Rheumatoid Nodules Predating Seroconversion and Rheumatoid Arthritis: An Uncommon Case Report

Roberta Gualtierotti Francesca Ingegnoli

doi:10.4172/2155-9899.1000167

Abstract

Rheumatoid nodulosis is a benign condition associated with mild or no arthritis. Differently from classical rheumatoid nodules, which are relatively common in patients with long-standing rheumatoid arthritis, particularly in rheumatoid factor (RF)-positive patients, rheumatoid nodulosis may rarely precede arthritis onset and even seroconversion. We describe the clinical course of a patient with isolated painful rheumatoid nodules, who subsequently experienced RF and anti-citrullinated protein antibodies (ACPA) seroconversion and finally developed overt rheumatoid arthritis. This case should raise clinical awareness to consider rheumatoid nodulosis as a possible diagnosis even in the absence of arthritis and of RF positivity, whenever facing with isolated subcutaneous nodules.

Highlights

Rheumatoid nodulosis is a benign clinical entity associated with mild or no arthritis
Its diagnosis is straightforward when its typical histological features are found in patients with established rheumatoid arthritis (RA) but, if the rheumatoid nodules predate the onset of RA, a thorough differential diagnosis must be made based on clinical, laboratory and histological findings, and sometimes only follow-up will unravel the final diagnosis
We report an uncommon case of a woman who initially came to our observation with isolated painful rheumatoid nodules, subsequently experienced rheumatoid factor (RF) and anti-citrullinated protein antibody (ACPA) seroconversion, and developed overt RA

Summary

Introduction

Rheumatoid nodulosis is a benign clinical entity associated with mild or no arthritis. We report an uncommon case of a woman who initially came to our observation with isolated painful rheumatoid nodules, subsequently experienced rheumatoid factor (RF) and anti-citrullinated protein antibody (ACPA) seroconversion, and developed overt RA. This 46-year-old woman came to our observation in 2008 because of the presence of erythematous, clearly circumscribed painful nodules on the extensor surface of the third distal interphalangeal (DIP) joint of the right hand and the third proximal interphalangeal (PIP) joint of the left hand (Figure 1) that had started to form gradually three years before. Physical examination revealed mobile and tender cutaneous nodules, but no signs of arthritis, and her complete blood count, C-reactive protein, serum and urine urate levels, and erythrocyte sedimentation rate were within the normal range She had undetectable serum RF, ACPA, antinuclear and anti-ds DNA antibody, and anti-extractable nuclear antigen levels. Subsequent treatment with penicillamine 600 mg per day improved both the joint and skin involvement

Discussion

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Conclusions