An 82-year-old white man with a past medical history of hypertension, coronary

artery disease, cerebrovascular accident, T12 compression fracture, and asthma presents with malaise, anorexia, hip and shoulder pain and stiffness, and an inability to rise from a chair, walk, and care for himself. On further questioning, he reports a 3-month history of fatigue, weight loss, and bilateral shoulder and hip stiffness. He recalls feeling relief from these symptoms after self-administration of tapered corticosteroid doses taken during episodes of asthma exacerbation.

On examination, he is afebrile, has limited range of motion of the hips and shoulders, and is unable to raise the right arm laterally above 30 degrees. Point tenderness at the subacromial bursa is noted. His examination is otherwise unremarkable. Brain CT shows no evidence of intracranial hemorrhage or recent infarct.

• Na+ 135 mEq/dL
• K+ 4.1 mEq/dL
• Blood urea nitrogen 21 mg/dL
• Creatinine 1.1 mg/dL
• HCO3− 23 mEq/dL
• White blood cells 5,300/mm3
• Hemoglobin 10.0 g/dL
• Platelets 389,000/μL
• Westergren sedimentation rate 99 mm/hour
• C-reactive protein 6.6 mg/L
• Creatine phosphokinase 241 U/L

He receives prednisone (20 mg/day) and exhibits a dramatic subjective and objective improvement after 24 hours. Ten days after the initiation of prednisone, he has no further complaints, and his Westergren sedimentation rate and C-reactive protein levels have decreased to 22 mm/hour and 0.3 mg/L, respectively. His Hgb level has increased to 12.3 g/dL. What is the most likely cause of this patient’s musculoskeletal symptoms?

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