RS3PE Syndrome

RS3PE (remitting seronegative symmetrical synovitis with pitting oedema) is an acute symmetrical inflammatory polyarthritis with prominent pitting oedema of hands and feet in older adults.

• Typical onset over age 60 (median 70 years), men more than women.

• Associated with paraneoplastic disease (solid tumours, haematological) in 10 to 20% of cases, and with HLA-B7.

• Elevated VEGF levels implicated in oedema.

• Overlaps with polymyalgia rheumatica; usually excellent steroid response and remission.

• Sudden onset (days) bilateral, symmetric swelling with pitting oedema over dorsum of hands and feet, wrist and finger synovitis, tenosynovitis, carpal tunnel syndrome.

• Morning stiffness, systemic symptoms (fever, weight loss), difficulty with grip.

• Hip and shoulder girdle pain in some.

• Features of malignancy if present: weight loss, night sweats, lymphadenopathy.

• Raised ESR and CRP, rheumatoid factor and anti-CCP negative.

• Ultrasound/MRI: tenosynovitis and subcutaneous oedema with minimal erosions.

• Radiographs normal.

• Exclude rheumatoid arthritis, polymyalgia rheumatica, gout, pseudogout, psoriatic arthritis, remitting seronegative polyarthritis, cardiac, renal or venous causes of oedema.

• Age appropriate malignancy screening (chest radiograph, CT, PSA, mammography, endoscopy as indicated); persistent or atypical disease requires targeted search.

• Prednisolone 10 to 20 mg daily (low dose) with rapid response in days; taper over 3 to 6 months (shorter than polymyalgia rheumatica), remission in most.

• NSAIDs for mild disease.

• Non-response or relapse: methotrexate 10 to 15 mg weekly, hydroxychloroquine 200 mg twice daily, sulfasalazine 1 to 2 g daily as steroid sparing agents.

• Investigate and treat underlying malignancy if identified; the syndrome often resolves with cancer treatment.

• Bone protection (calcium 1000 mg, vitamin D 800 IU daily; bisphosphonate if prolonged steroids).

• Follow up every 3 months for relapse and malignancy for at least 1 to 2 years.