Polymyalgia rheumatica with normal erythrocyte sedimentation rate: Clinical aspects

Polymyalgia rheumatica is a relatively common syndrome of the elderly chara cterized by severe pain and! stiffness in the neck shoulder and pelvic gird les, along with increased acute phase reactants. The current diagnostic cri teria include as a requirement an erythrocyte sedimentation rate (ESR) high er than 30 or 40 mm/1 hr. Nevertheless, in several reports, a sizable proportion of patients with PMR , from 7% up to 22%, had an ESR that was either normal or slightly increase d at the time of diagnosis, supporting the notion that an increased ESR sho uld nor be an absolute requirement for its diagnosis This subset is charact erized by a younger age, a less marked predominance of females, a longer di agnostic delay and a lower frequency of constitutional symptoms such as fev er or weight loss. When determined, a majority of these patients had increa sed levels of C reactive protein. The recognition of this subset of patients with PMR and a low ESR can be ve ry useful to the clinical avoiding unnecessary suffering of the patients an d the risks of ineffective therapy with non-steroidal antiinflammatory drug s. To avoid the over-diagnosis of PMR inpatients with a low ESR, we propose a set of criteria that can be easily applied in daily practice to patients with a clinical picture consistent with PMR but with a normal or slightly increased ESR.