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PALINDROMIC RHEUMATISM by STEPHEN MATTINGLY Department of Rheumatology and Physical Medicine, the Middlesex Hospital

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PALINDROMIC RHEUMATISM by STEPHEN MATTINGLY Department of Rheumatology and Physical Medicine, the Middlesex Hospital Ann Rheum Dis: first published as 10.1136/ard.25.4.307 on 1 July 1966. Downloaded from Ann. rheum. Dis. (1966), 25, 307. PALINDROMIC RHEUMATISM BY STEPHEN MATTINGLY Department of Rheumatology and Physical Medicine, The Middlesex Hospital Palindromic rheumatism was first described by Painful non-pitting tender swellings an inch or more Hench and Rosenberg in 1941, and three years later a in diameter, and occasionally much larger, appeared detailed account of their 34 cases appeared in the over the forearms, back of wrist, or heel. Some- Archives of Internal Medicine (Hench and Rosen- times the finger tips became swollen and transient berg, 1944). A number of individual case reports intra-cutaneous or subcutaneous nodules were subsequently appeared in the literature (Ameen, observed on the hands, but usually disappeared 1954; Cain, 1944; Ferry, 1943; Ginsburg, 1948; within a few days. Grego and Harkins, 1944; Gryboski, 1948; Hopkins Patients suffering from palindromic rheumatism and Richmond, 1947; Lewitus, 1954; Mazer, 1942; remained well and did not lose weight. Attacks were Neligan, 1946; Paul and Logan, 1944; Paul and usually afebrile. Radiographs were normal in most Carr, 1945; Perl, 1947; Rotes Querol, 1956; Salo- cases or showed coincidental degenerative changes. mon, 1946; Scheinberg, 1947; Thompson, 1942; Laboratory investigations usually gave normal Parkes Weber, 1946; Wingfield, 1945; Wirtschafter, results, although there was sometimes a transient Williams, and Gaulden, 1955; Wolfson and Alter, rise in the erythrocyte sedimentation rate during an 1948; Wassmann, 1950; Zentner, 1953). However, attack, the white cell count might show a relative there have been few reports of series of patients with lymphocytosis, and the serum fatty acids were in- this syndrome (Ansell and Bywaters, 1959; Dames creased in some patients. In a few cases, biopsy of acopyright. and Zuckner, 1961; Rotes Querol and Lience, 1959) joint during an attack revealed a non-specific acute and although reference is made to 140 cases seen at inflammation which subsided rapidly; the fibrino- the Mayo Clinic (Ward and Okihiro, 1959) these purulent joint fluid contained many polymorphs but have not yet been reported in the literature (Ward, was sterile on culture and contained no urates. 1965). Most patients experienced a succession of attacks Hench and Rosenberg (1941) coined the term affecting different joints at irregular intervals; they "palindromic rheumatism" to describe recurring might occur a few times a year or many times a week, attacks ofjoint pain and swelling. Usually only one and might continue indefinitely over 20 years or http://ard.bmj.com/ joint was affected at a time, although practically subside spontaneously. No treatment was of value. every joint in the body had been affected, including Hench and Rosenberg (1944) concluded that "des- the temporo-mandibular joint. The shoulder, knee, pite thousands of attacks suffered during a grand wrist, and small joints of the hand were most fre- total of 307 years of illness, not a single joint had quently involved and pain in the neck was common. been crippled permanently". The characteristics of The onset was often sudden and although an attack palindromic rheumatism as described by Hench and could start at any time of the day or night it fre- Rosenberg (1944) may be summarized as follows: on October 1, 2021 by guest. Protected quently began in the late afternoon. Each attack lasted a few hours or a few days, but rarely as long as Recurrent attacks of joint pain and swelling at a week. Pain was most severe a few hours after on- variable and irregular intervals lasting a few hours set and often prevented sleep; it could be very dis- or a few days. abling and even lead to admission to hospital. Any joint affected but especially fingers, wrists, Joint swelling was usually evident and the overlying shoulders and knees. skin was often red. The interval between attacks Para-articular attacks and transient nodules. was very variable and irregular, unlike that in inter- mittent hydrarthrosis, and between attacks the joints Good health; normal blood tests and x rays. appeared normal. Good prognosis: no effective treatment. One third of their patients experienced so-called "para-articular attacks" affecting the soft tissues near Their claim that the affected joints remained un- joints or even overlying muscles away from joints. damaged even after many years appears to be sub- 307 Ann Rheum Dis: first published as 10.1136/ard.25.4.307 on 1 July 1966. Downloaded from 308 ANNALS OF THE RHEUMATIC DISEASES stantiated by Fig. 1, which shows the duration of the injections had not previously been tried and that so disease in 48 patients reported in the literature, few reports on chrysotherapy have appeared in the including their own 34 cases. However it should be literature. noted that a third of the patients had had their This paper is based on a study of twenty patients disease for less than 5 years. (twelve men and eight women) with palindromic Many rheumatologists believe palindromic rheumatism seen at the Middlesex Hospital between rheumatism to be an atypical form of rheumatoid 1955 and 1965, and an attempt is made to answer the arthritis and have described cases which subsequently following questions: developed arthritis (Boland and Headley, 1948; Bywaters, 1949; Kuhns, 1945; McEwan, 1960; (1) Do patients with palindromic rheumatism Ropes and Bauer, 1945; Ward and Okihiro, 1959; develop signs of permanent joint damage if followed up for long enough? Ansell and Bywaters, 1959). For example, McEwan (2) If so, is this rheumatoid arthritis? (1960), found that seven out offourteen patients with (3) What is the effect of treatment with gold injec- palindromic rheumatism gave a positive test for the tions? serum rheumatoid factor, and six developed rheuma- toid arthritis within a few years. Middlesex Hospitld Series (1955-1965) Boland and Headley (1948) first reported the During the 10-year period 1955-1965, thirty patients favourable response to treatment with gold thio- were recorded as cases of palindromic rheumatism. glucose in three patients with typical palindromic Some of them did not have the syndrome described by rheumatism, and further cases were described by Hench and Rosenberg (1944), since joint pain and swell- Ginsburg (1948), Dames and Zuckner (1961), and ing persisted for weeks at a time, and these have been Lewitus (1950). However, remissions were often excluded from this study. Thus only twenty patients incomplete and the period of follow-up was less than (twelve men and eight women) with typical palindromic rheumatism have been reviewed so far, although a further 2 years. In view of the large number of treatments eight cases have been brought into the study group during previously tried and found wanting (including pur- the past year. ine-free diets, vaccines, colchicine, eradication of The age at onset of the disease is shown in Fig. copyright. 2 septic foci, antihistamines, and sulphonamides, to (opposite). mention only a few), it is rather surprising that gold The first attack usually occurred without warning in a I Males (25) U l U I * U I U * http://ard.bmj.com/ I U 0 5 10 I5 20 25 3 Fig. 1.-Duration of disease in 48 cases reported in the literature without serious on October 1, 2021 by guest. Protected joint damage, by sex (25 men and 23 women). i Females (23) 1S1 4! 0 lo 15 20 25 30 Duration of disease without permonent joint damage (yrs) Ann Rheum Dis: first published as 10.1136/ard.25.4.307 on 1 July 1966. Downloaded from PALINDROMIC RHEUMATISM 309 - =Normal x rays FEMALES (8) - -- = Arthritis on x- ray I I I Fig. 2.-Age at of I I onset I palindromic rheumatism I inrtwelve men and eight I I I women. a I I I MALES (12) 1 I~~a11 I I ~~~~I ~~I ~~~II I I ~~I ~~~I I I I I ~~~~~I I I I -- I I I I r I i 1 s I i I I I I I I 20 22 30 32 34 36 38 40 42 46 48 50 54 21 27 43' 45 51 Age at Onset (yrs) patient who was otherwise fit, although in five cases it was in the neck or jaw, and three had acute attacks affecting preceded by illness or operation (Table I). Four the big toe simulating acute gout. Each attack lasted women experienced their first attack during the meno- 1 to 3 days, although they sometimes subsided after a pause. few hours or persisted as long as a week. The interval TABLE I between attacks was very variable, even in the same PRODROMAL ILLNESS IN FIVE PATIENTS WITH patient; they might recur several times a week or PALINDROMIC RHEUMATISM only once or twice a year. They usually started in the late Case No. Prodromal Illness or Operation afternoon and pain was usually severe enough to prevent sleep. Five patients were admitted to hospital during copyright. an 11 Exacerbation of chronic osteomyelitis Sterile abscess of rib incised acute attack. 12 Acute chest infection Most of these twenty patients have remained in good 14 Severe attack of measles 19 Laparotomy for sterile tubovarian abscess general health throughout their illness without weight 20 Thyrotoxicosis recently treated with radioactive loss; ten have developed the clinical and radiological signs iodine of a low-grade polyarthritis, but only two men now aged 64 and 75 are much disabled by their joint disease after Any joint could be affected, apparently at random, and 25 years. Moreover, seventeen out of the twenty patients attacks were usually monarticular. However, some- under review have some clinical evidence ofjoint damage times one joint was involved immediately after another or tendon lesion, if one includes slight stiffness of thehttp://ard.bmj.com/ and, although each joint only remained painful for a day wrists or spindling of an interphalangeal joint; eight or two, the patient became disabled by a migratory patients have tendon lesions in hands or feet, including polyarthritis.
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