1813 01 REUMA3 Editoriale - ME/CFS Australia

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8 M. Cazzola et al.Table I - Characteristics of central and peripheral pain.CentralPeripheralSite Diffuse LocalisedIntensity Variable ConstantStimulus/response ratio Non-proportional ConservedModifying factors Environmental and/or psychological factors Mechanical factorsConcomitant sensitivity alterations (dysesthesia/paresthesia) Present Absentthat are usually innocuous, such as wearing clothes,as painful; if adequately questioned, they frequentlyreport associated paresthesia or dysesthsia(Tab. I).Other symptomsPain may be accompanied by numerous othersymptoms that are apparently unrelated. Asthenia,sleep disturbances, weakness, labile attention andmemory deficits, intolerance of cold or heat, visualand hearing disorders, vestibular symptoms, thesensation of dry mucosae, and inexplicable changesin weight are only the most frequent. “Allergic”phenomena such as rhinitis, sinusitis, nasal congestionand lower respiratory airway symptoms arereported more frequently by FM patients than controls,although these are almost always due to hypersensitivityand not immunoglobulin E (IgE)-mediated immune reactions. The most frequent comorbiditiesin women are dysmenorrhea, interstitialcystitis, vestibulitis and vulvodynia; in men,non-bacterial prostatitis is most common.Physical examinationPhysical examination is usually negative with theexception of hyperpathia upon pressure, particularlyat the TPs. However, the semiology of themusculoskeletal system must always be completedfor the purposes of differential diagnosis.Laboratory testsGenerally, lab tests are not useful except for differentialdiagnosis. One criterion for decidingwhich and how many laboratory tests to perform isthe duration of the disease: if the diagnosis wasmade several years ago, it is possible to limit thenumber of tests, whereas more recent or currentdiagnosis may require thorough investigation foraccuracy (Tab. II).Other investigationsThese are not usually necessary unless indicated onthe basis of findings from the physical examinationand laboratory screening (see Figure 4).Table II - Laboratory tests recommended at first observation.Symptom onset 12 monthsERSHemochromeTSHFibromyalgia-like symptoms >3 monthsEvaluate for other disordersComplete physical examination:• Check ESR, CRP, chemistry panel, TSH• Avoid ANA, RF unless indicatedNormal work-upDiagnose or “label”fibromyalgiaAbnormal work-upManage accordingly(may have comorbidfibromyalgia)Figure 4 - Algorithm for the diagnosis of fibromyalgia. Modified from:Clauw D. Fibromyalgia: defining the disorder and its diagnostic andtreatment approach. www.medscape.com, 2007.FM is often part of a wider syndrome encompassingmany symptoms from different organs otherthan muscles. Its clinical diagnosis is not easy becausefibromyalgia-like symptoms are frequentlyfound, and differential diagnosis with other causesof chronic pain is essential (Tabs. III, IV). When
Fibromyalgia syndrome: definition and diagnostic aspects 9the pain involves a large number of joints, it maybe confused with the widespread pain of FM. Thedegree of pain as measured by a visual analoguescale is not helpful in distinguishing FM from otherconditions such as arthritis or osteoarthritis (25).Furthermore, as FM can exist in association withimmunoinflammatory diseases, many rheumaticand non-rheumatic diseases can easily be misdiag-Table III - Possible causes of muscle pain.Causes of focal muscle painWith swelling or indurationNeoplasmTrauma (hematoma)Torn tendonRuptured Baker’s cystThrombophlebitisInfectionStreptoccal myositisGas gangrenePyomyositisTrichinosis, hydatid cyst, sparganosisPainful weakness in children with influenzaInflammationLocalised nodular myositisProliferative myositisPseudo-malignant myositis ossificansEosinophilic fasciitisSarcoidosis (nodular)IschemiaMuscle necrosis due to arterial occlusionDiabetes (thigh muscle infarction)Embolism (marantic endocarditis)Azotemic hyperparathyroidismToxic and metabolic disordersAcute alcoholic myopathyMyoglobinuria in drug-induced comaDrug-induced damageEffort-induced muscle damage (in normal subjectsor subjects with metabolic myopathies)Motor unit hyperactivity (stiff man syndrome, tetanus,strychnine poisoning)Without swelling or indurationEffort myalgiaNormal subjectsClaudicatio intermittensMetabolic myopathiesAcute brachialgiaIschemic mononeuropathyParkinsonismResting leg pain of obscure causeGrowing painsRestless legsPainful legs and tips of the fingersIdiopathic leg painCauses of generalised muscle painWith muscle weaknessInflammation (dermatomyositis and polymyositis)InfectionToxoplasmosisTrichinosisToxic myopathy (viral infections, leptospirosis,Gram-negative infections, toxic shock syndrome,Kawasaki’s syndrome)PoliomyelitisToxic and metabolic disordersAcute alcoholic myopathyHypophosphatemiaPotassium deficiencyTotal parenteral nutritionCarcinoma-induced necrotic myopathyHypothyroid myopathyDrugs (e-aminocaproic acid, clofibrate, emetine)Carnitine palmitoyltransferase deficiencyAmyloidosisBone pain and myopathy (osteomalacia,hyperparathyroidism)Acute polyneuropathy (Guillain-Barré syndrome, porphyria)Without muscle weaknessRheumatic polymyalgiaPainful muscle fasciculation syndromeMyalgia in infections or feverMyalgia in collagenovascular diseaseDiscontinuation of steroidsHypothyroidismPrimary myalgiaFabry’s diseaseParkinsonismModified from: Layzer RB: Muscle pain, cramps and fatigue. In Engel AG, Banker BQ (eds.): Myology. New York, McGraw-Hill, 1986, pp. 1907-1922.
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