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Patient case: Fibromyalgia

Patient case: Fibromyalgia

Discussion

A 38-year-old woman from a rural community in Sub-Saharan Africa presents to a local clinic with a five-year history of generalized musculoskeletal pain, persistent fatigue, and unrefreshing sleep. She describes the pain as a deep, aching sensation affecting her neck, shoulders, lower back, and legs. The symptoms have progressively worsened, significantly impacting her ability to perform daily activities, including farming and household chores.

She reports frequent headaches, memory difficulties, and periods of dizziness. Despite multiple visits to traditional healers and various pain relievers, her symptoms persist. Laboratory tests, including inflammatory markers and rheumatologic screening, are unremarkable. A tender point examination reveals multiple areas of hypersensitivity across characteristic sites.

Given the chronic, non-inflammatory nature of her symptoms, a diagnosis of fibromyalgia is made. She is counseled on lifestyle modifications, including gentle exercise, stress management, and improved sleep hygiene. Low-dose amitriptyline is initiated, and she is referred for physiotherapy and community support programs to improve function and quality of life.

Questions
1. What is the most likely diagnosis in this patient?

a) Rheumatoid arthritis

b) Fibromyalgia

c) Osteoarthritis

d) Systemic lupus erythematosus

2. Which of the following findings best supports the diagnosis of fibromyalgia?

a) Positive rheumatoid factor

b) Generalized muscle pain with multiple tender points

c) Joint swelling and erythema

d) Elevated inflammatory markers

3. What is the best initial management strategy for this patient?

a) High-dose corticosteroids

b) Long-term opioid therapy

c) Lifestyle modifications, low-dose amitriptyline, and physiotherapy

d) Immunosuppressive therapy

4. Which of the following symptoms is least likely associated with fibromyalgia?

a) Chronic fatigue

b) Unrefreshing sleep

c) Progressive joint destruction

d) Cognitive difficulties ("fibro fog")

Reveal answers

Answers

1. b) Fibromyalgia

The patient presents with widespread musculoskeletal pain, fatigue, and cognitive symptoms without signs of inflammation, making fibromyalgia the most likely diagnosis. Other conditions like rheumatoid arthritis and lupus typically present with inflammatory markers and joint involvement.

2. b) Generalized muscle pain with multiple tender points

Fibromyalgia is a diagnosis of exclusion, characterized by chronic widespread pain, tender points, fatigue, and sleep disturbances. Unlike inflammatory conditions, laboratory markers are usually normal.

3. c) Lifestyle modifications, low-dose amitriptyline, and physiotherapy

The mainstay of fibromyalgia management includes non-pharmacologic interventions (exercise, sleep hygiene, stress reduction) and medications like low-dose amitriptyline, which helps with sleep and pain. Opioids and corticosteroids are not recommended.

4. c) Progressive joint destruction

Unlike conditions like rheumatoid arthritis, fibromyalgia does not cause structural joint damage. However, it does lead to significant pain, fatigue, and cognitive difficulties, often referred to as "fibro fog."