Palindromic rheumatism

Palindromic rheumatism is an inflammatory kind of arthritis. For a short while the immune system turns on a joint and the tissue around it, causing a flare that then clears up entirely and leaves no lasting damage. No one can yet say why the inflammation switches on and off like this, and for most people no single cause turns up. It is better seen as a tendency to joint inflammation that recurs and settles by itself, not as an illness with one neat explanation.

It can begin at any age, though it seldom affects children, and unlike rheumatoid arthritis it affects women and men in about equal numbers. The closest link it has is to rheumatoid arthritis, a link made stronger by a positive test for rheumatoid factor or anti-CCP antibodies.

The on-off rhythm is the hallmark. You may notice:

• Joints that flare up without warning, turning painful, swollen and stiff, often one at a time or a few together
• Each attack lasting anything between a few hours and a few days, after which everything settles
• Stretches between attacks, while your joints are calm
• At times, swelling in the soft tissue around a joint

The condition reaches the joints and the tissue around them, and a rash is not usually part of it. Should a rash appear with your attacks, it can point to a different or additional diagnosis, lupus or psoriatic arthritis for example, and is worth telling your specialist about.

Many attacks come with no warning, and plenty of people never find a trigger. For some, an attack seems to follow hard physical effort, a stressful spell or a minor infection, and now and then a food comes under suspicion, but such patterns belong to the individual and do not hold from one person to the next. Jotting down when each attack happens, which joints it reaches and how long it lasts can help you and your specialist pick out a pattern and build up an accurate picture of the condition as time goes by.

Between attacks the joints usually seem entirely normal to look at and to touch, so the account of the pattern carries most of the weight, with an examination and blood tests in support. The best moment for a doctor to examine a joint is during an attack, before it settles; when that cannot be arranged, a photo of the swollen joint and a diary of the attacks fill much of the gap. A clear record helps with more than the diagnosis: it also guides the treatment and the follow-up.

No one test proves it. The diagnosis comes from the typical pattern of attacks that return and clear completely, once other causes have been ruled out, and X-rays are sometimes taken for that reason. Rheumatoid factor and anti-CCP antibodies are tested as a matter of course, because a positive result raises the chance of later developing rheumatoid arthritis and affects how closely you are followed.

Ultrasound can confirm the inflammation if a joint is seen while an attack is still under way, and research with ultrasound and MRI has found the tissue around a joint often more inflamed in an attack than the joint itself. Point-of-care ultrasound is part of the consultation with Dr Borukhson, so a joint caught in the middle of an attack can usually be examined by scan there and then. The ultrasound clinic page covers the scan step by step.

What treatment sets out to do is settle each attack, space the attacks out and, for some people, make a lasting arthritis less likely. The approach is tailored and reviewed over time, since the right plan rests on how often attacks come and on any test results, and it is always talked through with you.

For a single attack, an anti-inflammatory painkiller of the kind called an NSAID often brings relief. If attacks come often, a disease-modifying medicine (a DMARD), one that can change the course of the illness, is commonly started to space them out. Hydroxychloroquine is generally tried first, and some evidence suggests it may also reduce the chance of later rheumatoid arthritis; the evidence is limited, though, and rheumatoid arthritis still develops in some people who take it. Sulfasalazine, methotrexate or another DMARD is sometimes used in its place or beside it.

Most people feel completely well between attacks and can get on with life as usual, so there is no need to hold yourself back. Regular exercise, a healthy weight and not smoking all do the joints good, and giving up smoking matters all the more because there is some evidence that people who smoke may run a higher risk of rheumatoid arthritis.

Working with your specialist also helps: tell them how the pattern is shifting over time, so that the plan can change if it needs to. The outlook is encouraging. Many people carry on with the same on-off pattern for years, some find the attacks fade, and where a lasting arthritis begins to develop, regular review means it is found and treated early.

The attacks of palindromic rheumatism leave no lasting damage, but one can look like other causes of a hot, swollen joint, gout and an infection among them. The two lists below set out the signs that need a doctor quickly, the most pressing first, and the paragraph beneath them covers the rest.

Treat any of these as a 999 or A&E emergency: call 999 and do not drive yourself to A&E.

• Severe illness with suspected sepsis: a high fever with shaking, confusion, rapid breathing, or feeling dramatically worse over hours
• With a fever or feeling unwell, a rash that does not fade when you press it, a stiff neck with eyes that cannot bear bright light, or skin, lips or tongue turning blue, grey, pale or blotchy, since these can be signs of meningitis or sepsis, as can a very bad headache, confusion or a first seizure with a fever or feeling unwell; on black or brown skin the rash and the change of colour may be easier to see on the palms of the hands or the soles of the feet
• A joint you cannot put weight on or move, or that has moved out of place, or, after a fall or injury, very bad pain or any tingling or numbness
• Chest pain that is crushing, tight or like a pressure, that spreads to an arm, the jaw, the neck, the stomach or the back, that comes with breathlessness, sweating, feeling sick or feeling light-headed, or that came on suddenly and does not go away
• Vomiting blood, or bleeding from the back passage that is heavy or will not stop, most of all with faintness, confusion or pain in the abdomen, or vomit that is black or dark brown, since anti-inflammatory tablets, which many people take for their attacks, can make the stomach bleed
• Lips, mouth, throat or tongue that suddenly swell, a throat that feels tight, very fast breathing or a struggle to breathe or to swallow, skin, tongue or lips turning blue, grey or pale (on black or brown skin this may be easier to see on the palms of the hands or the soles of the feet), becoming suddenly very confused, drowsy or dizzy, or fainting and not being able to be woken, since this can be a severe allergic reaction, anaphylaxis, which can follow a dose of any medicine
• An eye that suddenly and completely loses its sight

Any of these needs an assessment that is urgent, on the same day, from your GP or NHS 111:

• A joint that is hot and swollen, with a fever or feeling unwell, since an infected joint has to be ruled out at once, at A&E or through NHS 111
• A joint that has become hot and very swollen suddenly, or is worsening quickly, even without a fever, since an infected joint does not always announce itself with one
• Joint pain with a fever, or feeling hot, cold or shivery, or generally unwell, since an infection in or around a joint has to be found the same day
• A fever, or feeling generally unwell, on immunosuppressant, biologic or steroid treatment, since an infection has to be treated early; where a rheumatology team looks after you, its advice line comes first
• Redness that spreads out from a joint, or an attack far more painful than your usual ones, since neither fits the pattern of palindromic rheumatism, and an infection in the joint (septic arthritis) or in the skin around it has to be ruled out; with a very high temperature or feeling hot, cold or shivery, a fast heartbeat or fast breathing, purple patches on the skin, which may be less obvious on black or brown skin, feeling dizzy or faint, confusion, or skin that is cold, clammy or pale, spreading redness is a 999 or A&E emergency: call 999 and do not drive yourself to A&E
• Black or dark red stools, on anti-inflammatory tablets, since a bleed in the stomach or gut has to be found that day
• A new red, painful eye, or sight that has blurred, dimmed or changed, which needs an eye casualty or urgent eye clinic the same day, as does an eye that light hurts, since hydroxychloroquine, the medicine most often used to prevent attacks, can, rarely, harm the back of the eye, and a red, painful eye needs an eye specialist's look whatever its cause; on hydroxychloroquine, a change in sight is also one to report to the team that prescribes it
• Being near someone with measles, chickenpox or shingles, while you take a medicine that weakens the immune system, since measles and chickenpox can be dangerous when the immune system is weakened, and you can catch chickenpox from someone with shingles if you have never had chickenpox; NHS 111 can tell you what to do that day

Short of the signs in the lists above, if you have no diagnosis yet and joint swelling keeps coming back, even when each bout clears, a specialist assessment within days, through your GP or booked directly, is the right step, since swelling that returns should be looked into, and an assessment while an attack is fresh is the most useful. Once the diagnosis is made, book a routine review with your team or GP if the pattern changes over the months, since a change can mean the diagnosis is shifting or was a different one all along: attacks arriving more often, lasting longer or growing worse in severity; a joint that remains swollen or stiff when it would normally settle; or a new rash, dry eyes or a dry mouth. If you cannot tell how urgent something is, asking is never a mistake.

In some people palindromic rheumatism may be an early stage of rheumatoid arthritis, which is why being assessed, followed up and treated at the right time counts for more than its passing attacks suggest. If joint pain and swelling keep coming back, arrange an assessment within days, through your GP or booked directly.

If my joints look normal between attacks, how can a doctor tell what it is?

Mostly from the pattern itself: attacks that come back and clear up completely each time, with an examination and blood tests to back it up once other causes have been ruled out. A brief diary of the joints involved and how long each attack lasts is a real help, and so is a clear photo of a joint while it is swollen. When an attack is still going on at the appointment, Dr Borukhson can scan the joint with point-of-care ultrasound during the visit and see the inflammation for herself.

Could it develop into rheumatoid arthritis?

Not for everyone; many people go on having attacks and nothing more. For some, though, it can turn out to be an early stage of rheumatoid arthritis. Testing the blood for rheumatoid factor and anti-CCP antibodies helps to tell, because a positive result makes that course more likely and calls for closer follow-up, although even then it is not certain to happen. Picking up such a change early, so that it can be treated, is one of the main reasons to be assessed.

Can the attacks be treated, or even prevented?

An anti-inflammatory medicine often eases a single attack. When attacks come often, a medicine that can change how the disease behaves is commonly started to make them rarer, hydroxychloroquine as a rule first, and some evidence suggests it may also cut the chance of going on to rheumatoid arthritis, though the evidence for that is limited. Which plan suits you depends on how often the attacks come and on your test results; you always have a say in it, and it is revisited over time.

During an attack, what helps, and when do I need a doctor?

While an attack runs its course of hours to a few days, rest for the joint and an anti-inflammatory, where that medicine is right for you, generally ease it, and a note of the joints involved and how long the attack lasts builds a useful record. A joint that will take no weight or cannot be moved is a 999 or A&E emergency, as the first list under When to seek help says, and so is redness spreading out from a joint with a very high temperature or feeling hot, cold or shivery, a fast heartbeat or fast breathing, purple patches on the skin, which may be less obvious on black or brown skin, feeling dizzy or faint, confusion, or skin that is cold, clammy or pale, as the second list says. Call 999 and do not drive yourself to A&E. Some attacks still need a doctor that day: a joint that has become hot and very swollen suddenly, or is worsening quickly, should be seen that day, at A&E or through NHS 111 if a fever or feeling unwell is part of the picture, and if not, by your GP or NHS 111, as should an attack far more painful than your usual ones and the other signs in the second list under When to seek help. Short of those lists, swelling that keeps coming back while you have no diagnosis, even when each bout clears, is for a GP within days; once the diagnosis is made, attacks that over the months come more often, last longer or grow more severe, a joint that stays swollen instead of settling, or a new rash with your attacks deserve a routine review with your team or GP, since they can point to a different diagnosis.

Should a rheumatologist see me about it?

If attacks of joint pain and swelling keep coming and going, a specialist assessment is worthwhile: a GP can refer you within days, or you can book one directly. The condition can be hard to catch in the act, since nothing shows in the joints once an attack has passed, and several other illnesses can resemble it. A rheumatologist can confirm what is going on, arrange the antibody tests and set up follow-up, so that any sign of the condition moving on is caught and treated promptly by your team, not missed.