Doc: Is permanent remission from rheumatica possible?
Dear Dr. Roach: I am a 69-year-old woman who has been recently diagnosed with polymyalgia rheumatica after three months of severe pain and no diagnosis. I am now on prednisone, with some pain relief. It is worse in the evening, and I take the prednisone before bed. There is a great deal of pain and some weakness in all my joints, but particularly in my shoulders and arms. There also is some random aching and pain in various parts of my body all day. What is this condition and its prognosis? Will I ever have a permanent remission?
Dear G.C.: “Polymyalgia” means “pain in many muscles”; “rheumatica” dates from the theory of humours, from a Greek word meaning “flow,” thought to be the reason people developed joint pains. The disease polymyalgia rheumatica occurs in about one person per 1,000 per year, almost exclusively in people over 50, and is most common in people in their 70s.
You have some classic features, and some that are not typical. The location of the worst pain being in the upper arms, shoulder and neck is classic, and it usually begins suddenly. However, nearly everybody I have seen with PMR has had symptoms that are worse in the morning, and one source I read stated that people who lack morning stiffness do not have PMR. Stiffness is worse after any period of inactivity.
The other reason I am not certain of the diagnosis is your response to prednisone. Patients with this disorder start feeling themselves getting back to normal within a few days, and are nearly 100 percent better within a few weeks. A laboratory test, the erythrocyte sedimentation rate (“sed rate,” or ESR), is almost universally very abnormal. There are other rheumatic diseases that I trust your doctors are considering.
If this is PMR, the prognosis is good, and the disease will run its course over time. Most people are on prednisone for a year or two. There are newer treatments being looked at to spare the bad effects of even moderate-dose steroids for that time.
Dear Dr. Roach: At age 6, I had a tonsillectomy. A few months afterward, I developed paralytic polio that included bulbar involvement, and I was in an iron lung. A few years later, I learned about a study that linked a higher rate of bulbar involvement in polio cases where there had been a tonsillectomy performed. Is there any truth to this? It has troubled me for decades.
Dear J.S.B: Polio is a type of virus that infected nearly everybody before the vaccine was available. A small number of people (about 0.1 percent) contracted poliomyelitis, also called “paralytic polio,” the most dangerous form of which, bulbar, involves the brainstem (the medulla oblongata, which looks a lot like a bulb). People with bulbar involvement often need respiratory support (the iron lung), but may still die due to blood pressure changes and other problems with the brainstem, which is involved with fundamental body functions.
It was recognized as early as 1910 that people with tonsillectomies may be at higher risk of developing the bulbar form of poliomyelitis. In 1950, data suggested that tonsillectomies tripled the likelihood of developing this severe form. It is now thought that tissue damage from infection or surgery allowed the virus easier access to the nerves to the brain.
At that time, children often underwent “routine” tonsillectomy. However, the tonsils are immune organs, and they are no longer routinely removed.
Now that poliovirus is almost extinguished from the earth (only Afghanistan and Pakistan have wild cases), the important lesson is to re-evaluate why in medicine we do things, and to be sure that there are more benefits than harms.
Email questions to ToYourGoodHealth@med.cornell.edu.