Blog | Thursday, November 8, 2018

A suffering man


Around 20 years ago, while I was still doing outpatient medicine, a 65-year-old construction worker came as a new patient with diffuse pain. His story gave many clues.

Three months prior, he was working on construction in the Mobile, Alabama area. One task of his involved carrying concrete blocks. One day he could no longer grip the blocks because of hand pain. This pain did not resolve with nonsteroidal anti-inflammatory drugs. He had to stop working.

Over the next months he developed more pain including his shoulders and hips. As he walked into the examine room, he was almost shuffling and clearly was uncomfortable. He had already seen three or four physicians who had tried a variety of pain meds without success.

As I shook his hand, he could not squeeze at all because of the pain. On further examination, his metacarpophalangeal and proximalinterphalangeal joints all had synovitis (boggy, spongy, painful) symmetrically. He had difficulty touching the top of his head, but this was clearly pain related as his strength was excellent.

He felt that he had had low grade fevers and general malaise.

I considered some diagnoses, ordered some tests and then reconsidered his condition.

I ordered an erythrocyte sedimentation rate, rheumatoid factor, complete blood count, and complete metabolic panel. His exam and history strongly suggested polymyalgia rheumatica, but also rheumatoid arthritis. I ordered hand films also.

At that time we did not have anti-cyclic citrullinated peptide testing and were not using C-reactive protein.

I empirically started him on 20 mg prednisone for presumptive polymyalgia rheumatica. My rheumatology colleagues had taught me that a quick response was an empiric diagnostic test.

I called him the next day and he told me that he had taken the pill, gone to sleep and awoke asymptomatic. Diagnosis likely confirmed.

The erythrocyte sedimentation rate came back greater than 80. Complete blood count was normal, as was the complete metabolic panel. Rheumatoid factor was negative. Hand films showed no destruction.

Over the next two years we would taper his prednisone. He periodically ran out of meds and symptoms returned, resolved once we restarted the prednisone.

Researching his problem I found (in the primer of rheumatic diseases) a description of overlap between seronegative rheumatoid arthritis and polymyalgia rheumatica. Given his response and elevated sed rate (and no progression to deforming rheumatoid arthritis) I have always assumed that he did have the overlap syndromes.

This article, “Polymyalgia rheumatica vs late-onset rheumatoid arthritis,” adds some confusion to my previous conclusions.

This abstract continues my confusion, “Presenting features of polymyalgia rheumatica (PMR) and rheumatoid arthritis with PMR-like onset: a prospective study.”

So I am not sure about the final diagnosis because he definitely had characteristics of both. The good news is that both respond to low-dose prednisone.

db is the nickname for Robert M. Centor, MD, MACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and the former Regional Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds regularly at the Birmingham VA and Huntsville Hospital. His current titles are Professor-Emeritus and Chair-Emeritus of the ACP Board of Regents. This post originally appeared at his blog, db's Medical Rants.