27-year-old female with a diagnosis of suspected fibromyalgia. Her history includes long standing widespread musculo – skeletal pain connected to a feeling of general slight illness, as well as a series of accompanying symptoms: frequent migraines, cervicalgia, stomach disorders, chest pain and tachycardia . Therefore, she has carried out various follow-ups that each time detected a different problem for which the relevant therapy was set out. Recently the situation is getting worse: the pains are unendurable, the patient began to have problems with walking, standing and carrying out the normal daily activities, she suffers from disordered sleep pattern, strong muscular rigidity, asthenia, tingling sensation in fingers, swelling of the feet, problems of blurred vision, recurrent cystitis, irritated colon, concentration problems, inability to manage the fatigue and strong pains at the right mandibular level.
1) What diagnosis do you infer?
2) Possible further diagnostic procedures to identify the cause of the clinical picture?
3) What therapy do you suggest?
Diagnosis: SUSPECTED FIBROMYALGIA
27 year old female, from Italy
History: The patient reports that she has been suffering, for a long time, from diffuse muscle skeletal pains connected to a feeling of general slight illness that shows up with disorders of different types. Therefore, she has carried out various follow-ups that each time detected a different problem for which the relevant therapy was set out.
The first pains appeared at lumbar level, therefore a pharmacological therapy has been set out based on Voltaren and Muscoril in the acute phases, physiotherapy (repeated yearly) and postural gymnastics.
Afterwards the patient has begun to suffer from intense and frequent migraines: Very violent attacks every 3-4 days or so. Following the neurologist’s indication she has taken 3 different specific drugs to heal migraine that caused her only dizziness without any relief. Afterwards the pain appeared also in the cervical region but a connection with the migraine has been excluded considering the cervicalgia to be a consequence of a strong cervical spine inflammation as per cervical spine X-ray report dated 10/2006: “Straightening of the physiological cervical spine lordosis. Signs of uncoarthrosis. Disc spaces preserved.” From the blood tests (attached blood chemistry values dated 05-2005 and 08-2009) the lymphocytes, neutrophils and ERS values are altered. Negative ANA screening test to exclude connectivity.
In the meantime the patient began suffering from some stomach disorders but nobody has made an accurate diagnosis connecting them to the presence of Helicobacter pylori. Chest pain and tachycardia have appeared in the end too. As a thyroid dysfunction has been excluded by means of ultrasound scan and endocrinology specialist visit, an echocardiography and a cardiology visit have been carried out which turned out to be within normal limits. However a pharmacological therapy with Isoptin 120 mg has been prescribed in order to reduce tachycardia. A psychological examination has also been carried out due to the anxiety and slight illness condition even if the patient did not show any sign of depression. Due to the increasing in the painful symptomatology strength, the patient saw the umpteenth orthopedist who found a strong muscular rigidity without succeeding in explaining the cause of the complained pains of too high intensity and however not due to the problems highlighted by the lumbar MR imaging scan dated 06/2007 with the following report: “Bulging of the Annulus L5-S1. Measured spinal canal diameters”. Therefore, a rheumatologist was consulted.
After specialist visit and a Tender Point test he made a diagnosis of “Fibromyalgia” prescribing the following therapy: - 1 tablet to take every day; Celebrex - 1 tablet daily for 20 days a month for 3 months; Samyr 200 mg - Efferalgan and injectable anti-inflammatory drug only when needed; - Physiotherapy; - Magnesium intake.
Recently the situation is getting worse although she is following the therapy. Pains are unendurable and they spread to the upper and lower limbs so that she began to have problems with walking, standing and carrying out the normal daily activities. The patient reports, moreover, that she does not sleep well and she wakes up many times during sleeping hours. In the morning she always feels as she did not sleep at all. Furthermore she feels a strong muscular rigidity, asthenia, a tingling sensation in her fingers, swelling of the feet, problems of blurred vision. She also shows unceasing cystitis problems and irritated colon. The body temperature is always 37.5°. Problems with concentration and inability to manage the fatigue still persist. In fact the patient is forced to stay in bed for half day. Strong pains appeared at the right mandibular level. Pains do not reduce even if she takes anti-inflammatory drugs.
27-year-old female with a diagnosis of suspected fibromyalgia. Her history includes long standing widespread musculo – skeletal pain, as well as a series of accompanying symptoms. Thus, symptoms suggestive of irritable bowel syndrome are described (presumably including abdominal pain and an “irritable colon” although not much detail of these symptoms is available). In addition, recurrent cystitis is described. The patient is suffering from a disordered sleep pattern, characterized by frequent nocturnal awakening and non-restorative sleep.
Recurrent imaging procedures performed on this patient have failed to detect a specific, anatomical etiology for her symptoms. The finding of cervical straightening of the physiological lordosis is non-specific, and merely reflects the increase in muscular tone and rigidity caused by chronic pain.
The patient additionally suffers from recurrent migraine and dizziness, as well as pain “in the mandibular area”. Difficulty with concentration, increasing fatigue and a progressive reduction in the level of functioning are also described in the recent course of this patient.
Physical examination performed by a rheumatologist is not reported in detail, but presumably no signs of synovitis were detected on examination (which undoubtedly would have been reported if present). The positive finding on examination is therefore reported as the presence of tenderness.
The broad blood tests performed on this patient have demonstrated a mild increase in inflammatory indices with no specific serological findings.
The case presented above carries classical clinical characteristics of the syndrome of fibromyalgia. The presence of widespread pain together with tenderness is sufficient for fulfilling the classification criteria set down by the American College of Rheumatology in 1990 for fibromyalgia. In addition, and beyond the scope of the ACR criteria, many of the other clinical features of this patient are highly compatible with this diagnosis. Female gender itself is associated with a high frequency of fibromyalgia. Sleep disorders, chronic fatigue, irritable bowel, difficulty with concentration and temporo –mandibular pain, all described in this patient, are associated and overlapping symptoms of the central sensitization spectrum of disorders, of which fibromyalgia is a prototype.
The only caveat which I must raise concerning this diagnosis relates to the possibility of the presence of a sero-negative spondyloarthropathy, such as Ankylosing Spondylitis (AS). AS is a diagnosis easy to miss, particularly in female patients. In the current case pain started in the lumbar area, and nocturnal pain persists. In addition, there is a mild increase in the levels of CRP and erythrocyte sedimentation rate. No details have been provided regarding the presence or absence of signs on physical examination which would help detect the possibility of sacro-ileitis (e.g. Schober's test or Fabere test). In addition, despite extensive imaging done, there is no direct imaging of the sacro-iliac joints.
Hence, despite the clear clinical presentation suggestive of fibromyalgia, it is my opinion that a directed workup should be performed in order to rule out the existence of a sero-negative inflammatory spondyloarthropathy. In this context I would like to point out, that fibromyalgia and AS may in fact coexist in some cases and obviously the diagnosis of fibromyalgia does not rule out the coexistence of AS or similar inflammatory disorders.
As indicated above I would recommend performing a diagnostic evaluation in order to rule out an inflammatory sero-negative spondyloarthropathy. In this context I would recommend a directed physical examination, an MRI examination of the sacro-iliac joints and performing a HLA-B27 test.
In absence of sacroileitis, it is my opinion that the patient should be treated vigorously for fibromyalgia. On this issue I would recommend the following interventions:
Moderate and regular exercise is a crucial component of the therapeutic approach to fibromyalgia. The recommended activity should be of an aerobic nature, such as walking, swimming or bicycle riding. The exercise should be performed on as regular a basis as possible (preferably every day) but should be tailored to the level appropriate for the patient in her current condition, taking into consideration the effects of deconditioning.
Hydrotherapy, preferably performed within warm water and supervised by a physiotherapist familiar with the management of fibromyalgia, is also beneficial.
Balneotherapy, i.e. bathing in natural hot water bodies (springs, spa etc.) has also been shown to be useful in the management of fibromyalgia.
As far as medical treatment is concerned, there are currently a number of medications with proven efficacy in the management of fibromyalgia. Pregabalin (Lyrica) and Duoloxetine (Cymbalta) are two such medications which have been approved by the US FDA for this indication. While no head - to - head studies have been performed, in the current case, in which depression has been apparently excluded, and hence an antidepressive effect is not necessary, I would recommend starting treatment with Pregabalin at a dose of 75 mg in the evening. After two weeks the dose may be
increased to 150 mg. Subsequently further increase of the dose up to 300 mg daily (divided into twice daily dosing) can be considered, based on the clinical response. As the effect of Pegabalin is gradual, pain may be managed in the short run with the use of Tramadol. I would recommend starting at a low dose (25 mg) 2-3 times daily as necessary. The dose can be gradually increased up to 200 mg daily.
In addition to the above mentioned modalities, cognitive – behavioral therapy (CBT) is a psychological strategy which has evidence-based efficacy in the management of fibromyalgia. If the patient would consent, I recommend attempting such treatment with the aid of a therapist familiar with CBT and with the syndrome of fibromyalgia.