Solution to "A Patient Suffering From Pain and Malaise"

Robert M. Centor, MD

Disclosures

March 22, 2006

This is the solution to a case we presented recently. You may review the case at http://www.medscape.com/viewarticle/524310.

Discussion and Solution

1. What is the likely diagnosis?

The patient has characteristics of both polymyalgia rheumatica (PMR) and seronegative rheumatoid arthritis (RA). His shoulder and hip complaints make one think of PMR, while his hand complaints and exam are most consistent with seronegative RA. His age is consistent with both diagnoses.

2. What diagnostic tests would you order?

I would choose to order a sedimentation rate, hand films, and rheumatoid factor.

3. Would you treat him at this time?

I would choose to give him a trial of prednisone 10 mg daily for 7 days, and see him back in the office to review lab tests, x-rays, and his response to prednisone. I reason that if he indeed had PMR, he would have a dramatic response to the low-dose prednisone.

Laboratory Results

ESR at presentation: 45

ESR 1 week later: 16

Rheumatoid factor negative

Hand films – no evidence of erosive arthritis

A literature search of PMR and seronegative RA produced a classic article that describes the patient perfectly.[1]

The patient had a dramatic overnight response to low-dose prednisone. The day after starting the prednisone, he had no pain or malaise. He was delighted.

Over the next 2 years, he had 2 relapses when running out of his prednisone. Each time, restarting the low-dose prednisone resolved his relapse.

Final Diagnosis

The overlap syndrome of PMR and seronegative RA.

Read and participate in the discussion of this case at http://www.medscape.com/px/discussions/29d4f79e , and watch for another new case soon.

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