© KOSMOS111/DOLLAR PHOTO CLUB • travel. recent or bites any insect of history no He has infection. transmitted asexually had never has 15 for and years married happily been He has interim. the in all at joint problems no had has but 10 previously, toms years symp of similar months afew had he that He remembers health. knee. a recently, most and, joints interphalangeal and knuckles wrists, shoulder, his have been affected sites The joint. in adifferent ­symptoms similar by replaced only tobe completely, resolve then and of weeks to acouple days several last area, affected in the develop mobility. Symptoms restricted and swelling heat, pain, severe with sequentially affected joints had He has months. few past the over migratory apparent an had has 38years, aged Anton, SCENARIO CASE managed? be he how and should young inthis man of bouts migratory transient causing is What SCHRIEBERLESLIE by Commentary arthritis transient recurrent of case A M North Shore Hospital, Sydney, NSW. School, of University Sydney, of and , Department Royal Medical Sydney at Medicine in Professor Associate is Schrieber Professor

edicineToday Anton has no systemic symptoms and has been in good general general in good been has and symptoms systemic no Anton has C-reactive protein (CRP) 75 (normal <5 protein range, mg/L) mg/L C-reactive level, rate (ESR),(normal 1to10 range, mm/h 40 mm/h) and e are: investigations of initial results Significant M levated inflammatory markers – erythrocyte sedimentation sedimentation –erythrocyte markers inflammatory levated edicineToday 2015; 16(2):67-68 PEER REVIEWED Copyright _Layout117/01/121:43 PMPage4 MB BS(Hons), MD, GradCertClinEd, FRACP GradCertClinEd, MD, BS(Hons), MB Downloadedfor personal use only. No other uses permitted without permission. ©

- • • • • damage. damage. joint with associated not usually are of arthritis attacks self-limiting recurrent the patients, these disorder. In systemic ­r However, palindromic some patients in erythematosus. lupus or systemic as such conditions, defined evolve more into clearly may subsequently episodes uncommon. are stiffness morning prolonged and symptoms Constitutional affected. rarely jaw are and spine The involved. often less are feet and elbows hips, The shoulders. and ankles knees, wrists, the joints, interphalangeal proximal and metacarpophalangeal the include joints affected commonly most The sexes. the between balance even relatively a with years, 45 is of age onset mean The joints. () to four or two one () affecting arthritis painful of episodes to weeks) self-limited (hours transient recurrent recurring’. palindromos Greek from by Rosenberg. Hench and reported first whenit was 1944 since entity an as recognised been has latter The . palindromic of typical arthritis of episodes transient recurrent apatient with describes scenario case This COMMENTARY treated? and investigated further

heumatism episodes continue without evolving into a into evolving without continue episodes heumatism What could be causing Anton’s arthritis? How should he be be he Anton’s How should causing be arthritis? could What chlamydial infection. chlamydial infection. n n s m Many forms of arthritis may commence this way. this The may commence of forms arthritis Many refers to that term adescriptive is rheumatism Palindromic erum uric acid and ferritin levels, low normal low levels, ferritin and acid uric erum egative by culture and PCR tests for gonorrhoea and and gonorrhoea for tests PCR and culture by egative antibodies antinuclear and factor rheumatoid for egative ild leucocytosis ild MedicineToday CLINICAL CASEREVIEW Medicine x

FEBRUARY 2015,VOLUME 16,NUMBER 2 oa 2015 Today , meaning ‘running back again, again, back ‘running , meaning . 1 The name derives derives name The

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Clinical Case Review CONTINUED

How to evaluate the patient those with inflammatory bowel disease. This is commenced at A thorough history and physical examination are required to 500 mg twice daily and, if well tolerated after a week, increased exclude infection and evaluate whether there are features of an to 1000 mg twice daily. Sulfasalazine can produce skin rashes, underlying systemic disease. This includes rashes, , weight nausea, abnormal liver function test results and depression of loss, Raynaud’s phenomenon, mouth ulcers, tophi and nodules. haemopoietic elements. Monthly counts and liver function The most common underlying disorder is rheumatoid arthritis tests are required to monitor for potential toxicities. Immuno- (30 to 60% of cases). Other differential diagnoses include crystal suppressive drugs such as methotrexate are seldom indicated. arthritis (, calcium pyrophosphate deposition disease), or other seronegative spondyloarthritides, sarcoidosis, Natural history familial Mediterranean fever and Behçet’s disease. Migratory The natural history of palindromic rheumatism is variable. arthritis associated with fever and weight loss should prompt Approximately 50% of patients with palindromic rheumatism investigation to exclude subacute bacterial endocarditis. develop rheumatoid arthritis.4 Less frequently, it evolves into Physical examination during an attack may reveal swollen systemic lupus erythematosus or seronegative spondyloarthritis. tender joints and surrounding tissue, often in an asymmetric However, in a substantial number of patients the condition does distribution. Between attacks there is usually nothing to find not evolve and they continue to experience repeated episodes on examination. of palindromic rheumatism. It is not easy to predict in individual patients whether palindromic rheumatism symptoms will Investigations develop into a more serious condition such as rheumatoid arthri- As a baseline, a full blood count and measurement of ESR and tis. The presence of , anti-CCP antibodies or CRP level, a biochemical profile, liver function tests, and serolo­ high-titre antinuclear antibodies should alert one to the likeli- gical tests for rheumatoid factor, anticyclic citrullinated peptide hood of subsequent evolution into a systemic disorder. antibody (anti-CCP) and antinuclear antibodies are warranted. During attacks there is a mild to moderate elevation of ESR levels. When to refer to a rheumatologist The presence of anti-CCP antibodies is predictive of the If the episodes of rheumatism are frequent and do not settle ­sub ­sequent development of rheumatoid arthritis.3 with NSAID treatment alone then referral of the patient to a rheumatologist is warranted for confirmation of the diagnosis Approach to management and consideration of DMARDs. Unless there is a contraindication, first-line treatment during attacks involves an oral NSAID. I usually prescribe naproxen CONCLUSION sustained release (either 750 or 1000 mg daily) or diclofenac Palindromic rheumatism needs to be considered in patients who (50 mg twice daily) taken with meals. These are generally well present with recurrent episodes of transient arthritis. Although tolerated but may cause dyspepsia. An alternative medication palindromic rheumatism does not usually cause joint damage, with a lower risk to the upper gastrointestinal tract is celecoxib it may be a source of considerable pain and disability. It may 200 mg once or twice a day. also evolve into a more serious condition, such as rheumatoid If the rheumatism attacks do not settle promptly with an arthritis. If attacks are frequent and do not settle rapidly with NSAID and the patient has unacceptable symptoms then a short NSAIDs then referral to a rheumatologist is warranted. MT course of a low-dose corticosteroid is warranted, such as pred- nisone 7.5 to 10 mg daily. REFERENCES If the attacks become frequent then referral to a rheumatol- ogist for further evaluation and consideration of a disease-­ 1. Hench JJ, Rosenberg EF. Palindromic rheumatism. Arch Intern Med 1944; modifying antirheumatic drug (DMARD) is warranted. 73: 293-321. ­However, there are no prospective randomised controlled trials 2. Ryan JG, Kastner DL. Palindromic rheumatism. In: Klippel JH, Stone JH, of drugs in palindromic rheumatism, which makes an evi- Crofford LJ, White PH, eds. Primer on the rheumatic diseases. 13th ed. Atlanta: dence-based approach to prescribing difficult. My preferred Springer; 2008. pp. 466-467. options include hydroxychloroquine, initially 200 mg twice 3. Russell AS, Devani A, Maksymowych WP. The role of anti-cyclic citrullinated daily for a month, then reducing to 200 mg daily. Although peptide antibodies in predicting progression of palindromic rheumatism to usually well tolerated, hydroxychloroquine can rarely produce rheumatoid arthritis. J Rheumatol 2006; 33: 1240-1242. retinal toxicity. A baseline ophthalmological assessment is 4. Koskinen E, Hannonen P, Sokka TJ. Palindromic rheumatism: long term essential. outcomes of 60 patients diagnosed in 1967-84. Rheumatol 2009; 36: ­1873-1875. An alternative agentCopyright is the _Layout sulfur-based 1 17/01/12 drug 1:43 sulfasalazine, PM Page 4 which is also used in patients with rheumatoid arthritis and COMPETING INTERESTS: None.

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