de Silva et al. Journal of Medical Case Reports 2010, 4:299 http://www.jmedicalcasereports.com/content/4/1/299 C A S E R E P O R T JOURNAL OF MEDICAL CASE REPORTS Open Access Presentations of perforated colonic pathology in patients with polymyalgia rheumatica: two case reports Punyanganie de Silva1*, Nagarajan Pranesh2, Guy Vautier3 Abstract Introduction: Polymyalgia rheumatica is an increasingly common disease in older people, which gives rise to arthralgia and is mainly treated with corticosteroids. Patients in this age group also have a higher incidence of other co-morbidities including colonic pathology. Corticosteroid usage may mask signs of sepsis or complications secondary to intra-abdominal pathology, thereby delaying diagnosis and treatment, with eventual adverse outcome. These two cases highlight the importance of awareness and prompt recognition of this condition in order to avoid significant morbidity and mortality. Case presentation Case 1: A 73-year-old Caucasian woman with a diagnosis of polymyalgia presented with symptoms of an exacerbation in her right hip joint. Despite standard therapy with corticosteroids she failed to improve and started to develop features of widespread sepsis. Specific questioning revealed that, at the very onset of her symptoms, she had experienced mild diarrheal symptoms. Investigations revealed perforated diverticular disease with a peri- femoral abscess. Case 2: A 69-year-old Caucasian woman with polymyalgia presented with left thigh pain and weakness associated with weight loss. A diagnosis of exacerbation of polymyalgia rheumatica was made and she was treated with corticosteroid therapy. Shortly afterwards she was admitted with generalized peritonitis. Laparotomy revealed a retroperitoneal abscess secondary to a perforated sigmoid colonic tumor. Conclusions: Patients with polymyalgia may have perforated colonic diverticular disease which mimics their rheumatic pathology. In such cases steroid therapy, which is the mainstay of polymyalgia therapy, can be detrimental. Primary and hospital practitioners are encouraged to be vigilant regarding non-specific gastrointestinal symptoms and consider alternative diagnoses in those patients whose symptoms do not resolve with standard therapy, as this can lead to an overall better outcome. Introduction Polymyalgia rheumatica (PMR) is one of the most com- mon chronic inflammatory conditions in elderly indivi- duals [1]. The disease can be seen in any ethnic group, and mainly affects those over the age of 65. It is rare in people under 50 and prevalence increases with age. The incidence of the disease in patients over 50 is between 50 and 100 per 100,000 [1,2]. Symptoms can be non- * Correspondence: punyanganie@yahoo.com 1Department of Gastroenterology, James Paget University Hospital, Lowestoft Road, Great Yarmouth, NR31 6LA, UK Full list of author information is available at the end of the article specific, but usually patients present with proximal joint pain and stiffness. Previous studies have revealed that corticosteroid therapy is the only known effective treat- ment [3]. However, several other autoimmune, infec- tious, endocrine, and malignant disorders can present with similar symptoms [4]. Therefore, it is important that prior to commencing treatment in previously known or new onset cases, other potential differential diagnoses are excluded as there is a possibility that cor- ticosteroid therapy may be detrimental. We highlight two such cases that presented in patients with known PMR. © 2010 de Silva et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.