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A 14-Year-Old With Diffuse Musculoskeletal Pain

A 14-year-old female, presented to rheumatology clinic with diffuse intermittent musculoskeletal pain of 4-month duration. The pains affected her bilateral shoulders and legs, neck, and back. She denied any swelling or morning stiffness. The patient had been taking ibuprofen with minimal improvement. Associated symptoms included progressive fatigue, unintentional weight gain of 25 pounds, dry skin, and irregular menses. She denied recent fevers, oral ulcers, photosensitivity, and rashes. She also denied any sleep disturbances or signs of depression or anxiety. Of note, she reported a significant amount of school stress, which has been worse since onset of musculoskeletal pain. Past medical history was significant for migraine headaches and tonsillectomy. Family history was significant for rheumatoid arthritis in the mother and hypothyroidism and fibromyalgia in maternal grandmother. On physical examination, the patient weight was 81.5 kg (above 97th percentile), height 161 cm (on the 50th percentile) and with a body mass index of 32 kg/m. Her blood pressure was 130/69 mm Hg. The skin showed no rashes but was diffusely dry. There were no oral lesions, and no alopecia was detected. She had no lymphadenopathy and no enlargement of the thyroid gland found. Cardiac examination revealed regular rate and rhythm without murmur. She had no signs of joint swelling or arthritis and had normal range of motion of all joints. Pertinent positive findings included tenderness to palpation at 18/18 fibromyalgia tender points without tenderness at control points. Neurologic exam revealed delayed deep tendon reflexes. It was thought that her symptoms were compatible with fibromyalgia syndrome and recommended low-impact exercise (walking, biking, and low-impact aerobics) and treatment with cyclobenzaprine 5 mg at bedtime was started. Initial laboratory tests done by her primary care physician showed positive ANA (antinuclear antibodies) screen. Tests done in our laboratory showed normal complete blood count and comprehensive metabolic panel, and normal urine analysis. Acute phase reactants, C-reactive protein, and erythrocyte sedimentation rate, were normal. Rheumatologic markers, including ANA profile, HLA-B27, and rheumatoid factor, all were negative. Complement components C3 and C4 and immunoglobulin levels were within normal limits. Additional tests showed that the thyroid-stimulating hormone was markedly elevated at 110 mIU/L (reference range, 0.363.74 m IU/L). Total and free T4 were decreased at 1.5 μg/mL (reference range, 4.2-13.0 μg/mL) and 0.16 ng/ mL (reference range, 079-1.50 ng/mL), respectively. Thyroglobulin and thyroid-peroxidase antibodies were present in high titers 6076 IU/mL (reference range, negative <2.0 IU/mL) and 2269 IU/mL (reference range, negative <9.0 IU/mL), respectively. The above thyroid test abnormalities were consistent with the diagnosis of autoimmune thyroididtis or Hashimoto thyroiditis with associated hypothyroidism. In addition, an endocrine evaluation by a pediatric endocrinologist confirmed the above diagnosis. She was placed on daily levothyroxine 100 μg. The patient was then seen in follow-up visit in 4 months and her diffuse musculoskeletal pain has completely resolved. She resumed physical activity and had improvement in her quality of life.