Palindromic Rheumatism

Palindromic rheumatism is recurrent, self-limited episodes of acute inflammatory arthritis or periarthritis lasting hours to days, with complete resolution and no joint damage between attacks.

• Peak onset 30 to 50 years, with equal sex distribution.

• Anti-CCP or rheumatoid factor positivity (about 50%) predicts progression: 30 to 50% evolve to rheumatoid arthritis within a few years, others to lupus or other connective tissue disease; the rest remain palindromic.

• Attacks affect fingers, wrists, knees, shoulders, heels.

• Sudden onset monoarticular or oligoarticular pain, swelling, erythema, peaking in hours, lasting 1 to 3 days (rarely a week), then fully resolving.

• Periarticular nodules, tendon sheath swelling.

• Asymptomatic intervals lasting days to months.

• No fever or systemic disease in most.

• Clinical, supported by symptom diary and photographs of attacks.

• During attacks: raised ESR/CRP, synovial fluid mildly inflammatory.

• Rheumatoid factor, anti-CCP (high titre strongly predictive), ANA, uric acid, HLA-B27.

• Radiographs normal; ultrasound may show synovitis during flares.

• Exclude gout, pseudogout (crystal analysis), reactive arthritis, Lyme disease, familial Mediterranean fever, Still disease, haemochromatosis.

• NSAIDs during attacks (naproxen 500 mg twice daily, diclofenac 50 mg three times daily); short prednisolone 10 to 20 mg if severe; intra-articular steroid.

• Frequent attacks or anti-CCP positive: hydroxychloroquine 200 to 400 mg daily (first line, reduces attack frequency and may reduce progression), sulfasalazine 1 to 3 g daily, methotrexate 10 to 25 mg weekly.

• Colchicine 0.5 mg twice daily is sometimes tried.

• Monitor every 3 to 6 months for evolution to rheumatoid arthritis (persistent synovitis, erosions); start treat-to-target DMARDs early if so.

• Counsel regarding unpredictability and reassure about absence of joint damage.