Rheuma Case: 31-year-old Woman with Body Aches

00:00 Today, we're going to talk about fibromyalgia and some related diseases. Stepping back for a moment, let's recall that while we've been focusing a lot on different types of joint problems, there's a number of different conditions for which patients may report joint pain but there actually isn't a joint problem at all. So this category of diseases are called soft tissue rheumatic diseases and the 3 broad categories are shown here. You've got things like enthesitis and fasciitis, those are types of peri-articular fibrous band type structures or insertion or attachment of ligaments and fascia. Then you've got this group called fibromyalgia, myofascial pain syndrome, and chronic fatigue syndrome. These are centralized pain problems for which patients experience pain to physical stimuli at lower thresholds than others might experience and then other peri-articular structures like bursitis and tendinosis. Today, we're going to focus on that group in the middle.

01:01 So, what is fibromyalgia. Well, it's an idiopathic, non-inflammatory central pain processing syndrome characterized by chronic, diffuse, musculoskeletal pain and often associated with neuropsychological symptoms and a variety of somatic complaints. Let's jump into a case to illustrate this condition. So we have a 31-year-old school teacher with a past medical history of interstitial cystitis who is presenting with "My body hurts. She states that something is wrong with me and wants an MRI." On further questioning, she reports that she has had pain in the muscles of her neck, her lumbosacral area, her thighs, her forearms for many years but now her pain has simply become unbearable. She has tried numerous over-the-counter nutraceuticals without improvement. She denies any fevers or weight loss or night sweats but she does report intermittent suprapubic pain with urination which goes along with her interstitial cystitis history though her last urinalysis was actually normal. She also reports fatigue and feeling unrested each morning.

02:11 No reported snoring. She is a non-smoker, no alcohol, no illicit drugs. She is a single mother with 3 young children at home. Sounds stressful. Family history is non-contributory and on review of systems we're not getting any story of dyspnea, there are no rashes, and she does report some frequent headaches. So a lot of information. Let's try and barrel down a few key variables here. It sounds like from a time course perspective this is a chronic problem. It may be accelerating somewhat but it's been there for many years. The pattern of joint involvement sounds diffuse but is it the joints that are involved, is it muscles, is it tendons, it's somewhat hard to tell based on the information we have so far. Evidence of joint inflammation, not entirely clear yet. We'll have to see what our physical exam shows. And then systemic involvement, same thing, there is clearly some other symptoms that are accompanying her muscular pain, but we can't quite say if this means there is a systemic process going on or not. Let's take a look at the physical exam. Well, she's afebrile, her heart rate looks normal, her blood pressure is fine, there is no evidence of lymphadenopathy which is always a reassuring finding, cardiopulmonary exam is benign, abdomen is benign, and then her musculoskeletal exam reveals diffusely tender to light to moderate palpation of muscles and tendinous insertions over her arms, her thighs, her lumbosacral areas but importantly at this time there's no evidence of any joint inflammation. No swelling or warmth around the elbows or knees, that sort of thing. Skin, nail exam no revealing findings. Neuro exam same thing. And you perform a PHQ-9 which is our basic screening test for depression. She scores a 9 on that, which suggests mild to moderate depression going on as well. So which of the following is the most likely diagnosis? Well, this lecture is called fibromyalgia so we're going to have to keep that in mind, but let's consider the other options as well. I've already told you that fibromyalgia is a non-inflammatory chronic musculoskeletal disease. Sounds kind of like what she's got. Let's go to the other ones as well.

04:28 Lupus, you don't want to miss lupus. It certainly is a disease that involves a lot of systemic symptoms which perhaps she is having some systemic symptoms. Her age and her gender fit with that as well, but we're not seeing any overt signs of inflammation on exam. She doesn't have any skin involvement and you typically do see some skin involvement with lupus but before we draw any conclusions we're going to need some evidence of other organ involvement and serologic testing. So we'll get that on the next slide. We'll keep it on the list for now.

05:00 Sarcoidosis, also a multisystem inflammatory disease and something to think about. Patients with multisystem inflammatory disease can have pain in certain areas but you wouldn't expect the diffuse musculoskeletal pain that she is reporting. That would be pretty atypical. And likewise, she doesn't have any other features that go along with sarcoidosis. No erythema nodosum, no pulmonary symptoms like dyspnea on exertion, and again no skin lesions. So I think we can at least safely take sarcoidosis off of our list. We haven't talked about myofascial pain syndrome though was on our list of centralized pain conditions but essentially myofascial pain syndrome is just a milder more localized version of fibromyalgia. Patients with this condition tend to have specific trigger points in a particularly localized area. She is describing her symptoms as both debilitating and diffuse. So, that doesn't seem to really go along with that condition either. So let's take that one off the list. And lastly, polymyositis. This woman is complaining of diffuse muscle pains. We have to consider those kinds of inflammatory myopathies.

06:11 We're going to need some blood work though before we can really take that diagnosis off our list. So, here's the blood work. Pretty routine stuff. Blood count is normal. Creatinine looks good. Liver test looks good. Her urinalysis importantly is normal. And perhaps most importantly her ANA is negative. So lupus, off the table. TSH is normal and a CPK of 37, that's really not supportive of any of those inflammatory myopathies so just from this very basic blood work and from the history and physical, we can safely say that we have a diagnosis of fibromyalgia.