CASE REPORT – OPEN ACCESS

International Journal of Surgery Case Reports 3 (2012) 354–355

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International Journal of Surgery Case Reports

journal homepage: www.elsevier.com/locate/ijscr

Polymyalgia rheumatica following robotic radical prostatectomy

T. Suntharasivam, V.J. Gnanapragasam ∗
Department of Urology, Addenbrookes Hospital, Hills Road, Cambridge CB2 0QQ, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: INTRODUCTION: Polymyalgia rheumatica (PMR) is an inflammatory syndrome of unknown etiology has
Received 19 February 2012 also been associated with concurrent malignancy. Here we report PMR occurring de novo in a man
Received in revised form 20 April 2012 following successful robotic radical prostatectomy.
Accepted 23 April 2012
PRESENTATION OF CASE: A 67-year-old gentleman underwent uneventful robotic assisted radical prosta-
Available online 27 April 2012
tectomy with complete excision of a T2C Gleason 7 tumour and a post-operative undetectable PSA. Three
weeks after surgery he developed pain and weakness of the upper arms requiring increasing doses of
Keywords:
opioids. Assessment identified a grossly elevated ESR and CRP consistent with a clinical diagnosis of PMR.
Polymyalgia rheumatica
Prostatectomy
Treatment with oral steroids led to a rapid resolution of symptoms.
Robotic DISCUSSION: There have been reported cases of polymyalgia rheumatica occurring following surgical
procedures but not with robotic prostate surgery. It has been proposed that surgical tissue injury can
cause a release of inflammatory markers. Surgical stress-related sympathetic activation can also stimulate
lymphocyte dependent inflammatory reactions by modulation of cytokine production and lymphocyte
expressed adrenergic receptors.
CONCLUSION: We present here the first reported case of PMR developing acutely after radical robotic
prostatectomy. It is possible that the surgical procedure in this case had triggered polymyalgia rheumatica
possibly through activation of immune-mediated systemic inflammatory responses.
© 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.

1. Introduction 2. Presentation of case

Polymyalgia rheumatica is an immune-mediated clinical syn-
drome of unknown etiology. It is characterized by proximal myalgia
of the hip and shoulder girdles with accompanying morning stiff-
ness. A causative relationship with genetic factors, infections,
and malignancies has been postulated. The disease is character-
ized by the presence of monocyte activation and raised levels of
interleukin-2 (IL-2) and interleukin-6 (IL-6).1 Dendritic cells also
seem to play a significant role in the pathogenesis of polymyalgia
rheumatica by triggering lymphocyte immune responses.2 It occurs
in genetically predisposed patient, when an environmental factor,
possibly a virus, causes monocyte activation which helps deter-
mine the production of cytokines that induce manifestations of the
disease. The disease is more common among northern Europeans3
and those aged over 50 with median age at diagnosis of 72 years.
It is also more prevalent in females.4 Although non-steroidal anti-
inflammatory medications may control symptoms in patients with
mild disease, most patients with polymyalgia rheumatica require
corticosteroids.
∗ Corresponding author at: Department of Urology, Box 43, Clinic 4A, Adden-
brooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road,
Cambridge CB2 0QQ, United Kingdom. Tel.: +44 1223 763363.
E-mail address: vjg29@cam.ac.uk (V.J. Gnanapragasam).
A 67-year-old gentleman was referred to the urology depart-
ment with a diagnosis of stage T2C adenocarcinoma of the prostate
with a presenting PSA of 7.2 ng/ml and Gleason 3 + 4 = 7 with
no nodal or metastatic disease. Following MDT discussion and
proper counselling, he underwent an uneventful robotic assisted
radical prostatectomy. His past medical history included mild
asthma, hypothyroidism, gastro-oesophageal reflux, hypercholes-
terolaemia and small abdominal aortic aneurysm which was under
observation. He also had a left total hip replacement 2 years ago.
Urological history included chronic pelvic pain syndrome, detrusor
overactivity and erectile dysfunction. He normally took seretide,
thryoxine, omperazole, Simvastatin and Viagra. There were no
known allergies and he was non-smoker.
He had an elective robotic assisted radical prostectomy under
general anaesthesia. The surgery was uneventful with no unex-
pected intra-operative events. He did not have a blood transfusion
and made an unremarkable recovery and was discharged on the
first postoperative day. He was given paracetamol, non-steroidal
anti-inflammatory drugs, Tramadol, laxatives and low molecular
weight heparin on top of his regular medication. The patient was
routinely reviewed in the clinic 2 weeks following the surgery and
had a successful removal of his catheter. The patient voided well
with reasonable bladder control and was otherwise well.
Three weeks later, the patient was seen by his general practi-
tioner with bilateral shoulder pain causing a lack of rest and sleep.

2210-2612/$ – see front matter © 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijscr.2012.04.012
 CASE REPORT – OPEN ACCESS
T. Suntharasivam, V.J. Gnanapragasam / International Journal of Surgery Case Reports 3 (2012) 354–355
He was treated with opioid analgesia and there was arrangement
made to investigate this further. He then presented to a local Dis-
trict General Hospital with urinary retention and was catheterised.
In the interim the patient’s shoulder pain and muscle stiffness had
progressed with increasing inability to raise his arms above his head
as well as general malaise and lethargy.
The patient was reviewed in the urology outpatient clinic and a
decision was made to admit him electively for further management
of his symptoms. On admission, there was a clinical suspicion of
polymyalgia rhuematica and inflammatory markers were checked.
The patient had raised inflammatory markers with erythrocyte sed-
imentation rate (ESR) of 88 (1-h) and C reactive protein of 242 but
with normal renal, liver and thyroid function tests. Urine culture
revealed no growth. The patient had a normal rigid cystoscopy and
the urinary symptoms and retention were presumed to be caused
by excessive analgesics consumption. He was then referred and
reviewed by the rheumatology team who concurred with the diag-
nosis. He was then commenced on a therapeutic trial of 15 mg
Prednisolone daily. His symptoms dramatically improved after 48 h
of treatment with steroids and he was discharged.
The patient was reviewed in clinic 6 weeks following the com-
mencement of treatment with repeat inflammatory markers. By
this time all symptoms had completely resolved with an ESR of 5
(1-h) and a CRP of 3. The prostate histology came back as organ
confined bilateral and multifocal microacinar type adenocarci-
noma with Gleason 3 + 4 = 7. His follow up PSA at 3 months was
<0.02 ng/ml which confirmed good disease control.
3. Discussion
There have been reported associations between malignan-
cies (including prostate cancer5,6 ) and polymyalgia rheumatica.
In many cases it has been quoted that symptoms of polymyalgia
rheumatica usually resolve following effective tumour control. In
this context, polymyalgia rheumatica represent a paraneoplastic
phenomenon which means disease occur at a distance from the
primary tumour or metastases and induced by the malignancy
through mediators such as hormones, peptides and antibodies.7
This might well have occurred as a co-incidence and not be related
to the operation or prostate cancer. There have, however previously
been reported cases of polymyalgia rheumatica occurring follow-
ing surgical procedures,8,9 but not with robotic prostate surgery.
The mechanisms for this trigger are unclear. It has been proposed
that surgical tissue injury can cause a release of inflammatory mark-
ers including cytokines and other cellular products, which mobilize
and activate dendritic cells.10 Surgical stress-related sympathetic
activation can also stimulate lymphocyte dependent inflammatory
reactions by modulation of cytokine production and lymphocyte
expressed adrenergic receptors.
Open Access
This article is published Open Access at sciencedirect.com. It is distributed under the IJSCR Supplemental terms and conditions, which
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credited.
355
4. Conclusion
In conclusion, it is possible that the surgical procedure in this
case had triggered polymyalgia rheumatica possibly through acti-
vation of immune-mediated systemic inflammatory responses. In
this case, this has happened following robotic radical prostatec-
tomy and to our knowledge is the first report of such an incident.
Conflict of interest statement
The authors declare that they have no competing interests.
Funding
Not applicable.
Ethical approval
Written informed consent was obtained from the patients for
publication of this case report and accompanying images. A copy
of the written consent is available for review by the Editor-in-Chief
of this journal.
Author contribution
TS and VG drafted the manuscript and cared for the patient.
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