¹Nasser Abunamos, ¹Akram Mohamed Takaleh, ¹Shamma Alnokhatha

¹Tawam hospital

Background (s): This case report discusses the diagnostic challenge posed by a 64-year-old female patient with a complex medical history, including ulcerative colitis, who presented with acute onset generalized pain, particularly in the bilateral shoulders and hips. The patient’s clinical presentation initially suggested polymyalgia rheumatica (PMR), but the diagnostic process revealed an unexpected twist.

Method(s): PMR is an inflammatory condition primarily affecting older adults. It typically presents with proximal muscle pain and stiffness. However, the clinical presentation can overlap with other conditions, making diagnosis challenging, especially in patients with multiple comorbidities.

Since there is no definitive test to diagnose PMR, the diagnostic process relies on the ACR/EULAR 2012 provisional classification criteria (1). These criteria added the value of using ultrasound in the assessment of findings, which may include subdeltoid bursitis, biceps tenosynovitis, glenohumeral synovitis, synovitis, and/or trochanteric bursitis.

The patient is a 64-year-old female with a history of diabetes mellitus type 2, ischemic heart disease, hyperlipidemia, ulcerative colitis (pancolitis), stage 3 chronic kidney disease, osteoporosis, and functional dyspepsia. She presented to the rheumatology clinic with the following complaints, acute onset generalized pain with a focus on bilateral shoulder and hip pain lasting for 5 days, inability to lift her arms above shoulder level, difficulty walking due to bilateral hip pain, morning stiffness lasting more than 30 minutes and fatigue. Review of symptoms revealed patient has ongoing abdominal pain associated with intermittent bloody stool for the past 6 months.

Result(s): Musculoskeletal examination of the bilateral shoulders revealed tenderness along the joint line, a restriction in the arm’s range of motion and bilateral hip tenderness at the trochanteric area.

Signs of inflammation were given by raised ESR 110 mm/h and CRP 65 mg/l, HB 11 mg/dl , GFR 48 and calprotectin>2100 ug/ml. While other basic blood tests were normal. Autoimmune diseases were ruled out by negative antinuclear antibody, rheumatoid factor, and anticyclic citrullinated peptide antibody.

Bilateral shoulder X-ray shows osteoarthritic changes and ultrasound findings demonstrates subacromial subdeltoid bursitis (Figure 1)

The patient’s complex medical history, including refractory ulcerative colitis (sulfasalazine) and polymyalgia rheumatica (PMR)-like symptoms, posed a significant therapeutic challenge. After a comprehensive evaluation, a novel approach was considered.

The patient was initiated on ustekinumab, a monoclonal antibody targeting interleukin-12 (IL-12) and interleukin-23 (IL-23), primarily as a treatment for refractory ulcerative colitis. Remarkably, over the course of one year of ustekinumab therapy, the patient experienced significant improvement in her overall clinical condition. Her PMR-like symptoms, including acute bilateral shoulder and hip pain, morning stiffness, and fatigue, notably subsided.

This favorable response to ustekinumab not only led to the successful management of her ulcerative colitis but also provided relief from the debilitating symptoms of polymyalgia rheumatica. The sustained improvement in her condition emphasizes the potential of ustekinumab as a therapeutic option for patients with concurrent inflammatory conditions, such as ulcerative colitis and PMR-like symptoms.

Conclusion(s): The patient’s response to treatment underscores the importance of personalized and innovative approaches in managing complex cases with overlapping symptoms and comorbidities