Case history

A 57 year old man, previously fit, presented to rheumatology clinic in November 1995 with a five year history of flitting arthralgia of the knees, elbows, and shoulders. The rheumatoid factor was negative and C reactive protein (CRP) normal. The diagnosis was unclear but shoulder joint injections with corticosteroid by the family doctor had given temporary symptomatic relief.

The following month he was assessed by a neurologist with complaints of continuous headache and episodic visual blurring. Examination and computed tomography of the brain were normal. Stress related anxiety was diagnosed.

In May 1996 the patient was admitted to hospital with severe central chest pain. Electrocardiogram showed anterior ST increase consistent with a myocardial infarction and streptokinase was given. Subsequent coronary angiography was performed that showed normal coronary arteries and normal left ventricular function; coronary spasm was evoked as the mechanism for the presentation.

The following month, June 1996, the patient was again admitted to hospital this time with complaints of lethargy, generalised headache, proximal myalgia but no stiffness or weakness, visual blurring, …