eMedicine Specialties > Rheumatology > Systemic Rheumatic Disease

Eosinophilia-Myalgia Syndrome: Follow-up

Author: Thomas A Medsger Jr, MD, Gerald P Rodnan Professor of Medicine, Director, Scleroderma Research Program, Department of Medicine, University of Pittsburgh School of Medicine
Coauthor(s): Mohammed Mubashir Ahmed, MD, Associate Professor, Department of Medicine, Division of Rheumatology, University of Toledo College of Medicine; Eisha Mubashir, MD, Fellow in Rheumatology, Department of Medicine, Fellow, Center of Excellence for Arthritis and Rheumatology, Louisiana State University Health Sciences Center, Shreveport; Shrilekha Sairam, MD, MBBS, Fellow, Department of Internal Medicine, Division of Rheumatology, University of Texas at Galveston; Jeffrey R Lisse, MD, FACP, Professor, Department of Internal Medicine, Chief, Section of Rheumatology, University of Arizona School of Medicine
Contributor Information and Disclosures

Updated: Oct 15, 2009

Follow-up

Further Inpatient Care

  • Patients who are acutely ill with eosinophilia-myalgia syndrome (EMS) may need hospitalization. A workup may be necessary to help rule out infections and neoplasms, which can mimic EMS.

Further Outpatient Care

  • Because symptoms of EMS tend to be prolonged, sometimes persisting for years, intermittent treatment with muscle relaxants and analgesics may be required.
  • Persistent muscle pain and spasm can interfere with activities of daily living.
  • Prolonged nursing support may be required.

Inpatient & Outpatient Medications

  • Treatment is based on symptoms. Persistent pain requires analgesics, occasionally including opiates. Muscle relaxants may be needed for the treatment of muscle spasms. A prolonged course of prednisone is neither effective nor indicated.

Transfer

  • Incapacitating myalgias may require transfer to a skilled nursing facility or rehabilitation unit for assistance with activities of daily living.

Deterrence/Prevention

  • Active exercise may result in relapse of myalgias in some patients. These patients should refrain from prolonged strenuous activity.
  • While case reports exist of patients with EMS tolerating a rechallenge with L-tryptophan from different manufacturers, the substance should be avoided.

Complications

  • Serious and life-threatening complications (eg, ascending polyneuropathy, cardiomyopathy, myocarditis, myocardial infarction, encephalopathy, stroke, thrombocytopenia) have been reported, but they occur only rarely.

Prognosis

  • Most patients with EMS continue to have some symptoms 3-4 years after the acute presentation. These are likely due to permanent tissue damage that occurred in the acute phase of the disease. In a patient-completed survey, signs of acute inflammation after the first year of disease were reported.8
  • In one series, only approximately 10% of patients with EMS reported complete recovery.
    • Persistent muscle pain, fatigue, and muscle spasm were the most common residual complaints.
    • Subjective memory loss and word-finding difficulties were also reported in this series. These symptoms were not responsive to any therapeutic intervention.
  • Patients who had severe disease at onset with internal organ involvement, neurologic findings, and skin thickening tended to have a worse prognosis.

Patient Education

  • Patients should be advised that over-the-counter medications are not subjected to rigorous testing for short- or long-term side effects. Their use could result in as yet unknown adverse health consequences.

Miscellaneous

Medicolegal Pitfalls

  • Failure to advise the patient to stop using the offending medication
  • Failure to consider other diagnoses (eg, malignancy, infection)
 


More on Eosinophilia-Myalgia Syndrome

Overview: Eosinophilia-Myalgia Syndrome
Differential Diagnoses & Workup: Eosinophilia-Myalgia Syndrome
Treatment & Medication: Eosinophilia-Myalgia Syndrome
Follow-up: Eosinophilia-Myalgia Syndrome
References
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References

  1. Hertzman PA, Clauw DJ, Duffy J, Medsger TA Jr, Feinstein AR. Rigorous new approach to constructing a gold standard for validating new diagnostic criteria, as exemplified by the eosinophilia-myalgia syndrome. Arch Intern Med. Oct 22 2001;161(19):2301-6. [Medline].

  2. Martínez-Cabot A, Messeguer A. Generation of quinoneimine intermediates in the bioactivation of 3-(N-phenylamino)alanine (PAA) by human liver microsomes: a potential link between eosinophilia-myalgia syndrome and toxic oil syndrome. Chem Res Toxicol. Oct 2007;20(10):1556-62. [Medline].

  3. Noakes R, Spelman L, Williamson R. Is the L-tryptophan metabolite quinolinic acid responsible for eosinophilic fasciitis?. Clin Exp Med. Jun 2006;6(2):60-4. [Medline].

  4. Barth H, Klein R, Berg PA. L-tryptophan contaminant 'peak E' induces the release of IL-5 and IL-10 by peripheral blood mononuclear cells from patients with functional somatic syndromes. Clin Exp Immunol. Nov 2001;126(2):187-92. [Medline].

  5. Smith MJ, Garrett RH. A heretofore undisclosed crux of eosinophilia-myalgia syndrome: compromised histamine degradation. Inflamm Res. Nov 2005;54(11):435-50. [Medline].

  6. Swygert LA, Maes EF, Sewell LE, et al. Eosinophilia-myalgia syndrome. Results of national surveillance. JAMA. Oct 3 1990;264(13):1698-703. [Medline].

  7. Silver RM. Pathophysiology of the eosinophilia-myalgia syndrome. J Rheumatol Suppl. Oct 1996;46:26-36. [Medline]. [Full Text].

  8. Pincus T. Eosinophilia-myalgia syndrome: patient status 2-4 years after onset. J Rheumatol Suppl. Oct 1996;46:19-24; discussion 24-5. [Medline].

  9. Belongia EA, Gleich GJ. The eosinophilia-myalgia syndrome revisited [editorial]. J Rheumatol. Oct 1996;23(10):1682-5. [Medline].

  10. Bulpitt KJ, Verity MA, Clements PJ, Paulus HE. Association of L-tryptophan and an illness resembling eosinophilic fasciitis. Clinical and histopathologic findings in four patients with eosinophilia-myalgia syndrome. Arthritis Rheum. Jul 1990;33(7):918-29. [Medline].

  11. Clauw DJ, Flockhart DA, Mullins W, et al. Eosinophilia-myalgia syndrome not associated with the ingestion of nutritional supplements. J Rheumatol. Dec 1994;21(12):2385-7. [Medline].

  12. Clauw DJ, Pincus T. The eosinophilia-myalgia syndrome: what we know, what we think we know, and what we need to know. J Rheumatol Suppl. Oct 1996;46:2-6. [Medline].

  13. Culpepper RC, Williams RG, Mease PJ, et al. Natural history of the eosinophilia-myalgia syndrome. Ann Intern Med. Sep 15 1991;115(6):437-42. [Medline].

  14. Freundlich B. Eosinophilia-myalgia syndrome. In: Kelley WA, Harris ED, Ruddy S, Sledge CB, eds. Textbook of Rheumatology. 4th ed. Philadelphia, Pa: WB Saunders; 1993:1150-7.

  15. Haseler LJ, Sibbitt WL Jr, Sibbitt RR, Hart BL. Neurologic, MR imaging, and MR spectroscopic findings in eosinophilia myalgia syndrome. AJNR Am J Neuroradiol. Oct 1998;19(9):1687-94. [Medline].

  16. Hertzman PA. Criteria for the definition of the eosinophilia-myalgia syndrome. J Rheumatol Suppl. Oct 1996;46:7-12. [Medline].

  17. Hertzman PA, Falk H, Kilbourne EM, et al. The eosinophilia-myalgia syndrome: the Los Alamos Conference. J Rheumatol. Jun 1991;18(6):867-73. [Medline].

  18. Kilbourne EM, Swygert LA, Philen RM, et al. Interim guidance on the eosinophilia-myalgia syndrome. Ann Intern Med. Jan 15 1990;112(2):85-7. [Medline].

  19. Lockshin MD. Which patients with antiphospholipid antibody should be treated and how?. Rheum Dis Clin North Am. Feb 1993;19(1):235-47. [Medline].

  20. Margolin L. Non-L-tryptophan related eosinophilia-myalgia syndrome with hypoproteinemia and hypoalbuminemia. J Rheumatol. Mar 2003;30(3):628-9. [Medline].

  21. Martin RW, Duffy J, Engel AG, et al. The clinical spectrum of the eosinophilia-myalgia syndrome associated with L-tryptophan ingestion. Clinical features in 20 patients and aspects of pathophysiology. Ann Intern Med. Jul 15 1990;113(2):124-34. [Medline].

  22. Philen RM, Posada M. Toxic oil syndrome and eosinophilia-myalgia syndrome: May 8-10, 1991, World Health Organization meeting report. Semin Arthritis Rheum. Oct 1993;23(2):104-24. [Medline].

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Further Reading

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Keywords

EMS, eosinophilia-myalgia syndrome, toxic oil syndrome, TOS, L-tryptophan, tryptophan, polyneuropathy, cardiopulmonary disease, superimposed infection

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Contributor Information and Disclosures

Author

Thomas A Medsger Jr, MD, Gerald P Rodnan Professor of Medicine, Director, Scleroderma Research Program, Department of Medicine, University of Pittsburgh School of Medicine
Thomas A Medsger Jr, MD is a member of the following medical societies: American College of Epidemiology, American College of Rheumatology, American Federation for Medical Research, and Society for Epidemiologic Research
Disclosure: Nothing to disclose.

Coauthor(s)

Mohammed Mubashir Ahmed, MD, Associate Professor, Department of Medicine, Division of Rheumatology, University of Toledo College of Medicine
Mohammed Mubashir Ahmed, MD is a member of the following medical societies: American College of Physicians, American College of Rheumatology, and American Federation for Medical Research
Disclosure: Nothing to disclose.

Eisha Mubashir, MD, Fellow in Rheumatology, Department of Medicine, Fellow, Center of Excellence for Arthritis and Rheumatology, Louisiana State University Health Sciences Center, Shreveport
Disclosure: Nothing to disclose.

Shrilekha Sairam, MD, MBBS, Fellow, Department of Internal Medicine, Division of Rheumatology, University of Texas at Galveston
Disclosure: Nothing to disclose.

Jeffrey R Lisse, MD, FACP, Professor, Department of Internal Medicine, Chief, Section of Rheumatology, University of Arizona School of Medicine
Jeffrey R Lisse, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, American College of Rheumatology, American Geriatrics Society, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Carlos J Lozada, MD, Director of Rheumatology Fellowship Program, Associate Professor, Department of Medicine, Division of Rheumatology and Immunology, Jackson Memorial Medical Center, University of Miami School of Medicine
Carlos J Lozada, MD is a member of the following medical societies: American College of Physicians and American College of Rheumatology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Lawrence H Brent, MD, Associate Professor of Medicine, Thomas Jefferson University; Chair, Program Director, Department of Medicine, Division of Rheumatology, Albert Einstein Medical Center
Lawrence H Brent, MD is a member of the following medical societies: American Association of Immunologists, American College of Physicians, and American College of Rheumatology
Disclosure: Genentech Honoraria Speaking and teaching; Genentech Grant/research funds Other; Amgen Honoraria Speaking and teaching; Wyeth Honoraria Speaking and teaching; Abbott Immunology Honoraria Speaking and teaching

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD, Professor of Medicine, Temple University School of Medicine; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital
Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, and Phi Beta Kappa
Disclosure: medifocus Honoraria Review panel membership; health dialogs Honoraria Consulting; West Penn Allegheny Health System None Board membership

 
 
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