Division of Rheumatology

Department of Internal Medicine

Polymyalgia Rheumatica
Gabriella Natalia
PATIENT IDENTITY
◈ Name : Ms MI
◈ Age : 67 years old
◈ Address : Makassar
◈ Occupation : Housewife
◈ Status : Married with 2 children
◈ Religion : Muslim
◈ Ethnic : Buginese
◈ Hospital : RS Wahidin Sudirohusodo
◈ MR : 168710
◈ Admission : Monday, March 4th 2019
HISTORY-TAKING
CHIEF COMPLAINT : JOINTS PAIN
• Patient comes to rheumatology clinic with chief complaint of pain in neck,
both shoulder, and pelvic girdles since 1 month ago. Pain is intermittent,
and worsen on activities like changing position or lifting heavy things. At
first patient felt pain on her one side of the body, but rapidly worsening on
both sides. Pain is presented with morning stiffness for > 1 hour and
subsides gradually.
• Patient sometimes take reliever (meloxicam 7,5mg 1x1) when the pain
arises.
◈ Defecation and urination are normal, there is no history of black
watery stool
◈ History of hypertension for about 5 years, on Amlodipine 10 mg
once daily, regularly
◈ History of Diabetes Mellitus is denied
◈ History of pain and inflammation on knees, toes, fingers are not
present
◈ History of hyperuricemia is denied
◈ History of trauma is denied
 PHYSICAL EXAMINATION
General Description
General condition: Moderate illness
Nutrition: well-nourished
⬥Height : 165
⬥Weight : 54
⬥BMI : 19,8 kg/m2
◈Vital Signs
⬥Awareness : Conscious (GCS 15 E4M6V5)
⬥Blood pressure : 130/80 mmHg
⬥Heart rate : 90 x/ min, irregular, strong
⬥Respiratory rate : 20 x/min, thoracoabdominal
⬥Temperature : 36.5°C (axilla)
⬥VAS : 3/10
 PHYSICAL EXAMINATION

• Head : Normocephal, straight black hair

• Face : Normal

• Eyes : Pupils isocor, normal light reflex, no anemic or jaundice

• Ear : No abnormalities, otorrhea (-)

• Nose : No abnormalities, epistaxis (-)

• Lips : No abnormalities, cyanosis (-)

• Oral cavity: No abnormalities, gingival hypertrophy (-), oral trush (-)

• Throat : No abnormalities, pharyngeal hyperemia (-), T1-T1 normal

• Neck : JVP R + 2 cmH2O, no lymphadenopathy, no enlargement of

thyroid gland, no deviation of the trachea.

Lung
– Inspection : Symmetrical left and right
– Palpation : No palpable tumor mass, normal tactile fremitus
– Percussion : Sonor
– Auscultation : Vesicular breathing sounds, no rhales or wheezing
Heart
– Inspection : Ictus cordis is not visible
– Palpation : Thrill is unpalpable
– Percussion : Dull, normal line border of the heart
– Auscultation : Heart sound I / II are regular, no murmur
Abdomen
– Inspection : Convex, no darm contour and steifung
– Auscultation : Bowel peristaltic (+) normal frequency
– Palpation : No ascites, no organomegaly
– Percussion : Tympani
Extremity : No edema observed
 RHEUMATOLOGICAL STATUS

◈Gait : Normal gait

◈Arm :

- Shoulder (D/S) : calor (-), dolor (-), rubor (-), tenderness (+),

crepitation (+) ROM limited when moved due to pain

◈Leg :

- Pelvic : Calor (-), dolor (-), rubor (-) tenderness (+),

ROM limited due to pain

◈Spine :

- Cervical : calor (-), dolor (-), rubor (-), tenderness (+),

ROM limited due to pain

 LABORATORY FINDINGS

04/03/2019 04/03/2019

• WBC : 8300 U/l • RBG : 136 mg/dl

• RBC : 4,5 X 10^6 • Ureum : 23
• Plt : 321.000 U/l • Creatinin : 0,85
• Hb : 13,6 gr/dl • SGOT : 21
• Na/K/Cl : 141/3,5/102 • SGPT : 24
• PT : 10,5 sec
• INR : 0,98
• aPTT : 24,8 sec
DIAGNOSIS

• Polymyalgia Rheumatica
• Hypertension on treatment
 PROBLEM LIST

Problems Planning Diagnostic Planning Therapy

Polymyalgia Rheumatica - Erythrocyte Sedimentation Meloxicam

Based on Bird Criteria (4/7) : Rate 7,5mg/24 hour/orally
- ANA profile
◈ Pain of shoulder and pelvic joints - Rheumatoid Factor Methylprednisolone
◈ Morning stiffness > 1 hour - Musculoskeletal USG 4mg/8 hours/orally
◈ Onset of >2 weeks
◈ Age > 65 yrs old

Diagnosis : 4/7
 PROBLEM LIST

Problems Planning Diagnostic Planning Therapy

Hypertension on Treatment Blood pressure monito Amlodipine tab

◈ History of hypertension ring, with target based 10 mg/24 hrs/orally
◈ Has been controlled for about 5 yrs on JNC 8 :
◈ Age > 65 yrs old < 140/80 mmHg
◈ BP : 130/80 mmHg
 Definition

Polymyalgia rheumatica (PMR) is characterized by inflammatory pain

and stiffness of the shoulder and/or pelvic girdles accompanied with
laboratory evidence of severe inflammation in a patient older than 50
years of age. Although this independent entity carries a good
prognosis, it can occur as a manifestation of a number of diseases, so
me of which are serious or require immediate treatments.
 Epidemiology & Etiology

• The exact cause (or causes) of PMR is unknown.

• The disease is more common among northern Europea
ns, which may indicate a genetic predisposition.
• Other risk factors for PMR are an age of 50 years or ol
der and the presence of GCA.
• An autoimmune process may play a role in PMR develo
pment.
 Clinical Manifestations

 Clinical Manifestation
• Inflamatory Pain (Usually around Shoulder, Pelvic
and Cervical)
• Morning Stiffness > 1 hour
• Constitutional Symptoms (Fever, Malaise, Anorexia
, Depresion, and Weight Loss)
 Additional Findings

 Laboratory Findings
• ESR > 40 mm/hour
• IL-6 Elevation
• ANA and RF Negative
 Imaging Findings
• USG / MRI found Bursitis and/or Synovitis
DIAGNOSTIC
CRITERIA
 PATHOPHYSIOLOGY

HLA-DR01
HLA-DR04

GENETIC Macrophages, T-Cell an

FACTOR d Cytokines (IL-1, IL-6,
TNF-alpha) activation

INFLAMATION

ENVIRONME
HORMONAL
NTAL
FACTOR
FACTOR PAIN and STIFFNESS
Adrenal Androgen
DHEA, DHEAS, ASD Viral Infection
THERAPEUTIC PRINCIPLE
 PROGNOSIS

Ad vitam: bonam

Ad functionam: dubia et bonam

Ad sanationam: dubia et bonam

 OPTIMIZING THE OUTCOMES

 PMR is usually  EULAR and ACR recommend

self-limited. With prompt
diagnosis and adequate
theraphy, the condition
has an excellent progno
sis
monitoring
• Every 4-8 weeks in the first
year of treatment
• Every 8-12 weeks in the
second year
• As indicated, in case of
relapse or prednisone is
tapered off
Thank you