Polymyalgia rheumatica and colon malignacy: case report
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- Kehler, T. & Ćurković, B. Clin Rheumatol (2006) 25: 764. doi:10.1007/s10067-005-0069-1
Polymyalgia rheumatica (PMR) is a relatively common disorder in the elderly. Whereas the relationship between polymyalgia rheumatica and giant cell arteritis (GCA) is well recognized, there is still controversy about PMR and malignancy. We are presenting a patient with PMR and adenocarcinoma of the sygmoid colon and hypothesize a paraneoplastic relationship.
KeywordsColon cancerParaneoplastic syndromePolymyalgia rheumatica
Polymyalgia rheumatica (PMR) is a clinical syndrome of the middle-aged and the elderly characterized by pain, stiffness of the shoulder and pelvic girdles, elevated sedimentation rate (ESR) and rapid clinical response to small doses of corticosteroids . PMR is a common inflammatory disease in adults over the age of 50, particularly in women . The diagnosis of PMR is still based on diagnostic criteria because no clear diagnostic test exists. Several clinical diagnostic criteria sets have been suggested, and recently, a European collaborating PMR group suggested the Bird 1979  or Hunder 1982  criteria for use whenever possible . European League Against Rheumatism (EULAR) response criteria for PMR are developed, too . Whereas the relationship between PMR and giant cell arteritis (GCA) is well recognized, there is still controversy about PMR and malignancy.
A 75-year-old female was referred to the rheumatology department, and a diagnosis of PMR was established according to the Bird 1979 criteria. She presented with pain and stiffness of her arms and pelvic girdle, morning stiffness for less than 1 h and ESR of 90 mm/h. Other haematology and biochemistry tests were normal. There was no history of headache, visual changes and weight loss. She was treated with 15 mg prednisolone in fast reduction manner with the rapid clinical response. ESR after 1 month dropped to 20 mm/h, and physical functions were recovered. The patient continued taking 5 mg of prednisolone for 2 years. Six months after corticosteroids were stopped, she returned with the same symptoms: pain and stiffness in both shoulders, pelvic girdle, general weakness, fatigue and constipation. The investigation revealed ESR of 88 mm/h, C reactive protein (CRP) 136 mg/dl, erythrocite 3.81, haemoglobin 11.7 g/dl, white blood cell 7.6, Fe 5, unsaturated binding capacity (UIBC) 34 and total iron binding capacity (TIBC) 39; repeated occult blood test was positive. Other haematology and biochemistry findings were normal. Chest x-rays were normal. Breast and gynecologic examination was without pathology. Ultrasound finding of abdomen shows cholelithiasis. Colonoscopy showed malignoma of the sygmoid colon, and computed tomography (CT) showed no affection of the regional lymph nodes. Pathohystology [PHD] showed well-differentiated tumour [DUKES-A] invaded to submucosis. Laparascopic resection of the sygmoid colon was performed. She recovered shortly after surgery. She was without rheumatic symptoms; the ESR and CRP dropped to 20 mm/h and 12 mg/dl, respectively. One year later, the patient was still asymptomatic.
Polymyalgia rheumatica is a relatively common disorder in patients over the age of 50. Genetic predisposition, infection and immunological abnormalities contribute to the etiology of PMR. In the past, PMR was considered a manifestation of GCA or a variant of elderly-onset rheumatoid arthritis . Many infectious causes have been suggested for PMR and/or giant cell arteritis, but the results of the investigations are still controversial, and it is not yet possible to sustain the hypothesis of an infectious cause for polymyalgia . The associations between HLA-DR4 and HLA-DRB1 and PMR are contradictory with regard to geographic area and ethnic background [9–11]. GCA and PMR have been considered as closely related conditions that form a spectrum of diseases. In a number of patients with typical polymyalgia and no symptoms from the cranial arteritis, biopsies showed arteritic changes in 10–15% . The association of PMR with malignancy is still controversial. Several prospective studies have shown that patients with classic PMR do not have an increased risk of developing malignancy. In contrast, kidney, lung and colon cancers are found in patients presenting with atypical PMR . Identifying rheumatic syndromes associated with cancer is difficult because the malignant tumours may be complicated by the rheumatic symptoms and, conversely, rheumatic disorders may be complicated by tumours. Several cases of PMR and malignancy association have not established a true causal relationship [13–16]. Whether PMR and malignancy are associated by chance or by a paraneoplastic relationship is still questionable. In our case, after treatment of neoplasia, musculoskeletal symptoms were completely resolved, and we can hypothesize that in our patient, PMR was a paraneoplastic manifestation. Although it is generally held that an extensive search for occult malignancy is not recommended, if the rheumatic disorder is accompanied by findings suggestive of malignancy, a wider screen for searching occult neoplasia is justified .