Q&A Medicine>>>>>Rheumatology
Question 2#

A 68-year-old man presents with pain in his shoulders, hips, and neck for the last 5 months. The patient reports that the pain is worse in the morning and typically resolves within a few hours. The patient is otherwise healthy and denies headache, visual disturbances, or difficulty chewing. Physical examination does not demonstrate swelling and normal range of motion is noted at all joints. Palpation of the scalp arteries fails to elicit tenderness. Laboratory results reveal the following.

Which of the following is the best next step in management for this patient’s condition?

a. High-dose corticosteroids
b. Low-dose corticosteroids
c. Temporal artery biopsy
d. Nonsteroidal anti-inflammatory drugs (NSAIDs)

Correct Answer is B

Comment:

: Low-dose corticosteroids. The patient in this question is presenting with signs and symptoms consistent with a diagnosis of polymyalgia rheumatica (PMR), including chronic pain in the shoulders and hips, morning stiffness, elevated ESR, and age greater than 50. Of note, the physical examination in PMR is usually insignificant and the range of motion is typically normal without any associated tenderness or pain. The treatment of choice for PMR is low-dose prednisone. PMR can be associated with temporal arteritis (also known as giant cell arteritis). (A, C) Symptoms of temporal arteritis include headache, vision loss, tenderness over the temporal artery, and jaw claudication. Since the patient denies these symptoms, temporal arteritis is highly unlikely; therefore, temporal artery biopsy is unnecessary at this time. The treatment for temporal arteritis is immediate high-dose corticosteroids in order to prevent blindness. (D) NSAIDs are helpful in PMR for mild pain or while patients are being tapered off of corticosteroids. However, they are not the first choice in management as they are not as effective as corticosteroids.