remitting seronegative symmetrical synovitis with pitting ... · remitting seronegative symmetrical...

Remitting seronegative symmetrical synovitis withpitting oedema (RS3PE) syndrome: a prospectivefollow up and magnetic resonance imaging study

Fabrizio Cantini, Carlo Salvarani, Ignazio Olivieri, Libero Barozzi, Luigi Macchioni,Laura Niccoli, Angela Padula, Pietro Pavlica, Luigi Boiardi

AbstractObjective—To determine the clinical char-acteristics of patients with “pure” remit-ting seronegative symmetrical synovitiswith pitting oedema (RS3PE) syndrome,and to investigate its relation with polymy-algia rheumatica (PMR). Magnetic reso-nance imaging (MRI) was used to describethe anatomical structures aVected by in-flammation in pure RS3PE syndrome.Methods—A prospective follow up studyof 23 consecutive patients with pureRS3PE syndrome and 177 consecutivepatients with PMR diagnosed over a fiveyear period in two Italian secondaryreferral centres of rheumatology. Handsor feet MRI, or both, was performed atdiagnosis in 7 of 23 patients.Results—At inspection evidence of handand/or foot tenosynovitis was present in allthe 23 patients with pure RS3PE syn-drome. Twenty one (12%) patients withPMR associated distal extremity swellingwith pitting oedema. No significant diVer-ences in the sex, age at onset of disease,acute phase reactant values at diagnosis,frequency of peripheral synovitis and car-pal tunnel syndrome and frequency ofHLA-B7 antigen were present betweenpatients with pure RS3PE and PMR. Inboth conditions no patient under 50 wasobserved, the disease frequency increasedsignificantly with age and the highest fre-quency was present in the age group 70–79years. Clinical symptoms for both condi-tions responded promptly to corticoster-oids and no patient developed rheumatoidarthritis during the follow up. However,the patients with pure RS3PE syndromewere characterised by shorter duration oftreatment, lower cumulative corticoster-oid dose and lower frequency of systemicsigns/symptoms and relapse/recurrence.Hands and feet MRI showed evidence oftenosynovitis in five patients and jointsynovitis in three patients.Conclusion—The similarities of demo-graphic, clinical, and MRI findings be-tween RS3PE syndrome and PMR and theconcurrence of the two syndromes suggestthat these conditions may be part of thesame disease and that the diagnosticlabels of PMR and RS3PE syndrome maynot indicate a real diVerence. The pres-ence of distal oedema seems to indicate abetter prognosis.(Ann Rheum Dis 1999;58:230–236)

In 1985 and 1990 McCarty et al described 23patients with remitting symmetrical synovitis ofupper limbs associated with pitting oedema ofthe dorsum of hands.1 2 The acronym RS3PE(remitting, seronegative, symmetrical synovitiswith pitting oedema) was used to define thissyndrome. Large joint arthritis and/or pittingoedema of the dorsum of feet coexisted in somepatients. All patients were negative for rheuma-toid factor. A symmetrical synovitis aVectingflexor tendon sheaths, wrists and joints of thehand was considered to be the prominent clini-cal finding. The syndrome occurred in elderlypatients and it was usually associated withincreased acute phase reactants. HLA-B7 wasobserved in 59% of the patients.

The clinical findings rapidly remitted with-out recurrences after a brief period of low dosesof corticosteroids. However, a residual de-creased motion of wrists or fingers, or both,attributable to flexion contractures was ob-served in 14 of 23 (61%) of the cases.1 2 Addi-tional cases of asymmetrical RS3PE syndromewere also reported.3 4 Subsequently, the clinicalfindings of RS3PE have also been described inother rheumatic diseases such as polymyalgiarheumatica,5 6 spondylarthropathies,7–9 psori-atic arthritis,10 rheumatoid arthritis,11 acutesarcoidosis.12 Moreover, a paraneoplasticRS3PE syndrome has been recentlyreported.13–15 Therefore, the acceptance ofRS3PE syndrome as an autonomous entity hasbeen questioned in recent papers.6 9 10 Swellingwith pitting oedema may represent a clinicalsign of a vigorous distal tenosynovitis commonto diVerent rheumatic conditions.

To evaluate the existence of RS3PE syn-drome as a distinct syndrome and its demo-graphic, clinical, and prognostic features, wehave prospectively followed up 23 consecutivepatients with this syndrome in its isolated formobserved over a five year period.

Hand or foot magnetic resonance imaging(MRI), or both, was performed to investigatethe anatomical structures aVected by inflam-mation. We have also compared the demo-graphic, clinical, and immunogenetic findingsof these patients with “pure” RS3PE syndromewith those of 177 consecutive polymyalgiarheumatica (PMR) patients diagnosed over thesame five year period in the same areas.

MethodsAll patients with distal extremity swelling withpitting oedema seen in two Italian hospitals(Prato and Reggio Emilia) over a five yearperiod (1992–1996) were considered suitable

Ann Rheum Dis 1999;58:230–236230

Unità Reumatologica,2nd Divisione diMedicina, Ospedale diPrato, Prato, ItalyF CantiniL Niccoli

Servizio diReumatologia,Azienda OspedalieraArcispedale S MariaNuova, Reggio Emilia,ItalyC SalvaraniL MacchioniL Boiardi

Servizio diReumatologiaI OlivieriA Padula

and Servizio diRadiologiaL BarozziP Pavlica

Azienda Ospedaliera,Ospedale SOrsola-Malpighi,Bologna, Italy

Correspondence to:Dr F Cantini,Unità Reumatologica,2nd Divisione di Medicina,Ospedale di Prato, PiazzaOspedale N 1, 59100 Prato,Italy.

Accepted for publication7 January 1999

on 6 Septem

ber 2018 by guest. Protected by copyright.

http://ard.bmj.com

/A

nn Rheum

Dis: first published as 10.1136/ard.58.4.230 on 1 A

pril 1999. Dow

nloaded from

http://ard.bmj.com/

candidates for the study. We also includedpatients with unilateral involvement of handsor feet, or both.

To evaluate only patients with pure RS3PEsyndrome, we excluded at diagnosis and duringthe follow up patients satisfying Healey criteriafor PMR,16 patients meeting the 1987 modifiedARA criteria for rheumatoid arthritis,17 pa-tients meeting the ESSG criteria for thespondylarthopathies,18 and those associatingpsoriasis, HLA-B27 antigen, inflammatorybowel diseases, radiological evidence of sacro-iliitis or chondrocalcinosis, acute sarcoidosisand neoplasia.

Twenty three patients with pure RS3PE syn-drome were identified and prospectively fol-lowed up. Temporal artery biopsy specimenswere obtained only in patients with cranialsigns or symptoms.

The patients were clinically assessed by thesame physician at presentation, monthly for thefirst six months and then every three monthsduring the follow up period.

A standardised data collection form wasused at every visit to record medical informa-tion. Arthritis was defined by the presence ofjoint swelling and pain. Tenosynovitis wasdefined by the presence of swelling and tender-ness along a well defined tenosynovial struc-ture. The clinical symptoms and the physicalfindings for carpal tunnel syndrome (CTS)(numbness or paresthesias of the thumb, index,middle and one half of the ring finger, usuallyworsening in nocturnal hours associated or notwith positivity of Tinel’s sign or Phalen’smanoeuvre, or both) were also assessed.

To assess the residual functional limitationafter the resolution of the acute phase at eachvisit the thickening of flexor and extensor ten-dons (evaluated by physical examination) andthe range of motion of wrists, ankles andfingers were evaluated considering as normalarticular range of motion the values reportedby Polley and Hunder.19

In the last seven consecutive patients thetenosynovial sheath and joint involvement dur-ing the acute phase were examined using mag-netic resonance imaging (MRI). Hand MRI

was performed also in five age matched healthycontrols. MRI of the hands or feet, or both, wasperformed using a 0.5T superconductive mag-net system (MR Max Plus, GE MedicalSystems, Milwaukee, WI). Patients were placedprone, with their arms extended above thehead. Both hands, joined in the “prayerposition” with a foam pad between them andimmobilised with tape, were positioned in thecentre of a 17 cm bore transmit-receiveextremity coil. To study the proximal and inte-mediated parts of the feet, each foot, in neutralposition with extended knee, was placed in thecentre of the same 17 cm bore transmit-receivecoil used for hand MRI. To avoid alterationsbecause of overturn, the forefoot was coveredin aluminium foil.

Pulse sequences included sagittal T1weighted (460/20/4 repetition time msec/echotime msec/excitations), axial proton density(2000/25/2) and T2 weighted (2000/90/2)scans. Sagittal and axial section thickeness were3 mm and 7 mm, respectively, with an intersec-tion gap of 1 mm. The field of view was 20 cm,and the matrix size 160 × 224 or 128 × 192.

Scan images were examined by two radiolo-gists (LB and PP) who had no knowledge ofthe physical examination. The joint space andsynovial sheaths of hand or foot tendons, orboth, were evaluated for fluid collection.

At diagnosis and during the follow up theerythrocyte sedimentation rate (ESR) (Wester-gren method) and C reactive protein (CRP)(nephelometric method, NA latex CRP kit,Behringwerke, Marburg, Germany) (normal <0.5 mg/dl) were determined. To detect jointerosions, chondrocalcinosis or sacroiliitisroentgenographs of the hands or feet, or both,and pelvis were performed in all patients at thefirst visit and during the follow up.

HLA-B27 was determined in all patients.Complete class I MHC antigens were deter-mined in 13 of 23 patients using a modificationof two stage National Institute of Health com-plement microcytotoxicity test.20 The healthycontrol group consisted of 126 blood donorvolunteers from the same geographical areas.

Table 1 Comparisons among the demographic and clinical characteristics of the patients with PMR with and without distal pitting oedema and “pure”RS3PE syndrome

Patients with PMRwithout distal pittingoedema (n=156) A

Patients with PMRand distal pittingoedema (n=21) B

Patients with pureRS3PE syndrome(n=23) C

p value

C v A C v B

Male/female (%) 33/67 43/57 52/48 0.06 NSAge at onset of disease (y) 70 (8) 75 (4) 74 (9) NS NSDuration of disease before diagnosis (months) 3.0 (1.2) 3.0 (1.1) 1.6 (0.8) 0.001 0.001Duration of treatment (months) 22 (20) 14 (8) 5 (5) 0.001 0.001Duration of follow up (months) 41 (23) 25 (16) 17 (15) 0.001 NSPeripheral arthritis (%) 26 19 22 NS NSCarpal tunnel syndrome (%) 15 9.5 22 NS NSSystemic symptoms and signs (fever, anorexia, weight loss) (%) 59 57 9 0.0001 0.001Biopsy confirmed GCA (%) 10 0 0 NS NSInitial prednisone dose (mg/day) 20 (12) 14 (4) 17.5 (5) NS 0.02Cumulative prednisone dose (g) 5.4 (4.1) 3.5 (1.8) 1.7 (1.1) 0.0001 0.001ESR at diagnosis (mm/1st h) 79 (25) 75 (29) 74 (30) NS NSESR <30 mm/1st h at diagnosis (%) 5 9 13 NS NSCRP at diagnosis (mg/dl) 6.5 (5.3) 7.0 (3.7) 6.3 (5.0) NS NSHLA-B7 (%)* 9 17 15 NS NSRelapse/recurrence (%) 32 43 13 0.08 0.04Residual contractures (%) 0 0 9 0.02 NS

*HLA-B7 was determined in 80 PMR patients without distal pitting oedema, 12 PMR patients with distal pitting oedema and 13 patients with pure RS3PE syndrome.Data shown as mean (SD).

Remitting seronegative symmetrical synovitis with pitting oedema 231

on 6 Septem


http://ard.bmj.com

/A

nn Rheum


pril 1999. Dow

nloaded from

http://ard.bmj.com/

Relapse and recurrence were consideredpresent if articular signs or symptoms occurredin a patient receiving the treatment or aftertreatment ended.

The end of the disease was the date ofpermanent cessation of treatment withoutrelapse or recurrence. The end point of patientfollow up was the date of the last visit or thedate of death.

During the same five year period weconducted a prospective follow up study toevaluate the clinical and demographic featuresof PMR.6 We identified 177 consecutivepatients. Twenty one of 177 (12%) presented atleast one episode of distal extremity swellingwith pitting oedema. Complete class I MHCantigens were determined in 80 of 156 PMR

patients without distal pitting oedema and 12of 21 PMR patients with pitting oedema. Thedemographic, immunogenetic, and clinicalfindings of the 23 patients with pure RS3PEsyndrome were compared with those of 177PMR patients with and without distal extrem-ity swelling with pitting oedema.

Statistical analysis was done using SPSS sta-tistical package (SPSS Inc, Chicago, Illinois).The ÷2 and t test for independent values wereused.

ResultsCLINICAL AND LABORATORY FINDINGS

Table 1 shows the clinical and demographiccharacteristics of the 23 patients with pureRS3PE syndrome. All the patients were sero-

Figure 1 MRI of the hands of RS3PE syndrome. (A)Axial proton density section through the midpoint of thepalm shows subcutaneous oedema in hand dorsum (blackarrows). (B) Axial T2 weighted section through themidpoint of the palm shows fluid collection in the extensorsynovial sheaths of the right hand (open arrows). (C)Axial T2 weighted section through themetacarpophalangeal joints shows fluid collection in theflexor synovial sheaths of the third digit of right hand(curved arrow) and joint eVusion of the corresponding joint(large and small arrowheads).

232 Cantini, Salvarani, Olivieri, et al

on 6 Septem


http://ard.bmj.com

/A

nn Rheum


pril 1999. Dow

nloaded from

http://ard.bmj.com/

negative for rheumatoid factor (Rose-Waalertitre <1:40 or nephelometric determination<20IU/ml on two or more occasions) andfluorescent antinuclear antibodies (titre<1:32). At the end of the follow up period all23 patients had withdrawn from treatment.

Twenty patients had a single episode and theother three had a second episode during thefollow up. At diagnosis 13 episodes (56%) weresymmetric and 10 unilateral (44%). The handsand wrists were involved in 17 episodes (74%),

feet in two episodes (9%) and both hands andfeet in four episodes (17%). In the threeepisodes of relapse the oedema involved hands.The swelling and pitting oedema were mostprominent over the dorsum of the hands andwrists, the ankles, and the tops of the feet. Atinspection swelling and tenderness were local-ised, especially along the course of hand exten-sor tendons in 21 of 23 patients (91%), flexortendons of the hand in nine of 23 (39%), footestensor tendons in six of 23 (26%), peroneal

Figure 2 MRI of the foot of RS3PE syndrome. (A) Sagittal T1 weighted section shows marked tenosynovitis of tibialisanterior tendon (black arrow). (B) Sagittal T2 weighted section shows marked tenosynovitis of tibialis anterior tendon(black arrow), ankle joint eVusion extending into Kager’s triangle (black/white arrow) and talonavicular joint eVusion(black/white arrow). (C) Coronal T2 weighted section at the apex of the talus shows talonavicular joint eVusion(black/white arrow), tenosynovitis of flexor hallucis longus tendon (double open arrowhead), tenosynovitis of flexordigitorum longus tendon (open arrowhead), tenosynovitis of tibialis posterior tendon (open white arrow) and tenosynovitisof peroneal tendons (black arrowhead). (D) Coronal T2 weighted section through the navicular bone shows markedtenosynovitis of tibialis anterior tendon (black arrow).


on 6 Septem


http://ard.bmj.com

/A

nn Rheum


pril 1999. Dow

nloaded from

http://ard.bmj.com/

tendons in three of 23 (13%), posterior tibialtendons in three of 23 (13%). Given thediYculty of clinical detection of joint synovitisbecause of the marked oedema, wrist synovitiscould be identified in 19 of 23 patients (83%).In five of 23 patients (22%) a concomitant kneearthritis was present. In two of these patientsaspiration of synovial fluid was possible andexamination showed 4.0 × 109/l white bloodcells in the first case and 5.2 × 109/l in the sec-ond, with neutrophils 52% and 68% atdiVerential count, respectively. CTS occurredin five of 23 patients (22%).

The radiographs showed no evidence ofarticular erosions, typical calcifications ofchondrocalcinosis, and/or sacroiliitis.

Nineteen patients were treated with pred-nisone and four with non-steroidal anti-inflammatory drugs (NSAIDs). The swellingand oedema promptly remitted (median: oneweek, range: 1–3 weeks) in all corticosteroidtreated patients, while the response to NSAIDswas more gradual (median: 3 weeks, range: 2–4weeks).

Residual mild contractures were observed intwo of 23 patients (9%). The first patients had amild limitation of dorsal and palmar flexion ofthe right wrist (range of motion reduced by 5–10degrees in both movements) with thickening ofwrist extensor and flexor tendons, the secondhad a mild flexion contracture of fingers withflexor thickening. None of the 23 patients devel-oped articular erosions on hand and/or footradiographs at the end of the follow up.

ESR was normal at diagnosis in three of 23patients (13%), while CRP was normal in oneof 23 (4%). One patient had both normal ESRand CRP values at diagnosis. HLA-B7 waspresent in two of 13 patients and 14 of 126controls (15% versus 11%, p=NS). No signifi-cant association with other class I HLAantigens was observed.

HAND AND FOOT MRI FINDINGS

Hand MRI was performed in five patients andfoot MRI in two. Tenosynovitis (defined by thepresence of fluid in the tenosynovial sheaths) ofhand extensor tendons was observed in threepatients, flexor hand tenosynovitis in onepatient and hand joint synovitis in two patients(fig 1). Tenosynovitis of peroneal tendons wasobserved in both the patients studied withMRI; one patient also associated tibialistendons, flexor hallucis longus tendon andflexor digitorum longus tendon tenosynovitisand foot joint synovitis (fig 2). None of the fivehealthy controls showed evidence of fluidcollection in hand flexor or extensor tenosyno-vial sheaths

COMPARISONS BETWEEN THE PATIENTS WITH

PURE RS3PE SYNDROME AND PMR WITH AND

WITHOUT DISTAL EXTREMITY SWELLING WITH

PITTING OEDEMA

The results of these comparisons are reportedin table 1. A trend of higher frequency in menwas observed for pure RS3PE compared withPMR without distal extremity swelling withpitting oedema (p=0.06). The distribution ofthe patients in 10 year age groups was similar in

the three conditions. No patients under 50were observed, the disease frequency increasedsignificantly with age and the highest frequencywas present in the age group 70–79 years.

Systemic signs or symptoms, or both, weresignificantly less frequent in pure RS3PEsyndrome compared with PMR with or with-out distal extremity swelling with pittingoedema. The duration of disease beforediagnosis, the duration of prednisone treat-ment, and the cumulative prednisone dosewere significantly lower in pure RS3PE patientscompared with the other two groups. Theduration of follow up was significantly shorterin pure RS3PE patients compared with pa-tients with PMR without distal oedema. Theinitial prednisone dose was significantly lowerin pure RS3PE syndrome compared with thepatients with PMR and distal oedema. Relapse/recurrences were significantly less frequent inpure RS3PE patients compared with PMRwith distal oedema, while a trend of reducedfrequency in comparison with PMR withoutdistal oedema (p=0.08) was observed. Residualmild contractures were significantly morefrequent in pure RS3PE syndrome comparedwith PMR patients without distal oedema.

DiscussionIn our prospective follow up study we examinedthe clinical features of 23 patients with isolatedRS3PE syndrome. Unlike the study by McCa-rty, we included patients with unilateral or lowerextremity involvement, or both. Those authorsempirically selected only patients with sym-metrical upper limb involvement, while thespectrum of this condition also includes patientswith unilateral findings.3 4 In our patients theclinical examination revealed an extensor teno-synovitis of the hands and feet as the predomi-nant lesions, while hand flexor, posterior tibialand peroneal tenosynovitis were less frequentlyobserved. Hand and foot MRI confirmed thatthe inflammation of the tenosynovial sheaths isthe hallmark of this condition and hand extensortendon apparatus is the anatomical structuremore frequently involved. Joint synovitis wasmore diYcult to appreciate at clinical examina-tion because of the impressive swelling andoedema involving the hands and feet. However,MRI demonstrated a concomitant joint synovi-tis in some patients.

In our series we observed a very low frequencyof residual hand contractures and tendon thick-ening. Only 9% of our patients presented thiscomplication in a mild form compared with61% observed by McCarty et al.1 2 In contrastwith the series of McCarty, the inclusion ofpatients with unilateral RS3PE and the prospec-tive design of our study may have contributed toevaluate less severe form of the disease and toexplain the low frequency of residual hand con-tractures observed in our series.

Furthermore, our study did not confirm theassociation of RS3PE syndrome with HLA-B7in Italian patients. Our findings confirm thefrequent association with knee synovitis andCTS. As in previous descriptions the clinicalfeatures rapidly responded to corticosteroidsand rarely recurred.


on 6 Septem


http://ard.bmj.com

/A

nn Rheum


pril 1999. Dow

nloaded from

http://ard.bmj.com/

Many similarities exist between RS3PE syn-drome and PMR. In addition, a percentage ofPMR patients oscillating between 8–12%presents distal extremity swelling with pittingoedema similar to that observed in RS3PE.5 6

These distal findings were part of PMRinflammatory processes (concurrence withproximal PMR manifestations, age at onset >50 years, prompt response to corticosteroids),whose clinical spectrum may be wider thanwhat has been believed, including patients withRS3PE syndrome. Our long term, prospectivefollow up study on PMR and pure RS3PE syn-drome have provided a unique opportunity toevaluate the relation between these two condi-tions. We separately compared patients withpure RS3PE syndrome and PMR with or with-out distal extremity swelling with pittingoedema. Even though there was a predomi-nance of men in pure RS3PE syndrome and ofwomen in PMR, the diVerence was not signifi-cant. The elderly age of disease onset, theabsence of rheumatoid factor, the increasedacute phase reactants, the similar frequency ofperipheral synovitis and CTS, the rapidresponse to corticosteroids are common char-acteristics of both PMR and RS3PE syndrome.Furthermore, the distribution of the patients in10 year age groups was similar in the two con-ditions. No patients under 50 were observed,the disease frequency increased significantlywith age and the highest frequency was presentin the age group 70–79 years.

Similar characteristics were also present in agroup of patients who had clinical features ofoverlap between the two syndromes. Further-more, no diVerences in the frequency of HLAclass I antigens, in particular of HLA-B7, wereobserved in the three groups of patients. Theconcurrence of the two syndromes and theirsimilarities suggest they might be manifesta-tions of the same disease. The group of patientswith PMR and pitting oedema may representthe ring of conjunction between the morefrequently encountered patients with onlyproximal symptoms and the less frequentpatients with prominent distal manifestations.Some of the patients with pitting oedema (withor without PMR proximal symptoms) wouldmeet the ACR criteria for RA17 at diagnosis.However, these distal manifestations promptlyremitted without developing erosions and noneof our patients experienced a course ofprolonged and persistent synovitis. Theirarticular disease is completely diVerent fromclassic erosive RA and seems to be part of theinflammatory processes of PMR. The presenceof distal swelling with oedema seems tocharacterise a more benign condition withshorter duration of treatment, lower cumula-tive corticosteroid dose and lower frequency ofsystemic signs/symptoms and relapse/recurrence.

We did not observe patients with biopsyconfirmed GCA in either the PMR with distaloedema group or the pure RS3PE group.However, the diVerences compared with thefrequency of biopsy confrimed GCA in pa-tients with PMR without distal pitting oedemawere not significant. A higher number of

patients with distal oedema need to be enrolledto evaluate if a reduced association with GCAis really present in this group of patients.

The similarities of MRI findings in PMRwith distal pitting oedema21 22 and pure RS3PEseem to indicate that the involvement of extra-articular synovial structures represents thecommon anatomical target of the inflamma-tory process in these two conditions.

In conclusion, our study confirms thepresence of patients with pure RS3PE syn-drome. The distal extremity oedema occursmore frequently in a symmetric pattern,predominantly in upper limbs, even if unilat-eral or isolated lower extremity involvementmay also occurr. MRI findings confirm theclinical impression of a predominant tenosyno-vial involvement. Flexor contractures wererarely observed and mild. No association ofpure RS3PE syndrome with HLA-B7 waspresent in Italian patients.

The clinical, demographic, and MRI find-ings observed in patients with RS3PE syn-drome suggest some similarities with those ofPMR patients.

1 McCarty DJ, O’DuVy DJ, Pearson L, Hunter JB. Remittingseronegative symmetrical synovitis with pitting edema.JAMA 1985;254:2763–7.

2 Russell EB, Hunter JB, Pearson L, McCarty DJ. Remitting,seronegative, symmetrical synovitis with pitting edema - 13additional cases. J Rheumatol 1990;17 633–9.

3 Parisier KM, Canoso JJ. Remitting, seronegative (A)sym-metrical synovitis with pitting edema - Two cases of RS3PEsyndrome. J Rheumatol 1991;18:1260–2.

4 Olivieri I, Padula A, Favaro L, Oranges GS, Ferri S. RS3PEsyndrome with unilateral involvement. [Letter]. J Rheuma-tol 1994;21:372.

5 Salvarani C, Gabriel S, Hunder GG. Distal extremity swell-ing with pitting edema in polymyalgia rheumatica. ArthritisRheum 1996;39:73–80.

6 Salvarani C, Cantini F, Macchioni L, Olivieri I, Niccoli L,Padula A, et al. Distal musculoskeletal manifestations inpolymyalgia rheumatica: a prospective follow-up study.Arthritis Rheum, 1998;41:1221–6.

7 Olivieri I, Padula A, Pierro A, Favaro L, Oranges GS, FerriS. Late onset undiVerentiated seronegative spondylar-thropathy. J Rheumatol 1995;22:899–903.

8 Olivieri I, Padula A, Favaro L, Pierro A, Oranges GS, Ferri S.Dactylitis with pitting oedema of the hand in longstandingankylosing spondylitis. Clin Rheumatol 1995;14:701–4.

9 Schaeverbeke T, Fatout E, Marcé S, Vernhes J-P, Hallé O,Antoine J-F, et al. Remitting seronegative symmetricalsynovitis with pitting oedema: disease or syndrome? AnnRheum Dis 1995;54:681–4.

10 Olivieri I, Salvarani C, Cantini F. Remitting distal extremityswelling with pitting edema: a distinct syndrome or a clini-cal feature of diVerent inflammatory rheumatic diseases? JRheumatol 1997;24:249–52.

11 Bhakta BB, Pease CT. Late-onset rheumatoid arthritis: ispitting oedema of the hands at onset a good prognosticindicator? Br J Rheumatol 1997;36:214–19.

12 Cantini F, Niccoli L, Olivieri I, Barozzi L, Pavlica P, BozzaA, et al. Remitting distal lower extremity swelling with pit-ting oedema in acute sarcoidosis. [Letter]. Ann Rheum Dis1997;56:565–6.

13 Olivo D, Mattace R. Concurrence of benign edematous pol-ysynovitis in the elderly (RS3PE syndrome) and endome-trial adenocarcinoma. Scand J Rheumatol 1997;26:67–8.

14 Tada Y, Sato H, Yoshizawa S, Kimura H, Kitamura M,Kusabe T, et al. Remitting seronegtive symmetrical synovi-tis with pitting edema associated with gastric carcinoma. JRheumatol 1997;24:974–5.

15 Cantini F, Olivieri I, Salvarani C. More on RS3PE as para-neoplastic syndrome. [Letter]. J Rheumatol 1998;25:188–9.

16 Healey LA. Long-term follow-up of polymyalgiarheumatica: evidence for synovitis. Semin Arthritis Rheum1984;13:322–8.

17 Arnett FC, Edworthy SM, Bloch DA, McShane DJ, FriesJF, Cooper NS, et al. The American Rheumatism Associa-tion 1987 revised criteria for the classification of rheuma-toid arthritis. Arthritis Rheum 1988;31:315–24.

18 Dougados M, van der Linden S, Juhlin R, Huitfeldt B, AmorB, Calin A, et al. The European spondylarthropathy studygroup preliminary criteria for the classification of spondyl-arthropathy. Arthritis Rheum 1991;34:1218–27.

19 Polley HF, Hunder GG. Rheumatologic interviewing andphysical examination of the joints. 2nd ed. Philadelphia: WBSaunders, 1978.


on 6 Septem


http://ard.bmj.com

/A

nn Rheum


pril 1999. Dow

nloaded from

http://ard.bmj.com/

20 Terasaki P, McClelland JD. Microdroplet assay of humanserum cytotoxins. Nature 1964;204:998–1000.

21 Salvarani C, Cantini F, Olivieri I, Barozzi L, Macchioni PL,Niccoli L, et al. Proximal bursitis in active polymyalgiarheumatica. Ann Intern Med 1997;127:27–31.

22 Olivieri I, Salvarani C, Cantini F, Barozzi L, Pavlica P, Mac-chioni PL. Distal extremity swelling with pitting edema inpolymyalgia rheumatica: a case studied with magnetic reso-nance imaging. [Letter]. Clin Exp Rheumatol 1997;15:710–11.

Historical imagesSeries editors: W Grassi, C Cervini

Figure 14 Hyperostosis of the fingers in a 20 year old woman. Kirmisson.Malattie degli arti. In: Duplay S, Reclus P, eds. Trattato di chirurgia. Turin: Unione Tipografico Editrice, 1895.


on 6 Septem


http://ard.bmj.com

/A

nn Rheum


pril 1999. Dow

nloaded from

http://ard.bmj.com/

remitting seronegative symmetrical synovitis with pitting ... · remitting seronegative symmetrical...

Documents