RELAPSING POLYCHONDRITIS – Clinical Manifestations, Diagnostic Evaluations and Management

Relapsing polychondritis is an episodic, inflammatory, and destructive disorder involving primarily cartilage of the ear and nose but also potentially affecting the eyes, tracheobronchial tree, heart valves, kidneys, joints, skin, and blood vessels. Diagnosis is by a combination of clinical, laboratory, imaging, and sometimes biopsy findings. Treatment usually requires prednisone and other immunosuppressants. Relapsing polychondiritis affects men and women equally; onset typically is in middle age. An association with RA, systemic vaculitis, SLE, and other connective tissue diseases suggests an autoimmune etiology.

CLINICAL MANIFESTATIONS

Acute pain, erythema, and swelling most commonly affect the pinna cartilage. Nasal cartilage inflammation is the next common, followed by arthritis that varies from arthralgias to symmetric or asymmetric nondeforming arthritis involving large and small joints, with a predilection for the costochondral joints. The next most common manifestations, in decreasing order of frequency, are inflammation of the eye (e.g. conjunctivitis, scleritis, iritis, keratitis, chorioretinitis); cartilaginous tissue of the larynx, trachea, or bronchi (causing hoarseness, cough, and tenderness over the laryngeal cartilage); internal ear; cardiovascular system (e.g. aortic regurgitation, mitral regurgitation, pericarditis, myocarditis, aortic aneurysms, aortitis); kidney; and skin. Bouts of acute inflammation heal over weeks to months, with recurrences over several years. Various rashes can develop.

Advanced disease can lead to destruction of supporting cartilage, causing floppy ears; saddle nose; pectus excavatum; and visual, auditory, and vestibular abnormalities. Tracheal narrowing can lead to dyspnea, pneumonia, or even tracheal collapse. Coexisting systemic vasculitis (leukocytoclastic vasculitis or polyarteritis nodosa), myelodysplastic syndrome, or cancer is possible.

DIAGNOSTIC EVALUTIONS

Diagnosis is established if the patient develops at least 3 of the following:

• Bilateral chondritis of the external ears
• Inflammatory polyarthritis
  
• Nasal chondritis
  
• Ocular inflammation
  
• Respiratory tract chondritis
  
• Auditory or vesticular dysfunction
  

 

Biopsy of involved cartilage, most often the pinna, is helpful if clinical diagnosis is not clear-cut.

Laboratory tests are done. They are not specific but may help to exclude other disorders. Synovial fluid analysis reveals mild inflammatory changes that are nonspecific but help to rule out an infectious process. Blood tests may show normocytic-normochromic anemia, leukocytosis, elevated ESR or a-globulin levels, occasionally positive rheumatoid factor, antinuclear antibodies (ANA), or, in up to 25%, antineutrophil cytoplasmic antibodies(ANCA). Abnormal renal function may indicate an associated vasculitis. A positive c-ANCA test(ANCA that are reactive mainly in proteinase – 3) suggests Wegener’s granulomatosis, which can cause similar findings. The upper and lower airways should be evaluated, including complete spirometric testing and chest CT, when the diagnosis is made.

TREATMENT

        Sometimes methotrexate or other immunosuppressants (eg, cyclosporine, cyclophosphamide, azathioprine) are administer. Mild recurrent ear disease may respond to NSAIDs in anti-inflammatory   doses, or dapsone (50 to 100 mg po once/day). However, most patients are treated with prednisone 30 to 60 mg po once/day, with tapering of the dose as soon as there is a clinical response. Some patients require chronic use. In such patients, methotrexate 7.5 to 20 mg po once/wk can reduce the requirement for corticosteroids. Very severe cases may require other immunosuppressants, such as cyclosporine, cyclophosphamide, or azathioprine. None of these therapies has been tested in controlled trials or has been shown to decrease mortality. If tracheal narrowing causes stridor, a tracheostomy or stent may be needed.

        More extensive tracheobronchial collapse may require tracheal reconstruction. Eye disease may sometimes be recalcitrant to treatment, especially when involving the sclera, and carries a poor prognosis. All patients should be closely monitored for atherosclerosis given the risk of premature atherosclerosis in systematic vasculitides. Patients on long-term corticosteroid therapy should receive osteoporosis prophylaxis.

 

RELAPSING POLYCHONDRITIS – Clinical Manifestations, Diagnostic Evaluations and Management