The differential diagnosis of generalized pain

How to diagnose fibromyalgia

This review discusses the basic pathophysiological mechanisms that are necessary to understand the principles of diagnosis and management of fibromyalgia, and outlines a practical diagnostic approach to patients presenting with chronic widespread pain.

Interrelationships between chronic tension-type headache, musculoskeletal pain, and vitamin D deficiency: Is osteomalacia responsible for both headache and musculoskeletal pain?

Background:

Headache, musculoskeletal symptoms, and vitamin D deficiency are common in the general population. However, the interrelations between these three have not been delineated in the literature.

Materials and Methods:

We retrospectively studied a consecutive series of patients who were diagnosed as having chronic tension-type headache (CTTH) and were subjected to the estimation of serum vitamin D levels. The subjects were divided into two groups according to serum 25(OH) D levels as normal (>20 ng/ml) or vitamin D deficient (<20 ng/ml).

Results:

We identified 71 such patients. Fifty-two patients (73%) had low serum 25(OH) D (<20 ng/dl). Eighty-three percent patients reported musculoskeletal pain. Fifty-two percent patients fulfilled the American College of Rheumatology criteria for chronic widespread pain. About 50% patients fulfilled the criteria for biochemical osteomalacia. Low serum 25(OH) D level (<20 ng/dl) was significantly associated with headache, musculoskeletal pain, and osteomalacia.

Discussion:

These suggest that both chronic musculoskeletal pain and chronic headache may be related to vitamin D deficiency. Musculoskeletal pain associated with vitamin D deficiency is usually explained by osteomalacia of bones. Therefore, we speculate a possibility of osteomalacia of the skull for the generation of headache (osteomalacic cephalalgia?). It further suggests that both musculoskeletal pain and headaches may be the part of the same disease spectrum in a subset of patients with vitamin D deficiency (or osteomalacia), and vitamin D deficiency may be an important cause of secondary CTTH.

Osteomalacia caused by skull base tumors: report of 2 cases

BACKGROUND AND IMPORTANCE

Tumor-induced osteomalacia (TIO) is an uncommon paraneoplastic syndrome rarely encountered in neurosurgical practice. We report on 2 cases of TIO caused by skull base tumors. Although the diagnosis of TIO is difficult to make and often is delayed because of the insidious nature of the symptoms, mostly systemic pain and weakness, it is curable once it is diagnosed and properly treated.

CLINICAL PRESENTATION

Both patients presented with severe pain developing in the lower extremities and moving out to the entire body, as well as difficulty moving. They were diagnosed with TIO several years after onset. A high level of serum FGF23 was confirmed, and whole-body imaging studies demonstrated tumors in the middle and anterior cranial base, respectively. The patient with the anterior cranial base tumor had a history of hemorrhage into the frontal lobe and partial resection. En bloc resection of tumor with surrounding skull bone was performed. The histological diagnosis for both cases was phosphaturic mesenchymal tumor, mixed connective tissue variant.

CONCLUSION

The level of FGF23 normalized immediately after surgery. Both patients experienced a dramatic relief of pain and recovery of muscle power. Although reports of osteomalacia caused by tumors in the neurosurgical field are extremely rare in the literature, its true incidence is unknown. We emphasize the importance of recognition of this syndrome and recommend total resection of tumors when possible.

Somatization and somatic symptom presentation in cancer: a neglected area

Abstract The recognition of somatization process in cancer patients is a challenging and neglected area, for the extreme difficulty in differentiating and assessing the psycho(patho)logical components from those biologically determined and related to cancer and cancer treatment, as well as for the scarce usefulness of rigid categorical DSM criteria. However, several dimensions of somatization (and the interconnected concept of abnormal illness behaviour) have been shown to be diagnosable in cancer patients and to negatively influence coping and quality of life outcomes. An integration of the formal DSM-ICD nosology with a system specifically taking into account the patients' emotional responses to cancer and cancer treatment, such as the Diagnostic Criteria for Psychosomatic Research (DCPR), is suggested. More data on some specific symptom dimensions, including pain, fatigue and sexual disorders, are needed to examine their possible psychological components. More research is also needed regarding the association of somatization with personality traits (e.g. type D distressed personality, alexithymia), developmental dimensions (e.g. attachment), and cultural issues (e.g. culturally mediated attributional styles to somatic symptoms). Also, the impact and effectiveness of specific therapeutic intervention in 'somatizing' cancer patients is necessary.

Thyroid autoimmunity may represent a predisposition for the development of fibromyalgia?

In our previous study, we observed that the presence of autoimmune thyroid disease worsens fibromyalgia (FM) symptoms. The aims of this study are to evaluate whether there is a predisposition for the development of FM in patients with Hashimoto's thyroiditis (HT) with or without subclinical hypothyroidism (SCH) and in patients with SCH alone and what is the weight of antithyroid antibody positivity and SCH on FM comorbidity. Fifty-two patients, 39 affected by HT with or without SCH and 13 by SCH, were matched with 37 patients affected by FM and 25 healthy subjects. Blood samples were collected from all study subjects for the determination of serum TSH, free triiodothyronine, free thyroxine, antithyroperoxidase antibody (TPOAb), antithyroglobulin antibody (TgAb) and non-organ-specific autoantibodies. Clinical assessment of patients and controls included the "Fibromyalgia Impact Questionnaire" (FIQ), while pain severity was evaluated using a visual analogue scale (VAS). Patients and controls were also characterized by the presence of diffuse pain, fatigue, paresthesiae, muscle spasms, non-restful sleep, tension headache and presence of mood disorders. FM comorbidity resulted in twelve HT subjects (31%) and none in SCH patient. In particular, FM comorbidity in HT patients without SCH was 33.3% and in HT patients with SCH was 28.5%. Based on our data, we speculate that maybe there is more than a hypothesis regarding the cause-effect relation between thyroid autoimmunity and the presence of FM, thus suggesting a hypothetical role of thyroid autoimmunity in FM pathogenesis.

The pathophysiology, diagnosis and treatment of fibromyalgia

Research in fibromyalgia has increased understanding of the possible genetic and environmental factors that could be involved in the etiology of fibromyalgia. There is now substantial evidence for augmentation of central pain processing in fibromyalgia. Because the clinical presentation of fibromyalgia is heterogeneous, treatment recommendations must be individualized for each patient. The rapid growth of trials in fibromyalgia in recent years has resulted in new evidence-based approaches to pharmacological and nonpharmacological treatment.

Chronic tension-type headache with vitamin D deficiency: casual or causal association?

The prevalence of tension-type headache and vitamin D deficiency are both very high in the general population. The inter-relations between the two have not been explored in the literature. We report 8 patients with chronic tension-type headache and vitamin D deficiency (osteomalacia). All the patients responded poorly to conventional therapy for tension headache. The headache and osteomalacia of each of the 8 patients responded to vitamin D and calcium supplementation. The improvement in the headache was much earlier than the improvements in the symptom complex of osteomalacia. We also speculate on the possible mechanisms for headache in the patients with vitamin D deficiency.

Musculoskeletal aspects of hypoadrenalism: just a load of aches and pains?

Musculoskeletal signs and symptoms of hypoadrenalism are less well described in the literature compared to other endocrine disorders such as diabetes mellitus and thyroid disease. This may in part be due to the difficulties associated with making a definitive diagnosis of hypoadrenalism where the general symptoms and signs can be very subtle. Hence, suspecting hypoadrenalism in a patient with mainly musculoskeletal features can be difficult and delayed. To illustrate this point, we present three cases of hypoadrenalism with varying degrees of rheumatological symptoms and signs. This article reviews all the cases of hypoadrenalism in the English, French and Spanish language medical literature, going back to the time of Thomas Addison. All the important clinical and laboratory features have been summarised to help clinicians diagnose and treat this disease.

The contribution of selected non-articular conditions to knee pain severity and associated disability in older adults

OBJECTIVE

To estimate the contribution of selected non-articular conditions (NACs) to pain severity and functional limitation in community-dwelling older adults with knee pain.

DESIGN

Population-based, cross-sectional study of 745 adults aged 50 years and over with knee pain. Self-complete questionnaires, clinical history and physical examination were used to identify the presence of selected NACs that could cause pain around the knee. Regression analyses were used to compare levels of knee pain severity (0-20) and functional limitation (0-68) (Western Ontario and McMaster Universities osteoarthritis index physical function subscale [WOMAC-PF]), between those with one or more NACs and those with none (NACs-absent).

RESULTS

Two hundred and seventy-three (36.6%) participants had at least one NAC: widespread pain, n=159; low back pain with index leg referral, n=102; full-leg pain, n=88; hip arthritis, n=65; prepatellar, infrapatellar or pes anserine bursitis, n=35. The NACs group had significantly higher levels of pain severity and functional limitation than the NACs-absent group: 8.2(+/-4.6) vs 5.4(+/-3.8) and 27.9(+/-15.8) vs 16.8(+/-13.2), respectively. The groups did not differ with respect to severity of radiographic osteoarthritis (ROA). Having one or more NACs accounted for a significant proportion of the variance in WOMAC scores, above that which could be explained by age, gender, body mass index and severity of ROA.

CONCLUSION

NACs appear to be common in older adults with knee pain. They make a significant contribution to knee pain severity and functional limitation and are likely to represent additional, rather than alternative, causes of knee pain/functional limitation to osteoarthritis (OA). These factors should be taken into account in epidemiological studies of knee pain and OA.

Rheumatic Disease in the Elderly: Rheumatoid Arthritis

This article summarizes the different aspects of rheumatoid arthritis and the spectrum of diseases that can present as rheumatoid arthritis in the elderly population. With the ageing of the western population, different forms of inflammatory arthritis' prevalence and incidence are increasing in elderly persons. Difficulties in establishing the diagnosis and introducing new treatment modalities in this patient group pose a great challenge for clinicians. The management of inflammatory arthritis in the elderly requires special consideration in regard to the comorbidities and increased frequency of adverse events. There is substantial need for improving aspects of diagnostic and therapeutic interventions that will reduce the impact of inflammatory arthritis in the growing elderly population.

Creating meaning in fibromyalgia syndrome

Gaining a diagnosis is considered to legitimate a person's illness, to both the self and the wider social world, while also giving hope that treatments, and possibly a cure, will be found. A further function of diagnosis from the patient's perspective is to give meaning to the illness experience, which is often uncertain and confusing. To do so, a diagnosis must itself have meaning. This paper explores the creation of meaning in a medically unexplained disorder, fibromyalgia syndrome (FMS). Semi-structured interviews, in which the diagnostic process was explored, were conducted with 17 people diagnosed with FMS in the United Kingdom, selected from a hospital database (16 women, 1 man). Documentary analysis was also undertaken on information available from support groups and health professionals. Although initially an acceptable diagnosis to sufferers, FMS was viewed as a mysterious label, which provided no meaning at the time of diagnosis. The sought information was accessed in an attempt to resolve its meaninglessness, but this proved problematic due to the ambiguous definition of FMS within the medical and support group literature, the invisible nature of the illness, and the lack of an environment where these uncertainties could be openly discussed. Informants varied in the degree of longer-term acceptance of a diagnosis of FMS, in relation to the concordance they achieved between the diagnosis and their experience of illness.

Rheumatic disease in the elderly: rheumatoid arthritis

This review summarizes the different aspects of rheumatoid arthritis and the spectrum of diseases that can present as rheumatoid arthritis-like arthritis in the elderly population. With the aging of Western population, different forms of inflammatory arthritis' prevalence and incidence are increasing in the elderly persons. Difficulties in establishing the diagnosis and introducing new treatment modalities in this patient group poses a great challenge for the clinicians. The management of inflammatory arthritis in the elderly requires special consideration in regard to the comorbidities and increased frequency of adverse events. There is definitely a substantial need for improving different aspects of diagnostic and therapeutic interventions that will reduce the impact of inflammatory arthritis in the growing elderly population.

Evaluation and management of the Chiari malformation type 1 for the primary care pediatrician

Diagnosis and treatment of CMI is undergoing reexamination that includes redefinition of the anatomic Chiari malformation and refinement and redefinition of the clinical syndrome. Children with SMI present with head pain of some kind, a neurologic deficit, or with signs of spinal cord dysfunction from syrinx. Some will present with no clinical syndrome at all. Presence of anatomic Chiari malformation or compelling clinical Chiari syndrome should lead to evaluation by a neurologist or neurosurgeon experienced with the syndromes and their treatment. Treatment options are varied but usually result in resolution of symptoms. When symptoms persist after surgery, management is complex and not uniformly successful, even in the most experienced hands.