Table 1

Differential diagnosis of oedema and arthritis of the hands

DiagnosisClinical featuresInvestigations
RS3PE syndromeElderly male. Exquisite response to low dose corticosteroids. Long term remission after withdrawalNegative RF and ANA. No erosion on radiography
Mixed connective tissue disease (Sharp syndrome)Young female Raynaud phenomenaHigh titre speckled ANA (U1-RNP specificity)
CPPD disease (chondrocalcinosis)Elderly patient, female predominance. Often asymmetric, absence of constitutional symptoms. Good clinical response to NSAIDsChondrocalcinosis on hands, knee and pelvic radiography. Crystal demonstration by synovial fluid analysis with polarised light
Reflex sympathic dystrophy (Sudeck’s disease, algodystrophy)Exquisitely painful oedema, vasomotor and skin alterations. Absence of true arthritis, presence of predisposing factorsAbsence of systemic inflammation. Radiological exams (standard radiographs, bone scintigram and RMI)
Amyloid arthropathyRare disease, firm and non-inflammatory pseudo-oedema Frequent nodules and carpal tunnel syndrome. Slow and insidious onset and no morning stiffness. Polyvisceral involvementProteinuria, monoclonal gammapathy or light chain in urine (AL type). Demonstration on free amyloid debris in synovial fluid and/or specific birefregence with Congo Red staining on biopsies
Reiter’s or psoriatic spondylarthropathyCutaneous, axial, ocular or urogenital signs and symptoms. Mostly asymmetrical, sausage fingers Occasionally firm and non-pitting lymphoedemaHLA-B27 positive. Sacroiliitis on radiography
Late onset spondylarthropathyAsymmetrical pitting oedema of lower limbs with oligoarthritis. Middle aged men. Severe constitutional symptoms. Poor response to corticosteroidsHLA-B27 positive. No axial disease
Rheumatoid arthritisFemale predominance, symmetrical synovitis of MCPs and IPs. Good but not dramatic response to corticosteroidsRF, erosions on radiography
Polymyalgia rheumaticaElderly patient (female predominance 1.5–2 :1). Rare true peripheral synovitis, usually mild. Dramatic response to corticosteroids but long duration of treatment and frequent flaresTemporal artery biopsy