Benign rheumatoid nodules

Introduction

Rheumatoid nodules are palpable subcutaneous nodules that occur in about 20% of patients with rheumatoid arthritis.[1] These nodules are almost invariably associated with more severe forms of the disease, wherein rheumatoid factor and antinuclear factor are frequently found in the serum. Here we report a case of anarthritic rheumatoid nodules.

Case Report

A 51-year-old healthy male reported with complaints of slow growing painless nodule over right elbow of two years duration. Six months after onset of the elbow lesion, he noticed similar painless nodules over the knuckles of right hand, palmar surface of right hand and over the left thumb. There was no history of itching, pain, discharge or ulceration of the nodules. He denied any past or present history of joint pains, swelling of joints, morning stiffness, subcutaneous nodules elsewhere on the body, deformities or any associated fever.

Dermatological examination revealed multiple, firm to hard, discrete, non tender nodular lesions on dorsal surface of knuckles of right hand, palmar surface of right hand, dorsa of interphalangeal joint of left hand and palmar surface of left thumb [Figure - 1]. There was a large nodule on the posterior aspect of the right elbow [Figure - 2]. Skin over the surface was normal. Nodules were not fixed to the tendons or bone. There were no yellowish deposits or any cutaneous signs of hyperlipidemia anywhere on the body. Investigations in the form of lipid profile, X-ray of hands and elbows and ESR were normal. Rheumatoid factor was strongly positive. Excision biopsy of elbow nodule revealed numerous necrobiotic histiocytic granulomas with cuffing of lymphocytes. Numerous Langhans giant cells were also seen. Histopathology thus was consistent with the clinical diagnosis of rheumatoid nodules.

The nodules were surgically removed for cosmetic benefit. There has been no recurrence for one year postoperatively though the patient needs further follow-up.

Discussion

Rheumatoid nodules occur generally in 20-25% of patients with severe rheumatoid arthritis and imply aggressive disease with poor prognosis.[1] However benign rheumatoid nodules have been reported in patients with little arthritis and no systemic disease. Rheumatoid factor may be positive in high titre, nodules usually involve elbows, hand and feet with a predilection for tendons and multiple cyst like intraosseous radioluscencies may be associated.[2] They occur particularly at sites of repeated minor trauma. Benign rheumatoid nodules are more common in children than in adults and are considered exceptional beyond the age of eighteen.[3] In the literature only two hundred cases in children and 25 cases in adults have been documented with histological confirmation.[3] Adult onset benign rheumatoid nodules are clinically and histologically identical to those found in rheumatoid arthritis. They often appear in women during their twenties, frequently resolved spontaneously or were adequately treated by excision and recurred in about one-third of patients. None of the patients in literature subsequently developed rheumatoid arthritis during follow-up periods for as long as 20 years.[4] Deep granuloma annulare may be considered in the differential diagnosis when it appears in adults.[5]

Surgical treatment is effective in treating benign rheumatoid nodules for cosmetic benefit or may be necessary if there is local pain, nerve impression, erosions, infection or limited range of motion.[6]