Case 2 — A 43-year-old woman with malaise and myalgia

A 43-year-old woman presents to her primary care physician complaining of general malaise and widespread myalgia. She has not had a good night’s sleep for years and always wakes up exhausted. The fatigue that she feels in the mornings lasts all day, which she says is greatly affecting her ability to work. She used to be active but now even her 5-block walk to work leaves her tired and short of breath. On the weekends, she spends all day in bed because she is unable to motivate herself to do anything but rest. In addition to her lack of energy, the patient also is suffering from muscle and joint pain, which is particularly bad in the mornings. The pain is mostly concentrated around her neck, shoulders, and back. The pain is sometimes so bad that even her clothing causes extreme discomfort. On examination has no inflammation or swelling of any joints but is tender to palpation over her shoulders bilaterally and her neck. Other than this, the patient’s entire neuromuscular examination is unremarkable. An extensive laboratory work-up, including red blood cell count, white blood cell count, erythrocyte sedimentation rate, antinuclear antibody, thyroid function testing, and muscle enzymes, is negative.

What conditions should be included in the differential diagnosis?

Numerous conditions are associated with chronic pain and fatigue:

1. Ankylosing spondylitis
2. Fibromyalgia
3. Hypothyroidism
4. Inflammatory myositis and metabolic myopathies
5. Myofascial pain syndromes
6. Polymyalgia rheumatica
7. Psychiatric disorders, sleep disturbances, and migraine
8. Systemic and rheumatic diseases (rheumatoid arthritis, Sjögren’s syndrome, systemic lupus eruthematosus)

What is the most likely diagnosis?

Fibromyalgia. While considered a diagnosis of exclusion, fibromyalgia should be diagnosed in patients who present with chronic myalgias and arthralgias but who have no evidence of joint or muscle inflammation on physical exam or laboratory testing. Fibromyalgia is ten times more common in women than in men, and it most often presents in people 30-50 years old. It is associated with depression, anxiety, sleep disorders, and irritable bowel syndrome (IBS).

How is this condition classified?

As defined by the American College of Rheumatologists, patients diagnosed with fibromyalgia will exhibit:

1. Excess tenderness in at least 11 of 18 predefined (bilateral) anatomic sites:
   1. Occiput, at the suboccipital muscle insertion
   2. Low cervical, at the anterior aspects of the intertransverse spaces (C5-7)
   3. Lateral epicondyle, 2 cm distal to the epicondyles
   4. Knee, at the medial fat pad proximal to the joint line
   5. Second rib, at the second costochondral junction
   6. Trapezius, at the midpoint of the upper border of the muscle
   7. Supraspinatus, above the spine of the scapula near the medial border
   8. Gluteus, in the upper outer quadrants of the buttocks in the anterior fold of muscle
   9. Greater trochanter, posterior to the trochanteric prominence
2. Widespread musculoskeletal pain for ?3 months

Fulfillment of both criteria is 80% sensitive for the diagnosis of fibromyalgia.

What is the most appropriate management for this patient?

Treatment focuses on utilizing multiple modalities to alleviate a patient’s symptoms. Analgesics such as tramadol are often effective in providing pain relief. Because inflammation is not a major part of this disorder, anti-inflammatory medications such as ibuprofen or glucocorticoids are not effective. Antidepressant medications are often used as initial treatment.

By Daniel Osei, MD, Resident in Orthopedic Surgery, Hospital for Special Surgery; in association with Le TT, Schabelman E, Shivaram A, and Klein J, eds: First Aid Cases for the USMLE Step 2 CK. New York: McGraw-Hill, 2007.