An 83-year-old patient with a history of polymyalgia rheumatica treated with glucocorticoids last year now presents with low‑grade fever, vomiting, and new leg weakness; could this be a flare of polymyalgia rheumatica or an alternative condition such as infection or adrenal insufficiency?

Adrenal Insufficiency Crisis Until Proven Otherwise

This 83-year-old patient with prior glucocorticoid exposure presenting with fever, vomiting, and acute leg weakness is experiencing a potential adrenal crisis, not a polymyalgia rheumatica flare, and requires immediate treatment with 100 mg hydrocortisone IV/IM followed by rapid fluid resuscitation before any diagnostic workup. 1

Why This is Adrenal Crisis, Not PMR

Clinical Features Point Away from PMR Flare

• Leg weakness is NOT a feature of polymyalgia rheumatica - PMR causes proximal shoulder and hip girdle pain/stiffness, not lower extremity weakness 2
• Vomiting and acute systemic collapse are hallmark features of adrenal crisis, not PMR exacerbation 1
• Fever with vomiting in a glucocorticoid-exposed patient is a classic trigger for adrenal crisis 1

High-Risk Patient Profile

This patient has multiple risk factors for glucocorticoid-induced adrenal insufficiency:

• Age >65 years (he is 83) - identified as a specific risk factor 1
• Prior long-term glucocorticoid therapy for PMR (treated "last year") 1
• Acute infection (fever) triggering increased cortisol demand 1
• Gastrointestinal illness (vomiting) preventing oral glucocorticoid absorption 1

Immediate Management Algorithm

Step 1: Treat First, Diagnose Later

• Administer 100 mg hydrocortisone IV or IM immediately 1
• Start rapid 0.9% saline resuscitation 1
• Do NOT wait for laboratory confirmation - treatment takes precedence over evaluation 1

Step 2: Identify the Trigger

• Infection workup: The fever suggests an underlying infection (respiratory, urinary, gastrointestinal) 1
• Treat any identified infection aggressively while continuing stress-dose steroids 1

Step 3: Assess Glucocorticoid History

Critical questions to ask:

• What was the exact dose and duration of prednisone last year?
• When was it stopped or tapered?
• Is he currently on any glucocorticoids (including inhaled, topical, or intra-articular)? 1

Key threshold: Risk for adrenal insufficiency exists if he received >4-6 mg prednisone daily for >3-4 weeks 1

Why Leg Weakness Occurred

The acute leg weakness represents:

1. Profound muscle weakness from cortisol deficiency during physiologic stress (infection)
2. Possible hypovolemic shock affecting perfusion and consciousness 1
3. NOT polymyalgia - which causes pain/stiffness, not acute weakness 2

Critical Pitfalls to Avoid

Common Misdiagnosis Trap

• Do not attribute these symptoms to PMR flare - PMR does not cause vomiting, acute weakness, or collapse 2
• Do not delay treatment for diagnostic testing - mortality occurs when adrenal crisis goes unrecognized 1

The "Last Year" Problem

• Patients can develop adrenal insufficiency months after stopping glucocorticoids 1
• Mortality risk peaks in the first 3-6 months after cessation of long-term glucocorticoids 1
• HPA axis recovery is unpredictable and varies greatly between individuals 1

Post-Crisis Management

Once stabilized:

Determine Current Adrenal Status

• Morning cortisol (8-9 AM) after acute illness resolves 1
• If <5 μg/dL: confirmed adrenal insufficiency
• If 5-15 μg/dL: consider ACTH stimulation test
• If >15 μg/dL: HPA axis likely recovered

Patient Education (Often Neglected in PMR Patients)

Critical finding: Patients with glucocorticoid-induced adrenal insufficiency from PMR treatment are less aware of their diagnosis and engage less with preventative strategies compared to other adrenal insufficiency causes 1

Provide:

• Emergency steroid card (ESE steroid emergency card) 1
• Injectable hydrocortisone for home use
• Sick day rules: double or triple oral dose during illness 1
• Clear instructions on when to seek emergency care

The Bottom Line

This presentation - fever, vomiting, weakness, inability to stand - in an elderly patient with prior glucocorticoid exposure is adrenal crisis until proven otherwise. The 2-day prodrome of fever followed by acute decompensation is textbook for infection-triggered adrenal crisis. Polymyalgia rheumatica does not cause vomiting or leg weakness, and treatment delay can be fatal. Immediate parenteral hydrocortisone is both diagnostic and life-saving 1.