INFO: Atypical Rheumatoid Arthritis

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Atypical Rheumatoid Arthritis



Question

I have a 47-year-old female patient with yearly bouts of severe,

symmetrical wrist MCP, elbow and knee pain for 8 years. RF is

negative, ESR during bouts is 25, and there is no objective evidence

of inflammation during flares. She was given a diagnosis of

seronegative rheumatoid arthritis (RA) by a rheumatologist and was

started on methotrexate with relief. Nonsteroidal anti-inflammatory

drugs (NSAIDs) do not provide relief and hand x-rays have been read

as negative. Can RA present like this?

Lucy Malisan, MD



Response from Stanley B. Cohen, MD

Clinical Professor, University of Texas Southwestern Medical Center

at Dallas; Medical Director, Radiant Research, Dallas, Texas



This patient probably falls under the category of " atypical

rheumatoid arthritis. " These patients do not fulfill the criteria for

RA but may be included under this category. Whether this represents a

variant of RA is unclear. It is possible with newer imaging

techniques such as MRI or ultrasound that subclinical synovitis may

be present.

Palindromic rheumatism is an example of an inflammatory arthritis

that is characterized by flare-ups of synovitis occurring at

intervals from weeks to months.[1] The joint involvement is generally

oligoarticular in contrast to the symmetrical arthritis exhibited by

this patient, and different joints may be involved in separate flare-

ups. These flare-ups generally last for 2-3 days and then resolve

without any evidence of radiographic damage. Approximately 50% of

these patients progress to classic RA over time.

These " atypical " patients do not have the progressive destructive

course of classic RA. Management often consists of symptomatic

treatment with NSAIDs as needed, corticosteroids, or analgesics. If

the flares occur frequently, treatment with disease-modifying

antirheumatic drugs (DMARDs), such as hydroxychloroquine,

sulfasalazine, or, as in this case, methotrexate, may be used to

decrease the frequency and severity of the episodes.

In summary, this presentation accounts for less than 1% to 2% of RA

patients and the prognosis for these patients is generally good.

Because the patients do not fulfill the American College of

Rheumatology criteria for RA, they would be excluded from clinical

trials, and limited evidence-based information is available on their

treatment response.

http://www.medscape.com/viewarticle/501829