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Palindromic Rheumatism: Causes & Treatment

Palindromic rheumatism is a rare joint condition characterised by sudden, recurring episodes of joint inflammation that resolve completely between attacks.

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Things worth knowing about "Palindromic Rheumatism"

Palindromic rheumatism is a rare joint condition characterised by sudden, recurring episodes of joint inflammation that resolve completely between attacks.

What is Palindromic Rheumatism?

Palindromic rheumatism is a rare, episodic inflammatory joint condition characterised by sudden attacks of joint pain, swelling, and redness that appear without warning and resolve completely within hours to days, leaving no permanent joint damage. The term “palindromic” is derived from the Greek word for “running back again,” reflecting the recurrent and fully reversible nature of the condition. It was first described by Hench and Rosenberg in 1944.

Causes

The exact cause of palindromic rheumatism is not yet fully understood. It is considered to be an autoimmune disorder in which the immune system mistakenly attacks the body's own joint tissues. Several contributing factors have been identified:

Genetic predisposition, including specific HLA gene variants
Dysregulation of the immune system
Association with rheumatoid arthritis: a proportion of patients eventually develop classic rheumatoid arthritis
Presence of rheumatoid factor and anti-CCP antibodies in some patients

Symptoms

Symptoms of palindromic rheumatism appear suddenly and without warning, typically resolving completely within hours to a few days. Common features include:

Rapid onset of joint swelling, most commonly affecting the hands, wrists, shoulders, and knees
Significant joint pain (arthralgia) ranging from mild to severe
Redness and warmth around the affected joint
Restricted movement of the affected joint during an attack
Occasional inflammation of periarticular tissues (soft tissue around the joint)
Complete resolution of symptoms between attacks, with no lasting joint damage

The frequency of attacks varies widely between individuals – some experience only a few episodes per year, while others may have several per week.

Diagnosis

Diagnosing palindromic rheumatism is often a process of exclusion, as there is no specific test that definitively confirms the condition. The following investigations are typically performed:

Medical history and clinical examination: The characteristic episodic, fully reversible pattern of joint inflammation is a key diagnostic indicator
Blood tests: Measurement of inflammatory markers (CRP, ESR), rheumatoid factor, and anti-CCP antibodies
Imaging: X-rays or MRI to rule out permanent joint damage or erosions
Exclusion of other conditions: Including gout, psoriatic arthritis, reactive arthritis, and rheumatoid arthritis

Treatment

Since attacks resolve spontaneously and completely, treatment focuses on relieving acute symptoms and reducing the frequency of future attacks. Treatment options include:

Acute Management

Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen for pain relief
Short-term corticosteroids for severe attacks
Local cooling of the affected joint

Long-term Treatment

Hydroxychloroquine (an antimalarial agent) is the most commonly used medication to reduce the frequency of attacks
Methotrexate or other disease-modifying antirheumatic drugs (DMARDs) when there is progression towards rheumatoid arthritis
Regular rheumatological monitoring to detect early transition to chronic arthritis

Outlook and Prognosis

The course of palindromic rheumatism varies considerably between individuals. In some patients – particularly those who are anti-CCP antibody positive – the condition eventually transitions into rheumatoid arthritis. In others, the episodic pattern persists throughout life without developing into a chronic condition. Because no permanent joint damage occurs during the palindromic phase, quality of life with appropriate treatment is generally good.

References

Hench P.S., Rosenberg E.F. - Palindromic rheumatism. A “new” oft-recurring disease of joints (arthritis, periarthritis, para-arthritis) apparently producing no articular residues. Archives of Internal Medicine, 1944.
Guerne P.A., Weisman M.H. - Palindromic rheumatism: part of or apart from the spectrum of rheumatoid arthritis. American Journal of Medicine, 1992.
Firestein G.S. et al. - Kelley & Firestein's Textbook of Rheumatology, 10th Edition, Elsevier, 2017.

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