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673 - Knee Pain on a Schedule: A Case Report

Thursday, February 27, 2025

5:00 PM - 6:30 PM MST

Presenting Author(s)

Ted Miclau, MD

Resident Physician
Mayo Clinic
Rochester, Minnesota, United States

Co-Author(s)

BK

Ben Kopecky, DO

Chief Resident Physician
Mayo Clinic
Rochester, Minnesota, United States
CP

Cara C. Prideaux, MD

Assistant Professor PM&R, PM&R Residency Program Director
Mayo Clinic
Rochester, Minnesota, United States

Case Diagnosis: Palindromic rheumatism in a 63-year-old female patient presenting with recurrent left knee pain and swelling.

Case Description: The patient reported 1-2-day episodes of pain and swelling in the left knee occurring every 2 weeks with symptom-free periods in between. She remained physically active with no known trauma or identifiable triggers. On exam, there was tenderness to palpation at the patellar facets and posteromedial joint line with a small effusion. Lab results demonstrated mildly elevated rheumatoid factor (20 U/mL) with normal CRP and ANA. Synovial fluid was negative for crystals, infection, and inflammatory changes. X-ray and MRI demonstrated moderate joint effusion, synovitis, and degenerative changes. Intra-articular injection provided no relief, as swelling episodes persisted. Rheumatology referral resulted in a diagnosis of palindromic rheumatism with components of degenerative joint disease. Hydroxychloroquine was initiated, leading to significant improvement. She has maintained on hydroxychloroquine for 5 years requiring only one corticosteroid injection for a flareup in her 5th proximal interphalangeal joint.

Discussions: Palindromic rheumatism is a rare subtype of inflammatory arthritis characterized by recurrent, abrupt, and self-limiting episodes of isolated joint pain and inflammation lasting from hours to days. In between episodes, symptoms are completely resolved without permanent joint damage or deformity. Pathogenesis is not well understood but is believed to be autoimmune and is associated with chronic rheumatic diseases, with about half of affected patients progressing to rheumatoid arthritis (RA). NSAIDs and corticosteroid injections can help manage symptoms, but hydroxychloroquine is required to reduce the severity/frequency of episodes and may prevent progression to RA.

Conclusions: This case underscores the importance of considering rare rheumatologic conditions in patients with periodic joint swelling, negative synovial fluid analyses, and unremarkable autoimmune labs. When properly identified, management with disease-modifying antirheumatic drugs such as hydroxychloroquine can improve patient outcomes and quality of life.