Aug 8, 2013
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A 65-year old woman complains of periodic headaches in the temporal region,visual disturbances ,and neck stiffness. Appropriate medical therapy in initiated early, and biopsy of scalp artery is consistent with arteritis. This patient comes to the physician 6 months later because of weakness. Her headaches are gone , but she has difficulty climbing stairs and getting up form a chair.Her blood pressure is 120/70mm Hg, pulse 82/min and respiration are 12/min.Physical examination show 4/5 muscle power in her proximal lower extremities bilaterally. Her creatine kinase level and ESR are normal.Which of the following is the most likely cause of this patients current complain?

A. Polymyalgia rheumatica
B. Mononeuritis multiplex
C. Symmetric polyneuropathy
D. Inflammatory myositis
E. Multiple sclerosis
F. Drug induced myopathy
G. Neuromuscular junction disease

Is it A?
 
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Feb 28, 2013
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NMJ--> stem doesnt really sound like a nmj issue
drug induced myopathy--> CK would be up
MS--> ESR would be up and the typical MS symptoms aren't really present
Inflammaory--> no rise in CK
Polymyalgia is immune related so ESR i feel would be up

note that the stem said her most current symptoms
soooo Im stuck between:
- mononeuritis multiplex
- symmetrical poly neuropathy<----this is what i would pick and go to the next question

Is this from a qbank where we can get an answer lol
bc I'm hand wavinggggg!

Thanks :)
 
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shigella123
Aug 8, 2013
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I found some questions on my hard drive and can't locate the answers to them. So, thought I discuss it with you guys.

I was thinking since they mentioned giant cell arteritis symptoms+ stiffness regardless of not haivng ESR elevation at the the moment that it might be Polymyalgia Rhumatica.
 
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notbobtrustme

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It's definitely A. A large proportion of patients with Giant Cell Arteritis (her initial clinical presentation) also have polymyalgia rheumatica.
yep, that's literally the only thing we need to know about it as well.

also, it's not a myopathy.
 

haloschief

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Hmm.. I would go with A since it usually presences with GCA. The only problems I have with polymalgia rheumatica is:

-Weakness is atypical
-She's on corticosteroids already which should be treating PMR
-ESR normal
 
Feb 28, 2013
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yeahhh that's the only reason i was ehh about polymyalgia bc FA says no weakness and ESR would be elevated.... what does yall's source say for presentation?
 
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shigella123
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found the answer from somewhere else:

This patient has a history of temporal arteritis(i.e giant cell arteritis), which is usually treated with high dose oral steroids tapered over a prolonged period of time.Steroid-induced myopathy is the most common cause of drug-induced myopathy and can occur weeks to months after starting steroid therapy.The mechanism of steroid myopathy is thought to be decreased protein synthesis, mitochondrial alteration, increased protein degradation, and electrolyte and carbohydrate metabolism disturbances .
Acute steroid myopathy occurs within 1 week of drug initiation (relatively uncommon) and is cahrachterized by muscle weakness and rhabdomyolysis. The chronic form is more common and has an insidious onset after prolonged steroid use. patient present with proximal muscle weakness (lower extremity before upper ) without significant pain and difficult getting up from a chair , climbing stairs or brushing their hair.For both acute and chronic forms, the Diagnosis is clinical and no difinitive diagnostic test.
Muscle power imporves after discontinuation of the steroids, but the improvement can take weeks to months.

Choice APolymyalgia rheumatica can be seen in up to 50% of the patients with temporal arteritis. Patients typically presents with aching and morning stiffness with pain in the shoulder, hip girdleand neck. The ESR is usually elevated and symptoms usualy improve with steriods.

Choice BMononeuritis multiplex is usually seen in vasculitis and is caused by nerve damage in two or more nerves in seperate parts of the body.Patient typically presents with peripheral nerve findings ,such as wrist or foot drop.

Choice C Symmetrical poluneuropathy involves more dista; than proximal muscles and is not consistent with the patients presentation.

Choice D Muscle enzymes are elevated

Choice G Myasthenia gravis causes more upper than lower extremity disease and typically occular symptoms.

Additional reference http://www.ncbi.nlm.nih.gov/pubmed/20471889
 
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haloschief

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Googled the question and it came from another source... This was the answer. I guess knee-jerk response would be going with PMR.

Answer is drug-induced myopathy from steroids:

Steroid myopathy
is usually an insidious disease process that causes weakness mainly to the proximal muscles of the upper and lower limbs and to the neck flexors.
In chronic (classic) steroid myopathy, serum levels of creatine kinase typically are within the reference range.
glucocorticoid down-regulation of protein synthesis may lead to decreased levels of these proteins in chronic steroid myopathy.

This patient has a history of temporal arteritis(i.e giant cell arteritis), which is usually treated with high dose oral steroids tapered over a prolonged period of time.Steroid-induced myopathy is the most common cause of drug-induced myopathy and can occur weeks to months after starting steroid therapy.The mechanism of steroid myopathy is thought to be decreased protein synthesis, mitochondrial alteration, increased protein degradation, and electrolyte and carbohydrate metabolism disturbances .
Acute steroid myopathy occurs within 1 week of drug initiation (relatively uncommon) and is cahrachterized by muscle weakness and rhabdomyolysis. The chronic form is more common and has an insidious onset after prolonged steroid use. patient present with proximal muscle weakness (lower extremity before upper ) without significant pain and difficult getting up from a chair , climbing stairs or brushing their hair.For both acute and chronic forms, the Diagnosis is clinical and no difinitive diagnostic test.
Muscle power imporves after discontinuation of the steroids, but the improvement can take weeks to months.

Choice A Polymyalgia rheumatica can be seen in up to 50% of the patients with temporal arteritis. Patients typically presents with aching and morning stiffness with pain in the shoulder, hip girdle and neck. The ESR is usually elevated and symptoms usualy improve with steriods.

Choice B Mononeuritis multiplex is usually seen in vasculitis and is caused by nerve damage in two or more nerves in seperate parts of the body.Patient typically presents with peripheral nerve findings ,such as wrist or foot drop.

Choice C Symmetrical poluneuropathy involves more dista; than proximal muscles and is not consistent with the patients presentation.

Choice D Muscle enzymes are elevated

Choice G Myasthenia gravis causes more upper than lower extremity disease and typically occular symptoms.

Additional reference http://www.ncbi.nlm.nih.gov/pubmed/20471889
 
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Feb 28, 2013
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Hahah and its for step2CK... good question but hopefully we wont see this question until then!! thanks for posting it got the wheels turning!!
 
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shigella123
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Toy303, you're a Speedy Gonzales. lol... I should say Dr. Speedy Gonzales. loll..
 
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