Remitting seronegative symmetrical synovitis with pitting oedema as the first manifestation of psoriatic arthropathy

L. Díez-Porres, S. Muñoz-Fernández, P. Aguado, M. Alonso and E. Martín-Mola

Rheumatology Unit, Hospital Universitario La Paz, Universidad Autónoma de Madrid, Spain

SIR, In 1985, McCarty et al. [1] described a series of patients from the heterogeneous group of elderly patients with polyarthritis. They presented acute onset bilateral symmetrical synovitis of upper and/or lower limbs associated with a marked pitting oedema of the dorsum of the hands and/or feet, with an excellent prognosis.The acronym RS3PE (‘remitting, seronegative, symmetrical synovitis with pitting oedema’) was used to define this syndrome. The principal characteristics reported by McCarty were confirmed 5 yr later with 13 additional cases and in numerous reports in the literature [24].

The clinical findings originally described for the syndrome have also been observed in other rheumatic diseases such as polymyalgia rheumatica and temporal arteritis, late onset RA, ankylosing spondylitis, acute sarcoidosis and spondyloarthropathies. Some reports have related it to connective tissue diseases such as polyarteritis nodosa or other vasculitides. RS3PE syndrome has also been described as a paraneoplastic condition in some recently documented cases [5, 6].

Psoriatic arthropathy (PsA) is an inflammatory arthritis associated with psoriasis that is usually seronegative for rheumatoid factor (RF). It has been reported in 7–42% of patients with psoriasis [7]. However, arthritis with the clinical and radiographic features of PsA may occur in patients without cutaneous involvement or before the development of psoriasis [8, 9].

In the recent literature, there has been only one report of remitting distal extremity swelling with pitting oedema in psoriatic arthritis caused by tenosynovitis, which responded promptly and completely to corticosteroids [10].

We describe a patient who presented with distal extremity swelling and pitting oedema as the first manifestation of psoriasis. A 74-yr-old woman developed sudden, bilateral, painful swelling of her metacarpophalangeal (MCP) and proximal interphalangeal joints (PIP), wrists and ankles. She was seen for the first time in our outpatient clinic in October, 1999. Bilateral pitting oedema of dorsum of both hands and feet was observed (Fig. 1Go). Radiographs of the hands were normal, except for the presence of juxta-articular osteopenia.



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FIG. 1. Oedema of the dorsum of the hand in a patient with RS3PE as the first manifestation of psoriasis.

 
Laboratory data showed an erythrocyte sedimentation rate (ESR) of 41 mm/h and a C-reactive protein (CRP) level of 9.8 mg/l. The haematological values and biochemical markers were found to be normal except for haemoglobin (10.9 g/dl), leucocyte count (2980/mm3 with a normal differential cell count) and lactate dehydrogenase (659 U/l). RF, antinuclear antibodies, Mantoux and hepatitis B and C antibodies were negative.

We performed chest X-ray, bilateral mammography, abdominal ultrasonography and a gynaecological examination to exclude neoplasia. The results of all of these procedures were negative.

A diagnosis of RS3PE was made and the patient was treated with low-dose prednisone (10 mg/day) plus calcium and vitamin D supplements, and complete remission of distal swelling and oedema was achieved within 4 weeks. Prednisone was slowly tapered and stopped 6 months after the first dose.

A few days after prednisone was withdrawn, joint pain and swelling returned, accompanied by erythematous, desquamative, circular skin lesions on all four extremities and the trunk (Fig. 2Go). The patient was referred to a dermatologist who diagnosed psoriasis. Prednisone was reintroduced to treat the arthritis, and the cutaneous lesions and joint symptoms improved. Prednisone was gradually and slowly tapered over 8 months and, at present, she remains asymptomatic, receiving only topical treatment.



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FIG. 2. Cutaneous lesions that appeared after tapered withdrawal of prednisone treatment and were diagnosed as psoriasis.

 
Inflammatory swelling with pitting oedema is a non-specific finding that may be observed in a number of inflammatory rheumatic and malignant diseases [11]. The clinical spectrum of psoriatic arthritis can range from the typical features of spondyloarthropathy to a pseudorheumatoid disease. There is only one report of symmetrical, bilateral psoriatic arthritis due to tenosynovitis resembling a typical case of RS3PE [10]. The patient had a 33-yr history of cutaneous disease. There may be additional cases in which the oedema is due to impaired lymphatic drainage, as demonstrated by lymphoscintigraphy. The patients in these cases did not respond well to corticosteroids and their disease had an asymmetric pattern of presentation [11].

To our knowledge, this is the first case of RS3PE as the presenting manifestation of psoriasis. In our patient, psoriasis appeared after prednisone had been withdrawn. Lymphoedema has not been excluded. However, the bilateral and polyarticular involvement and the good response to prednisone are more suggestive of tenosynovial involvement than of impaired lymphatic drainage.

In conclusion, in our opinion, the possible presence of psoriatic arthritis should be considered in patients with RS3PE, even in the absence of cutaneous lesions.

Notes

Correspondence to: S. Muñoz-Fernández, Servicio de Reumatología, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046 Madrid, Spain. Back

References

  1. McCarty DJ, O'Duffy DJ, Pearson L, Hunter JB. Remitting seronegative symmetrical synovitis with pitting edema. RS3PE syndrome. JAMA1985;254:2763–7.[Abstract]
  2. Russell EB, Hunter JB, Pearson L, McCarty DJ. Remitting, seronegative, symmetrical synovitis with pitting edema—13 additional cases. J Rheumatol1990;17:663–9.[ISI][Medline]
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  4. Olivé A, Del Blanco J, Pons M, Vaquero M, Tena X and the Catalán group for the Study of RS3PE. The clinical spectrum of remitting seronegative symmetrical synovitis with pitting edema. J Rheumatol1997;24:333–6.[ISI][Medline]
  5. Dudler J, Gerster JC, So A. Polyarthritis and pitting oedema. Ann Rheum Dis1999;58:142–7.[Free Full Text]
  6. Olivieri I, Salvarani C, Cantini F. Remitting distal extremity swelling with pitting edema: a distinct syndrome or a clinical feature of different inflammatory rheumatic diseases? (editorial). J Rheumatol1997;24:249–52.[ISI][Medline]
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  9. Pitzalis C, Pipitone N. Psoriatic arthritis. J R Soc Med2000;93:412–5.[Free Full Text]
  10. Salvarani C, Cantini F, Olivieri I, Niccoli L, Senesi C, Macchioni L et al. Distal extremity swelling with pitting edema in psoriatic arthritis: evidence of 2 pathological mechanisms. J Rheumatol1999;26:1831–4.[ISI][Medline]
  11. Olivieri I, Salvarani C, Cantini F. RS3PE syndrome: an overview. Clin Exp Rheumatol2000;18(Suppl. 20):S53–5.
Accepted 13 May 2002





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