Dry synovitis, RF-negative: a rare entity distinct from juvenile idiopathic arthritis - Case report letter to the editor

Sep 30, 2026

Juvenile idiopathic arthritis (JIA) can include RF-negative polyarthritis, with a rare manifestation termed dry synovitis (DS). DS presents progressive stiffness, functional impairment, and radiologic joint damage without marked swelling or significant inflammatory laboratory markers, making it prone to underdiagnosis and delayed treatment. A 6.5-year-old girl with RF-negative polyarticular JIA developed clinical features suggestive of DS, required treatment escalation with prednisone and methotrexate adjustments, and later switched to leflunomide due to methotrexate intolerance, achieving notable improvement.

LanguageEnglish

CategoryHealthcare

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Letter to the Editor (Case report)

Dry synovitis in RF-negative polyarticular JIA

Case presentation and diagnosis

Treatment course and follow-up

Radiologic findings

Letter to the Editor (Case report) Dry synovitis, RF-negative: a rare entity distinct from juvenile idiopathic arthritis Raghad Dghaish1, Mahmoud Qouqas 2, Anas Manhal 2, Jamal Abdallah 2, Anas Nairoukh3, Basel Zaben4, 􀀃 , and Fawzy Abunejma2 1Faculty of Medicine, Palestine Polytechnic University, Hebron, Palestine 2Faculty of Medicine, Hebron University, Hebron, Palestine 3 Paediatric Department, Palestinian Red Crescent Hospital, Hebron, Palestine 4Faculty of Medicine, Al Quds University, Jerusalem, Palestine 􀀃 Correspondence to: Basel Zaben, Internal Medicine, PMC/Al-Quds University-School of Medicine, Abu-Dis, East Jerusalem, Ramallah, P602, Palestine. E-mail: [Basel.253.111@gmail.com](Basel.253.111@gmail.com) DEAR EDITOR, Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic condition in children, with significant potential for long-term disability [1] . It encompasses several subtypes, including RF-negative polyarthritis, which may present with a rare form called dry synovitis (DS) [1, 2] . DS is characterized by progressive stiffness, functional limitation and radiologic damage without marked joint swelling or significant laboratory inflammation. Because of its subtle presentation, DS is often underdiagnosed, leading to delayed treatment and irreversible joint damage [2] . Here we describe the case of a young Palestinian child with RF-negative polyarticular JIA complicated by DS, a rare and challenging manifestation within the JIA spectrum. This case aims to raise awareness of DS, emphasize its diagnostic and therapeutic challenges and highlight the importance of early recognition, particularly in resource-limited settings. A 6.5-year-old girl with a weight of 22 kg and height of 105 cm was referred to the paediatric rheumatology clinic following a diagnosis of uveitis at an ophthalmology clinic anda 3-month history of bilateral hand pain associated with morning stiffness lasting more than 1 h. She had no history offever, rash, oral ulcers, diarrhoea, weight loss or constitutional symptoms. Her past medical history was notable for chronic abdominal pain, and she had been diagnosed with Helicobacter pylori infection 6 months earlier, for which she received standard triple therapy. Her family history was unremarkable for autoimmune diseases. On initial physical examination, there was tenderness over the right 4th and 5th PIP joints, but no swelling, warmth, erythema or limitation in the range of motion. No other joints were involved and systemic examination was unremarkable. Initial laboratory investigations revealed a normal ESR and unremarkable urinalysis. ANA was positive at a titre of 1:160 with a speckled pattern, while RF and anti-CCP antibodies were negative. Hand X-rays interpreted by a paediatric radiologist showed decreased joint space in the PIP joints and periarticular osteopenia of small joints in the hands and feet (Fig. 1). Based on these investigations, a provisional diagnosis of RF-negative polyarticular JIA was made. The patient was started on naproxen 250 mg twice daily and methotrexate 7.5 mg weekly, with folic acid supplementation. MTX was initiated at a conservative dose of 7.5 mg/week orally (􀀙9.3 mg/m2) after discussion within a multidisciplinary team. This decision was influenced by the lack of definitive inflammatory signs (no joint swelling, normal ESR/CRP) and the patient’s young age (estimated BSA 􀀙0.8 m2). Three weeks later the patient came to our clinic complaining of worsening morning stiffness and new joint discomfort, with mild swelling in the knees, wrists and ankles. On physical examination, there was tenderness in the right wrist but still no overt signs of synovitis such as warmth, redness or restricted range of motion. Despite these symptoms, repeated laboratory tests remained normal, including ESR, CRP, complement levels (C3, C4) and complete blood count. Renal and liver function tests were also within normal limits. Given the persisten

FAQs

What clinical and laboratory features characterize dry synovitis in this case?

Dry synovitis is described as progressive stiffness and functional limitation with radiologic damage but without marked joint swelling or significant laboratory inflammation; in this case ESR/CRP and other inflammatory markers repeatedly remained normal while stiffness and imaging changes progressed.

How was the diagnosis of RF-negative polyarticular JIA made before DS was considered?

Initial labs showed normal ESR with negative RF and anti-CCP and a positive ANA (1:160, speckled). Hand X-rays demonstrated decreased PIP joint space and periarticular osteopenia, supporting a provisional diagnosis of RF-negative polyarticular JIA.

Why did the treatment change from methotrexate to leflunomide?

After treatment escalation and subsequent follow-up, the patient developed gastrointestinal symptoms attributed to methotrexate, along with joint discomfort. To avoid worsening methotrexate side effects, the regimen was switched to leflunomide 10 mg/day.

Sep 30, 2026

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