Can a 36-year-old be diagnosed with Polymyalgia Rheumatica (PMR)?

Polymyalgia Rheumatica Can Occur in Younger Adults, Including at Age 36

While polymyalgia rheumatica (PMR) is rare in individuals under 50 years of age, it can occur in younger adults, including at age 36, and should be considered in the differential diagnosis when appropriate symptoms and laboratory findings are present. 1

Epidemiology and Age Distribution

• PMR is predominantly a disease of older adults, typically affecting those over 50 years of age
• It is 2-3 times more common in women than men 2
• Early-onset PMR (before age 50) is rare but documented in medical literature 1

Diagnostic Considerations in Younger Patients

When considering PMR in a younger patient (age 36), special attention should be paid to:

Key Diagnostic Features

• Bilateral shoulder and hip girdle pain and stiffness
• Morning stiffness lasting >45 minutes
• Elevated inflammatory markers (ESR, CRP)
• Rapid response to low-dose glucocorticoids

Differential Diagnosis

In younger patients, it's particularly important to rule out:

• Rheumatoid arthritis
• Inflammatory myopathies
• Spondyloarthropathies
• Systemic lupus erythematosus
• Malignancy
• Infection
• Immune checkpoint inhibitor-related PMR-like syndrome 3

Diagnostic Approach for Suspected PMR in Younger Adults

1. Laboratory evaluation:

   • Complete blood count
   • ESR and CRP (typically elevated)
   • Rheumatoid factor and anti-CCP antibodies (to exclude RA)
   • Creatine kinase (to exclude myositis)
   • Thyroid function tests
   • Additional serological tests as indicated (ANA, ANCA)

2. Imaging studies that may be helpful:

   • Ultrasound of shoulders and hips (may show bursitis, tenosynovitis)
   • MRI in selected cases
   • FDG-PET/CT has been shown to be particularly helpful in diagnosing early-onset PMR 1

3. Specialist referral:

   • The EULAR/ACR guidelines recommend specialist referral for atypical presentations, including age <60 years 3, 4

Management Considerations

If PMR is diagnosed in a younger patient:

1. Initial treatment:

   • Oral prednisone 12.5-25 mg/day as recommended by EULAR/ACR guidelines 3
   • Clinical improvement should be noted within 2-4 weeks

2. Monitoring:

   • More frequent follow-up may be appropriate for younger patients
   • Regular assessment of disease activity and glucocorticoid-related adverse effects

3. Steroid-sparing strategies:

   • Consider early introduction of methotrexate (7.5-10 mg/week) 4, 5
   • Newer biologic agents like IL-6 inhibitors may be considered in refractory cases 5

Important Caveats

• Age <50 years is considered an atypical feature for PMR and warrants thorough investigation
• Younger patients with PMR-like symptoms should undergo more extensive evaluation to exclude mimicking conditions
• The diagnosis of PMR in younger patients should be made with caution and typically by specialists with experience in rheumatic diseases

Conclusion

While uncommon, PMR can occur in patients as young as 36 years old. The diagnosis should be considered in patients with characteristic symptoms and laboratory findings, regardless of age, after appropriate exclusion of other conditions. Specialist referral is strongly recommended for younger patients with suspected PMR.