QD101 - Episodic Arthritis Save
QD Clinic - Lessons from the clinic
Palindromic Rheumatism - Differential Dx and Rx
Features Dr. Jack Cush
Transcription
Hey. It's Monday, and this is QD Clinic. I'm Jack Cush with RheumNow. QD Clinic is brought to you by our coverage of virtual ACR twenty twenty. RheumNow is where you can go to read, view, listen, vote, discuss, and sign up for emails on the topics that you like most for this year's meeting.
Check it out. Our case this week is episodic arthritis. The gal is a 42 year old white female who's had a seven year history of intermittent arthritis, almost always affecting the left ankle, sometimes the right ankle, and rarely the knees. She has a history of nail psoriasis only. She's been worked up in the past by two different rheumatologists and been treated with nonsteroidals, prednisone, hydroxychloroquine, really with no disease control per se.
But, workup has been pretty unrevealing, meaning she's rheumatoid factor and CCP negative, she's ANA negative. And since she's seen so many rheumatologists, she's had a lot of tests, you know, so all the negative infectious tests including HBV, HCV, QuantiFERON. She's had a negative ANCA, negative b 27. She does have an elevated SED rate and CRP. The SED rates range from 31 to 80, and the CRPs have ranged from, my goodness, 16 to as high as 82.
She has had a positive Vectra at 56. I didn't order it. So the question is, what does she have? Well, she has palindromic rheumatism. She's been labeled as rheumatoid, reactive arthritis, and seronegative RA, but she really fits the mold of palindromic rheumatism by having episodic attacks, oligoarticular or monarticular, in joints that last for roughly, seven to ten days.
She does get swelling and erythema, and I've actually witnessed these attacks. So what is palindromic rheumatism? It is defined as episodic, attacks of monarthritis or polyarthritis, affecting the joints or periarticular structures, meaning you can get tenosynovitis associated with this. And, of course, the deal here is that there's a subset of these people that will go on to develop rheumatoid arthritis. My chapter in Rheumatology, I wrote it's about one third develop RA and then, you know, really one third wax and wane, over the years that they have this, and about one third will remit.
So, this brings up a few issues. Actually, there's a recent, study, not a recent study, actually, it's, ten years old from J. Rheum, on the natural history, in a cohort of one hundred and twenty seven patients with palindromic rheumatism, and what they showed is what others have said. If you're factor positive or CCP positive, you increase the odds of going on to develop rheumatoid arthritis. In that study of one hundred and twenty seven patients, exactly thirty four percent went on to develop another connective tissue disease with rheumatoid arthritis leading the way, a few getting psoriatic arthritis or lupus and, and other diagnoses, but they're too few to even mention here.
So what is predictive? In that study, predictive factors for development of another connective tissue disease, mostly rheumatoid arthritis, was first, seropositivity for RF or CCP. Second, PIP or MCP involvement. Those gave about a 2.5 fold increased risk of developing RA. And lastly, femaleness, is that a word?
Had a 2.2 increase, a 2.2 increased risk such that if you were a woman with hand involvement and seropositive with palindromic RA, you had an eight fold greater chance of developing RA over time. So, in this gal who's 42, and not had hand involvement and she's seronegative, not surprising that after a number of years she hasn't yet evolved. It brings up the greater question, when you see people like this, what are you gonna label them? In my lecture that I have on seronegative disease, so I think the seronegative actually has a lot of different diagnoses, many that actually stay seronegative RA, but then there's the ones that will progress to another connective tissue disease. There's, and also in this group are undifferentiated, seronegative polyarthritis patients.
Those are the ones that will go into remission, once they get treated with steroids or other therapies, and they go into remission. Also in this group, there's a palindromic group, and then also, polymyalgia rheumatic, older patients, they're seronegative. They meet they often have, swelling in, hands and upper extremity, joints, so they could meet the definition as well. So how do these people get treated, symptomatically? My gal is currently just taking Tylenol, and she has prednisone if she gets an attack.
Interestingly, she has not had an attack in more than a year, and that's good news for her. Some people will just take PRN steroids. Some people will have frequent attacks, and ones that you're worried about because they are seropositive, they have hand involvement, you might use, medications like hydroxychloroquine or methotrexate and consider them almost a preclinical RA patient. And by being seropositive, they have a greater than fifty percent chance of progressing to RA, why not treat them? That's palindromic RA.
Hope you enjoyed this story. Tune in tomorrow for another QD clinic. Again, for the ACR, you give us two hours, we'll give you the meeting. Take care.
Check it out. Our case this week is episodic arthritis. The gal is a 42 year old white female who's had a seven year history of intermittent arthritis, almost always affecting the left ankle, sometimes the right ankle, and rarely the knees. She has a history of nail psoriasis only. She's been worked up in the past by two different rheumatologists and been treated with nonsteroidals, prednisone, hydroxychloroquine, really with no disease control per se.
But, workup has been pretty unrevealing, meaning she's rheumatoid factor and CCP negative, she's ANA negative. And since she's seen so many rheumatologists, she's had a lot of tests, you know, so all the negative infectious tests including HBV, HCV, QuantiFERON. She's had a negative ANCA, negative b 27. She does have an elevated SED rate and CRP. The SED rates range from 31 to 80, and the CRPs have ranged from, my goodness, 16 to as high as 82.
She has had a positive Vectra at 56. I didn't order it. So the question is, what does she have? Well, she has palindromic rheumatism. She's been labeled as rheumatoid, reactive arthritis, and seronegative RA, but she really fits the mold of palindromic rheumatism by having episodic attacks, oligoarticular or monarticular, in joints that last for roughly, seven to ten days.
She does get swelling and erythema, and I've actually witnessed these attacks. So what is palindromic rheumatism? It is defined as episodic, attacks of monarthritis or polyarthritis, affecting the joints or periarticular structures, meaning you can get tenosynovitis associated with this. And, of course, the deal here is that there's a subset of these people that will go on to develop rheumatoid arthritis. My chapter in Rheumatology, I wrote it's about one third develop RA and then, you know, really one third wax and wane, over the years that they have this, and about one third will remit.
So, this brings up a few issues. Actually, there's a recent, study, not a recent study, actually, it's, ten years old from J. Rheum, on the natural history, in a cohort of one hundred and twenty seven patients with palindromic rheumatism, and what they showed is what others have said. If you're factor positive or CCP positive, you increase the odds of going on to develop rheumatoid arthritis. In that study of one hundred and twenty seven patients, exactly thirty four percent went on to develop another connective tissue disease with rheumatoid arthritis leading the way, a few getting psoriatic arthritis or lupus and, and other diagnoses, but they're too few to even mention here.
So what is predictive? In that study, predictive factors for development of another connective tissue disease, mostly rheumatoid arthritis, was first, seropositivity for RF or CCP. Second, PIP or MCP involvement. Those gave about a 2.5 fold increased risk of developing RA. And lastly, femaleness, is that a word?
Had a 2.2 increase, a 2.2 increased risk such that if you were a woman with hand involvement and seropositive with palindromic RA, you had an eight fold greater chance of developing RA over time. So, in this gal who's 42, and not had hand involvement and she's seronegative, not surprising that after a number of years she hasn't yet evolved. It brings up the greater question, when you see people like this, what are you gonna label them? In my lecture that I have on seronegative disease, so I think the seronegative actually has a lot of different diagnoses, many that actually stay seronegative RA, but then there's the ones that will progress to another connective tissue disease. There's, and also in this group are undifferentiated, seronegative polyarthritis patients.
Those are the ones that will go into remission, once they get treated with steroids or other therapies, and they go into remission. Also in this group, there's a palindromic group, and then also, polymyalgia rheumatic, older patients, they're seronegative. They meet they often have, swelling in, hands and upper extremity, joints, so they could meet the definition as well. So how do these people get treated, symptomatically? My gal is currently just taking Tylenol, and she has prednisone if she gets an attack.
Interestingly, she has not had an attack in more than a year, and that's good news for her. Some people will just take PRN steroids. Some people will have frequent attacks, and ones that you're worried about because they are seropositive, they have hand involvement, you might use, medications like hydroxychloroquine or methotrexate and consider them almost a preclinical RA patient. And by being seropositive, they have a greater than fifty percent chance of progressing to RA, why not treat them? That's palindromic RA.
Hope you enjoyed this story. Tune in tomorrow for another QD clinic. Again, for the ACR, you give us two hours, we'll give you the meeting. Take care.
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