Dr. Naval Mendiratta
Rheumatology
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hello doctor,
My 85-year-old father had mild pain in his thighs and shoulder girdle for two months which intensified in the past two weeks to the point that he could not get up from his bed. He was started on oral steroids 30 mg once daily for the past three days and has shown a 40% response but cannot stand. Blood tests were done yesterday showing normal serum electrolytes, bilirubin, TSH, and CBC with some iron deficiency. Raised values are CPK - 272, BUN - 50, SGOT - 50, SGPT - 100, and leucocytes - 29000. His Hb is 9 and his eosinophilia 42 since before. Kindly suggest the diagnosis.
Hello,
Welcome to icliniq.com.
Well as per your history, it does look like a diagnosis of polymyalgia rheumatica. I would like to ask you a few more queries related to his illness. When is the pattern of pain more mornings or evenings? Does he experience morning stiffness as well? Any history of weight loss or appetite loss? Any history of jaw pain or headache or fever? Do you have his reports of ESR (erythrocyte sedimentation rate), CRP (C-reactive protein), and rheumatoid factor available? As they are the most important to monitor and diagnose. Did they do any scans of the chest and abdomen? As of now, the reports do not seem very great with high leukocyte count and low Hb. Diagnosis of polymyalgia rheumatica looks certain but we should rule out any underlying trigger.
Patient's Query
Hello doctor,
The pain is reduced. There is no specific stiffness and my weight and appetite are fine. I have attached some blood reports. ESR - 72, CRP - 38. ANA is negative and X-rays are not possible at present. He is on 20 mg of Prednisone once daily and has recovered. He also has numbness in the right wrist. He does not seem to have any other symptoms. The fever is not there for one week. He had a mild fever two weeks ago. There is no jaw pain or headache. What would you suggest to add clinically? Are any exercises required? Oral Atorvastatin was stopped last week. His Eosinophilia has been high for one year and Hb has always been low but no bowel issues.
Hello,
Welcome back to icliniq.com.
Well, as of now the treatment line looks fine. We should taper and remove his steroids in three to four weeks' time. Most patients of polymyalgia rheumatica do not need a second course of therapy. But there is a high chance of relapse as well. And in case it relapses, we will have to start with Methotrexate alongside it. Physical exercises, he can do whatever his body permits. Because of the inflammation, it may be difficult to do much but ask him to walk daily for 20-30 minutes. Secondly, for a while avoid any nonvegetarian food as that has shown to be a trigger for autoimmune disease as well. I would suggest we taper and remove steroids over three to four weeks and repeat his blood test as well after a month. If inflammation is all settled we can remove the drugs and then just observe. Make sure calcium and vitamin D supplementation is being given alongside.
I hope this helps you.
Thank you.
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Rheumatology
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