More case histories

Polymyalgia rheumatica

"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.

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.
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."
Four months later her ESR had dropped to normal (4 mm in 1 hour.)
She ended up on 3.5mg for a year and then we were able to slowly reduce it to 1mg over the next 2 1/2 years. This was now late 1985. She finally ceased it in 1989.
In 1994 she developed pain over her lower thoracic spine on some movements, on vigorous coughing and getting jolted in the car. She had a zygapophyseal joint subluxation but there was only temporary improvement with mechanical correction and when pain returned worse than before I woke up and started her on prednisolone again. She recovered overnight. Her ESR had risen again to 30 and was down to 8 when repeated 6 months later.

Vitamin B 12 deficiency

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.

He had recently had a gastroscopy for vomiting, which showed "minor antral erosive disease of minimal significance." The value judgement of the gastroenterologist implied then was "if there's no huge ulcer it doesn't matter." No test was done for Helicobacter pylori even then, 12 years after Barry Marshall and Robin Warren had proven it's role in gastritis.

It is very likely that this chap had H pylori infection and vitamin B 12 deficiency as a result. This was probably part of the reason for his strokes.

Current medical opinion is divided but I lean to the view that is is important. From a recent article
"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."

Chaotic Clotting Consequence

"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.

Years before that, they had megaloblastic anaemia, with haemoglobin 11.5 (11.5-16.5) and average size of red cells 104 (80-96,) serum vitamin B12 167 (150-700) and folate 2.0 (6.3-30.)
They had one vitamin B12 injection then and took folic acid tablets 5mg with each meal and had started to feel better after a few days.

Fast forward 4 years and Haemoglobin 13.2, MCV 84 down from 104 and vitamin B 12 210. This time they had three injections of B12 and again felt less fatigued.

A few more years and calamity struck. The MCV was now back up to 103 and this time I ordered homocysteine. It was elevated at 34.2 (3.7-13.9) and on repeating after a vitamin B 12 injection was 109.4 - one of the highest I've seen.

Folic acid 5mg daily was restarted and three months later the homocysteine was 9.3. Two months later on the MCV was down to 86. Both were normal.

This was not a success story. The pulmonary embolism had almost certainly been preventable.

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