Polymyalgia Rheumatica or Something Else? Bilateral Shoulder, Arm, and Thigh Pain with Diffuse Marrow Edema Revealing B-cell Acute Lymphoblastic Leukemia
Abstract
Background B-cell acute lymphoblastic leukemia (B-ALL) is an uncommon malignancy in adults. Polymyalgia rheumatica-like syndromes are rare and present features that can lead to a diagnostic delay. Magnetic resonance imaging (MRI) may reveal diffuse bone-marrow abnormalities. However, these findings are often nonspecific. Case Presentation A Japanese woman in her 40s presented with persistent pain in the bilateral shoulders, upper arms, and thighs. Initial laboratory tests showed anemia and elevated C-reactive protein levels, but no blasts were detected in the peripheral blood. Polymyalgia rheumatica was suspected; however, her age, absence of morning stiffness, and symmetrical diaphyseal pain were atypical for this condition. MRI revealed diffuse T2-short tau inversion recovery hyperintensity and patchy enhancement in the femoral and humeral shafts and adjacent muscles, without the dominant bursitis or synovitis typical of polymyalgia rheumatica. Bone marrow biopsy revealed hypercellularity with numerous CD19-positive lymphoblasts, leading to a diagnosis of B-ALL. Induction chemotherapy resulted in rapid pain relief and normalization of the clinical findings. Conclusion This case highlights that hematologic malignancies, including B-ALL, can present with polymyalgia rheumatica-like symptoms in adults. MRI is useful for detecting bone marrow infiltration and should prompt early bone marrow examination. Recognizing atypical features in presumed polymyalgia rheumatica and avoiding premature glucocorticoid therapy may prevent delays in the diagnosis of life-threatening conditions such as leukemia.
Related
- The 2026 British Society for Rheumatology guideline for the treatment of polymyalgia rheumatica
- More is less: Glucocorticoid-sparing agents in polymyalgia rheumatica
- Imaging for diagnosis, monitoring and outcome prediction in polymyalgia rheumatica: a systematic literature review and meta-analysis informing an international task force
- Influence of Sex on Glucocorticoid Toxicity Profiles in Polymyalgia Rheumatica
- 2025 EULAR recommendations for the management of polymyalgia rheumatica and primary large vessel vasculitis
BibTeX
@article{matsumoto2026polymyalgia,
title = {{Polymyalgia Rheumatica or Something Else? Bilateral Shoulder, Arm, and Thigh Pain with Diffuse Marrow Edema Revealing B-cell Acute Lymphoblastic Leukemia}},
author = {Kazuya Matsumoto and Yoshinori Matsumoto and Shoichi Nawachi and Moe Tokunaga and Natsuki Kubota and Yuya Terajima and Kei Hirose and Manami Watanabe and Takato Nakadoi and Keigo Hayashi and Yoshia Miyawaki and Haruki Watanabe and Eri Katsuyama and Takayuki Katsuyama and Mariko Takano-Narazaki and Jun Wada},
journal = {Internal Medicine},
year = {2026},
month = aug,
doi = {10.2169/internalmedicine.7374-26},
url = {https://www.jstage.jst.go.jp/article/internalmedicine/advpub/0/advpub_7374-26/_article},
note = {CC BY-NC-ND},
}
RIS
TY - JOUR
TI - Polymyalgia Rheumatica or Something Else? Bilateral Shoulder, Arm, and Thigh Pain with Diffuse Marrow Edema Revealing B-cell Acute Lymphoblastic Leukemia
AU - Kazuya Matsumoto
AU - Yoshinori Matsumoto
AU - Shoichi Nawachi
AU - Moe Tokunaga
AU - Natsuki Kubota
AU - Yuya Terajima
AU - Kei Hirose
AU - Manami Watanabe
AU - Takato Nakadoi
AU - Keigo Hayashi
AU - Yoshia Miyawaki
AU - Haruki Watanabe
AU - Eri Katsuyama
AU - Takayuki Katsuyama
AU - Mariko Takano-Narazaki
AU - Jun Wada
PY - 2026
DA - 2026/08/08
JO - Internal Medicine
DO - 10.2169/internalmedicine.7374-26
UR - https://www.jstage.jst.go.jp/article/internalmedicine/advpub/0/advpub_7374-26/_article
AB - Background B-cell acute lymphoblastic leukemia (B-ALL) is an uncommon malignancy in adults. Polymyalgia rheumatica-like syndromes are rare and present features that can lead to a diagnostic delay. Magnetic resonance imaging (MRI) may reveal diffuse bone-marrow abnormalities. However, these findings are often nonspecific. Case Presentation A Japanese woman in her 40s presented with persistent pain in the bilateral shoulders, upper arms, and thighs. Initial laboratory tests showed anemia and elevated C-reactive protein levels, but no blasts were detected in the peripheral blood. Polymyalgia rheumatica was suspected; however, her age, absence of morning stiffness, and symmetrical diaphyseal pain were atypical for this condition. MRI revealed diffuse T2-short tau inversion recovery hyperintensity and patchy enhancement in the femoral and humeral shafts and adjacent muscles, without the dominant bursitis or synovitis typical of polymyalgia rheumatica. Bone marrow biopsy revealed hypercellularity with numerous CD19-positive lymphoblasts, leading to a diagnosis of B-ALL. Induction chemotherapy resulted in rapid pain relief and normalization of the clinical findings. Conclusion This case highlights that hematologic malignancies, including B-ALL, can present with polymyalgia rheumatica-like symptoms in adults. MRI is useful for detecting bone marrow infiltration and should prompt early bone marrow examination. Recognizing atypical features in presumed polymyalgia rheumatica and avoiding premature glucocorticoid therapy may prevent delays in the diagnosis of life-threatening conditions such as leukemia.
SN - 1349-7235
SN - 0918-2918
ER -