INFO - Rheumatoid nodules

[Guest guest]

Brillian thanks. Not sure what a lot of it means, but I guess I should just

trust my rheumatologist's opinion

Thanks for the data

Sussann

<Matsumura_Clan@...> wrote:

Canadian Family Physician

January 2005

Rheumatoid nodules

Rheumatoid nodules are the most common extra-articular manifestation of

rheumatoid arthritis (RA); about 25% of adult patients with RA have them.1,2

About 90% of patients with RA and subcutaneous nodules test positive for

rheumatoid factor, and 40% of all seropositive patients with RA have

subcutaneous nodules.3 Rheumatoid nodules are clinical predictors of more

severe arthritis, seropositivity, joint erosions, and rheumatoid

vasculitis.2 The presence of rheumatoid nodules often suggests a need for

more aggressive treatment of the underlying RA to prevent sequelae.

Rheumatoid nodules are firm, nontender, and movable within the subcutaneous

tissue; however, they could also be attached to underlying structures such

as the periosteum, fascia, and tendons.3 The lesions range from 2 mm to >5

cm,4 and can enlarge or regress, recur, or persist indefinitely.3 Most

subcutaneous nodules are found on bony prominences, extensor surfaces, or

adjacent to joints. They are most frequently found on extensor surfaces of

the proximal ulna and olecranon, metacarpophalangeal and proximal

interphalangeal joints, ischial tuberosities, joints in the foot, and

sacrum.4 Occasionally, they manifest on the sclera, pinna of ears, heart,

vocal cords, lungs, nervous system, abdominal wall, and muscle.4,5

Histologically, rheumatoid nodules present as a palisading granulomatous

reaction, and mature nodules have a classic three-layer structure.1

The exact etiology of rheumatoid nodules is unknown. Experts speculate that

a series of events beginning with local vascular trauma and pooling of

rheumatoid factor immune complexes, followed by activation and mobilization

of local monocytes or macrophages; fibrinoid deposition by procoagulants;

tissue necrosis by cytotoxins, proteinases and collagenase secretion from

macrophages; and chemotactic attraction of macrophages to the necrotic zone

is responsible for formation of rheumatoid nodules.1,6 This hypothesis is

consistent with the clinical findings of higher titres of rheumatoid factor

and vasculitis often reported in patients with RA who have rheumatoid

nodules.2 Since rheumatoid nodules most commonly arise in areas prone to

trauma, a local tissue reaction that creates a focus of granulation tissue

might also contribute to initial formation of these lesions.1

Rheumatoid nodules are not exclusive to RA. Histologically identical nodules

are sometimes a feature of systemic lupus erythematosus (SLE), subcutaneous

granuloma annulare, necrobiosis lipoidica diabeticorum, rheumatic fever, and

foreign body granulomas.2,3,7,8 Subcutaneous nodules have also been reported

in 5% to 10% of children with juvenile rheumatoid arthritis,3 and benign

rheumatoid nodules have been described in children and adults with no

evidence of RA.2,7 Rheumatoid nodulosis syndrome, which presents with

numerous rheumatoid nodules, a high titre of rheumatoid factor, but mild or

no RA, has been reported in a few patients.3,7,8

Diagnosis

A diagnosis of rheumatoid nodules is made in the clinical context of the

disease. Symmetric inflammatory polyarthritis, seropositivity for rheumatoid

factor, and other associated symptoms, such as vasculitis, are highly

suggestive of RA. Subcutaneous nodules with a history of gout or current

podagra could lead to a diagnosis of tophaceous gout. Violaceous papules or

nodules (Gottron's papules) with muscle weakness and heliotrope rash are

characteristic of dermatomyositis. Lichen planus is a pruritic, papular

eruption characterized by its violaceous-purple colour, flat-topped

polygonal shape, and sometimes, fine scale. It is most commonly found on the

flexor surfaces of the upper extremities (especially wrists), genitalia, and

mucous membranes (called Wickham striae in the mouth).

Although biopsies of subcutaneous nodules are occasionally done, they are

not useful for diagnosis since many different types of subcutaneous nodules

are histologically identical to rheumatoid nodules. Many rheumatoid nodules

occur in areas difficult to biopsy, such as over extensor tendons. A

complete history and physical examination, focusing on cutaneous and

rheumatologic aspects, and occasionally laboratory testing (eg, rheumatoid

factor, serum urate) are sufficient to diagnose rheumatoid nodules.

Management

Rheumatoid nodules typically present asymptomatically as a cosmetic

complaint. Indications for treatment include areas exposed to repetitive

trauma and nodules on weight-bearing prominences that might cause

progressive erosions and severe pain, neuropathy, limitation of motion, or

deformity, and damage to underlying structures.8 Some nodules rupture and

lead to deep infections.4

There are very few treatment options for rheumatoid nodules. Large nodules

can be excised, but they frequently recur within scar tissue, especially if

subjected to repetitive trauma. Injecting corticosteroids directly into the

lesion sometimes reduces its size. While this procedure is most effective

for deep lesions in the olecranon bursa, nodules on the buttocks and feet

tend to ulcerate and are likely to become infected. Once they are infected,

surgical excision or drainage is required.8 Oral corticosteroids and

hydroxychloroquine can also be used,3,8 but their effects on rheumatoid

nodules vary, as most patients with RA already receive these medications for

the chronic condition. Rheumatoid nodules occasionally resolve without

medical or surgical intervention.

References

1. Ziff M. The rheumatoid nodule. Arthritis Rheum 1990;33:761-7.

2. Jorizzo JL, s JC. Dermatologic conditions reported in patients with

rheumatoid arthritis. J Am Acad Dermatol 1983;8:439-57.

3. Kaye BR, Kaye RL, Bobrove A. Rheumatoid nodules. Review of the spectrum

of associated conditions and proposal of a new classification, with a report

of four seronegative cases. Am J Med 1984;76:279-92.

4. Sibbitt WL Jr, RC Jr. Cutaneous manifestations of rheumatoid

arthritis. Int J Dermatol 1982;21:563-72.

5. Hurd ER. Extraarticular manifestations of rheumatoid arthritis. Semin

Arthritis Rheum 1979;8:151-76.

6. Sokoloff L, McCluskey RT, Bunim JJ. Vascularity of the early subcutaneous

nodule of rheumatoid arthritis. Arch Pathol 1953;55:475-95.

7. Veys EM, de Keyser F. Rheumatoid nodules: differential diagnosis and

immunohistological findings. Ann Rheum Dis 1993;52:625-6.

8. McGrath MH, Fleischer A. The subcutaneous rheumatoid nodule. Hand Clin

1989;5:127-35.

http://www.cfpc.ca/cfp/2005/Jan/vol51-jan-clinical-2.asp

Not an MD

I'll tell you where to go!

Mayo Clinic in Rochester

http://www.mayoclinic.org/rochester

s Hopkins Medicine

http://www.hopkinsmedicine.org

[Guest guest]

My nodules on my elbows disappeared sometime afer I started Enbrel. I

say good riddance to them, because they made my elbows look like

witches' elbows, LOL. Sue

On Tuesday, May 10, 2005, at 07:37 AM, wrote:

>

> Rheumatoid nodules occasionally resolve without

> medical or surgical intervention.

[Guest guest]

About.com: Arthritis

Last updated 27 Oct 2007

" Rheumatoid nodules " :

http://arthritis.about.com/cs/nodules/a/rheumanodules.htm

**********************************************

WebMD

30 Mar 2009

" Rheumatoid nodules " :

http://www.webmd.com/rheumatoid-arthritis/guide/rheumatoid-nodules

Not an MD