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A patient’s diary
A 71-year-old farmer worked a large and successful farm in
the South Island without any medical problems apart from a hip replacement, and
vague occasional pains around the neck. He retired to the Bay of Plenty at 70
years.
In April 2005 he felt acutely weak, ill, and tired:
something he had not experienced before. He kept a diary of his illness which is
recorded here:
- For
several weeks he noticed tenderness over the right side of his scalp, as if the
skin there was sunburnt. At the same time there was constant dull headache above
the eyes on the lower forehead; the neck and temples were also painful. The neck
was especially painful behind the right ear. When he chewed solid food his jaw
muscles became painful, but this stopped when he stopped eating.
- His
general practitioner, a locum tenens, suggested a blood test for polymyalgia
rheumatica. He referred the patient to a neurologist.
- The
neurologist noted that the erythrocyte sedimentation rate (ESR) was normal, and
felt that there were no particular features of temporal arteritis. His
neurological examination was normal. He commented that the thoracic spine was
slightly kyphotic, and there was mild limitation of neck movements. Cervical
spine X-rays showed moderate degenerative changes with marked disc-narrowing. He
considered that the headache did not emanate from the neck, but as it had lasted
for 6 weeks (which was unusual for the patient), he requested a computed
tomography (CT) brain scan to exclude meningioma—the scan was normal.
- The
GP prescribed synflex and nortryptilline, with no effect. Nurofen Plus (2
tablets 4 hourly) achieved some pain relief.
- His
usual GP then explained that he did not have polymyalgia, because the ESR was
“too low”, but he would keep this diagnosis at the back of his mind.
The patient questioned the level of 7 mm fall in 1 hour, in the context of
polymyalgia.
- The
patient in late June instigated eye tests and bought new spectacles due to
continuing headaches.
- An
orthopaedic surgeon, recommended by golf friends, was persuaded to undertake an
MRI scan of the patient’s cervical spine, which confirmed degenerative
changes at C3/C4, but no nerve compression .There was no pressure or distortion
of the spinal cord. He did not recommend surgery.
- In
July, August, and September, the patient’s headache symptoms progressively
worsened and additional symptoms occurred: sore shoulders, weak arms and thighs,
difficulty in standing up, and the first three steps when attempting to walk
were tentative. Pain extended to his buttocks and knees. The neck became
extremely painful: “...feels like a concrete block—worse at night
and in the morning”. An osteopath performed therapeutic massage, with no
effect.
- Fortuitously,
the patient’s aunt came to stay for a short holiday in September. She said
that she had polymyalgia and observed that the symptoms of the patient were
exactly the same as hers. What is more, she had immediate relief from
prednisone!
- The
patient then saw his GP, related this conversation, and asked to be put on
prednisone. He pleaded: “In the short term what have I got to lose?”
With reluctance, the GP prescribed prednisone 30 mg per day.
- Within
15 hours there was significant pain relief of headaches and scalp pain, neck
pain, buttock pain, and knee pain. Within 3 days there was complete cessation of
pain in every part of his body. By September 24 he had his first night’s
sleep for 5 months. The patient slowly reduced his dose of prednisone, but kept
to a small dose. He has had no further
pain.
Comment and
discussion—The patient’s diary gives a clinically relevant
narrative indicating temporal arteritis and polymyalgia rheumatica, described in
his own vernacular. Frustration in coping with unrelenting pain prompted his
problem-solving that was complementary to his GP’s.1 Diagnosis and
treatment eventually emerged by serendipity (the aunt’s arrival). She even
provided a medical reference paper (by Dr JG Jones of Rotorua). The patient got
more information from the Internet.
In both conditions, the ESR is usually high, but may be
within normal range in about 25% of cases. Undue reliance on a single ESR
misleads. Temporal arteritis and polymyalgia are commonly associated conditions
in the elderly, but the respective aetiologies may be different.2
Temporal arteritis is a systemic vasculitis that targets
medium and large arteries. Granulomas in the artery wall are formed by CD4 T
cells and macrophages , provoking intimal hyperplasia and vessel occlusion.
Clinical manifestations relate to tissue ischaemia (the patient experienced
claudication of jaw vessels). Headache may take any form, and may resemble any
primary headache.3 Corticosteroids are the cornerstone of treatment.
Polymyalgia rheumatica is an inflammatory condition of
unknown origin, comprising aching and stiffness in the shoulder and pelvic
girdles, and in the neck. Arthroscopic, radioisotopic, and magnetic resonance
imaging investigations identify synovitis around proximal limb joints and
periarticular structures, causing pain. Recent studies have not implicated
vasculitis. Normal ESR does not exclude the diagnosis. Corticosteroids are the
main treatment.4
References:
- Charon
R. Narrative and medicine. New Engl J Med. 2004;350:862–4.
- Cantini
F. Are polymyalgia rheumatica and giant cell arteritis the same disease? Semin
Arthritis Rheum. 2004;33:294–301.
- Ward
TN. Headache in giant cell arteritis and other arteritides. Neurol Sci.
2005;26(Supp 2):S134–7.
- Best
SC. Polymyalgia rheumatica. Pract Res Clin Rheumatol.
2004;18:705–22.
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