"Thank you for your referral of this patient and for your detailed notes about her. I could only confirm with her my concurrence with your diagnosis and the need for low dose steroids in treatment.We had been trying NSAID medications, acupuncture, elimination diet, manual therapy and finally a tricyclic anti-depressant all with no avail. On prednisolone she reported "very good, lot of improvement."
Although she does describe pain in both knees and hips, it does seem clear that the discomfort involves the muscles themselves and there has been some involvement, as you well know, of a shoulder girdle as well as the hip girdle regions. This in combination with mild anaemia and a high ESR (61) with a relatively sudden onset and no overt joint symptoms or suggestion of other systemic disease all seems very consistent with the diagnosis of polymyalgia rheumatica and even a very tiny dose of 1mg of prednisolone b.d., seems to have been moderately effective in controlling her symptoms.
It has been my practice usually to initiate therapy with 5mg b.d., and it may well be, I think, that Mrs X will need a little more steroid to obtain adequate symptomatic relief. I have suggested a repeat ESR and perhaps doubling her current dose.
(He suggested) a chest X-ray and a creatine kinase (CK) test, (as a) reasonable precaution just in case one overlooks a malignant myopathy or perhaps misjudges a true polymyositis.
Mr. X was "driving 2 nights ago, started slurring his speech, wrong words came out, for about one minute or so - and for 2 -3 minutes he was blinking deliberately to try and clear his vision. His vision then went off but he was unaware of it until he hit the kerb when he realized he could only see in his left upper quadrant. He stopped and his vision returned and he drove home." This was in 1988.
He had previously had an X-ray of his neck arteries which showed no major blockages. I asked him to start acetyl salicylic acid, reduce his caffeine intake, increase his water intake and temporarily eat only raw foods.
Two weeks later he reported that his "speech was a bit slower, needs to think to put words together where they would normally fall into place. Everything is a hassle. Continual headache since."
At this second visit I gave him an injection of vitamin B 12.
A few days later he "feels better in himself - from the day after the injection." On examination he was tender in his epigastrium (mid-line of upper abdomen.)
The vitamin B 12 was not continued and seven years later in 1995 when he had shoulder pain from calcific tendonitis of his rotator cuff, his blood showed lowish B 12 (185.) he had more injections and after the first felt "lighter and brighter - much better generally" and after three days his shoulder was improving.
"It is now widely recognized that B vitamin therapy reduces tHcy levels, which leads to a reduced risk of stroke. Several studies and meta-analyses, including the HOPE-2 trial, the French SuFolOM3 trial, a subgroup analysis of the Vitamin Intervention for Stroke Prevention trial that excluded patients with renal failure, and a subgroup analysis of the VITATOPS trial that excluded patients on antiplatelet therapy, all showed a reduced risk of stroke."
"Multiple pulmonary emboli are demonstrated. The largest is seen both lower lobe pulmonary arteries with suggestion of filling defect also seen in the main right pulmonary artery as well as in the right upper lobe pulmonary artery."Not great grammar but very serious. Blood clots from a leg vein had floated up to their lung. The person nearly died and was left disabled.