Idiopathic Presentation of Remitting Seronegative Symmetrical Synovitis with Pitting Edema in an Older Man.

Abstract

To the Editor: A 67-year-old man presented to the outpatient clinic because of swelling, morning stiffness, and pain in the both hands for 6 months. He had no other constitutional symptoms such as fever, fatigue, sweating, and weight loss. There was a past medical history of hypertension and diabetes mellitus. In his examination, he had tenderness of the metacarpal and proximal interphalangeal joints and edema of the dorsal side of both hands (Figure 1A). Initial laboratory tests showed an erythrocyte sedimentation rate of 112 mm/h (normal range 0–20 mm/h), C-reactive protein of 88 mg/L (normal range 0–10 mg/L), and hemoglobin of 9.8 g/L (normal range14–16 g/L). Serum uric acid and total free prostate-specific antigen levels were normal. Tests for rheumatoid factor (RF), anticyclic citrullinated peptide antibodies (anti-CCP), antinuclear antibody (ANA), and human leukocyte antigen (HLA)-B27 were all negative. A plain radiograph of the wrist showed diffuse soft tissue swelling and distal interphalangeal osteoarthritis of the hands. Ultrasound showed tenosynovitis. He was diagnosed with remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome and treated with prednisolone (10 mg/d), acemetacin (120 mg/d), and hydroxychloroquine (400 mg/d). He was screened and investigated for associated malignancies. Thoracoabdominopelvic computed tomography and abdominal ultrasonography were normal. Joint pain and edema improved within 4 weeks (Figure 1B), and acute-phase reactants decreased. At follow-up 4 weeks later, prednisolone was slowly tapered and stopped at 2 months. RS3PE syndrome, a rare inflammatory arthritis, mostly affects older adults. It can present as acute-onset polyarthritis with associated pitting edema of the extremities.1 It can be associated with solid tumors such as prostatic, rectal, gastric, colic, endometrial, hepatocellular, ovarian, pancreatic, and undifferentiated adenocarcinoma and with hematological malignancies.2 Its etiology is unknown. It can occur as an idiopathic phenomenon but also in association with various types of rheumatic diseases, most frequently late-onset rheumatoid arthritis and polymyalgia rheumatica.3 RS3PE can also be associated with gout, especially in men and elderly people.4 Individuals with RS3PE should be monitored for neoplasia with prudent age- and sex-specific surveillance for a long period of time. Long-term follow-up keeping is critical in management of RS3PE. Conflict of Interest: The authors declare that they have no conflict of interest. Author Contributions: All authors contributed to this paper. Sponsor's Role: None.