Polymyalgia rheumatica is a systemic inflammatory disease that almost exclusively affects people aged 55 and above. How this disease occurs and why it more-or-less exclusively affects the elderly is poorly understood. Like most autoimmune diseases, it’s thought that something in the environment be it a virus, bacteria, or in the case of polymyalgia rheumatica seasonal variation, triggers autoimmunity in a genetically susceptible person.
The hallmark symptoms of polymyalgia rheumatica include severe pain and stiffness involving the shoulder and or pelvic muscles.
However, it’s very important to understand that polymyalgia rheumatica is a diagnosis of exclusion. It’s important to rule out other conditions before making this diagnosis.
Polymyalgia rheumatica statistics
Polymyalgia rheumatica is the second most common autoimmune condition. It affects 2.4% of women and 1.7% of men. It can affect people as young as 50 years, but mainly affects people aged 60 years and above. Finally, Caucasians are mainly affected. It very rarely affects African Americans, Asians, or people of Hispanic descent.
What are the signs and symptoms of polymyalgia rheumatica?
People suffering from polymyalgia rheumatica typically describe a slow and insidious process of worsening stiffness and pain involving their shoulders and their pelvis. Sometimes the process is quick but typically it progresses over 3 months. Usually there is a dramatic loss of function. This includes difficulty getting up from a seated position, difficulty getting out of bed, difficulty dressing.
“I feel 20 years older than I am”.
What are some other symptoms of polymyalgia rheumatica?
Some other symptoms include fevers, chills, drenching night sweats, and unintentional weight loss. Importantly, giant cell arteritis, a type of vasculitis, can occur in about 15% of people suffering from polymyalgia rheumatica.
People suffering from giant cell arteritis typically report very similar symptoms, as well as the following:
- Recent onset headache
- A cramping sensation while chewing
- Change in vision
- A recent change in hearing, taste, as well as smell
- Tenderness of the scalp
I’ll go into this later, but people suffering with giant cell arteritis usually do NOT improve with 20 mg of prednisone, whereas, people with pure polymyalgia rheumatic do.
Do people with polymyalgia rheumatica get arthritis?
The simple answer is yes they can. About 30% of people with polymyalgia rheumatica develop inflammatory arthritis that can look a lot like rheumatoid arthritis. However, unlike rheumatoid arthritis, this type of arthritis does not cause permanent damage.
How do you differentiate polymyalgia rheumatica from rheumatoid arthritis?
This can get very tricky and sometimes can take months of observation to finally figure it out. However, here are some distinguishing features that can help:
- Absence of rheumatoid factor and other rheumatoid arthritis antibodies
- Lack of involvement of small joints
- Lack of joint damage
What are some differential diagnoses in polymyalgia rheumatica?
| Diagnosis | Features |
| Fibromyalgia | Tender points and normal inflammation |
| Underactive thyroid (hypothyroidism) | Normal thyroid tests, normal inflammation |
| Depression | Normal inflammation |
| Osteoarthritis, rotator cuff, frozen shoulder | Abnormal x-rays and MRI, normal inflammation |
| Myositis | Mainly weakness, elevated muscle enzymes, abnormal nerve conduction test |
| Infection | Clinical suspicion and positive cultures |
| Cancer | Clinical suspicion with positive workup |
| Rheumatoid arthritis | Positive rheumatoid factor, small joints involved |
| Spondyloarthritis | History of psoriasis or inflammatory bowel disease[1] |
How is polymyalgia rheumatica diagnosed?
The diagnosis of polymyalgia rheumatica is predominantly clinical. It’s very important to exclude other potential diagnoses as listed above. Levels of inflammation are typically very high but can be normal in select cases.
The American College of Rheumatology and EULAR have established criteria, but these are not the greatest in the world. They have a sensitivity of 68% and specificity of 78%. Finally, sometimes ultrasound studies and a PET scan can help as well.
How is polymyalgia rheumatica treated?
Steroids. People suffering from polymyalgia rheumatica often describe a dramatic resolution or improvement of the symptoms on 15 to 20 mg of prednisone a day. By dramatic I mean it typically take less than 24 hours for symptoms to resolve. In about 25% of cases, the response will not be dramatic and will take a few more days or a higher dose of prednisone.
Unlike other rheumatic conditions, prednisone must be tapered very slowly in polymyalgia rheumatica. It’s not uncommon for a person to be on steroids for over two years. At times, we need to taper by 1 mg every month or two!
My best friend, my worst enemy
Prednisone is both your best friend and worst enemy. Unfortunately, it remains the mainstay of therapy. While on high doses of steroids for a prolonged period of time, it’s very important to remain active and pay attention to possible side effects such as osteoporosis, diabetes, heartburn/stomach ulcers, and infection. Not to mention an ever expanding waist line.
Regular weight-bearing exercise, vitamin D supplementation, as well as keeping up-to-date with vaccines (flu shot, pneumonia shot, shingles shot) are essential.
Conclusion
If you think you or one of your loved ones suffers from polymyalgia rheumatica, I encourage you to make an appointment with your local rheumatologist.
Medical Disclaimer
This information is offered to educate the general public. The information posted on this website does not replace professional medical advice, but for general information purposes only. There is no Doctor – Patient relationship established. We strongly advised you to speak with your medical professional if you have questions concerning your symptoms, diagnosis and treatment.
References
Rheumatology Secrets, 3rd edition
UpToDate
[1] Adapted from Rheumatology Secrets, 3rd edition