Differentiating between PMR and paraneoplastic PMR-like syndromes

Bhaskar Dasgupta

Malignancies often mimic polymyalgia rheumatica (PMR), especially in the first months of the disease. Are there any distinguishing features of paraneoplastic PMR-like syndromes?

Bhaskar Dasgupta: Yes, I think there are some important distinctions. One of the features that we get with PMR, giant cell arteritis (GCA), or any other rheumatologic inflammatory problems is what we call constitutional symptoms: low-grade fever, drenching night sweats. In malignancies, what we normally see is patients losing weight, whereas although we see weight loss in patients with PMR, [it is] associated with all these other constitutional features, which you can distinguish from malignancy.

The biggest difference between PMR and PMR-like symptoms of malignancy occurs in the morning: patients who have PMR and PMR pain cannot get out of bed in the morning, they cannot reach for things, they cannot dress, undress, or go to the toilet, and so on. You do not see early morning disability with malignancy. In malignancy you see night pain; PMR is more associated with morning stiffness.

One of the important features of PMR is measurement of the HAQ, health assessment questionnaire, which in malignancy may be normal, and in PMR [shows] great abnormalities. Nevertheless, I think it is quite important that whenever you are treating a patient with suspected PMR who actually has lost quite a bit of weight or has raised inflammatory markers, you should do a chest radiograph or things like that – simple things; in men, you must do a prostate-specific antigen (PSA) test for prostate cancer and a few similar tests. In the follow-up of these patients, you must keep in mind that malignancy may be a cause of paraneoplastic syndrome. So I think you need to keep your regular surveillance for malignancy in a patient with PMR while you are following with steroids.

You can differentiate between the two, but nevertheless it is important that you keep in mind that malignancy can be related [to the symptoms].

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