Fibromyalgia Case Study: Symptoms, Investigations, Diagnosis and Management of Chronic Widespread Pain

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Fibromyalgia Case Study: Symptoms, Investigations, Diagnosis and Management of Chronic Widespread Pain

Clinical Case Presentation

1. Patient Profile

Parameter

Details

Age

25 years

Sex

Female

Presenting Problem

Chronic widespread musculoskeletal pain

Duration

Approximately 1 year

2. Chief Complaints

  • Polyarthralgia for approximately 1 year
  • Generalized myalgia
  • Lower back pain
  • Pain predominantly worsening at night
  • Requirement for frequent/daily NSAID use for pain relief

3. History of Presenting Illness

A 25-year-old female presented with a history of generalized joint pain (polyarthralgia) for approximately one year, associated with widespread muscle pain and lower back pain.

There was no history of early morning stiffness or clinically apparent joint swelling. The patient reported that the pain was more prominent at night and required frequent/daily use of NSAIDs for symptomatic relief.

There was no history of fever, night sweats, significant weight loss, or other constitutional symptoms.

Clinical assessment demonstrated diffuse tenderness involving multiple areas of the body, without objective evidence of inflammatory arthritis.

4. Rheumatological Examination

Joint Examination

  • Swollen Joint Count (SJC): no
  • Initial Tender Joint Count (TJC): yes
  • Subsequent Tender Joint Count (TJC): intermediate
  • Diffuse tenderness present throughout the body
  • No clinically significant joint swelling
  • No obvious joint deformities
  • No malar rash noted

The absence of objective synovitis, together with widespread tenderness, was suggestive of a non-inflammatory pain syndrome.

5. Initial Clinical Impression

The initial clinical impression was fibromyalgia/chronic widespread pain syndrome.

A rheumatological evaluation was performed to assess for possible inflammatory or autoimmune disorders.

6. Investigations

6.1 Hematological Investigations

Investigation

Result

Interpretation

Hemoglobin

12.10 g/dL

Within normal range

Eosinophils

9.5%

Mildly elevated

Absolute Eosinophil Count

0.84 thou/mm³

Mild eosinophilia

6.2 Inflammatory Markers

Investigation

Result

Interpretation

ESR

11 mm/hr

Normal

CRP

1.5 mg/L

Normal

There was no laboratory evidence of significant systemic inflammation.

6.3 Autoimmune and Immunological Investigations

Investigation

Result

Interpretation

ANA Screening

21.3 Units

Moderate positive

Anti-CCP Antibody

0.50 U/mL

Negative

Rheumatoid Factor

Negative/not elevated as documented

No supportive evidence of rheumatoid arthritis

The positive ANA screening result was not accompanied by clinical or laboratory features strongly suggestive of an active systemic inflammatory autoimmune disease.

6.4 Metabolic and Endocrine Investigations

Investigation

Result

Interpretation

Vitamin D

49.27 nmol/L

Deficient

TSH

1.61

Normal

HbA1c

5.1%

Normal

6.5 Infectious Disease Screening

  • HIV: Non-reactive
  • HBsAg: Non-reactive
  • Anti-HCV: Non-reactive

7. Other Clinical Finding

Breast ultrasonography demonstrated a small lesion reported as consistent with a fibroadenoma.

This was an incidental finding and was not considered contributory to the presenting widespread musculoskeletal symptoms.

8. Psychiatric and Psychological Assessment

During subsequent clinical evaluation, the patient reported:

  • Low mood
  • Anger outbursts
  • Persistent chronic pain symptoms

Given the association between chronic widespread pain and psychological/affective symptoms, Psychiatry follow-up was advised as part of a multidisciplinary management approach.

9. Treatment and Clinical Management

9.1 Initial Management

The initial treatment included:

  • Pregabalin 75 mg + Nortriptyline 10 mg
  • Naproxen 500 mg for symptomatic pain relief
  • Rheumatological investigations and imaging

9.2 Subsequent Management

Treatment was subsequently modified to include:

  • Pregabalin 75 mg
  • Fluoxetine 20 mg
  • Single dose of Albendazole, as documented
  • Continued psychiatric follow-up

9.3 Psychiatric Management

The patient was subsequently started on:

  • Amitriptyline 10 mg at bedtime
  • Clonazepam 0.25 mg at bedtime

At psychiatric follow-up, Desvenlafaxine was introduced at 50 mg initially, with a planned increase to 100 mg.

Later records documented treatment with:

  • Desvenlafaxine 150 mg
  • Amitriptyline 25 mg
  • Pregabalin 75 mg
  • Clonazepam 0.5 mg

10. Clinical Course

The clinical course was characterized by persistent chronic widespread musculoskeletal pain with marked tenderness but without objective evidence of inflammatory arthritis.

Rheumatological investigations showed:

  • Normal ESR and CRP
  • Negative Anti-CCP
  • No objective joint swelling
  • No characteristic systemic features of connective tissue disease

Although ANA screening was moderately positive, the overall clinical picture did not demonstrate convincing evidence of an active systemic inflammatory rheumatological disorder.

The presence of vitamin D deficiency and mild eosinophilia were notable laboratory findings.

Management subsequently evolved toward a multidisciplinary approach involving Internal Medicine, Rheumatology, and Psychiatry, with the use of neuromodulators and antidepressant therapy for chronic pain and associated mood symptoms.

11. Working / Clinical Diagnosis

Primary Clinical Diagnosis

Fibromyalgia / Chronic Widespread Pain Syndrome

Associated Findings

  • Vitamin D deficiency
  • Mild eosinophilia
  • Positive ANA screening without clear clinical evidence of systemic autoimmune disease
  • Associated low mood and anger outbursts

12. Differential Diagnosis

1. Fibromyalgia / Chronic Widespread Pain Syndrome

Favored by the presence of widespread pain and diffuse tenderness, combined with the absence of objective synovitis and normal inflammatory markers.

2. Inflammatory Arthritis

Less likely because of the absence of joint swelling, early morning stiffness, and elevated inflammatory markers.

3. Systemic Autoimmune / Connective Tissue Disease

Less likely in the absence of characteristic clinical manifestations despite a moderately positive ANA screening result.

4. Vitamin D Deficiency-Associated Musculoskeletal Pain

Vitamin D deficiency may contribute to generalized musculoskeletal pain and myalgia.

5. Psychological/Affective Factors Associated With Chronic Pain

Relevant given the documented low mood and anger outbursts and the subsequent involvement of Psychiatry.

13. Key Clinical Learning Points

  • Widespread pain with diffuse tenderness does not necessarily indicate inflammatory arthritis.
  • The absence of objective synovitis and the presence of normal ESR/CRP favor a non-inflammatory pain disorder.
  • A positive ANA alone does not establish a diagnosis of systemic autoimmune disease and should always be interpreted in the context of the patient's clinical findings.
  • Negative Anti-CCP and the absence of objective joint swelling make rheumatoid arthritis less likely in this clinical context.
  • Vitamin D deficiency should be identified and appropriately addressed as a potentially contributory factor to musculoskeletal symptoms.
  • Chronic widespread pain may benefit from a multidisciplinary management strategy, including appropriate psychological and psychiatric assessment.
  • Management of fibromyalgia is generally individualized and may involve pharmacological as well as non-pharmacological interventions.

14. Final Clinical Summary

A 25-year-old female presented with approximately one year of chronic widespread musculoskeletal pain, polyarthralgia, generalized myalgia, and lower back pain. Clinical examination demonstrated marked diffuse tenderness without objective joint swelling or deformity.

Laboratory investigations revealed normal ESR and CRP, negative Anti-CCP, and no convincing laboratory or clinical evidence of inflammatory arthritis. ANA screening was moderately positive; however, there were no corresponding clinical features to establish a systemic autoimmune connective tissue disorder.

Additional findings included vitamin D deficiency and mild eosinophilia.

Overall, the clinical presentation was most consistent with fibromyalgia/chronic widespread pain syndrome. Management subsequently incorporated a multidisciplinary approach involving rheumatological evaluation and psychiatric care for associated mood and somatic symptoms, with treatment including pregabalin and antidepressant medications.

References

  1. Clauw DJ. Fibromyalgia: A Clinical Review. JAMA. 2014;311(15):1547–1555. doi:10.1001/jama.2014.3266.
    Online source: https://pubmed.ncbi.nlm.nih.gov/24737367/

  2. Macfarlane GJ, Kronisch C, Dean LE, et al. EULAR revised recommendations for the management of fibromyalgia. Annals of the Rheumatic Diseases. 2017;76(2):318–328. doi:10.1136/annrheumdis-2016-209724.
    Online source: https://pubmed.ncbi.nlm.nih.gov/27377815/

  3. Wolfe F, Clauw DJ, Fitzcharles MA, et al. 2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria. Seminars in Arthritis and Rheumatism. 2016;46(3):319–329. doi:10.1016/j.semarthrit.2016.08.012.
    Online source: https://pubmed.ncbi.nlm.nih.gov/27916278/

  4. American College of Rheumatology. Antinuclear Antibodies (ANA). Updated February 2025.
    Online source: https://rheumatology.org/patients/antinuclear-antibodies-ana

  5. Endotext. Fibromyalgia: 2016 Revisions to the 2010/2011 Fibromyalgia Diagnostic Criteria. National Library of Medicine, National Center for Biotechnology Information.
    Online source: https://www.ncbi.nlm.nih.gov/books/NBK279092/

  6. Häuser W, Ablin J, Fitzcharles MA, et al. Fibromyalgia. Nature Reviews Disease Primers. 2015;1:15022. doi:10.1038/nrdp.2015.22.

  7. Goldenberg DL. Diagnosis and differential diagnosis of fibromyalgia. American Journal of Medicine. 2009;122(12 Suppl):S14–S21. doi:10.1016/j.amjmed.2009.09.007.

  8. EULAR. Managing Fibromyalgia: Patient Version of the EULAR Recommendations. European Alliance of Associations for Rheumatology.
    Online source: https://www.eular.org/document/download/251/cfc1fc15-1cab-4262-b7f8-4d50cb60be84/267

Disclaimer

This clinical case is presented in a de-identified and anonymized format for educational purposes. Patient-identifying information has been omitted. The information presented should not be considered a substitute for professional medical evaluation, diagnosis, or treatment.

Important Note on Patient Confidentiality

This case presentation has been de-identified. Patient name and unnecessary personally identifying information have been omitted to maintain patient confidentiality. Only clinically relevant information has been retained for educational purposes.

Medical Disclaimer: The information provided in this article is strictly for educational, study, and exam-preparation purposes. It does not constitute professional medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider for clinical decisions.

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