Palindromic rheumatism

Palindromic rheumatism is a rare episodic form of inflammatory arthritis – meaning the joint pain and swelling come and go ¹. Palindromic rheumatism is a periodic idiopathic arthritis characterized by sudden, transient, recurring, episodes of mono or oligo-arthritis, is not associated with imaging abnormalities ² and lasting from a few hours to several days, which resolved spontaneously without residual joint damage, and is associated with positive acute phase reactant during attacks ³. Between attacks, the symptoms disappear and the affected joints go back to normal, with no lasting damage. Half of the people who have palindromic rheumatism eventually develop rheumatoid arthritis, which does cause permanent joint damage. Palindromic rheumatism affects men and women equally, and typically affects people between the ages of 20 and 50.

Palindromic rheumatism was first described by Hench and Rosenberg in 1944 as multiple recurring afebrile episodes of acute arthritis, periarthritis, and sometimes swelling near the joints, lasting from a few hours to several days, disappearing completely, and producing no residual articular effects ⁴. The prevalence of palindromic rheumatism in the population has been estimated at 5% ⁵; however, a recent study on the prevalence of palindromic rheumatism as diagnosed by rheumatologists found a prevalence nearly 10 times greater ⁶.

Palindromic rheumatism key points

• Palindromic rheumatism is characterized by recurrent attacks of arthritis which last for hours to days, and resolves completely with no articular damage.
• Palindromic rheumatism is characterized by the absence of fever and negative laboratory tests and radiographic tests. The typical clinical features can help to differentiate it from other causes of joint pain. It must be considered as a diagnosis of exclusion in patients with no positive laboratory or imaging tests.
• Prognosis with palindromic rheumatism is varied; one-third of patients experience remission; one-third experience recurrence, and one-third progress to rheumatoid arthritis (RA).
• Nonsteroidal anti-inflammatory drugs (NSAIDs) are useful in control of acute attacks and anti-malarials help to prevent attacks and reduce their frequency and severity.

Palindromic rheumatism causes

The cause of palindromic rheumatism is unknown, although a possible allergic origin has been suggested.

Palindromic rheumatism symptoms

Palindromic rheumatism is characterized by sudden, multiple, and recurring attacks of joint pain and swelling. Each episode may last from several hours to several days. The frequency of attacks varies, from one episode a day to several during the course of a year. Usually two or three joints are involved, but different joints may be involved in different episodes. The soft tissues around the joints may also be affected. Episodes of recurrence form a pattern, with symptom-free periods between attacks lasting for weeks to months. The joint usually returns back to normal without any permanent joint damage.

Some individuals with this condition develop chronic joint inflammation and go on to develop rheumatoid arthritis.

Palindromic rheumatism diagnosis

Your doctor may diagnose palindromic rheumatism after a complete medical history, physical examination, and possibly X-rays. Laboratory tests may be ordered to rule out rheumatoid arthritis. No one test can diagnose palindromic rheumatism.

Diagnostic criteria for palindromic rheumatism ⁷

• A history of brief sudden-onset, recurrent attacks of monoarthritis
• Direct observation of one attack by a physician
• Three or more joints involved in different attacks
• More than five attacks in the last 2 years
• Negative x-rays, acute phase reactants and rheumatoid factor
• Exclusion of other recurrent monoarthritis: gout; chondrocalcinosis; intermittent hydrarthrosis; and periodic diseases

Palindromic rheumatism treatment

Treatment may include nonsteroidal anti-inflammatory drugs (NSAIDs) for acute attacks. Antimalarials, such as hydroxychloroquine, have been helpful in reducing the frequency and duration of attacks and may reduce the likelihood that palindromic rheumatism will progress to rheumatoid arthritis.

Managing flares of palindromic rheumatism requires balancing activity and rest, eating a nutritious diet, and following the recommended treatment plan. Self management involves making lifestyle choices and addressing both the physical and emotional effects of arthritis. It encompasses the choices made each day to live well and stay healthy.

Palindromic rheumatism prognosis

Prognosis with palindromic rheumatism is varied; one-third of patients experience remission; one-third experience recurrence, and one-third progress to rheumatoid arthritis (RA).

References

1. Palindromic rheumatism. https://www.arthritis.org/about-arthritis/types/palindromic-rheumatism/
2. Hardo HG. Palindromic rheumatism: a review. J R Soc Med. 1981;74:521–524. doi: 10.1177/014107688107400713
3. Kaushik P. Palindromic rheumatism: a descriptive report of seven cases from North Dakota and a short review of literature. Clin Rheumatol. 2010;29(1):83–86. doi: 10.1007/s10067-009-1280-2
4. Hench PS, Rosenberg EF. Palindromic rheumatism. “new” oft-recurring disease of joints (arthritis, periarthritis, para-arthritis) apparently producing no articular residues. Report of thirty-four cases; its relation to “angio-neural arthrososis,” “allergic rheumatism” and rheumatoid arthritis. Arch Intern Med 1944;73:293–321.
5. Pasero G, Barbieri P. Palindromic rheumatism: you just have to think about it. Clin Exp Rheumatol 1986;4:197–199.
6. Powell A, Davis P, Jones N, et al. Palindromic rheumatism is a common disease: comparison of new-onset palindromic rheumatism compared to new-onset rheumatoid arthritis in a 2-year cohort of patients. J Rheumatol 2008;35:992–994.
7. Pasero G, Barbieri P. Palindromic rheumatism: you just have to think about it! ClinExp Rheumatol. 1986;4(3):197–199.