1) Polymyalgia Rheumatica (PMR)
- It is a disease of adults. Occurs almost exclusively in those over the age of 50. The average age at diagnosis is 70.
- Presents with aching and morning stiffness greater than 30 minutes in the hip and shoulder girdles, neck, and torso.
- Does NOT typically present with muscle weakness.
- Associated with giant cell arteritis (GCA)/temporal arteritis. PMR occurs in about 50 percent of patients with GCA, while approximately 15 to 30 percent of patients with PMR eventually develop GCA.
- Diagnostic criteria includes an ESR>40 mm/h, although we typically see ESR in excess of 100 mm/h.
- Prompt response of symptoms with 24 hours to low-dose glucocorticoids (e.g. prednisone 15 mg daily) is classically seen.
Follow the link below for a review article on "Polymyalgia Rheumatica and Giant Cell Arteritis" from NEJM (2002):
2) Massive Hemoptysis
- Always remember your ABCs! Stabilize the patient first. Do not hesitate to ask for help.
- The differential diagnosis includes:
Bronchiectasis
Tuberculosis
Fungal infections (e.g. aspergillosis, histoplasmosis, blastomycosis)
Lung infection/abscess
Malignancy (especially bronchogenic carcinoma)
Autoimmune lung disease (e.g. pauciimmune vasculitidies, including granulomatosis with polyangiitis/Wegener's granulomatosis, microscopic polyangiitis; Goodpasture's syndrome; SLE)
Pulmonary AVM (such as in hereditary hemorrhagic telangiectasia)
Mitral stenosis
PE
3) Optic Neuropathies
- Clinical features include vision loss, eye pain, RAPD in the affected eye, central scotoma. Remember, findings may not be apparent upon fundoscopy if the disease is retrobulbar.
- The differential diagnosis is broad, and includes:
Optic neuritis (inflammatory demyelinating process that can be idiopathic, or also associated with multiple sclerosis or neuromyelitis optica)
Ischemic optic neuropathy (common in older patients with vascular risk factors)
Infections (including neurosyphyllis, Lyme disease, West Nile virus)
Sarcoidosis
Autoimmune disease (such as SLE, Sjogren's)
Paraneoplasic causes
Malignancy (such as mass effect)
Drugs and toxins (such as ethambutol)
- Prompt investigations (such as imaging, LP) and referral to the appropriate specialties (such as Ophthalmology, Neurology, Neurosurgery) is of utmost importance.
Click on the link for review article on "Optic Neuritis" from NEJM (2006):
