Is per­ma­nent re­mis­sion from polymyal­gia rheumat­ica pos­si­ble?

The News Herald (Willoughby, OH) - - Your Daily Break - Keith Roach Con­tact Dr. Roach at ToYourGoodHealth@med. cor­nell.edu.

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? — G.C. DEAR READER » “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. — J.S.B. DEAR READER » 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 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.

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