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A 74 year old white man presented with an abrupt onset of metacarpophalangeal (MCP) and interphalangeal (IP) joint pains associated with swelling of both hands. He had two hours of morning stiffness but no other joint complaints or history of constitutional symptoms. Past medical history was unremarkable except for diabetes mellitus type 2 treated with oral antidiabetic drugs.
RS3PE is a definite subset of the seronegative symmetrical polyarthritis of the aged characterised by dramatic pitting oedema of the hands, male predominance, old age, exquisite response to corticosteroids, and long term remission after withdrawal.
RS3PE may be part of a paraneoplastic syndrome and heightened suspicion for underlying malignancy is important, especially if the response to corticosteroids is poor.
The differential diagnosis of arthritis that presents with prominent peripheral oedema needs to be considered before making a diagnosis.
Examination showed gross pitting oedema of the dorsum of both hands with swollen and tender MCPs, severe tenosynovitis of the flexor tendons, and swollen and limited wrist movements. Both knees had painless small effusions. Other joints showed no signs of inflammation and no nodules were palpated.
The erythrocyte sedimentation rate was increased at 55 mm in the first hour. Except for a mild inflammatory anaemia and hyperglycaemia between 8 to 10 mmol/l, the full blood count, renal, liver and thyroid function tests were within normal limits. Electrophoresis demonstrated an acute and subacute inflammatory pattern without monoclonal peak and rheumatoid factor and ANA were negative. Four millilitres of clear synovial fluid were aspirated from the left knee. Cell count was 198/mm3 with no crystals.
The patient was treated with prednisone with a rapid clinical response. Maximal dose was 20 mg per day, slowly tapered over four months to zero. No flare up was observed and after two years the patient was still …
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