Various Manifestations of Rheumatic Disorders: Case 5 Rheumatoid Nodules

March 2, 2004

A 65-year-old woman, who was confined to a wheelchairbecause of severe rheumatoid arthritis, was concernedabout nodules that had erupted on her fingers and handsduring the previous 3 weeks (A). Her medical historyincluded colon cancer, chronic renal insufficiency, anemia,and hypertension. The nonpruritic nodules were painfulwhen they began to form under the skin; however, oncethey erupted, the pain disappeared.

A 65-year-old woman, who was confined to a wheelchairbecause of severe rheumatoid arthritis, was concernedabout nodules that had erupted on her fingers and handsduring the previous 3 weeks (A). Her medical historyincluded colon cancer, chronic renal insufficiency, anemia,and hypertension. The nonpruritic nodules were painfulwhen they began to form under the skin; however, oncethey erupted, the pain disappeared.Four firm, irregular nodules at various stages of developmentwere noted on the dorsa of the fingers andhands. One of the lesions had exuded a yellow-whitechalky material from several locations. The patient reportedthe occurrence of similar nodules in the past; 8 monthsearlier, a lesion erupted over the left fifth metacarpophalangealjoint, and more recently, a nodule developed overthe ulnar surface of the left forearm. Both lesions dischargedmoist, yellow material and resolved spontaneouslywithin several days.The patient's medical history raised the possibilityof cutaneous calcium deposition. However, roentgenogramsof the hands revealed osteopenia and lytic lesionsaround the joints but no calcium deposits. Erosive andcystic changes were demonstrated at the proximal interphalangealjoints of the second through fifth fingers; similarchanges were more prominent at the second and thirdmetacarpophalangeal joint space of the right hand (toprow) than of the left (bottom row). The diagnosis of rheumatoidnodules was confirmed clinically.Rheumatoid nodules are found in approximately onethird of patients with rheumatoid arthritis. Usually, they areassociated with more severe disease and a high rheumatoidfactor titer. These lesions also occur in about 5% of personswith systemic lupus erythematosus. Most often locatedover bony prominences or extensor surfaces--notablyon the forearms, elbows, knuckles, feet, and knees--thenodules tend to be deep and asymptomatic. The presentationof eruptive nodules in this patient was atypical.Intralesional corticosteroids were injected into thelargest nodule, after which all of the developing and fullydeveloped lesions disappeared completely. At the 4-monthfollow-up, no recurrence of lesions was noted despite thepatient's refractory arthritis.

(Case and photographs courtesy of Drs Jessica Krant and Yelva Lynfield.)