PMR Case Study with Remaining Questions as of 09-04-2025

Background
1. PMR 40 -20-15-10-7.5-5-2.5-0 mg/daily tapering over 5 months, 77-yr old male in great shape. PMR triggered overseas dive trip (Malaysia) unexpectedly and exceedingly fast and unrecognizable. Total disruption of routine activities. Could not get out of bed with major pain in shoulders, biceps, deltoids, buttocks, hips, back, wrists, tingling in right toes eliminating ability to push up from bed, floor, chair or table.
2. Pain - Originally neck, back, shoulders, deltoids, hips, thighs, buttocks, overall leg cramps. Feet, tickling legs, ankles, feet and toes mainly right side
3. Pain tapering - dizziness, both shoulders ache
4. Post PMR - dizziness, shoulders, deltoids, buttocks (not severe and managed with 2 mg Tylenol daily)
5. Muscle weakness of 20 to 30% loss
6. Water retention 10 to 15 pounds, slowly losing with help of 25 mg daily hydrochlorothiazide (HCTZ) diuretic for 10 days
7. Fatigue - 50% energy loss, coming back very slowly
8. Golf - indicator, lost 30 to 40 yards distance, added 10 strokes to score usually unable to complete round due to dizziness. Peloton bike - unable to use for months, when returned 30 to 40% of normal (baseline) wattage expenditure.
9. Attitude - must find a way, but also realization age and life may be different henceforth.
10. Reading and fatigue - fall asleep often while reading
11. Health status prior - normal. CBC and other blood test markers abnormal on inflammation across the board and did not reduce (see below).
12. BP: 122/62, Resting Pulse: 66, O2 Saturation: 97%
13. Predisone taper over 8 weeks (20 to 2.5 to 0 mg daily), full stop now
14. Predisone withdrawal symptoms (see Questions below)

Medications
1. Prednisone (5 mg tablets, max 8 daily)
2. Tylenol (500 mg tablets, max 6 daily)
3. Cyclobenzaprine Hydrochloride (10 mg, max 10 mg daily)
4. Meloxicam (15 mg, max 15 mg daily)
5. Hydrochlorothiazide 25mg, max 25 mg daily)

Abnormal Lab Tests
1.CBC with Auto differential:
• RDW-SD: 52fL (high)
• # Immature Granolocytes: 0.07 K/uL (high)
• Lymphocytes Absolute: 0/9 k/uL (low)
• Neutrophil% (Auto): 75.2% (high)
• Lymphocyte% (Auto): 11.9% (low)
2. Sedimentation Rate
• 36 mm/hr (high)
3. ANA, Reflex
• ANA Screen: Positive (Abnormal)
4. ANA Titer Reflex Panel
• ANA Titer: 1.40 (high)
• ANA Pattern: Nuclear, Homogeneous (Abnormal)
3. C-Reactive Protein
• CRP: 76 to 34.30 mg/L (high)

Lingering Questions or Comments Requested
1. Fatigue (lethargy) still exists, how to reduce/eliminate?
2. Muscle loss -resume regular routines?
3. Shoulder pain - exercise routine helping or hurting and ongoing or aggravating pain?
4. Sleep - 1.5 to 2 hrs max sleep period all night, wake up, pee back to sleep. Tried, not drinking liquids, drinking liquids, reducing liquids, nothing seems to work?
4. Apprehension for good health and handicaps of others (only positive for this journey).
5. Appreciation for good medical access, but major delay in scheduling visit with rheumatologist specializing in PMR. However, Primary Care Physician consulted with the rheumatologist to confirm approach.
6. PMR is “not one size fits all” and requires medical advocate (self or others) to ask questions, do research and provide support. Realization that PMR is not a candidate for an instantaneous fix, but may take weeks, months, years or not render a total repair.
PMR meds introduce a range of side effects that must be managed depending on meds.
7. Underlying cause may or may not be discovered. Relapses are uncertain. It appears one is never rid of the disease. Have had medical and non-medical "experts" suggest, viral, parasite, and bacterial infection that triggered auto immune system activation in some on our international trip, but gastrointestinal reactions in other occurred for the body to attack the virus or infection.
8. Markers may not be reliable in short term as they may be lagging indicators. Use personal body feelings also as indicators or progression, relapse or non-improvement. Medical experts will disagree. Seek help from rheumatologist and Primary Care Physician that know you and your normal baseline body indicators.
9. Do not mix alcohol or other non-prescription drugs without investigating contra indications.
10. Physical exercise is difficult, but continuation is most helpful.
11. Dehydration aggravates the disease. Stay hydrated.
12. Research supplements and foods are needed to counteract the nasty results of Prednisone, e.g. bone strengthening calcium and vitamin D, bowel regularity and composition. Do not take other NSAIDs (Aleve, Advil, Motrin – ibuprofen anti-inflammatory drugs. Tylenol (Acetaminophen) is okay.
13. Establish a plan A and B for recurrence of symptoms of PMR and have meds on hand to address.
14. Vaccines – when to take flu, Covid, RSV after Predisone withdrawal?
15. No mental degradation, no headaches, no memory issues other than dizziness, but still comes and goes, especially when focusing on short putts? How or when does this disappear?