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Identification of a distinct imaging phenotype may improve the management of palindromic rheumatism
  1. Kulveer Mankia1,2,
  2. Maria-Antonietta D’Agostino1,3,4,
  3. Richard J Wakefield1,2,
  4. Jackie L Nam1,2,
  5. Waqar Mahmood1,
  6. Andrew J Grainger2,5,
  7. Paul Emery1,2
  1. 1 Department of Rheumatology, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
  2. 2 Department of Rheumatology, NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
  3. 3 Department of Rheumatology, APHP, Hopital Ambroise Paré, Paris, France
  4. 4 Department of Rheumatology, INSERM U1173, Laboratoire d’Excellence INFLAMEX, UFR Simone Veil, Versailles-Saint-Quentin University, Versailles, France
  5. 5 Department of Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
  1. Correspondence to Professor Paul Emery, Leeds Institute of Rheumatic and Musculoskeletal Medicine, Chapel Allerton Hospital, Leeds LS7 4SA, UK; p.emery{at}


Objectives To use high-resolution imaging to characterise palindromic rheumatism (PR) and to compare the imaging pattern observed to that seen in new-onset rheumatoid arthritis (NORA).

Methods Ultrasound (US) assessment of synovitis, tenosynovitis and non-synovial extracapsular inflammation (ECI) was performed during and between flares in a prospective treatment-naive PR cohort. MRI of the flaring region was performed where possible. For comparison, the same US assessment was also performed in anticyclic citrullinated peptide (CCP) positive individuals with musculoskeletal symptoms (CCP+ at risk) and patients with NORA.

Results Thirty-one of 79 patients with PR recruited were assessed during a flare. A high frequency of ECI was identified on US; 19/31 (61%) of patients had ECI including 12/19 (63%) in whom ECI was identified in the absence of synovitis. Only 7/31 (23%) patients with PR had synovitis (greyscale ≥1 and power Doppler ≥1) during flare. In the hands/wrists, ECI was more prevalent in PR compared with NORA and CCP+ at risk (65% vs 29 % vs 6%, p<0.05). Furthermore, ECI without synovitis was specific for PR (42% PR vs 4% NORA (p=0.003) and 6% CCP+ at risk (p=0.0012)). Eleven PR flares were captured by MRI, which was more sensitive than US for synovitis and ECI. 8/31 (26%) patients with PR developed RA and had a similar US phenotype to NORA at progression.

Conclusion PR has a distinct US pattern characterised by reversible ECI, often without synovitis. In patients presenting with new joint swelling, US may refine management by distinguishing relapsing from persistent arthritis.

  • early rheumatoid arthritis
  • anti-CCP
  • magnetic resonance imaging
  • ultrasonography

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  • Handling editor Josef S Smolen

  • Contributors KM designed the study, collected and analysed the data and wrote the manuscript. MADA designed the study, scored the ultrasound and MRI images and helped write the manuscript. RJW helped design the ultrasound protocol and performed some of the ultrasound scans. JLN was one of the study clinicians and performed some of the ultrasound scans. WM helped with data analysis. AJG was responsible for MRI protocols. PE designed and led the study. All co-authors read and revised the manuscript.

  • Funding The study was supported by the National Institute for Health Research (NIHR) Leeds Clinical Research Facility. Additional support was provided by Arthritis Research UK (ARUK grant number 7174).

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval NHS Health Research Authority National Research Ethics Service Committee Yorkshire and the Humber, Leeds West.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available from this study.