Palindromic rheumatism (PR) is a rare, episodic form of inflammatory arthritis that causes sudden and recurrent attacks of joint pain, swelling, and stiffness. Unlike rheumatoid arthritis (RA), PR does not cause permanent joint damage between episodes, and affected individuals often experience complete relief between attacks. However, because up to 70% of patients may later develop RA, understanding PR is essential for both patients and healthcare providers. 

This article explores the key aspects of palindromic rheumatism, including what it is, its causes, risk factors, signs and symptoms, diagnosis, and treatment options. It also provides practical information for people living with PR and discusses ways to manage flare-ups and reduce the risk of progression to more chronic arthritis. 

Palindromic rheumatism is a relapsing-remitting type of arthritis. People with PR experience recurrent, self-limiting attacks of joint inflammation that last from a few hours to several days. After each attack, symptoms completely disappear, leaving the joints normal in appearance and function. 

The name “palindromic” comes from the Greek term meaning “running back again,” referring to its recurring pattern. While PR was once thought to be a benign condition, it is now recognized as a possible early stage of rheumatoid arthritis, particularly in people who test positive for specific antibodies such as rheumatoid factor (RF) or anti-cyclic citrullinated peptide (anti-CCP). 

Diagnostic features include: 

• Sudden-onset attacks of joint pain and swelling 

• Episodes lasting from a few hours up to 3 days 

• Symptom-free intervals between attacks 

• No evidence of chronic inflammation or joint damage on imaging 

Palindromic rheumatism is considered uncommon, affecting an estimated 1 to 5 out of every 100,000 people. The condition can occur at any age but is most commonly seen in adults aged 30 to 50 years. Women are affected more often than men, with a female-to-male ratio of about 2:1. PR has been reported in all ethnic groups worldwide. 

The exact cause of PR is unknown, but researchers believe it involves an autoimmune process, in which the body’s immune system mistakenly attacks its own joint tissues. Genetics, environmental factors, and infections may all play a role. 

Potential triggers and risk factors include: 

• Genetic predisposition: Certain genes, such as HLA-DR4 and HLA-DR1, are associated with PR and RA. 

• Autoantibodies: Presence of RF and anti-CCP antibodies suggests an autoimmune mechanism. 

• Infections: Viral or bacterial infections may act as triggers in some individuals. 

• Environmental factors: Smoking, pollution, and chronic stress may increase susceptibility. 

• Trauma or physical strain: Minor injuries to joints can occasionally precipitate attacks. 

Because PR and RA share many immunologic characteristics, some researchers consider PR to be part of a spectrum of autoimmune joint diseases. 

Palindromic rheumatism involves transient episodes of joint inflammation that resolve spontaneously. The inflammation may begin with the activation of immune cells, which release cytokines and inflammatory mediators into the synovial (joint) tissue. 

Key processes include: 

• Immune dysregulation: The presence of RF and anti-CCP antibodies indicates autoimmune activity. 

• Synovial inflammation: During attacks, the lining of the joint (synovium) becomes inflamed, causing pain and swelling. 

• Cytokine release: Elevated levels of pro-inflammatory cytokines such as TNF-α, IL-1, and IL-6 contribute to inflammation. 

• Resolution: After each flare, inflammation subsides completely, leaving the joint undamaged. 

In some patients, repeated immune activation may lead to persistent inflammation and eventual progression to rheumatoid arthritis. 

The hallmark of PR is sudden, painful joint attacks that come and go. These attacks may affect one or several joints and are usually accompanied by visible swelling and redness. 

Common features include: 

• Rapid onset of joint pain, often within hours 

• Swelling, redness, and warmth over the affected joint 

• Attacks lasting from several hours to three days 

• Complete resolution between attacks 

Commonly affected joints: 

• Hands and fingers (especially knuckles) 

• Wrists 

• Knees 

• Ankles 

• Shoulders 

• Elbows 

Other possible symptoms: 

• Mild fever and fatigue during attacks 

• Soft tissue swelling or tenosynovitis (inflammation around tendons) 

• Transient nodules under the skin 

Between attacks, people with PR usually feel completely normal, with no pain, stiffness, or swelling. 

Because there is no specific test for PR, diagnosis is based on the clinical pattern of symptoms and exclusion of other joint diseases. A rheumatologist typically performs a detailed medical history, physical examination, and blood tests. 

Key diagnostic tests include: 

• Rheumatoid Factor (RF): Positive in about half of patients. 

• Anti-CCP antibodies: Found in 40–60% of cases and strongly linked to progression to RA. 

• ESR and CRP: Elevated during flares, but normal between attacks. 

• Synovial fluid analysis: Shows inflammatory cells during attacks but no infection or crystals in most cases. 

• Imaging (X-ray, ultrasound, MRI): Typically normal; ultrasound may show temporary inflammation during flares. 

Proposed diagnostic criteria: 

• At least three episodes of arthritis involving one or more joints 

• Episodes lasting less than 7 days 

• Symptom-free periods between attacks 

• Exclusion of other arthritic conditions such as gout or RA

Because PR symptoms overlap with several other rheumatic diseases, doctors must rule out other causes of recurrent arthritis. 

Conditions to consider include: 

• Rheumatoid arthritis (especially in early stages) 

• Gout or pseudogout (crystal-induced arthritis) 

• Systemic lupus erythematosus 

• Reactive arthritis 

• Seronegative spondyloarthropathies 

• Recurrent infectious arthritis 

Distinguishing features of PR: 

• Complete remission between attacks 

• No erosive changes on imaging 

• Lack of chronic synovitis 

The goals of treatment are to relieve pain during attacks, reduce flare frequency, and monitor for potential progression to rheumatoid arthritis. 

Managing acute attacks: 

• NSAIDs (nonsteroidal anti-inflammatory drugs): Common first-line therapy for pain and inflammation. 

• Short courses of corticosteroids: May be prescribed for severe attacks, either orally or as local injections. 

Long-term management: 

• Hydroxychloroquine (Plaquenil): Shown to decrease the frequency and intensity of attacks; may reduce the risk of developing RA. 

• Colchicine: Occasionally used to prevent attacks in patients with frequent flares. 

• DMARDs (Disease-Modifying Antirheumatic Drugs): Methotrexate or sulfasalazine may be considered for those with anti-CCP positivity or early signs of persistent arthritis. 

Lifestyle strategies: 

• Maintain regular medical checkups to detect early RA changes. 

• Protect joints and avoid repetitive strain. 

• Engage in gentle exercise during remission periods. 

• Manage stress and get adequate sleep. 

• Identify and avoid possible triggers such as infections or injuries. 

Palindromic rheumatism itself does not cause permanent joint damage, but complications can arise from recurrent flares or progression to chronic arthritis. 

Potential complications include: 

• Progression to rheumatoid arthritis: Occurs in about 30–70% of patients over time. 

• Emotional and physical stress: Frequent attacks can cause anxiety or depression. 

• Temporary disability: Pain and swelling can limit daily activities during attacks. 

Monitoring with a rheumatologist is essential to detect early signs of chronic arthritis and adjust treatment accordingly. 

The outlook for PR varies among individuals. Some people experience only a few attacks in their lifetime, while others have frequent recurrences. For many, the disease remains intermittent without long-term damage. 

Types of disease course: 

• Non-progressive PR: Attacks become less frequent over time and may eventually stop. 

• Progressive PR: Symptoms evolve into persistent inflammation consistent with rheumatoid arthritis. 

Factors associated with progression include positive anti-CCP antibodies, high flare frequency, and evidence of synovitis during attacks. 

Although there is no proven way to prevent PR, certain measures can reduce attack frequency and the risk of progression to RA. 

Prevention tips include: 

• Early use of hydroxychloroquine in frequent or severe flares. 

• Regular monitoring for RA-related antibodies (RF and anti-CCP). 

• Treat infections promptly to avoid triggering flares. 

• Maintain a healthy lifestyle with balanced nutrition and physical activity. 

• Stop smoking, as it may worsen autoimmune inflammation. 

Living with PR can be challenging due to its unpredictable nature. However, with proper management and support, most people can lead full, active lives. 

Practical advice includes: 

• Keep a symptom diary to track triggers, flare frequency, and response to medications. 

• Work with a rheumatologist for regular evaluations. 

• Learn joint protection techniques and ergonomic modifications for daily tasks. 

• Seek support groups or counseling to manage the emotional aspects of chronic illness. 

• Communicate openly with healthcare providers about symptoms and treatment goals. 

Education and early intervention are key to minimizing attacks and preventing progression. 

Palindromic rheumatism is an uncommon but clinically important form of episodic arthritis. While many people experience self-limiting attacks, a significant proportion develop rheumatoid arthritis over time. Early recognition, patient education, and appropriate use of medications such as hydroxychloroquine can help reduce the frequency of attacks and improve quality of life. 

Ongoing research into the autoimmune mechanisms behind PR continues to provide insights that may one day help predict and prevent its progression to chronic inflammatory arthritis. 

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