• Insidious (55%–65%): Onset with arthritic symptoms of pain, swelling and stiffness, with the number of joints increasing over weeks to months.
• Subacute (15%–20%): Similar to insidious onset but more systemic symptoms.
• Acute (10%): Severe onset, some have fever.
b) Variant patterns of onset (10% of patients)
• Palindromic (episodic) pattern: Usually involves less than five joints and resolves within several days. After an asymptomatic period, a flare in the same or another joint(s) occurs. Over time, 33% to 50% evolve into RA involving more joints persistently. Seropositive patients and those with elevated acute-phase reactants are more likely to progress to RA. The optimal treatment for individuals with “palindromic/episodic” RA is not known; however, antimalarial therapy may decrease the frequency of attacks and progression to RA.
• Insidious onset of elderly (>65 years): Present with severe pain and stiffness of limb girdle joints often with diffuse swelling of hands, wrists, and forearms. May be difficult to differentiate from polymyalgia rheumatica and RS3PE.
• Arthritis robustus: Typically seen in men. Patients have bulky, proliferative synovitis causing joint erosions and deformities, but the patient experiences little pain or disability.
• Rheumatoid nodulosis: Patients with recurrent pain/swelling in different joints, subcutaneous nodules, and subchondral bone cysts on radiographs.