Rheumatology 2001; 40: 347-348
© 2001 British Society for Rheumatology
Letters to the Editor |
Polymyalgia rheumatica and IUCDs
Department of Rheumatology, Law Hospital, Carluke, Lanarkshire ML 8 5ER, UK
SIR, It is well recognized that polymyalgia rheumatica (PMR) is a diagnosis of exclusion, and that many other disorders can mimic PMR. I describe two cases that had features suggestive of PMR, where retained intra-uterine contraceptive devices (IUCDs) were implicated, and discuss the possible role of these devices in the presentation.
A 69-yr-old woman was referred to the rheumatology clinic as a possible case of polymyalgia rheumatica, having presented to her general practitioner (GP) with fatigue and lack of energy for a few months in association with pains in her neck, shoulders and feet. Initial investigations had revealed haemoglobin 7.8 g/dl, erythrocyte sedimentation rate (ESR)>140 mm/1st h and creatinine 219 µmol/l. When seen in the clinic, she was generally well and examination revealed tenderness of the shoulder girdles, but no other significant abnormality. Further investigations carried out at the clinic confirmed the anaemia and high ESR. C-reactive protein was also significantly elevated at 148 mg/l. Haematinic assays, immunoelectrophoresis, renal function, liver function, thyroid function and a chest X-ray were all normal, as were rheumatoid and antinuclear factor assays and an isotope bone scan. Urine microscopy was positive for both red and white cells but bacteriological culture was negative. Ultrasound of the abdomen was performed and revealed bilateral hydronephrosis. The radiologist also commented that the bladder appeared thick-walled, suggestive of bladder carcinoma, and an area of calcification was noted posteriorly. The patient was therefore referred for cystoscopy which revealed an indurated and oedematous bladder, with a visible intrauterine contraceptive device (Safe T coil), and this was removed vaginally. Bladder biopsy revealed inflammatory changes only, with no features of malignancy. A urinary catheter was inserted and the patient improved clinically, with complete resolution of her inflammatory indices. The urinary catheter was removed about a month later, and the patient remains well with no urinary or systemic symptoms. A follow-up ultrasound scan performed 6 months later showed a normal right kidney, although the left kidney remained hydronephrotic. Some thickening of the bladder wall persists and the patient is scheduled for follow-up cystoscopy. On questioning, the patient recalled having had an IUCD fitted approximately 25 yr earlier, but she thought it had been removed.
A 53-yr-old woman presented to her GP for removal of an IUCD which had been fitted 24 yr previously. The GP was unable to remove the coil and the patient was referred to a gynaecologist. The coil was removed. High vaginal swabs taken at the time of removal grew Actinomyces howellii and she was treated with oral penicillin. Five weeks following removal, the patient developed sudden onset of very marked stiffness in her neck with pain and stiffness in a limb girdle distribution such that she found it difficult to turn in bed. ESR at that time was elevated at 88 mm/1st h and she was referred to the rheumatology clinic as a case of possible PMR. When seen at the clinic, the patient reported partial resolution of her symptoms, and examination was unremarkable apart from hypertension, with blood pressure 180/100. ESR at that time was 51 mm/1st h, with C-reactive protein <6 mg/l. Serum biochemistry, including renal and liver function, was normal, as were thyroid function tests and full blood count. Rheumatoid factor and antinuclear factor tests were negative. Chest X-ray was normal. The patient's symptoms continued to resolve without the need for steroid therapy, and she was discharged from the rheumatology clinic 6 months after the onset of symptoms. At that time she had only mild stiffness of her shoulders and the ESR had fallen to 31 mm/1st h.
Both these patients presented with symptoms suggestive of PMR which we believe were related to a retained IUCD. In the first patient, the coil had been completely forgotten about and at the time of presentation had eroded through the uterine wall to invade the bladder and set up a significant inflammatory reaction. This highlights the point that PMR is a diagnosis of exclusion and a full history and examination are required to exclude other disorders in patients with myalgia and raised inflammatory indices. In the second patient, removal of a coil after 24 yr was associated with the development of myalgia and raised inflammatory indices a month after removal. Swabs taken at the time of coil removal had grown Actinomyces and the patient had received antibiotic therapy despite being asymptomatic at that time. A recent review of bacteriological culture of removed IUCDs revealed a 34% rate of culture of various species of Actinomyces, although no correlation was found with symptoms, and this study questioned the need for antibiotic therapy in this setting [1]. We postulate that, in our patient, the IUCD had become embedded in the uterine wall as a result of the long duration in situ, and that a local inflammatory reaction was stimulated when the device was removed, resulting in a self-limiting period of systemic illness masquerading as PMR. That IUCDs can stimulate an inflammatory reaction within the uterine wall is well recognized and is indeed thought to be relevant to their contraceptive effectiveness, those producing the greatest inflammatory reactions being the most effective contraceptive devices [2].
These cases highlight an unusual cause of polymyalgic symptoms and serve as a reminder that, with an estimated 100 million women or more worldwide now fitted with an IUCD, the forgotten coil may become an increasingly frequent phenomenon.
References
- Lewis R. A review of bacteriological culture of removed intrauterine contraceptive devices. Br J Fam Plann1998;24:95–7.[Medline]
- Mishell DR. Intrauterine devices: mechanisms of action, safety and efficacy. Contraception1998;58:45S–53S.[Web of Science][Medline]
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