Quick cases in rheumatology

Our latest CPD module explores five common rheumatology presentations in general practice, using case-based clinical scenarios to advise on practical strategies for assessment, investigation, initial management and appropriate referral. Complete the full module on Pulse 364 today.

GPs frequently encounter patients presenting with musculoskeletal symptoms, inflammatory markers of uncertain significance and concerns about autoimmune disease or medication side effects.

Distinguishing inflammatory rheumatological disease from common mimics can be challenging, particularly in time-pressured consultations where symptoms are often non-specific.

This module uses practical, case-based discussions to explore common rheumatology presentations seen in general practice, including polymyalgia rheumatica, early inflammatory arthritis, fibromyalgia, methotrexate management and statin-associated muscle symptoms.

Learning objectives

This module will support GPs’ confidence to:

Recognise atypical presentations of polymyalgia rheumatica, including cases with normal inflammatory markers, and identify appropriate differential diagnoses and red flags.
Differentiate inflammatory arthritis from mechanical or non-inflammatory musculoskeletal pain through targeted history-taking, examination and interpretation of investigations.
Apply an evidence-based approach to the assessment of suspected fibromyalgia, including appropriate use of investigations to exclude alternative diagnoses without over-testing.
Prescribe safely for patients receiving methotrexate by recognising important drug interactions, managing intercurrent infection appropriately and advising on NSAID use.
Assess and manage statin-associated muscle symptoms, including identifying features suggestive of true myopathy and counselling patients regarding ongoing lipid-lowering therapy.

Case 1: PMR symptoms but normal inflammatory markers

A 78-year-old woman presents with classic polymyalgia rheumatica (PMR) symptoms – shoulder and hip girdle aching, morning stiffness >45 minutes, difficulty turning over in bed – yet her ESR and CRP are normal. Can polymyalgia rheumatica (PMR) still be a consideration?

The short answer to this is: yes, but it’s rare and should prompt caution.

In 7% to 22% of PMR patients, ESR is normal at the time of diagnosis – but in these patients, CRP is usually raised. A normal ESR and CRP is possible but rarer, occurring in around 1.2% of PMR patients. In these cases, the diagnosis hinges on clinical pattern and response to steroids. However, before jumping to a trial of prednisolone, it is important to step back and re-examine for mimics, such as hypothyroidism, inflammatory myopathies, malignancy, osteoarthritis, depression or even late-onset rheumatoid arthritis. Check TFTs, CK, calcium, LFTs and immunology.

If, as in a case like this, the pattern is textbook and mimics have been excluded, and no red flags are present, a therapeutic trial of low-dose prednisolone (usually 15 mg daily) is justified, with careful documentation of baseline symptoms and function. A dramatic improvement within a week is strongly supportive; lack of response should lead to immediate review and reconsideration. Always screen for giant cell arteritis symptoms – scalp tenderness, jaw claudication, visual change – even if ESR/CRP are normal, and refer urgently if suspected.

In short, PMR with normal markers exists but is a diagnosis of exclusion; treat only when confident of the pattern and ensure follow-up within 1–2 weeks to confirm steroid response.

Sources

Dejaco C et al. 2015 Recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative. Ann Rheum Dis 2015;74:1799–1807
Manzo C, Milchert M. Polymyalgia rheumatica with normal values of both erythrocyte sedimentation rate and C-reactive protein concentration at the time of diagnosis: a four-point guidance. Reumatologia 2018;56(1):1-2

Case 2: Joint pains in a young woman worried about inflammatory arthritis

A 32-year-old woman has multiple joint pains and is worried that she might have an inflammatory arthritis, because her mother apparently had rheumatoid arthritis (RA). What are the key features in the history or examination that I as a GP might be able to elicit to support or refute the diagnosis, and in a case like this, how reassuring are normal blood tests?

A woman in her 30s with polyarthralgia and a family history of RA is a relatively common presentation. The key here is to tease apart mechanical, inflammatory and non-articular causes through history and examination.

Inflammatory arthritis has certain hallmarks: prolonged early morning stiffness (>30 minutes), improvement with movement, joint swelling or bogginess (rather than bony enlargement), symmetrical small joint involvement (MCPs, PIPs, MTPs) and functional loss (difficulty with rings, jars or walking on toes). Systemic features (fatigue, low-grade fever, weight loss) also add weight. Conversely, pain worse with activity, no swelling and fluctuating sites over days suggests mechanical or fibromyalgic pain.

Blood tests help but do not rule the diagnosis in or out. Rheumatoid factor and anti-CCP are specific but not perfect – about a third of early RA cases are seronegative. Similarly, normal ESR/CRP doesn’t exclude early or mild inflammatory disease. The message to patients is that arthritis is a clinical diagnosis first, a laboratory one second. If suspicion persists – especially with clear joint swelling – refer to rheumatology early, even with normal bloods.

Sources