RS3PE Syndrome — SCE Rheumatology MCQ

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ModerateRheumatology EmergenciesRS3PE SyndromeSCE Rheumatology

A 72-year-old woman with recently diagnosed colorectal carcinoma develops abrupt-onset pain and stiffness affecting both wrists, hands and ankles. Examination shows symmetrical wrist and metacarpophalangeal synovitis with marked pitting oedema over the dorsum of both hands and feet. Rheumatoid factor and anti-CCP antibodies are negative. What is the most likely diagnosis?

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Correct answer: E — RS3PE syndrome

RS3PE (remitting seronegative symmetrical synovitis with pitting oedema) is characterised by abrupt-onset symmetrical distal synovitis, prominent pitting oedema of the dorsal hands and/or feet, and negative rheumatoid factor; anti-CCP antibodies are also usually negative. Its association with a recently diagnosed malignancy supports a paraneoplastic presentation. Seronegative rheumatoid arthritis may cause symmetrical synovitis but marked acute dorsal pitting oedema is much more characteristic of RS3PE. Cellulitis would not usually be bilaterally symmetrical or cause polyarticular synovitis. Heart failure may cause dependent leg oedema but does not explain inflammatory hand and wrist synovitis. Polyarticular gout is generally less symmetrical and would require supportive crystal or typical clinical evidence.

Reference: Ohta R et al. Paraneoplastic Remitting Seronegative Symmetrical Synovitis With Pitting Edema: A Systematic Review of Case Reports and Observational Studies on Clinical Features, Treatment Response, and Outcomes. 2025. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12593150/