Palindromic rheumatism
Palindromic rheumatism is a relapsing-remitting inflammatory arthritis and periarthritis with attacks lasting hours to a few days and a normal joint exam between episodes, diagnosed clinically and treated first with hydroxychloroquine to reduce attack frequency and limit progression to rheumatoid arthritis.
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What this article covers
- Overview
Palindromic rheumatism is a relapsing-remitting inflammatory arthritis and periarthritis: sudden attacks of joint and periarticular pain and swelling that resolve within hours to 3 days, leaving no residual damage.
- Epidemiology
Age: Onset most often falls in the fourth or fifth decade of life, with a range from young adulthood into the seventh decade.
- Risk factors
Family history of rheumatoid arthritis: A first-degree relative with rheumatoid arthritis makes it more likely that palindromic rheumatism is an early, intermittent phase of that disease.
- Pathophysiology
Synovial and periarticular inflammation: An acute influx of neutrophils and activated T cells into synovium, tendon sheaths, and periarticular soft tissue produces the pain and swelling of an attack…
- Clinical features
Attack pattern: Sudden onset, often overnight, of pain and swelling that peaks within hours and subsides within a few hours to 3 days.
- Differential diagnosis
Early rheumatoid arthritis: Symmetric small-joint synovitis with prolonged morning stiffness that persists and progresses, unlike palindromic rheumatism where the exam is entirely normal between attacks.
- Diagnosis
What establishes the diagnosis: A clinical diagnosis made from a history of recurrent, self-limited attacks with a normal interval exam, after excluding crystal arthropathy, infection, and other…
- Management
First, treat the acute attack: Start naproxen 250 to 500 mg PO twice daily at onset and continue through the episode, typically 1 to 3 days; a short oral glucocorticoid course treats a severe attack unresponsive to an NSAID.
- Complications
Progression to rheumatoid arthritis: The principal complication, more likely in seropositive patients and typically emerging within a few years.
- Prognosis
Attack course: Individual episodes are self-limited and leave no permanent joint damage, with long symptom-free intervals possible between attacks.
- Prevention
No primary prevention: There is no established way to prevent onset itself, since the underlying trigger is not fully defined.
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