Presentations of perforated colonic pathology in patients with polymyalgia rheumatica: two case reports

A 73-year-old Caucasian woman with a diagnosis of polymyalgia presented with a one month history of progressive pain and stiffness in her right hip, and myalgia of the right thigh. She had had intermittent diarrhea over the past four weeks but no bleeding or mucous appeared in her stool. Although treated as a rheumatic flare by her general practitioner, and low dose corticosteroids (prednisolone 20 mg daily) had been commenced three weeks prior to admission, she had failed to improve and therefore in-patient assessment was sought. Her past medical history consisted of hypertension and two successful normal vaginal deliveries. There was no significant family history. Apart from prednisolone, her only other medication was bendrofluazide 2.5 mg once daily. On admission to hospital, examination revealed reduced right hip and knee power of 4/5. Her diarrhea had settled by the time of admission to hospital. She was apyrexial, with a white cell count of 22.6×10⁹/dL, neutrophils 18.36, C-reactive protein (CRP) 279 mg/L and her body mass index (BMI) was 27 kg/m². Hip, pelvic, chest and abdominal X-rays, ultrasound scan of the abdomen, pelvis and stool cultures were unremarkable. Sigmoidoscopy revealed mild active proctitis and diverticulosis. A diagnosis of exacerbation of PMR was made and corticosteroid dosage increased to 40 mg daily. In view of raised inflammatory markers, intravenous broad spectrum antibiotics were also commenced (Tazocin (piperacillin and tazobactam) and gentamicin). Despite this her limb weakness and hip pain became progressively worse and inflammatory markers continued to rise. Magnetic resonance imaging (MRI) of the spine and pelvis was therefore arranged on day five of admission. This revealed a posterior diverticular perforation into the pre-sacral space resulting in large bilateral gluteal abscesses. There was also gas extending around the right femoral head (Figures 1 and 2). Although an urgent percutaneous computed tomography (CT)-guided drainage with a view to proceed to laparotomy and Hartmann's procedure was arranged, she became increasingly septic and died.

A 69-year-old Caucasian woman with PMR presented to her general practitioner with a three-week history of left thigh pain. She also had left-sided abdominal pains for six months, which were treated with paracetamol 1 g and mebeverine 135 mg as required. Her bowels usually alternated between constipation and diarrhea with no recent change or rectal bleeding. She had reduced appetite and weight loss of 3 kg over three months. BMI was 20 kg/m². Her past medical history was unremarkable apart from known polymyalgia and she had had one previous normal vaginal delivery. There was no significant family history. She was normally on 10 mg of prednisolone daily. She was on no other medication. Mild weakness of left hip flexion was noted and a white cell count 19.6×10⁹/dL, CRP 230 mg/L.

A diagnosis of exacerbation of PMR was made and her steroid dose increased to 30 mg daily. She was admitted a week later with severe abdominal pain, tachycardia and a fever of 38°C. Abdominal examination confirmed generalized peritonitis.

Laparotomy revealed fecal peritonitis and a large retroperitoneal abscess due to an obstructing proximal sigmoid tumor with perforation. She underwent a Hartmann's procedure followed by a further laparotomy for a residual retroperitoneal abscess (Figure 3). Tazocin and gentamicin were administered as antibiotics. Histopathology confirmed a T4 N2 Mx moderately differentiated adenocarcinoma with incomplete resection margins. After a protracted stay in intensive care with multi-organ failure, she was discharged home and received palliative chemotherapy.