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Received: 2019.02.04
Accepted: 2019.03.10
Published: 2019.05.08
1859 1 — 25
Myalgia with Elevated Inflammatory Markers
in an Obese Young Female: Fibromyalgia or
Polymyalgia Rheumatica?
ABCDEF 1,2 Rabia Cheema
ACDE 3 April Chang-Miller
ABCDEF 3 Fawad Aslam
Corresponding Author: Fawad Aslam, e-mail: aslam.fawad@mayo.edu
Conflict of interest: None declared
Patient: Female, 38
Final Diagnosis: Fibromyalgia
Symptoms: Myalgia • pain
Medication: —
Clinical Procedure: —
Specialty: Rheumatology
Objective: Mistake in diagnosis
Background: Fibromyalgia (FM) is a common disorder of diffuse musculoskeletal pain. It is distinctly different from polymy-
algia rheumatica (PMR), a disease seen in people over the age of 50 years. Hallmark features of PMR are the
presence of elevated erythrocytes sedimentation rate (ESR) and/or C-reactive protein (CRP). These markers are
normal in FM. Obesity in itself can be associated with elevated CRP and ESR, and when obese patients pres-
ent with myalgia and elevated inflammatory markers, diagnostic confusion can ensue.
Case Report: We describe a case of 38-year-old female with diffuse musculoskeletal pain and elevated ESR and CRP who
was initially misdiagnosed with PMR and responded partially to steroids. She developed severe adverse effects
from chronic steroid use. She was ultimately diagnosed with FM.
Conclusions: We highlight features to help clinicians avoid the pitfall of diagnosing PMR in young obese patients with FM
and elevated inflammatory markers. In this case report, we discuss the features of FM, PMR, PMR-like symp-
toms presentation, and the association of obesity with elevated inflammatory markers.
MeSH Keywords: C-Reactive Protein • Fibromyalgia • Obesity • Polymyalgia Rheumatica
Full-text PDF: https://www.amjcaserep.com/abstract/index/idArt/915564
Authors’ Contribution:
Study Design A
Data Collection B
Statistical Analysis C
Data Interpretation D
Manuscript Preparation E
Literature Search F
Funds Collection G
1 Department of Medicine, St. Mary’s Hospital, Waterbury, CT, U.S.A.
2 Department of Medicine, Frank H. Netter MD School of Medicine, North Haven,
CT, U.S.A.
3 Division of Rheumatology, Mayo Clinic, Scottsdale, AZ, U.S.A.
e-ISSN 1941-5923
© Am J Case Rep, 2019; 20: 659-663
DOI: 10.12659/AJCR.915564
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Background
Polymyalgia rheumatica (PMR) is characterized by pain and
stiffness, primarily in the shoulder and hip girdles. An age of
50 years or above is required for classifying a patient with
PMR [1]. PMR is common in those with northern European
ancestry and is accompanied by significantly elevated inflam-
matory markers. It is extremely rare in African-Americans [2].
Fibromyalgia (FM) is a common condition seen in 2–4% of the
general population [3], manifested by chronic widespread mus-
culoskeletal pain, and often accompanied by fatigue, cogni-
tive disturbance, psychiatric symptoms, and multiple somatic
symptoms. It can occur at any age but is most common in
middle-aged females.
One of the features distinguishing FM from inflammatory
conditions is the absence of elevated inflammatory markers
in FM [4]. More recently, inflammatory fibromyalgia has also
been described, although the subjects’ body mass index (BMI)
was not reported [5]. Obesity has been independently linked
to elevated inflammatory markers [6–8]. About 39.6% of the
US population is obese [9]. Since obesity and FM are common,
providers will likely encounter patients with FM who are obese
and have elevated inflammatory markers. These patients can
present a diagnostic dilemma and may receive unnecessary
treatment. We describe a case of a 30-year-old obese female
with FM who had elevated inflammatory markers and was ini-
tially diagnosed with PMR. She received prolonged treatment
with steroids and then methotrexate. She developed significant
adverse effects from the prednisone and came to our clinic for
a second opinion, where she was diagnosed with FM. We aim
to highlight the association of obesity and inflammation and
discuss how it can confound the diagnosis of FM. This case
emphasizes the importance of treating the patient and not fo-
cusing exclusively on abnormal lab test results.
Case Report
A 30-year-old African-American woman with a past medial
history of hypertension, asthma, gastroesophageal reflux dis-
ease, migraines, obesity (BMI of 41), and obstructive sleep ap-
nea presented for evaluation of myalgia with elevated inflam
-
matory markers. Her symptoms started the previous year with
sudden onset of dysphagia, generalized muscle tenderness,
and tender neck lymphadenopathy. Her primary care physi-
cian treated her with antibiotics and a prednisone taper. It is
unclear why the prednisone was given initially. She responded
fairly well, but the muscle symptoms recurred when the pred-
nisone was stopped. She was placed back on prednisone (av-
erage dose of 25–35 mg daily) while awaiting a rheumatology
consultation. Over this time, her myalgia became more wide-
spread. Three months into the course of her disease, she was
seen by a rheumatologist and an extensive autoimmune work
up was negative except for an elevated ESR (100 mm/h, nor-
mal <29) and CRP (35 mg/L, normal <8.0). A magnetic reso-
nance imaging (MRI) scan of the neck showed mild degener-
ative disk disease. A presumptive diagnosis of PMR was made
and methotrexate was added to allow tapering of prednisone.
The minimal effective prednisone dose that kept her functional
was 20 mg daily. Higher doses provided more relief but not
resolution of her symptoms. A malignancy evaluation by an
oncologist, including computed tomography (CT) scan of the
chest, abdomen, and pelvis, was reportedly negative. She also
reported orthostatic symptoms, and evaluation by a neurol-
ogist, including tilt-table testing, was unremarkable. During
this treatment period, she developed steroid-induced hyper-
tension, steroid-induced diabetes, steroid-induced peripheral
edema, and a 30-pound weight gain.
At our rheumatology clinic, she reported a history of diffuse
muscle pain and said that she hurt all over and had exquisite
tenderness to touch. At one time, her pain was so severe that
she could not get out of the bed. She endorsed muscle pain and
denied joint pain. She described extreme fatigue; her sleep ap-
nea was untreated. She denied any fever, rashes, bowel symp-
toms, claudication, or giant cell arteritis symptoms. She did
not smoke or drink alcohol. She was a mechanical engineer
by profession. Her younger sister had complex regional pain
syndrome that developed after a foot surgery.
At the time of her evaluation, she had been tapered off the
prednisone for 3 weeks. She reported feeling achier. An exam-
ination revealed a cushingoid female with generalized tender-
ness to touch in multiple areas. She had full range of motion
of her joints and had no difficulty in getting up from a sitting
position. A joint exam revealed no synovitis. Muscle strength
was intact. Her peripheral pulses were strong and symmet-
rical. Extensive autoimmune testing, including a myomarker
panel, and serum protein electrophoresis were negative. ESR
at our visit was 53 (normal less than 20 mm/h) and CRP was
27 (normal less than 8 mg/L).
Due to her protracted history, significant adverse effects from
her current treatment, and elevated inflammatory markers, fur-
ther evaluations were pursued while she remained off immu-
nosuppressive therapy. She was referred to neurology, where
an underlying muscle disease was ruled out. An electromyogra-
phy of the left upper extremity was negative. A positron emis-
sion tomography (PET)/CT scan was unremarkable for any ar-
eas of inflammation or malignancy.
She was given a diagnosis of fibromyalgia. She was advised
to stop the methotrexate and not to resume the prednisone.
Fibromyalgia management principles were discussed and she
was advised to treat her sleep apnea. She was also started on
660
Cheema R. et al.:
Fibromyalgia mimicking polymyalgia rheumatica
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muscle relaxants, dietary modifications, and physical activity.
On verbal follow-up several weeks later, she remained off im-
munosuppressive agents. She felt somewhat better and was
relieved to no longer take prednisone. Her inflammatory mark-
ers continued to remain variably high.
Discussion
This case highlights the confounding influence of elevated CRP/
ESR on medical decision-making. A young African-American fe-
male was diagnosed with PMR and treated with prednisone
for several months. She developed significant adverse effects
and her condition did not improve. This patient was a 30-year-
old African-American, obese, had diffuse muscle pain rather
than shoulder and hip girdle stiffness and pain, and she had
not responded significantly to prednisone. All these features
make the diagnosis of PMR unlikely. In this review, we briefly
discuss features of PMR and FM and the influence of elevated
inflammatory markers and obesity on clinical decision-making.
FM is the most common cause of generalized musculoskele-
tal pain in women between the ages of 20 and 55 years. FM
is characterized by widespread musculoskeletal pain and fa-
tigue, often accompanied by other somatic symptoms, as well
as cognitive and psychiatric disturbance. FM is usually a diag-
nosis of exclusion in patients who present with chronic my-
algias. Rendering a diagnosis of FM requires a careful clinical
evaluation for any underlying condition that may be responsi-
ble for the FM. Clinical exam is negative for any synovitis and
characterized by muscle tenderness. Laboratory testing is usu-
ally carried out to exclude other conditions such as spondylo-
arthritis, systemic autoimmune disorders, polymyalgia rheu-
matica, inflammatory myopathy, and hypothyroidism.
The annual incidence of PMR is up to 50/100 000 population
starting from age 50 years, with peak above age 70 years [10].
Age above 50 years is a required criterion for PMR classifica-
tion [1]. A diagnosis of PMR is extremely rare in young patients,
especially at the age of 30, as in our patient. PMR in 40-year-
old patients has been reported. These cases were confirmed
to have PMR by PET imaging [11]. PET scanning has very good
accuracy in diagnosing PMR [12]. Uptake at the ischial tuber-
osity, lumbar spinous process, and greater trochanter provide
a high yield for diagnosing PMR [13]. Our patient had a neg-
ative PET scan.
Another distinct characteristic of PMR is a rapid and effective
therapeutic response to low-dose glucocorticoids. A 75% im-
provement in clinical and laboratory parameters within 7 days
of treatment with 15 mg of prednisone equivalent is consis-
tent with PMR [14]. Our patient required high doses of pred-
nisone, which were only marginally effective. She did initially
get some symptomatic relief from the prednisone. Steroids
are not effective in fibromyalgia management [15]. It is not
entirely clear why she responded partially to the prednisone.
Inflammatory foci have been found in the skin of a subset of
FM patients and it is postulated that this may account for the
response to non-steroidal anti-inflammatory drugs in some
FM patients [16]. It is unclear if steroids have any role in pain
modulation in FM patients with obesity-related inflamma-
tion. Inflammatory FM remains an open area for further re-
search [17].Steroids are used as adjuvants in many pain con-
ditions [18]. Some of the response in this case could also have
been a placebo effect.
There is increasing evidence that obesity is characterized by
chronic and low-grade systemic inflammatory response. An as-
sociation between abdominal obesity and increased levels of
inflammatory markers such as CRP has been noted [6,7,19].
Abdominal adipose tissue is a major source of cytokines,
including tumor necrosis factor-alpha and interleukin-6, which
in turn increase hepatic CRP production [20,21]. An association
between CRP and the presence of obesity and comorbidity has
been reported in FM as well [22]. Careful interpretation of clin-
ical data is necessary in obese patients, as elevated CRP and
ESR may be a non-specific finding and not necessarily reflec-
tive of any underlying disease process.
Elevated inflammatory markers in an obese patient, however,
should not be automatically attributed to obesity. An appro-
priate workup should be pursued based on clinical evaluation.
More common rheumatologic disorders such as rheumatoid
arthritis, spondyloarthritis, or connective tissue diseases can
present with symptoms compatible with FM and must be ruled
out. Sometimes, PMR-like symptoms in young females can be
the initial manifestation of rare disorders such as Takayasu ar-
teritis [23]. In patients younger than age 50, typical PMR is an
uncommon diagnosis and should be distinguished from what
has been described as atypical PMR, which can be a manifes-
tation of occult malignancy [24]. We refer to atypical PMR as
PMR-like presentation. Features of PMR-like symptoms include
age under 50 years, absence of prolonged morning stiffness,
involvement of only 1 site, ESR <40 or >100 mm/h, peripheral
arthritis, asymmetric involvement at atypical sites, and partial
or delayed response to steroids. Patients with such presenta-
tion should be investigated for disseminated cancer, connec-
tive tissue disease, or other vasculitic disorders [25]. Our pa-
tient did not have any of these conditions. PMR is very unlikely
in young patients; therefore, a careful evaluation for condi-
tions presenting with PMR-like symptoms should be pursued.
The high CRP and ESR in our patient likely prompted a diag-
nosis of PMR but was emanating from the underlying obesity.
The classic teaching is that CRP and ESR are not elevated in
FM. However, as our case illustrates, an exception is the patient
661
Cheema R. et al.:
Fibromyalgia mimicking polymyalgia rheumatica
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with FM who is obese. Our patient’s history was typical for fi-
bromyalgia. Her symptoms responded more favorably with fi-
bromyalgia treatment and without the prednisone. Table 1 pro-
vides comparative features of FM, PMR, PMR-like symptoms,
and FM with elevated inflammatory markers.
Conclusions
PMR is almost exclusively a diagnosis made in patients over
50 years old. FM and PMR can have some similarities but they
are distinct disorders. Obesity and FM are common conditions
and obese patients with FM may present with elevated in-
flammatory markers. It is important for the treating provider
to understand the association between obesity and elevated
CRP and ESR. However, before labelling obese patients pre-
senting with elevated inflammatory markers as having FM,
appropriate clinical workup should be pursued to exclude al-
ternate diagnoses.
Department and Institution where work was done
Division of Rheumatology, Mayo Clinic, Scottsdale, AZ, U.S.A.
Conflicts of interest
None.
Fibromyalgia
(FM)
Polymyalgia rheumatic
(PMR)
Polymyalgia rheumatica
like presentation
Fibromyalgia in obese
patient
Common age (years) 30–50 >50 <50 <50
Sex Females>Males Females>Males Variable Females>Males
Race Variable Caucasian Variable Variable
Anatomic areas Diffuse Shoulder and hip girdle Variable Diffuse
Somatic symptoms Dominant Minimal Minimal to variable Dominant
Peripheral synovitis Absent May be present May be present Absent
Inflammatory markers Normal Elevated Variable Elevated
Response to 15 mg
prednisone Usually none Excellent Partial None to partial
Table 1. Comparative features of fibromyalgia, polymyalgia rheumatica, and their variants.
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