Polymyalgia rheumatica

Polymyalgia rheumatica (PMR) is a condition that causes muscle pain and stiffness.  The symptoms may be most notable in older people who have these symptoms in the hips or shoulders.  They may be symptoms that are more apparent in the morning, and for that reason this condition is often confused with other kinds of arthritis.

PMR may be suspected based on the history of the symptoms and a bedside exam.  Blood tests are also helpful. These are a complete blood count, ESR or sed rate, and CRP measurement.

Treatment of PMR is normally manageable with NSAID medications for pain and corticosteroids.  Relapses of this condition are common, and sometimes small doses of steroids are used for a long time.  Because of the risk of side effects of steroids, treatment with calcium and vitamin D supplements is often recommended.

There is a related condition to PMR that causes headaches, blurred vision, and sometimes pain in the muscles we use for chewing.   This is called Giant Cell arteritis or sometimes just temporal arteritis. This condition is a medical emergency because of the risk of visual loss.  This condition also is treated by corticosteroids, and often a blood test and arterial biopsy are used to make the diagnosis.

Sjogren syndrome

Sjögren syndrome is in autoimmune disorder. It may interfere with the tear glands, salivary glands, and cause symptoms of fatigue, muscle pain, or cognitive dysfunction. Rheumatoid arthritis and systemic lupus are associated with this condition.

The diagnosis of Sjogren’s syndrome is suspected in people with dry eyes or mouth, enlargement of the parotid glands, unexplained cavities, or blood test abnormalities. These are often blood tests for SSA or SSB antibodies. There is no specific test for Sjögren syndrome, it is a condition that requires exclusion of other diagnoses.

The diagnostic criteria for Sjögren syndrome in 2016 have been suggested as the following:

An abnormal blood test for Anti-SSA antibody and/or lymphocyte infiltration of the salivary glands

an abnormal Schirmer’s test or decreased salivation rate

and signs and symptoms of Sjogren’s syndrome.

Some medical conditions exclude this diagnosis. These include: sarcoidosis, lymphoma, AIDS, hepatitis C, radiation treatment to the head or neck, graft versus host disease, or medications that cause dry mouth

Treatment of Sjogren’s syndrome depends on the symptoms that each patient has. This may be an immune system inhibitor, symptomatic remedies for dry eyes or dry mouth, and occasionally anti-inflammatory medications for muscle or joint pain.

References

Shiboski, CH. et al., 2016 American College of Rheumatology: rheumatism classification criteria for primary Sjogren’s syndrome, Annals of Rheumatologic disease, 2016, October 26

Fibromyalgia

Fibromyalgia (FM) is a condition that causes pain in the muscles and joints, trouble sleeping, changes in thinking, and fatigue.  The cause of this condition is unknown.  Despite being a disabling physical and psychological condition, patients with FM improve with management in the majority of cases.  The response to treatment varies.  

People with fibromyalgia often complain of fatigue, muscle aches, widely distributed pain, depression or anxiety, the need to urinate, and sometimes trouble thinking.  People with fibromyalgia are diagnosed based on several findings, including tenderness to touch on certain points or joints in the body.

There is a FibroDetect quiz tool that helps to make the diagnosis.

There is no blood test, xray ultrasound or MRI test that diagnoses fibromyalgia.  These tests are normally used to make sure there are not other causes of the symptoms.

Treatment cornerstones for Fibromyalgia

Aerobic exercise

Counseling

Medicines to help with sleep, mood or pain

Physical therapy to keep the muscles and joints healthy

Examples of medicine treatments include duloxetine, gabapentin, pregabalin, or amitriptyline, medicines that are often used to treat the mood, pain or seizures.

Rheumatoid arthritis

Rheumatoid arthritis (RA) is an inflammatory condition that causes joint pain, stiffness, and/or swelling.  Normally symptoms affect the entire body, sometimes they may affect one joint. This may be the wrist, knee, hip, ankle, or shoulder.

Pain and swelling of the affected joints is often determined by exam. Tenderness with pressure applied to a joint is a key feature. Normally the joints affected are furthest away from the body, including those in the hands, feet, or the neck. Changes in the knuckles are common. There may be swelling in the hands, reduced grip strength, or symptoms of carpal tunnel syndrome. When the feet are affected, a person may feel heel pain, tenderness of the toe joints, or they may have difficulty standing on the heels or extending the toes.

Lab tests may show white blood cells in the fluid of a swollen joint, a positive RF test, and sometimes antinuclear antibodies.  Xray results show bony erosions in the affected joints.  Bony erosion of the 3d, 4th of 5th MTP (the toe joint with the foot) is a helpful clue for RA, as most other conditions do not cause these.

Treatment for RA

RA can be treated by methotrexate (MTX), prednisone, hydroxychloroquine, sulfasalazine, and TNF-alpha inhibitors (etanercept, infliximab, adalimumab, golimumab).  The choice of medication relies on the disease severity, whether there are other medical conditions, the cost and patient preference.

Mixed connective tissue disorder

Connective tissue disease is not a specific disorder, it is a syndrome that incorporates several symptoms and clinical observations.  Many connective tissue disorders have specific names.  These include Rheumatoid arthritis, Sjogren syndrome, dermatomyositis, polymyositis, scleroderma and SLE.  When the definitions of these conditions are not respected, the term “mixed connective tissue disorder” is considered.

People with mixed connective tissue disorders may have these symptoms:

Fatigue, hand swelling, fevers, muscle or joint pains, Raynaud phenomenon (color changes in the fingers or toes)

Blood testing is not normal in the setting of mixed connective tissue disorders.  Abnormal antibodies in the blood, such as U1 RNP antibodies, may be found. This was once called the ENA.  Other lab abnormalities may be a positive ANA, speckled ANA pattern, or Anti 68 kD and A’, or C antibodies.

There is a significant overlap in laboratory findings of Mixed connective tissue disorder with systemic lupus erythematosis (SLE).  The conditions are not considered to be the same however.

What is lupus?

Lupus is an autoimmune disease that can affect the skin, muscles, joints, blood cells, brain, kidneys or heart. It is also referred to as systemic lupus erythematosus or SLE.

Common symptoms of this condition are fever, fatigue, rashes, muscle pain, or joint pain. A combination of clinical history, physical exam, and blood tests may be used to make the diagnosis. These blood tests may include the anti-nuclear antibody (ANA), double-stranded DNA antibody,  anti phospholipid antibody, complete blood count, and sometimes other blood tests.

Treatment for lupus varies. Some people may find effective treatment with Tylenol, ibuprofen, or aspirin, but sometimes prescription medications are used. These include corticosteroids (for example prednisone) and antimalarial medicine such as Plaquenil.  Sometimes more specialized medications that suppress the immune system are used (cyclophosphamide, methotrexate, azathioprine).

Ankylosing spondylitis

Ankylosing spondylitis is an inflammatory disease of the spine which can result in deformity.  It can cause symptoms of pain in the spine and pelvis and deformity.  Curvature of the spine (forwards or to the side) is referred to as kyphosis.

This condition is associated with a blood immune marker called HLA-B27.  It is also associated with inflammatory changes at the base of the spine (the sacro iliac joints).

Medications that are used to treat ankylosing spondylitis vary in effectiveness, cost and safety.  These include NSAIDs such as ibuprofen to prescription drugs such as sulfasalazine, methotrexate, corticosteroids, adulimumab and secukinumab.