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, fibromyalgia, and remitting seronegative symmetrical synovitis with pitting edema.
Differentiating Polymyalgia Rheumatica from other Diseases
PMR must be differentiated from the following conditions:
- Rheumatoid arthritis: PMR and late onset rheumatoid arthritis (RA) can initially present with similar clinical features like synovitis. These patients are treated initially as PMR with glucocorticoids. 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. This differentiation between these entities may be difficult in elderly patients. Proper history, complete physical examination, ESR, creatine kinase levels and muscle biopsy help in establishing the proper diagnosis.[3] [4]
- Malignancy (such as myeloma): 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 occurs in age groups 20-50 years. Patients have characteristic tender points. Unlike PMR, the active phase proteins and ESR are normal.
- Hyperparathyroidism: Hyperparathyroidism presents with proximal stiffness and bone pain with elevated parathyroid hormone levels and often raised calcium levels without elevation of ESR levels.
- Chronic infection (subacute bacterial endocarditis (SBE)): Rheumatologic symptoms seen in infective endocarditis can present as a clinical picture suggestive of polymyalgia rheumatica hindering the correct diagnosis.[7]
- Hypothyroidism: Patients with hypothyroidism 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): RS3PE presents with symmetrical synovitis and pitting edema, usually in patients over 50 years of age and lack rheumatoid factor. Unlike PMR, the symptoms commonly manifest distally.
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.