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.

Further Inpatient Care

Patients who are acutely ill with EMS may require hospitalization for supportive care, inpatient workup for infections, auto-immune diseases, neoplasms, and other mimics of EMS, and consideration of corticosteroid therapy.

Inpatient & Outpatient Medications

Treatment is based on symptoms. Persistent pain requires analgesics. 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

Exercise may result in relapse of myalgias in some patients, and they should be advised to avoid any activities that cause or worsen symptoms. Patients should avoid L-tryptophan and other possible causative medication(s) or supplement(s).

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 (90%) 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. 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^[28].

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.

Questions

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. 2001 Oct 22. 161(19):2301-6. [QxMD MEDLINE Link].
Hertzman PA. Criteria for the definition of the eosinophilia-myalgia syndrome. J Rheumatol Suppl. 1996 Oct. 46:7-12. [QxMD MEDLINE Link].
Silver RM. Pathophysiology of the eosinophilia-myalgia syndrome. J Rheumatol Suppl. 1996 Oct. 46:26-36. [QxMD MEDLINE Link].
Belongia EA, Gleich GJ. The eosinophilia-myalgia syndrome revisited [editorial]. J Rheumatol. 1996 Oct. 23(10):1682-5. [QxMD MEDLINE Link].
Hertzman PA, Falk H, Kilbourne EM, et al. The eosinophilia-myalgia syndrome: the Los Alamos Conference. J Rheumatol. 1991 Jun. 18(6):867-73. [QxMD MEDLINE Link].
Klarskov K, Gagnon H, Boudreault PL, Normandin C, Plancq B, Marsault E, et al. Structure determination of disease associated peak AAA from l-Tryptophan implicated in the eosinophilia-myalgia syndrome. Toxicol Lett. 2018 Jan 5. 282:71-80. [QxMD MEDLINE Link].
Philen RM, Posada M. Toxic oil syndrome and eosinophilia-myalgia syndrome: May 8-10, 1991, World Health Organization meeting report. Semin Arthritis Rheum. 1993 Oct. 23(2):104-24. [QxMD MEDLINE Link].
Allen JA, Varga J. Eosinophilia-myalgia syndrome, eosinophilic fasciitis, and related fasciitis disorders. Katirji B, et al. Neuromuscular Disorders in Clinical Practice. New York: Springer Science+Business Media; 2014. 1561-73.
Noakes R, Spelman L, Williamson R. Is the L-tryptophan metabolite quinolinic acid responsible for eosinophilic fasciitis?. Clin Exp Med. 2006 Jun. 6 (2):60-4. [QxMD MEDLINE Link].
Mendoza FA, Purohit S, Kenyon L, Jimenez SA. Severe eosinophilic syndrome associated with the use of probiotic supplements: a new entity?. Case Rep Rheumatol. 2012. 2012:934324. [QxMD MEDLINE Link].
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. 1996 Oct. 46:2-6. [QxMD MEDLINE Link].
Okada S, Kamb ML, Pandey JP, Philen RM, Love LA, Miller FW. Immunogenetic risk and protective factors for the development of L-tryptophan-associated eosinophilia-myalgia syndrome and associated symptoms. Arthritis Rheum. 2009 Oct 15. 61(10):1305-11. [QxMD MEDLINE Link]. [Full Text].
Smith MJ, Garrett RH. A heretofore undisclosed crux of eosinophilia-myalgia syndrome: compromised histamine degradation. Inflamm Res. 2005 Nov. 54(11):435-50. [QxMD MEDLINE Link].
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. 1990 Jul 15. 113(2):124-34. [QxMD MEDLINE Link].
Swygert LA, Maes EF, Sewell LE, et al. Eosinophilia-myalgia syndrome. Results of national surveillance. JAMA. 1990 Oct 3. 264(13):1698-703. [QxMD MEDLINE Link].
Allen JA, Peterson A, Sufit R, Hinchcliff ME, Mahoney JM, Wood TA, et al. Post-epidemic eosinophilia-myalgia syndrome associated with L-tryptophan. Arthritis Rheum. 2011 Nov. 63(11):3633-9. [QxMD MEDLINE Link].
Swygert LA, Back EE, Auerbach SB, Sewell LE, Falk H. Eosinophilia-myalgia syndrome: mortality data from the US national surveillance system. J Rheumatol. 1993 Oct. 20 (10):1711-7. [QxMD MEDLINE Link].
Culpepper RC, Williams RG, Mease PJ, et al. Natural history of the eosinophilia-myalgia syndrome. Ann Intern Med. 1991 Sep 15. 115(6):437-42. [QxMD MEDLINE Link].
Pincus T. Eosinophilia-myalgia syndrome: patient status 2-4 years after onset. J Rheumatol Suppl. 1996 Oct. 46:19-24; discussion 24-5. [QxMD MEDLINE Link].
Haseler LJ, Sibbitt WL Jr, Sibbitt RR, Hart BL. Neurologic, MR imaging, and MR spectroscopic findings in eosinophilia myalgia syndrome. AJNR Am J Neuroradiol. 1998 Oct. 19(9):1687-94. [QxMD MEDLINE Link].
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. 1990 Jul. 33(7):918-29. [QxMD MEDLINE Link].
Clauw DJ, Flockhart DA, Mullins W, et al. Eosinophilia-myalgia syndrome not associated with the ingestion of nutritional supplements. J Rheumatol. 1994 Dec. 21(12):2385-7. [QxMD MEDLINE Link].
Rieber N, Belohradsky BH. AHR activation by tryptophan--pathogenic hallmark of Th17-mediated inflammation in eosinophilic fasciitis, eosinophilia-myalgia-syndrome and toxic oil syndrome?. Immunol Lett. 2010 Feb 16. 128 (2):154-5. [QxMD MEDLINE Link].

Media Gallery

of 0

Author

William E Monaco, MD Rheumatologist, MaineGeneral Rheumatology

William E Monaco, MD is a member of the following medical societies: American College of Rheumatology

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: AbbVie<br/>Received income in an amount equal to or greater than $250 from: AbbVie; Janssen.

Coauthor(s)

Stephanie Danielle Mathew, DO Fellowship Program Director, Dartmouth-Hitchcock Medical Center

Stephanie Danielle Mathew, DO is a member of the following medical societies: American College of Physicians, American College of Rheumatology, American Osteopathic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Lawrence H Brent, MD Associate Professor of Medicine, Sidney Kimmel Medical College of 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 for the Advancement of Science, American Association of Immunologists, American College of Physicians, American College of Rheumatology

Disclosure: Stock ownership for: Johnson & Johnson.

Chief Editor

Herbert S Diamond, MD Visiting Professor of Medicine, Division of Rheumatology, State University of New York Downstate Medical Center; 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, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Carlos J Lozada, MD Director of Rheumatology Fellowship Training Program, Professor of Clinical Medicine, Department of Medicine, Division of Rheumatology and Immunology, University of Miami, Leonard M Miller School of Medicine

Carlos J Lozada, MD is a member of the following medical societies: American College of Physicians, American College of Rheumatology

Disclosure: Received honoraria from Pfizer for consulting; Received grant/research funds from AbbVie for other; Received honoraria from Heel for consulting.

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 Rheumatology

Disclosure: Nothing to disclose.

Acknowledgements

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.