Central  South  Dakota Medical News
The Clinical View
by  Phillip  E.  Hoffsten
22  Aug  2002

POLYMYALGIA RHEUMATICA - ANOTHER MYSTERY DISEASE  

    Medical knowledge is rather like an inverted pyramid. It seems the more that is learned, the more there is to learn. In the past several weeks, I have described two mystery diseases that are relatively common and yet we haven't any meaningful knowledge on the cause of schizophrenia or the cause of toxemia of pregnancy. There is another well described relatively common illness that occurs in the elderly that falls into this same group. Specifically, polymyalgia rheumatica is a condition for which we have very good treatment and we don't have a clue as to what causes it.

    I often wonder why medical conditions have to have such great big names. Actually, polymyalgia is made up of several pieces all strung together. Poly means occurring in multiple sites. Mya refers to muscles. Algia refers to hurting. Rheumatica refers to "because of an inflammation". Thus a person with polymyalgia rheumatica has a bunch of muscles that hurt due to an inflammation in the muscle. It doesn't say anything about what causes the inflammation because we don't know. This condition tends to begin relatively slowly over several months time in which the person notices their shoulders and neck hurt more than usual. This may be accompanied by a low grade fever but not always. The majority of people with this condition are in their 70's and the condition is rare before age 50. As you might imagine, someone 70 years old complaining of aching in the muscles of their shoulders and their neck gets accused of having the achy-moany-groany's but it takes awhile before they are given the respect of having a specific disease condition causing the symptom. Symptoms are often attributed to "old age" or unaccustomed exercise. There are no x-ray findings and the condition isn't really an "arthritis" because the joints don't seem to be involved. The aching is in the muscles.

    When a person finally comes to the doctor for attention, the only blood test that is abnormal is called a sedimentation rate. In this day of modern high technology, a sedimentation rate has got be a real throw-back. All that is done is put a tube with the person's blood standing for an hour and then measure how far the red blood cells drop toward the bottom of the tube. It was noted a long time ago that people who were sick tended to have high sedimentation rates so the red cells drop pretty far down the tube by the time the hour is up.  In spite of all our modern technology and laboratory tests, a high sedimentation rate is still the basis of diagnosing polymyalgia rheumatica.

    Once the diagnosis is made, treatment is relatively easy. The person is treated with cortisone. Initially with modest doses, then with a very small dose for an extended period of time. For people with diabetes and high blood pressure, even these small doses of cortisone can be a problem but the welcome relief that this medication brings makes cortisone treatment well worth the risks. On the average, treatment is required for one to two years with a few people being treated as long as seven years until the polymyalgia rheumatica resolves. This condition by itself doesn't kill you but a person can have a lot of pain until it resolves.A very small percentage of people with polymyalgia rheumatica progress to a more serious condition called "giant cell arthritis". When the disease extends in this manner, it tends to involve the arteries around the eyes and can cause blindness. The arteries to the arms tend to be blocked and very frequently taking the person's pulse in their wrist is not possible because so little blood goes out to the arms. When this condition is diagnosed, it is much more of a medical emergency to protect vision.

    Polymyalgia rheumatica is a relatively common disease affecting 1 in every 133 people over age 50. Once the condition is suspected, diagnosis is very easy at your local clinics. Treatment is even very easy with small doses of cortisone unless the person is diabetic. In cases where the individual has diabetes and cortisone presents a major problem, a drug called methotrexate can have a cortisone sparing affect by decreasing the dose of cortisone necessary and thereby cutting down the side affects. As with all illnesses, care begins at your local clinic and specialist referral can follow from there.

    The reason this topic came to mind is the case of a gentleman who recently had a case of polymyalgia rheumatica but thought he needed a specialist. He waited for two months to get an appointment with a rheumatologist. The rheumatologist made the right diagnosis and started the gentleman on cortisone appropriately. However, this gentleman believed in fractionating his care having multiple physicians caring for him, no two of which knew what the other ones were doing. This is a very bad practice. I was trying to control his blood sugars and couldn't begin to figure out why they had all of a sudden gone from being well controlled to values of 300 mg% or more daily. Then he mentioned, "Oh by the way, I have polymyalgia rheumatica and Dr. X has given me cortisone". Then the problem became clear. He could have been seen much sooner than a two month wait and had continuity of care had he started at his local clinic.