What is palindromic rheumatism?

Palindromic rheumatism is a form of inflammatory arthritis. It's also known as palindromic arthritis. People who have it get attacks of joint pain and inflammation. These flare-ups start in one joint but may spread to others before settling down completely. The joints appear normal between attacks.

Palindromic rheumatism gets its name from the term 'palindrome'. A palindrome is a word or phrase which reads the same forwards or backwards (for example 'level' or 'madam'). A typical palindromic attack begins and ends in the same way and is at its worst point during the middle.

Symptoms

Attacks of palindromic rheumatism usually start in one or two joints, which quickly become painful, stiff and swollen. Other symptoms can include:

  • hot and tender joints
  • the skin over the joint looking red
  • inflamed, painful and swollen tendons and areas around the joint (the periarticular area)
  • feeling generally unwell
  • fatigue
  • mild fever
  • nodules under the skin near affected joints.

Typically the joints involved at the start improve after a short period but the attack moves from joint to joint, building up to its worst point. Finally the attack disappears and the joints and tendons return to normal. No matter how often they occur, these attacks don't cause damage to the joint.

Attacks of palindromic rheumatism come and go over time, but the pattern – how often they happen, how long they last and what joints are involved – is different for everyone. Some people get less than one attack a year but others get attacks more than once a week. Some people's attacks last only a few hours but for others they may last several days. You may notice that your attacks have a repeating pattern.

People with palindromic rheumatism usually have no symptoms in between attacks. This sets palindromic rheumatism apart from other forms of inflammatory arthritis such as rheumatoid arthritis. People with these conditions have joint problems most of the time, although the level of the problem may vary.

Causes

Because palindromic rheumatism is rare, there hasn't been very much research into the condition. However, studies have shown that inflammatory cells move into the lining of the joint, which causes the features of inflammation – redness, swelling and the production of extra fluid – which is very similar to what you see when you get a cut or wound in your skin. It's likely that similar changes affect involved tendons, areas around the affected joints and the skin.

We don't yet know what triggers this inflammation. Although there may be genetic links, this isn't the whole story – it may be that other triggers play a part, such as infection, hormones or trauma.

Unlike many other rheumatic diseases, palindromic rheumatism affects both men and women equally and can occur at any age.

How will palindromic rheumatism affect me?

Palindromic rheumatism varies a great deal from person to person so it's impossible to predict what to expect. In the longer term:

  • about 10–15% of people find their symptoms completely disappear
  • 30–50% have only occasional attacks.
  • 30–40% have greater problems.

Some people who fall into this final group may later develop rheumatoid arthritis. This is particularly likely in people whose blood tests show rheumatoid factor or anti-CCP, which are positive in rheumatoid arthritis. It's very important to note, however, that not everyone with palindromic rheumatism who is positive for these antibodies will develop rheumatoid arthritis.

Very rarely, a small number of people develop lupus. This is more likely in people whose blood tests show anti-nuclear antibodies, which are present in lupus.

Attacks of palindromic rheumatism don’t damage your joints, but damage may occur in people who go on to develop rheumatoid arthritis.

Diagnosis

Palindromic rheumatism is very rare, so your GP may not have seen many cases. It can sometimes be confused with conditions like rheumatoid arthritis, where early treatment is vital to prevent joint damage. Because of this, your GP should refer you to a specialist rheumatologist to confirm your diagnosis.

There's no specific test for palindromic rheumatism so a diagnosis is based on your symptoms. Your doctor may also ask questions and examine you to help rule out other forms of inflammatory arthritis like rheumatoid arthritis or gout. It may help if they can examine you during an attack because symptoms disappear once the attack has finished.

Taking a photo of the affected joints during an attack may be helpful. If the picture is good enough, it may help your doctor make a diagnosis.

Once the diagnosis has been confirmed, you’re likely to be looked after in a shared care system by your GP and a specialist rheumatologist (possibly with a rheumatology nurse specialist). They’ll need to monitor your condition to make sure you're not developing an ongoing form of inflammatory arthritis like rheumatoid arthritis, as this would need more intensive treatment.

Tests

Blood tests like the erythrocyte sedimentation rate (ESR) and the C-reactive protein (CRP) can show raised levels of inflammation in your body during an attack. Other blood tests can check for antibodies such as rheumatoid factor, anti-CCP antibodies and anti-nuclear antibodies.

X-rays of affected areas will be normal as palindromic rheumatism doesn't damage your joints.

Treatment

Different types of drugs can be used to treat palindromic rheumatism:

Type of drug Effect
Non-steroidal anti- inflammatory drugs (NSAIDs) NSAIDs are used to reduce pain and inflammation during the attacks. Examples include diclofenac, naproxen and ibuprofen.
Steroid injections Steroid injections can bring fast relief to an inflamed joint.
Disease-modifying anti-rheumatic drugs (DMARDs) Drugs such as hydroxychloroquine, sulfasalazine and occasionally methotrexate can be used to prevent attacks or reduce their frequency in people with more serious disease.

Non-steroidal anti-inflammatory drugs (NSAIDs)

Non-steroidal anti-inflammatory drugs block the inflammation that occurs in the lining of your joints and can be very effective in controlling pain and stiffness. Your symptoms will improve when you take these drugs, but the effects aren’t long-lasting so you have to take the tablets regularly. You’ll need to take them as soon as an attack starts and then continue until after it’s finished. Some people who have a lot of attacks find it works better to take them all the time.

If you find that a particular NSAID works well for a while but then becomes less effective, it sometimes helps to try a different NSAID. There are many NSAIDs available, and your doctor will advise you on the best choices for you.

Your doctor might recommend steroid injections if your joints are particularly painful or your ligaments and tendons have become inflamed.

Injections aren’t given regularly, but you may be given them if you have one or more very inflamed joints/tendons. They usually work within a few days. Some GPs give them but they’re usually given by your consultant team in hospital.

Managing symptoms

During an attack

The following tips can help you during an attack:

  • When the pain is severe, you should rest your joints. Wrist splints and insoles for your shoes may be helpful.
  • You may need to increase your medication with advice from your doctor or rheumatology nurse specialist.
  • Ice or heat pads can also help ease pain and swelling, although you should take care to not apply them directly to your skin. Relaxation exercises and swimming or bathing in warm water can also help.
  • Pacing your activities will help conserve energy and reduce fatigue.
  • Once severe inflammation has settled down, you should get moving again.

Exercise

Exercise is important to keep your joints working properly but you may feel too tired during attacks. You’ll need to find out for yourself the right balance between rest and exercise. Your doctor or physiotherapist will be able to give you advice on suitable forms of exercise such as stretching exercises and hydrotherapy.

Living with palindromic rheumatism

You can help your family and friends to understand your condition by discussing it with them and by showing them this information.

Any long-term condition can affect your moods, emotions and confidence, and it can have an impact on your work, social life and relationships. Talk things over with a friend, relative or your doctor if you find your condition is getting you down.

Work

If you have mild palindromic rheumatism, you're unlikely to have big problems with work. However, if you have attacks more often or have worse attacks, you may experience some difficulties. You may be able to adapt your work, for example by working shorter hours or moving to a less physically demanding role. If this isn't possible, you may need a work assessment and retraining, which can be arranged through your local Jobcentre Plus.

If you're unable to work or have mobility problems, benefits are available. A health or social worker or your local Citizens Advice Bureau will be able to advise you on benefits you can claim.