HOD, Rheumatology, Manipal Hospital, Dwarka, New Delhi
Part 4 of 8 in Diagnosis and Management of Rheumatoid Arthritis
Palindromic Rheumatism and Preclinical RA: Recognising Early and Atypical Presentations
September 1, 2024
Not every RA-adjacent presentation looks like classic rheumatoid arthritis. Dr. Ajmani described palindromic rheumatism as a distinct entity: brief, intense joint inflammation lasting from a few hours to a few days, usually affecting a single joint, that resolves completely between attacks.
Distinguishing palindromic rheumatism from gout
It can be mistaken for gout, but the distinguishing features are the duration and the serology: gout attacks typically last more than two days, while palindromic rheumatism resolves in under two days, and rheumatoid factor and anti-CCP antibody are typically positive in palindromic rheumatism, while uric acid remains normal. Around one-third of patients with palindromic rheumatism go on to develop full rheumatoid arthritis.
Preclinical RA and treatment of the palindromic phase
Preclinical RA describes a period of autoimmunity before any joint symptoms develop: subclinical inflammation may be present, with joint pain but no actual joint swelling. In these patients, a positive anti-CCP carries a high risk of progression to full rheumatoid arthritis. For palindromic rheumatism itself, hydroxychloroquine is the treatment Dr. Ajmani reaches for, addressing a direct question on management raised during the session.
This article is based on a Jivo Masterclass session conducted by Dr. Sajal Ajmani, HOD, Rheumatology, Manipal Hospital, Dwarka, New Delhi. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
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This guide is based on a live Jivo Masterclass: Dr. Sajal Ajmani taught doctors across Africa on September 1, 2024.
FROM THE LIVE Q&A
Moderator
Beyond the joints, what organs can rheumatoid arthritis affect, particularly the heart, and how is that treated?
Dr. Sajal Ajmani
Extra-articular involvement is rare, but the lungs can develop interstitial lung disease, the eyes can develop scleritis and dryness, the heart very rarely can develop pericarditis and pericardial effusion, the kidneys very rarely can be affected by glomerulonephritis or amyloidosis, and the skin can develop vasculitis. For cardiac involvement specifically, treatment is steroids combined with methotrexate.
Frequently Asked Questions
What is the recommended medical treatment for palindromic rheumatism?▼
Hydroxychloroquine.
What is the definition of sustained remission?▼
Sustained remission is defined as at least 12 months of remission before any therapy is decreased.
Why does rheumatoid arthritis show a preferential pattern of joint involvement, and why are certain interphalangeal joints spared?▼
DIP (distal interphalangeal) joint involvement is less common in rheumatoid arthritis because there is less synovium in the DIP joints compared to the more commonly affected proximal interphalangeal and metacarpophalangeal joints.
What is the place of pulse or bolus intravenous corticosteroids (solumedrol) in an acute crisis of rheumatoid arthritis, generalised disabling joint pain with high fever?▼
Steroid pulse therapy can be given in severe RA in patients with many swollen and tender joints, usually methylprednisolone 500mg to 1000mg intravenously once a day for one to three days.
Beyond the joints, what organs can rheumatoid arthritis affect, particularly the heart, and how is that treated?▼
Extra-articular involvement is rare, but the lungs can develop interstitial lung disease, the eyes can develop scleritis and dryness, the heart very rarely can develop pericarditis and pericardial effusion, the kidneys very rarely can be affected by glomerulonephritis or amyloidosis, and the skin can develop vasculitis. For cardiac involvement specifically, treatment is steroids combined with methotrexate.
How is palindromic rheumatism different from gout?▼
Palindromic rheumatism resolves in under two days with normal uric acid and typically positive RF/anti-CCP, while gout attacks usually last more than two days.
What is the recommended treatment for palindromic rheumatism?▼
Hydroxychloroquine.
In This Series: Diagnosis and Management of Rheumatoid Arthritis
- 1.Diagnosis and Management of Rheumatoid Arthritis
- 2.Diagnosing Rheumatoid Arthritis: From the 1987 to the 2010 ACR/EULAR Criteria
- 3.Why Rheumatoid Factor and Anti-CCP Alone Don't Diagnose Rheumatoid Arthritis
- 4.Palindromic Rheumatism and Preclinical RA: Recognising Early and Atypical Presentations
- 5.Monitoring Disease Activity: DAS28, SDAI, CDAI and the ACR Response Criteria
- 6.Treat-to-Target: The EULAR 2016 Recommendations and the DMARD Ladder
- 7.Managing Severe Flares: Steroid Pulse Therapy and Achieving Sustained Remission
- 8.Extra-Articular Rheumatoid Arthritis: Lung, Eye, Heart, Kidney and Skin Involvement