Palindromic rheumatism: symptoms, diagnosis and treatment

Arthritis UK explains that palindromic rheumatism is a form of inflammatory arthritis. It causes attacks, or flare-ups, of joint pain and inflammation that come and go. Unlike rheumatoid arthritis, in which people have joint problems most of the time, people with palindromic rheumatism usually have no symptoms between attacks and the joints return to normal.

It is sometimes known as palindromic arthritis. The charity says it is rare, so a GP may not have seen many cases. It affects women and men equally and can start at any age, though it rarely affects children.

During an attack the joints involved, and the tendons and area around them, feel painful and stiff and may look swollen. They might also feel tender and hot, and the skin over the joints may look red. Attacks usually start in one or two joints, often the hands, which quickly become painful, stiff and swollen.

Attacks can move from joint to joint and usually last for a few days, after which the joints and tendons return to normal. Some people feel very tired after an attack, which can last for days or weeks. The pattern is different for everyone: some people have attacks lasting just a few hours, while others have attacks lasting several days. Some people also have a fever during an attack or develop nodules under the skin near affected joints.

• Sudden pain, stiffness and swelling in one or two joints, often in the hands.

• Tenderness, heat and redness over the joint.

• Attacks that move between joints and last hours to several days.

• Normal joints and feeling well between attacks.

• Fatigue after an attack, sometimes with fever or nodules under the skin.

Arthritis UK says that in palindromic rheumatism the immune system attacks the joints by mistake, causing redness, swelling and extra fluid in and around the joints. It says we do not yet know what causes the inflammation. Although there may be genetic links, other triggers such as infection, hormones or injury are likely to play a part.

This sits within the wider group of inflammatory arthritis. The NHS describes rheumatoid arthritis as an autoimmune disease, where the immune system attacks the cells that line the joints by mistake, which is why the two conditions are sometimes discussed together.

Palindromic rheumatism cannot be diagnosed through one specific test, so a diagnosis is based on symptoms, blood tests and scans. The doctor asks questions and examines the joints to rule out other forms of inflammatory arthritis. It can sometimes be confused with gout and rheumatoid arthritis, and Arthritis UK says your GP should refer you to a rheumatologist.

Arthritis UK suggests that ideally a doctor should examine you during an attack. If you cannot get to a doctor in time, taking a good-quality photo of the affected joints and keeping a symptom diary can help. Blood tests for ESR and CRP show levels of inflammation, and other tests check for antibodies such as rheumatoid factor, anti-CCP antibodies and anti-nuclear antibodies. X-rays may be requested, mainly to rule out other conditions.

Arthritis UK says palindromic rheumatism varies from person to person. Some people find symptoms disappear completely between attacks, while others have attacks only occasionally. Some people experience more problems over time and may develop rheumatoid arthritis, which is particularly likely in people whose blood tests show rheumatoid factor or anti-CCP. While palindromic rheumatism does not cause permanent joint damage, rheumatoid arthritis can.

The charity also says that, very rarely, a small number of people develop lupus, more likely in those with anti-nuclear antibodies. The NHS says that diagnosing rheumatoid arthritis quickly is important because early treatment can prevent it getting worse and reduce the risk of joint damage, so it is worth telling your GP or rheumatologist if the pattern of your attacks changes.

Arthritis UK says that once the diagnosis is confirmed your care is likely to be shared between your GP and a rheumatologist, and you may also see a specialist nurse. The main treatments are drugs to treat the pain, drugs to reduce inflammation and drugs to treat the condition itself.

During an attack Arthritis UK suggests resting painful joints, using wrist splints or insoles, ice or heat pads (not directly on the skin), relaxation exercises and pacing your activities. Once inflammation settles you should start moving again with gentle exercise, and a doctor or physiotherapist can advise. No specific diet has been found to affect the condition, but keeping to a healthy weight reduces strain on joints.

For work, some people have few problems while others with frequent or severe attacks may need adjustments; the charity notes your employer has a legal obligation to make reasonable adjustments and that Access to Work can help. It says there is nothing to suggest the condition itself affects your chances of having a family, but some medicines, especially methotrexate, can cause problems in pregnancy, so discuss plans with your doctor.

On the NHS the route is GP to an NHS rheumatology department, where shared care with the GP and a specialist nurse is typical. Because the condition is rare and attacks are short, getting seen during an attack can be difficult, so photographs and a symptom diary are valuable.

Some people see a private rheumatologist for a faster first appointment or a second opinion. The tests, such as blood antibody tests and X-rays, and the drugs are the same. Because DMARDs need regular blood monitoring, ask how monitoring will be arranged and who will prescribe, so that care is coordinated with your GP.