Polymyalgia

Generalized muscular pain may be the presenting symptom of many conditions in which the final diagnosis can be made only after consideration of a wide spectrum of disease. The symptom is commonly associated with disease of bones or joints, but may also occur when skeletal or articular changes are minimal or absent. Diagnosis of cases in this latter category is often difficult and may be reached only after extensive investigation. In recent years there has been increasing interest in the classification of these cases. In some, no obvious pathology can be demonstrated. In others, inflammatory changes in muscle are present and such changes may be accompanied by cutaneous lesions. In a further group, changes in muscle are present but may be obscured by the co-existence of other disorders of connective tissue. The concept of the syndrome now generally known as polymyalgia rheumatica has evolved gradually. Kersley (1951) described a myalgic syndrome of the aged with signs of systemic disturbance. Bagratuni (1953, 1956) reported a group of elderly patients in whom generalized aching pain was associated with fever and loss of weight; he suggested that the syndrome was allied to rheumatoid arthritis and proposed the descriptive term "anarthritic rheumatoid disease". Barber (1957), Gordon (1960), and Todd (1961) observed patients with similar symptoms and suggested the term polymyalgia rheumatica. Paulley and Hughes (1960) expressed the view that such symptoms could be a manifestation of an arteritis of the aged. Bagratuni (1963) has recently reported the course of the disease in some fifty patients with this syndrome, emphasizing its benign prognosis and commenting on the absence of pathological changes in muscle; he found no evidence of the giant-cell arteritis later reported by Alestig and Barr (1963) in seven of ten cases of polymyalgia rheumatica. Wagner (1863) introduced the term "polymyositis'" to describe a fatal case of acute inflammatory disease of muscle, but it should be noted that cutaneous lesions were also present in this patient. This syndrome is now well authenticated and has been extensively reviewed by Walton and Adams (1958) and Pearson and Rose (1960). Unverricht (1887) usedthe term "dermatomyositis" to describe cases in which lesions in muscle were associated with changes in skin. Dermatomyositis has been reported more frequently than polymyositis, and Williams (1959), reviewing the literature, noted over 600 cases. An important feature of this condition is its association with malignant disease and Pearson (1962) has estimated that co-existence of dermatomyositis with malignancy may be as much as 18 per cent. Diffuse involvement of muscle is a fairly constant finding in cases of rheumatoid arthritis. Histological studies have demonstrated irregularlydistributed micro-nodules together with areas of degenerative change in muscle fibre. Clinically obvious myositis, however, is not common. Conversely, articular symptoms were reported by Eaton (1954) in twelve of 41 cases of myositis, and by Walton and Adams (1958) in ten of 40 patients. In this report, details of 22 patients in whom myalgia was a prominent symptom will be given and the criteria applied in reaching a final diagnosis will be discussed.