S3261 A Case of Rheumatoid Nodules in the Liver

Abstract

Introduction: Rheumatoid arthritis (RA) has a prevalence of 0.5-1%. Extra-articular manifestations, including rheumatoid nodules (RNs), can be present in up to 40% of individuals. Rarely, RNs can manifest in the gastrointestinal system. We present a case of a 52-year old female with RA who presented with hepatic nodules and fever. Case Description/Methods: A 52-year-old woman with seronegative RA on sulfasalazine 1000mg BID presented with three weeks of fevers ranging from 101 – 103 F. She had been on adalimumab until one year ago, which was stopped after she developed a psoriatic rash. Six months ago she diagnosed with an incidental left upper lobe pulmonary nodule but IR biopsy was non-diagnostic. On admission, the patient was afebrile with stable vital signs, and the following labs: WBC 25, CRP 6.44, ESR 70, and ALP 179, with normal ALT, AST, and bilirubin. A chest, abdomen and pelvis contrast CT scan showed reduced size of the previous lung nodule but multiple new hypodensities within the liver, with the largest lesion 2cm in diameter (Figure 1a). Liver MRI confirmed numerous hepatic lesions (Figure 1b). After admission, she remained afebrile and her WBC resolved without antibiotics. Infectious, malignancy, and autoimmune workup were negative. The patient underwent a colonoscopy with no concerning signs for malignancy. She then underwent an IR liver biopsy and pathology revealed multiple necrotizing granulomas with plasma cells, most concerning for RNs. Rheumatology and hepatology were consulted and planned to increase her sulfasalazine and get repeat abdominal imaging at her next visit. Discussion: Although extra-articular disease is evident in RA, RNs in the liver are rare. A postmortem analysis of a patient from 1986 identified multiple nodules up to 5mm. In 2019, a 62 year-old female had abdominal pain and was found to have a 5cm RN in the liver. A 61 year-old male in 2020 had a 4cm liver mass resected with histology revealing a necrotizing granulomatous inflammation suggestive of a RN. Additionally, prior studies have shown that cells in RNs produce similar proinflammatory cytokines as those in synovial membranes. This could suggest cytokine release due to RNs as a cause of our patient's fevers. Although she had well controlled RA, she was also previously treated with TNF inhibitors which have been noted to cause RNs in the lungs. This may have led to her pulmonary and hepatic nodules. Overall, our case adds to the data highlighting uncommon gastrointestinal manifestations of RA.Figure 1.: Figures 1a and 1b. CT and MRI Studies Revealing Multiple Hepatic Hypodensities.