Palindromic rheumatism. Clinical and immunological studies.

Hench and Rosenberg (1944) described 34 patients with recurring episodes of arthritis and periarthritis usually lasting less than a week and named by them 'palindromio rheumatism'. The features they emphasized may be summarized as follows: (1) Recurrent attacks ofjoint pain and swelling at variable and irregular intervals lasting a few hours or a few days. (2) Any joint affected but especially fingers, wrists, shoulders and knees. (3) Para-artioular attacks and transient nodules. (4) Good health: normal blood tests and x-rays. (5) Good prognosis-no effective treatment. Several case reports have appeared since then, though few series of patients have been followed up (Ward and Okihiro, 1959; Rotes Querol and Lience, 1959; Dames and Zuckner, 1961; Ansell and Bywaters, 1959). The main differential diagnosis is from crystal synovitis which may be due either to sodium urate or to calcium pyrophosphate. In these conditions, attacks are usually monarticular, occurring in favoured joints and frequently lasting for about a week. In those due to sodium urate, erosions may be detected, there is hyperuricaemia, and crystals of monosodium urate may be detected in tophi and synovial fluid. In those due to calcium pyrophosphate, calcification of articular cartilage may be seen, and the diagnosis is supported by the demonstration of calcium pyrophosphate crystals in synovial fluid; hyperuricaemia may or may not be associated. Intermittent hydrarthrosis is a condition distinguished by the regularity of attacks, which nearly always affect one or both knees, though other joints may rarely be involved (Mattingly, 1957). The differentiation of palindromic rheumatism from episodic rheumatoid arthritis is not easy, though Hench (1947) mentioned that the latter tended to occur in favoured joints, para-articular manifestations were less frequent, and the finger pads were not involved. The duration of attacks was longer, intervals between attacks tended to be shorter, and there were often symptoms between attacks. The erythrooyte sedimentation rate was increased, and x rays and joint biopsy showed changes characteristic of rheumatoid arthritis. Nevertheless, some authors have expressed the view that palindromic rheumatism is a variant of episodic rheumatoid arthritis or a stage in its development (Ansell and Bywaters, 1959; Robinson, 1963; Mattingly, 1966).