Relapsing polychondritis affects men and women equally; onset typically is in middle age. An association with rheumatoid arthritis Rheumatoid Arthritis (RA) Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease that primarily involves the joints. RA causes damage mediated by cytokines, chemokines, and metalloproteases. Characteristically... read more , systemic vasculitis Overview of Vasculitis Vasculitis is inflammation of blood vessels, often with ischemia, necrosis, and organ inflammation. Vasculitis can affect any blood vessel—arteries, arterioles, veins, venules, or capillaries... read more , systemic lupus erythematosus (SLE) Systemic Lupus Erythematosus (SLE) Systemic lupus erythematosus is a chronic, multisystem, inflammatory disorder of autoimmune etiology, occurring predominantly in young women. Common manifestations may include arthralgias and... read more , and other connective tissue disorders suggests an autoimmune etiology.
Symptoms and Signs of Relapsing Polychondritis
Acute pain, erythema, and swelling most commonly affect the pinna cartilage. Nasal cartilage inflammation is the next most common manifestation, 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 and knees.
The next most common manifestations, in decreasing order of frequency, are inflammation of the
Eye (eg, conjunctivitis, scleritis, iritis, keratitis, chorioretinitis)
Cartilaginous tissue of the larynx, trachea, or bronchi (causing hoarseness, cough, and tenderness over the laryngeal cartilage)
Cardiovascular system (eg, aortic regurgitation, mitral regurgitation, pericarditis, myocarditis, aortic aneurysms, aortitis)
Bouts of acute inflammation heal over weeks to months, with recurrences over several years.
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.
Diagnosis of Relapsing Polychondritis
Diagnosis of relapsing polychondritis is established if the patient develops at least 3 of the following:
Bilateral chondritis of the external ears
Respiratory tract chondritis
Auditory or vestibular dysfunction
Biopsy of involved cartilage, most often the pinna, is helpful if clinical diagnosis is not clear-cut but is rarely required.
Laboratory tests are not specific but are done when necessary to help exclude other disorders. Synovial fluid analysis reveals mild inflammatory changes that are nonspecific but help rule out an infectious process. Blood tests may show normocytic-normochromic anemia, leukocytosis, elevated erythrocyte sedimentation rate (ESR) or gamma-globulin levels, and occasionally positive rheumatoid factor, antinuclear antibodies (ANA), or, in up to 25% of patients, antineutrophil cytoplasmic antibodies (ANCA). Abnormal renal function may indicate an associated glomerulonephritis. A positive c-ANCA test (ANCA that are reactive mainly to proteinase-3) may suggest granulomatosis with polyangiitis Diagnosis Granulomatosis with polyangiitis is characterized by necrotizing granulomatous inflammation, small- and medium-sized vessel vasculitis, and focal necrotizing glomerulonephritis, often with crescent... read more , which can rarely cause chondritis.
The upper and lower airways should be evaluated, including complete spirometric testing and chest CT, when the diagnosis is made.
Prognosis for Relapsing Polychondritis
Mortality rates have decreased with newer therapies. Survival is now 94% after 8 years, with death typically resulting from collapse of laryngeal and tracheal structures or from cardiovascular complications such as large-vessel aneurysm, cardiac valvular insufficiency, or systemic vasculitis.
Treatment of Relapsing Polychondritis
Nonsteroidal anti-inflammatory drugs or dapsone for mild ear disease
Sometimes methotrexate or other immunosuppressants (eg, cyclosporine, cyclophosphamide, azathioprine, anti-tumor necrosis factor drugs)
Mild recurrent ear disease may respond to nonsteroidal anti-inflammatory drugs in anti-inflammatory doses, or oral dapsone (50 to 100 mg once a day). However, most patients are treated with oral prednisone 30 to 60 mg once a day, with tapering of the dose as soon as there is a clinical response. Some patients require chronic use. In such patients, oral methotrexate 7.5 to 20 mg once a week can reduce the requirement for corticosteroids. Very severe cases may require other immunosuppressants, such as cyclosporine, cyclophosphamide, anti-tumor necrosis factor drugs (eg, infliximab, etanercept), or azathioprine (see Immunomodulatory, cytotoxic, and immunosuppressive drugs Immunomodulatory, cytotoxic, and immunosuppressive drugs Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease that primarily involves the joints. RA causes damage mediated by cytokines, chemokines, and metalloproteases. Characteristically... read more ). 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 has a poor prognosis. Patients on long-term corticosteroid therapy should receive osteoporosis prophylaxis Prevention Osteoporosis is a progressive metabolic bone disease that decreases bone mineral density (bone mass per unit volume), with deterioration of bone structure. Skeletal weakness leads to fractures... read more . Prophylaxis for opportunistic infections, such as Pneumocystis jirovecii (see prevention of Pneumocystis jirovecii pneumonia Prevention Pneumocystis jirovecii is a common cause of pneumonia in immunosuppressed patients, especially in those infected with human immunodeficiency virus (HIV) and in those receiving systemic... read more ), should be added if combination immunosuppressive therapy is used.
Endotracheal intubation can be technically difficult because of tracheal involvement and narrowing; also, intratracheal manipulation can lead to life-threatening postanesthetic deterioration by causing further glottal or subglottal inflammation. Thus, endotracheal intubation should be avoided whenever possible (eg, instead using local and regional anesthesia). When endotracheal intubation is unavoidable, preparations should be made for emergency cricothyrotomy.
Consider relapsing polychondritis if patients develop inflammation of the pinna or nasal cartilage, particularly with symptoms and signs compatible with respiratory tract chondritis or unexplained arthritis, ocular inflammation, or auditory or vestibular dysfunction.
Biopsy the affected cartilage only if necessary to confirm the diagnosis.
Treat mild ear disease with nonsteroidal anti-inflammatory drugs or dapsone.
Treat more severe disease with corticosteroids and sometimes methotrexate or other immunosuppressants.
Avoid endotracheal intubation or, if it is unavoidable, prepare for emergency cricothyrotomy.
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