Postgrad Med J: first published as 10.1136/pgmj.31.362.627 on 1 December 1955. Downloaded from 627 THE RARER ARTHROPATHIES By F. DUDLEY HART, M.D., F.R.C.P. Westminster Hospital, London Pains referable to muscle, bone or joint may (i) Malignant or submalignant conditions; car- occur in almost all diseases in the medical diction- cinoma of bronchus, lymphadenoma. ary; were one to list the causes of arthralgia very (j) Primary haematological conditions; leu- few conditions would be left out of the differential kaemia, haemophilia and other bleedingconditions, diagnosis. It is necessary, therefore, to confine thrombocytopenic purpura. ourselves to those conditions which show definite (k) Allergic conditions; anaphylactoid purpura swelling of joint structures accompanied by some (Osler-Sch6nlein), serum sickness. degree of pain or discomfort and' some disability. (1) Vitamin deficiency; scurvy, rickets. Even so the list is long and only those more likely (m) Endocrine disorders; acromegaly. to be encountered will be considered. The im- (n) Drug induced arthropathy; e.g. sulpha portance of recognizing these rare arthropathies drugs, penicillin. Protected by copyright. lies not only in the fact that they may need specific This list is not intended to be comprehensive therapy but also that misdiagnosed as rheumatoid and does not include bony metastastic disease, or osteoarthritis the true diagnosis may be delayed osteomyelitis, bursitis, Paget's disease, reflex several weeks or months or even occasionally years dystrophy, herpes zoster, the osteochondroses or a to the detriment of the patient. It is all too easy host of other disorders which may cause pain but in any speciality in medicine to think only in terms rarely a true arthropathy. Only some of the of a handful of disease processes common in that conditions listed above will be considered. speciality and to forget that the whole field of medicine may contribute cases very similar in Palindromic Rheumatism external features but of quite different aetiology. This disease was described by Hench and A list of such arthropathies might include: Rosenberg as a specific entity, the essential feature (a) Those syndromes which are merely a variant of which was a recurrent swelling of the joints of rheumatoid arthritis and do not need to be unaccompanied by fever, the joint structures consi(ered as an no or entity apart; Felty's syndrome, suffering degenerative inflammatory change http://pmj.bmj.com/ arthritis mutilans, Still's disease, Sj6gren's syn- with the passage of time. While Hench and drome. Rosenberg insisted that their cases were not a (b) Those syndromes which, though due to a variant of rheumatoid arthritis, the majority ofsuch variety of cifferent causes, are commonly mani- cases seen in this country are in the final analysis festations of rheumatoid arthritis; e.g. Palindromic and after the passage of time shown to be examples rheumatism, intermittent hydrarthrosis. of this disorder. Rheumatoid arthritis is a (c) Reiter's (Brodie's) syndrome. remitting-relapsing disease and this palindromic (d) Psoriatic arthropathy. syndrome when we have seen it has merely been on September 27, 2021 by guest. (e) The disseminated ' collagen' or ' para- rheumatoid arthritis turned, as it were, off and rheumatic' disorders; disseminated lupus ery- on, demonstrating the essential reversibility of this thematosus, polyarteritis nodosa, scleroderma, disease in its early stages. These patients have in dermatomyositis. their tissues the ' reversibility factor' operating (f) Manifestations of a generalized granulo- perhaps every few days; a patient with swollen matous disease; e.g. tuberculosis, syphilis, yaws, painful joints on Monday may be completely free leprosy, sarcoidosis. from signs and symptoms on Wednesday, only to (g) Manifestations of otherbacterial infective dis- be affected again the next day. In time the com- orders; undulant fever, enteric fever, meningo- plete restitution to normality fails to occur and coccal fever, gonorrhoea. rheumatoid arthritis of the established usual type (h) The neuropathies; Charcot's tabetic joint, slowly develops. We have seen cases where the syringomyelia. palindromic phase has lasted 30 years only to Postgrad Med J: first published as 10.1136/pgmj.31.362.627 on 1 December 1955. Downloaded from 628 POSTGRADUATE MEDICAL JOURNAL December 1955 merge gradually into the pattern of a classical Finnish Army some 13 days after the onset of rheumatoid arthritis after this time. While other flexner dysentery. Many cases but by no means all disorders, for example lymphadenoma and un- follow exposure to venereal infection, though the dulant fever, may give a similar picture and while gonococcus is not isolated; in some cases the dis- there are reported cases of an apparently specific order commences two to four weeks after successful primary palindromic syndrome those patients we penicillin therapy of a known gonococcal infection. have seen with this disorder have in almost all The L or pleuropneumonia-like organism has been cases in the course of time been revealed as considered by some workers as the possible causa- sufferers from rheumatoid arthritis. tive agent but the bulk of evidence is against it. Though the male sex is predominantly affected, Intermittent Hydrarthrosis female cases do occur. The skin condition, While many conditions may produce inter- keratoderma blenorrhagicum, commonly co-exists, mittent effusion into joints, as with palindromic as it does with gonorrhoeal infection. Indeed, in rheumatism, most cases in our experience eventu- these days of readily-available rapidly-effective ally demonstrate other signs of rheumatoid disease, antibiotic therapy one wonders if many of these either arthritis or spondylitis, and become classical cases of Reiter's syndrome do not follow gonococcal examples of one or other of these disorders. The infection immediately treated. The latent interval knees are the most common joints affected, and the development after a variety of pelvic unilaterally or bilaterally. infections makes it appear to be a non-specific A typical history is that of a male patient I have arthropathy fired off by a variety of infections. seen who had suffered recurrent swelling of one or Nevertheless, on occasion its almost epidermic both knees for nine years. The swelling was not form suggests a more specific aetiological agent. several at a but in a number of cases of painful and lasted only days time, Ford, following up Protected by copyright. considerable inconvenience was experienced. Skin gonococcal and non-gonococcal urethritis, found tests for allergic reactions revealed a reaction to that four developed changes in the sacro-iliac certain dusts, long courses of which given by joints after earlier arthritis of the ankles and feet. injection failed to affect the subsequent course of Such cases he considers a variant of ankylosing events though every natural remission was hope- spondylitis, as did Buckley some years previously. fully attributed to the latest injection given. It is clear that much work remains to be done in Spinal stiffness and pain gradually increased and he this rather untidy corner in the field of was eventually correctly diagnosed as a case of rheumatology. ankylosing spondylitis. In both this disorder and in rheumatoid arthritis such intermittent swelling Psoriatic Arthropathy may precede the classical features by several There is still a difference of opinion as to this months or years. Nevertheless, not all cases can condition, whether it is merely a variant of rheuma- be accounted for by these two disorders and a toid arthritis in association with the skin condition number of other underlying causes are occasionally or whether it is a separate disease entity. In many found, for instance-trauma, tuberculosis or cases it appears to be no different from any other http://pmj.bmj.com/ undulant fever. Some patients may suffer also case of rheumatoid arthritis, in others it presents a from an associated recurrent iridocyclitis; this more irregular asymmetrical form with a tendency again suggests a rheumatoid aetiology, ankylosing to involve the terminal interphalangeal joints and spondylitis being more common in this association thumbs. This involvement of all finger joints, than rheumatoid arthritis. metacarpo-phalangeal, proximal and distal inter- phalangeal, gives rise to the 'sausage' finger Reiter's described Dr. at a of the (Brodie's) Syndrome by Francon meeting on September 27, 2021 by guest. Benjamin Brodie described six patients suffering Heberden Society. Where involvement of the from polyarthritis, urethritis and conjunctivitis distal joint occurs there is frequently, but not early in the i9th century; Ioo years later, in I9I6, invariably, the tell-tale pitting or more diffuse Reiter described a single similar case which involvement of the nail in that digit. There is no followed bacillary dysentery. This syndrome has doubt that the association between psoriasis and a been exciting considerable interest lately as cases rheumatoid type of arthritis is more common than come to the fore in war time and the years could be accounted for by mere chance. Wassman immediately following; nevertheless, singularly (I949) found psoriasis in only 0.43 per cent. of little is generally agreed on in this disorder and the Io,ooo medical patients, but inI3.I per cent. of aetiology is still obscure. ,000o patients with rheumatoid arthritis; Cecil Certain features are apparent. The triad may (i949) found it in 5.6 per cent. of 930 rheumatoid follow infective disease of the lower colon and sufferers. Fawcett (I950) has described fhe rectum; Paronen described many cases in the radiological features. Postgrad Med J: first published as 10.1136/pgmj.31.362.627 on 1 December 1955. Downloaded from December I955 DUDLEY HART: The Rarer Arthropathtes 629 ··...;: ..:I·;... .i'.. bl·. :i :i..*ii.i·i"iiii· ·I:· i.., ·::::··· :I; ·;···· ·!· · ···:.-98611: '781 1R5ini.·'::i.··: ""'·i· i... :':i:.: i. :ia.ss.nsi.i.as. ,iiip.aa ;i' IIPssP$B.Ps..P...:ii· :· b' ii: ai :·· ;:H:ill%rsllliiPrs.%k I.BI. i. 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