Image of the month: Remitting seronegative symmetrical synovitis with pitting oedema (RS3PE): An important spot diagnosis

Haswadi F Hassan; Richard Conway

doi:10.7861/clinmed.2020-0357

KEYWORDS:

Case presentation

An 80-year-old man and former international table tennis player presented with a 4-week history of dramatic sudden onset bilateral hand swelling in conjunction with early morning stiffness in both hips and shoulders. He had a background history of hypertension and previous sports-related shoulder injuries. He was prescribed olmesartan and paracetamol/codeine and had no known drug allergies.

Both hands, including the fingers, were diffusely swollen with pitting oedema, Fig 1. He was unable to straighten his fingers, make a fist or remove his ring. Due to this, he had ceased playing table tennis. There was restricted range of motion in shoulder abduction to 15 degrees on the right and 30 degrees on the left. C-reactive protein was 96 mg/L and erythrocyte sedimentation rate of 60 mm/hr. Rheumatoid factor and anti-cyclic citrullinated peptide were negative. X-rays of shoulders, hands and hips were normal aside from minor degenerative changes.

Fig 1.

Photograph of diffusely swollen hands with pitting oedema.

Based on the classical clinical examination findings shown in Fig 1 and a consistent clinical and biochemical picture, a diagnosis of remitting seronegative symmetrical synovitis with pitting oedema (RS3PE) in association with polymyalgia rheumatica (PMR) was made. He commenced prednisolone 15 mg daily with full resolution of his symptoms and signs, and resumption of sporting activity, within 1 week.

Discussion

RS3PE is an inflammatory disorder of unknown aetiology affecting the elderly. It is characterised by sudden onset arthritis in association with distinctive bilateral pitting oedema of the dorsum of the hands. It is frequently seen in association with symptoms consistent with PMR and may be part of the same disease spectrum.¹ It is typically exquisitely sensitive to glucocorticoids with rapid relief of the disabling symptoms. Prompt recognition of the clinical findings can lead to expedited treatment and avoidance of unnecessary investigations, diagnostic delay and functional limitation.