRP (may be more sensitive) Elevated IL6 levels may be related to disease activity in TA

12. Differential  Occult infection  RA  Hypothyroidism  Endocarditis  Fibromyalgia  Polymyositis  OA  Malignancy and paraneoplastic syndromes  Bursitis  Tendinitis  Vasculitis Gottron’s sign in polymyositis

13. Polymyalgia Rheumatica  Treatment Prednisone 10-20 mg a day (40mg-80 daily at if temporal arteritis is present) with subsequent taper Always be on the lookout for temporal arteritis (temporal artery tenderness, headache, jaw pain, visual loss, and evidence of non-cranial ischemia) Relapse 25-50% MTX a consideration if patients at high risk of glucocorticoid side effects