JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Vol. XXV, No.

4
Copyright Cll977 by the American Geriatrics Society Printed in U.s.A.

Palindromic Rheumatism: An Allergic

Manifestation?
JACK MARGOLIS, MD* and LAWRENCE S. MARGOLIS, BA

Veterans Administration Hospital, Big Spring, Texas

ABSTRACT: A case of palindromic rheumatism is presented in which the arthritic

attacks usually were accompanied by an allergic vasculitis and dermatitis. Although
this is not proof of the etiology, the constant association is suggestive of an allergic
cause. A brief review of palindromic rheumatism is included.

In 1941-1944, Hench and Rosenberg (1, 2) re-
ported 34 patients who had recurring episodes of
arthritis and periarthritis, usually lasting less
than a week. They named the syndrome "palin-
dromic rheumatism." The chief features were: 1)
recurrent attacks of joint pain and swelling at
variable intervals lasting a few hours 01" a few
days; 2) involvement of any joint but especially
the fingers, wrists, shoulders and knees; 3) epi-
sodes of para-articular disease and transient nod-
ules; 4) good health of the patient, with normal
blood values and x-ray findings; and 5) a good
prognosis, but no effective treatment.
Since that time, fewer than 250 cases have
been reported (3). The etiology is unknown. In
this article, we are reporting an interesting case
of palindromic rheumatism because the disease is
uncommon and also because our findings might
help to clarify the etiology. A brief review is also
presented.
CASE REPORT
The patient was a 58-year-old, white male who
was a retired hardware-store manager. He was
admitted to our hospital for the seventh time in
seven years. The chief complaints were joint
pains, swelling of the hands, arms and feet, and a
skin rash.
The first attack began in 1970 with swelling of
the feet and legs at night; the swelling would
disappear by morning. After the first attack,
there were hundreds of recurrences during which
• Associate Clinical Professor, Texas Tech University
School of Medicine, Lubbock, TX; Chief, Medical Service,
VA Hospital, Big Spring, TX.
Address for correspondence: Chief, Medical Service, VA
Hospital, Big Spring, TX 79720.
189
the joints (usually the hands and feet) would
swell and become red, tender and painful. The
swelling, redness and pain would last a day or
two and then disappear, leaving no residual.
Most of the time, after the first year, the joint
swelling would be accompanied by a reddish pur-
puric rash, primarily on the legs and thighs. This
rash usually would begin to fade when the joint
swelling receded, and within a few days would
disappear completely. The attacks followedno set
pattern. Sometimes the rash and joint swelling
would last a few hours, whereas at other times
they would last four to five days. No relationship
to food, activity, or any other factor could be
elicited. Medication had no effect on the course of
the disease.
The past history was unrevealing. Several bi-
opsy specimens of the skin and muscle during
quiescent periods were normal.
The patient had smoked two to three packs of
cigarettes daily for 30 years.
The family history provided no clues. Both par-
ents and four siblings were alive and healthy.
Physical examination - At the time of this ad-
mission the right wrist and right knee were hot,
swollen and tender, and there was a reddish pur-
puric rash over the legs, thighs and forearms.
Otherwise the findings were essentially nega-
tive.
A biopsy of a representative skin lesion showed
a heavy, subacute, inflammatory reaction which
chiefly involved the blood vessels, with subse-
quent extension in patchy fashion throughout the
thickness of the dermis. There were no signifi-
cant changes in the epidermis. Most of the leuko-
cytes were segmented forms. There was a minor
degree of eosinophilia. Vessels of all sizes and
types were involved, and inflammatory cells were
 MARGOLIS AND MARGOLIS
seen in all layers of the vessel wall. The endothe-
lial cells were somewhat swollen, but very few
thrombi could be found. Many leukocyte nuclei
were fragmented. Patchy hemorrhage was pres-
ent in the superficial dermis, but this appeared to
be of more recent origin than the inflammation.
Scattered small deposits of hemosiderin were in-
dicative of previous bleeding.
The diagnosis was allergic vasculitis and der-
matitis.
Several appropriate laboratory determinations
and x-ray examinations were made, e.g., re-
peated complete blood counts, erythrocyte sedi-
mentation rates, serologic tests, bone marrow
examinations, platelet counts, rheumatoid ar-
thritis tests, and determinations of serum elec-
trolytes levels, serum electrophoretic fractions,
immunoelectrophoretic fractions, C-reactive pro-
tein, serum complement, triiodothyronine and
thyroxine levels, antinuclear antibody, cryoglob-
ulins, and routine SMA tests. All of these gave
negative findings during both the quiescent pe-
riod and the acute attack. X-ray films of most
joints showed nothing abnormal.
DISCUSSION
Ours is the first case demonstrating that skin
biopsy findings are normal during the inactive
phase of palindromic rheumatism but that al-
lergic vasculitis and dermatitis are present dur-
ing the active phase.
The rash usually accompanies the arthritis and
often lasts longer. At times the rash is present
alone, although this is uncommon. At other
times there is no rash although the joints are hot
and swollen. Our patient had the arthritis for
about a year before the rash appeared. If the
interval between attacks is more than a week,
the rash usually disappears completely.
This association of acute arthritis with allergic
vasculitis (4) and dermatitis certainly raises the
suspicion (in our patient at least) of an allergic
etiology. The rapid onset and disappearance of
the arthritis also is suggestive of an allergic reac-
tion. Yet a detailed history of allergy could not
clarify the problem further. It is noteworthy that
our patient became nervous during these attacks,
and this phenomenon would disappear after the
joints and skin had cleared.
Attempts at therapy (salicylates, antihista-
mines, and steroids) did not materially affect the
course of the disease. There was no x-ray or clini-
cal evidence of residual joint damage.
The term "palindromic" comes from the Greek
190
Vol. XXV
and means to run back or to recur (2). This is a
most appropriate term since our patient had
hundreds of attacks and others have had variable
numbers of recurrences. King (3) described two
patients with over 1000 flare-ups but no x-ray
evidence of damage.
After reviewing many of the reported cases, a
composite picture of palindromic rheumatism
emerged. Most of the patients have joint pain,
usually beginning suddenly and resembling an
attack of acute gout. The pain is variable, rang-
ing from a dull ache to a feeling of intense burst-
ing pressure. The peak of the pain usually is
reached in a few hours. The duration of the ar-
thritis varies from a few hours to a few days,
rarely more than three days. The attacks often
begin in the late afternoon. Swelling and redness
usually accompany the pain. Morning stiffness
rarely develops. The pattern of joint attacks
tends to be fairly characteristic in a given pa-
tient. Over anyone period, only a few joints are
simultaneously involved. Symptoms may in-
crease in a new joint while decreasing in joints
affected in the previous attack. Intervals between
attacks may vary from a few days to months. On
the whole, the established pattern continues rela-
tively unchanged for the duration of the illness.
The knee is probably the most commonly affected
joint. Para-articular attacks occur in about one-
third of the pateints. Transient subcutaneous
nodules are also a feature of this disorder (1, 2, 5-
7).
Mattingly (8) reported a strong family history
of palindromic rheumatism and a high incidence
of joint disease in the mothers of his patients.
Laboratory results usually are normal or, at
most, indicate only transient abnormalities. The
findings in the joint fluid are relatively unre-
markable. X-ray films usually do not show any
abnormalities except for the soft-tissue swelling
at the time of the attack (5).
The prognosis is variable. A follow-up of 140
patients with palindromic rheumatism at the
Mayo Clinic (9), conducted for at least five years,
revealed that more than half suffered continued
attacks. Almost 10 percent experienced complete
remission during the period of observation. Rheu-
matoid arthritis developed in more than one-
third of the patients, and gout, systemic lupus
erythematosus, or other arthritides in the re-
mainder.
REFERENCES
1. Hench PS and Rosenberg EF: Palindromic rheumatism,
Proc Staff Meet Mayo Clin 16: 808, 1941.
April 1977 PALINDROMIC RHEUMATISM AND ALLERGY
2. Hench PS and Rosenberg EF: Palindromic rheumatism;
report of 34 cases, Arch Int Med 73: 293, 1944.
3. King BG: Palindromic rheumatism. An unusual case of
the inflammatory joint, J Bone & Joint Surg 56A: 142,
1974.
4. Shazo RD: The spectrum of systemic vasculitis, Postgrad
Med 58: 78, 1975.
5. Hollander JL: Arthritis and Allied Conditions. A Text-
book of Rheumatology. Philadelphia, Lea & Febiger,
1960.
6. Ferguson RH and Polley HF: Variants of rheumatoid
arthritis, Med Clin N America, 52: 503, 1968.
7. Williams MH: Palindromic rheumatism, Ann Rheum
Dis 30: 375, 1971.
8. Mattingly S: Palindromic rheumatism, Ann Rheum Dis
25: 307, 1966.
9. Ward LE and Okihiro MM: Palindromic rheumatism: a
followup study. Presented at the Second Pan-American
Congress on Rheumatic Diseases, AIR 2: 208, 1959.
191