Palindromic Rheumatism

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Introduction[edit | edit source]

Palindromic rheumatism (PR) is an intermittent disease characterized by recurring, self-resolving attacks of inflammation in the articular and periarticular tissues. These attacks usually affect only one joint and can last from a few hours to a few days. Interestingly, during the attacks, patients do not experience any symptoms. The joints most commonly involved in these attacks are the knees, wrists, metacarpophalangeal joints, and proximal interphalangeal (PIP) joints.[1][2]

The key distinguishing feature between PR and Rheumatoid arthritis (RA) is the relapsing-remitting clinical presentation of PR, as opposed to the generally persistent joint involvement in RA that does not remit unless treated.[2]

Palindromic rheumatism is named after the term 'palindrome', which refers to a word or phrase that reads the same way forwards and backward, such as 'level' or 'madam'. During a typical palindromic attack, the symptoms begin and end in the same way, with the most severe point occurring in the middle.

Etiology[edit | edit source]

The exact cause of Palindromic Rheumatism (PR) is still unknown. However, research indicates that PR is linked to the development of autoimmune rheumatic diseases, particularly rheumatoid arthritis (RA). Studies have shown that after a varying follow-up period, approximately 15% to 66% of patients with PR went on to develop RA.

Several factors predict the progression of psoriatic arthritis to rheumatoid arthritis (RA), including genetic background, ultrasonographic findings of synovitis, the presence of anti-cyclic citrullinated peptide antibodies (ACPA), positive rheumatoid factor, and hand involvement. Conversely, some genetic backgrounds, like HLA-DRB1, may increase susceptibility to Palindromic Rheumatism(PR) but not RA, indicating that PR is distinct from RA.

Epidemiology[edit | edit source]

Several studies have shown that up to 50% of patients with PR will develop persistent arthritis, most commonly RA, indicating that PR often progresses into RA. This suggests that for many patients, PR evolves into RA, making PR a prodrome or forme fruste of RA. A prior study suggested a 5% frequency of PR compared to RA, but in our 2-year cohort, it was 10 times more frequent.[3]

Clinical Presentation[edit | edit source]

Individuals with palindromic rheumatism typically do not experience symptoms during periods between attacks. Recurrent episodes of joint pain and swelling that resolve spontaneously distinguish it from other forms of inflammatory arthritis like rheumatoid arthritis. People with these conditions have joint problems most of the time, although the level of problem may vary. During an attack of palindromic rheumatism, symptoms may include pain, swelling, stiffness, tenderness, and redness in and around the joints(called the periarticular area). Some people may have a fever and other systemic symptoms.

Diagnosis[edit | edit source]

Palindromic rheumatism is diagnosed based on symptoms and a physical examination during an attack, as there are no specific tests for it. This approach helps to rule out other forms of arthritis. Taking an X-ray of the affected joints during an attack may also help confirm the diagnosis.[4]Blood tests may also help provide support for the diagnosis and for ruling out other conditions.

The differential diagnosis of PR is quite extensive due to the various diseases that can cause an intermittent pattern of arthritis. Thus, short-lasting episodes characterize PR, differentiating it from other types of arthritis with intermittent courses.[5]

References[edit | edit source]

  1. Kavandi H, Hashemi SZ, Khalesi E, Khabbazi A. Treatment of palindromic rheumatism: A systematic review. International Journal of Clinical Practice. 2021 Sep 20;75(11). ‌
  2. 2.0 2.1 Corradini D, Di Matteo A, Emery P, Mankia K. How should we treat palindromic rheumatism? A systematic literature review. Semin Arthritis Rheum [Internet]. 2021;51(1):266–77.
  3. Mankia K, Emery P. What can palindromic rheumatism tell us? Best Practice & Research Clinical Rheumatology. 2017 Feb;31(1):90–8. ‌
  4. Palindromic rheumatism Condition Palindromic rheumatism [Internet]. [cited 2023 Nov 29]. Available from:
  5. Sanmartí R, Frade-Sosa B, Morlà R, Castellanos-Moreira R, Cabrera-Villalba S, Ramirez J, et al. Palindromic Rheumatism: Just a Pre-rheumatoid Stage or Something Else? Frontiers in Medicine. 2021 Mar 25;8. ‌