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Polymyalgia rheumatica causes symmetrical stiffness in the neck, shoulder, and pelvic girdles, and affects middle aged and elderly people, with a higher incidence among women. A group of systemic, non-specific complaints such as weight loss, moderate fever, asthenia, and persistent high erythrocyte sedimentation rate are other clinical features.
A 73 year old woman was admitted for the evaluation of pericardial effusion and mild anaemia. Polymyalgia rheumatica was suspected because the patient had had asthenia, stiffness, and pain in the shoulders and hips for about a year before coming to hospital. She had also lost 5 kg in a few months. A few days before admission she had presented worsening dyspnoea.
An echocardiogram showed large pericardial effusion and initial findings of cardiac tamponade (right atrial and right ventricular diastolic collapse), so a pericardiocentesis was done: polymerase chain reaction tests in the pericardial fluid for Mycobacterium tuberculosis and cultures for aerobes and anaerobes were negative; tumoral cells were absent. Serological tests for antibodies to cytomegalovirus, herpes simplex and Epstein-Barr viruses, anti-smooth muscle, antinuclear, anti-DNA, and anti-extractable nuclear antigen antibodies were negative; Schirmer's test and the break-up time were also normal. The erythrocyte sedimentation rate (ESR) was 130 mm/1st h and C reactive protein (CRP) was 85 mg/l.
The patient was first treated with indometacin (50 mg twice a day) for a week, with no improvement, and then with low doses of prednisone (10 mg/day): the symptoms markedly improved and the ESR and CRP dropped to 27 mm/1st h and 12 mg/l, respectively, in a few weeks. An echocardiogram a month later was negative for pericardial effusion; ESR and CRP were also normal.
The patient has remained entirely well after a follow up of one year.
The presenting symptoms (girdles bilateral and symmetrical stiffness and pain) accompanied by systemic features (fatigue, weight loss, raised ESR) and the marked improvement after prednisone confirm the diagnosis of polymyalgia rheumatica.
As far as we know this is the first report of pericardial tamponade requiring pericardial drainage in this disease.