Rheumatoid Nodulosis Research Articles

OA19 A complex case of bilateral pneumothoraces due to probable certolizumab driven rheumatoid lung nodules

OA19 A complex case of bilateral pneumothoraces due to probable certolizumab driven rheumatoid lung nodules

Cutaneous Manifestations of Rheumatoid Arthritis

ABSTRACT Rheumatoid arthritis is a chronic systemic autoimmune inflammatory arthritis with various extra-articular manifestations. In this first series examining the cutaneous manifestation of rheumatic diseases, we will discuss the most common dermatologic findings in patients with rheumatoid arthritis. Cutaneous lesions are the most common extra-articular findings. Rheumatoid nodules, accelerated rheumatoid nodulosis, and rheumatoid vasculitis are found especially in those with long-standing rheumatoid-factor-positive disease. Several neutrophilic dermatoses such as pyoderma gangrenosum, rheumatoid neutrophilic dermatoses, and Sweet's syndrome are also seen in association with rheumatoid arthritis. Patients may also present with various cutaneous adverse effects related to their arthritis therapy. It is important to recognize these dermatologic manifestations to better understand the underlying disease process, thus optimizing therapy and patient care.

Methotrexate-Induced Acute Rheumatoid Nodulosis in Liver and Spleen Imitating Metastatic Malignancy.

From the First Division of Internal Medicine, Faculty of Medicine, University of Ioannina, Ioannina, Greece. The authors declare no conflict of interest. Correspondence: Maria Kosmidou, MD, PhD, Department of Internal Medicine, University Campus 45110, Ioannina, Greece. E-mail: [email protected].

Granulomatous drug reactions from targeted therapeutics

Granulomatous drug reactions have been associated with many medications, including targeted therapeutics such as biologics and small molecule inhibitors. The four main clinicopathologic reaction patterns are drug-induced sarcoidosis-like reaction, reactive granulomatous dermatitis, granuloma annulare, and accelerated rheumatoid nodulosis. These reactions often develop months after exposure to the causative medication and clinically can mimic other granulomatous diseases or metastatic cancer, which may be differentiated with biopsy, tissue culture, and radiographic imaging. Granulomatous inflammation may be limited to the skin, where early recognition helps to facilitate diagnosis. Cutaneous manifestations vary by reaction pattern, ranging from erythema nodosum-like lesions to painful rheumatoid nodules to annular indurated plaques. Systemic granulomatous inflammation is typically only observed in sarcoidosis-like reaction or accelerated rheumatoid nodulosis and most often involves the lungs or lymph nodes. Targeted therapeutics implicated in granulomatous drug reactions are TNFα inhibitors, BRAF and MEK inhibitors, immune checkpoint inhibitors and, to a lesser extent, other cytokine modulators. TNFα inhibitors, in particular, are among the most common drugs in any class associated with the four primary granulomatous drug eruptions. We review the current literature on granulomatous reactions to these agents, including proposed mechanisms and the range of clinical manifestations. Management may include drug discontinuation, topical therapy, or systemic immunosuppression depending on the severity of the granulomatous drug reaction. In the setting of malignancy, granulomatous inflammation does not appear to be of prognostic value, although more studies are needed.

Skin manifestations of rheumatoid arthritis.

Rheumatoid arthritis is a chronic systemic disease that, in addition to articular involvement, may exhibit a variety of extraarticular manifestations. The skin is frequently involved mainly in the most severe forms of the disease. Rheumatoid nodules, accelerated rheumatoid nodulosis, rheumatoid nodulosis, Felty syndrome, rheumatoid vasculitis, pyoderma gangrenosum, rheumatoid neutrophilic dermatosis, interstitial granulomatous dermatitis, and palisaded neutrophilic granulomatous dermatitis are reviewed both clinically and histologically. Moreover, cutaneous reactions related to treatments of rheumatoid arthritis, in particular to biologic agents, are described. Early recognition of these entities through a clinical and histological correlation permit to optimize the management of patients.

Skin Manifestations of Rheumatoid Arthritis, Juvenile Idiopathic Arthritis, and Spondyloarthritides.

Extra-articular manifestations of rheumatoid arthritis, juvenile idiopathic arthritis, and various spondyloarthritides including psoriatic arthritis, ankylosing spondylitis, reactive arthritis, and inflammatory bowel disease-associated spondyloarthritis often involve the skin and may occur before or after diagnosis of these rheumatic diseases. Cutaneous manifestations encompass a wide range of reactions that may have a notable negative impact not only on the physical but especially on the emotional and psychosocial well-being of these patients. Several cutaneous manifestations have been related to rheumatoid arthritis such as subcutaneous nodules including classical rheumatoid nodules, accelerated rheumatoid nodulosis, and rheumatoid nodulosis; vascular disorders like rheumatoid vasculitis, livedo racemosa, and Raynaud's phenomenon; and neutrophilic and/or granulomatous diseases like pyoderma gangrenosum, Sweet's syndrome, rheumatoid neutrophilic dermatitis, interstitial granulomatous dermatitis with arthritis, as well as palisaded neutrophilic and granulomatous dermatitis. In juvenile idiopathic arthritis, the main cutaneous manifestations include an evanescent rash, rheumatoid nodules, as well as plaque and guttate psoriasis. Plaque psoriasis is also the main skin disease involved in spondyloarthritides. Furthermore, other forms of psoriasis including guttate, inverse, erythrodermic, pustular, and particularly nail psoriasis may also occur. In addition, a variety of drug-induced skin reactions may also appear in these diseases. Early recognition and understanding of these different dermatologic manifestations together with an interdisciplinary approach are often needed to optimize management of these diseases.

Granulomatous Drug Eruptions.

Granuloma formation is usually regarded as a means of defending the host from persistent irritants of either exogenous or endogenous origin. Noninfectious granulomatous disorders of the skin encompass a challenging group of diseases owing to their clinical and histologic overlap. Drug reactions characterized by a granulomatous reaction pattern are rare, and defined by a predominance of histiocytes in the inflammatory infiltrate. This review summarizes current knowledge on the various types of granulomatous drug eruptions, focusing on the 4 major types: interstitial granulomatous drug reaction, drug-induced accelerated rheumatoid nodulosis, drug-induced granuloma annulare, and drug-induced sarcoidosis.

Rheumatoid Nodulosis with Recurrent Nodules: A Case Report

Correspondence to Jiwon Hwang, M.D. Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 135-710, Korea Tel: +82-2-3410-3439, Fax: +82-2-3410-3849, E-mail: ninedw.hwang@samsung.com *Conflict of Interest: The authors disclose no potential conflicts of interest. Copyrightc 2015 The Korean Association of Internal Medicine This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 반복하여 재발한 류마티스 결절증(nodulosis) 1예

Occurrence of pulmonary rheumatoid nodules following biological therapies

In rheumatoid arthritis (RA), disease activity is generally determined by the joint involvement, but the treatment outcome is often influenced by extra-articular manifestations. Authors present a 74-year-old female patient's case history, who was treated with seropositive RA. Marked disease activity was observed even following combined traditional disease-modifying antirheumatic drug (DMARD) treatment (disease activity score in 28 joints (DAS28) = 6.6). Therefore, the patient received TNF-α antagonist therapy. Golimumab was administered subcutaneous (SC) once monthly which resulted in significant improvement in both clinical and laboratory signs (DAS28 = 3:43). However, the follow-up chest x-ray indicated multiple intrapulmonary foci and enlarged lymph nodes. Biopsies and histology excluded malignancy; rheumatoid nodules were confirmed. Anti-TNF therapy was discontinued and tocilizumab treatment was initiated. The IL-6 receptor inhibitor suppressed arthritic activity, and 2 months later, the follow-up chest x-ray showed a regression of chest nodules. Our cases, as well as reports from other centers, suggest that TNF blockade may induce rheumatoid nodulosis and the use of alternative biologics may be feasible as further treatment of RA.

Soft tissue swellings in the foot: Rheumatoid nodulosis

Background rheumatoid nodulosis is a rare disease characterised by multiple subcutaneous nodules, a high titre of rheumatoid factor, radiologically detectable cystic bone lesions, but with none or few of the systemic manifestations or joint activity of rheumatoid disease. Histopathologically, nodulosis is the same as the nodules found in rheumatoid arthritis. It is considered to be a benign variant of rheumatoid arthritis. A 69 year old male presents with multiple subcutaneous nodules on the feet. This case study highlights the benefits of ultrasound in establishing a correct diagnosis and management. Although rare, rheumatoid nodulosis is a consideration in the differential diagnoses of soft tissue swellings in the feet.

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

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.

Seronegative rheumatoid nodulosis: a new case report

ejd.2012.1696 Auteur(s) : Yue-Ping Zeng gvtao@yahoo.com.ch, Tao Qu Department of Dermatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China Rheumatoid nodulosis (RN), a benign variant of rheumatoid arthritis (RA), is characterized by multiple rheumatoid nodules, recurrent articular symptoms, minimal clinical or radiological involvement with frequent rheumatoid factor (RF) positivity [1, 2]. Here, we [...]

A Seropositive Nodular Rheumatoid Polyarthritis without Arthritis: Does It Exist?

The rheumatoid polyarthritis is the most frequent chronic polyarthritis. It affects essentially the woman between 40 and 60 years. Rheumatic subcutaneous nodules and tenosynovitis are usually associated with seropositive symptomatic rheumatoid polyarthritis. It is, however, rare that they constitute the essential clinical expression of the disease. In this case, it makes dispute another exceptional form of rheumatoid arthritis such as rheumatoid nodulosis. A 60-year-old woman was hospitalized for tumefaction of the dorsal face of the right hand evolving two months before. The clinical examination found subcutaneous nodules from which the exploration ended in rheumatoid nodules with tenosynovitis. The evolution after four years was favourable under corticosteroid therapy, methotrexate, and colchicine.

Unusual Draining Nodules in a Patient with Rheumatoid Nodulosis and Hepatitis C Virus Infection

To the Editor: Rheumatoid nodulosis is an uncommon condition with a combination of multiple rheumatoid nodules, recurrent joint symptoms, but without erosions, and usually positive tests for rheumatoid factor (RF). We describe a case of rheumatoid nodulosis with followup exceeding 10 years. The nodules first developed during treatment for hepatitis C virus (HCV) infection with interferon (IFN). A nodule biopsy confirmed the presence of a rheumatoid nodule. This association of draining nodules, rheumatoid nodulosis, and HCV is rare and raises the possibility that it might have been precipitated by the IFN therapy. A 53-year-old man presented with an 11-year history of hepatitis C and a 10-year history of poorly characterized asymmetrical arthritis and nodules. In February 1999, he was diagnosed elsewhere with hepatitis C based on laboratory tests and started therapy with ribavirin/α-IFN. After 1 year, he stopped ribavirin/α-IFN due to absence of effect on the viral load and did not follow up with his hepatologist. In August 1999, multiple subcutaneous nodules developed on his fingers. The nodules would gradually enlarge, discharge necrotic-appearing material, and then develop a central crater and at that time became painful. In January 2001, aspiration of one of the nodules was negative for crystals. A large finger nodule mass with dimensions 3.0 × 2.5 × 1.0 cm was excised for biopsy. Some individual nodules were injected with intralesional depot methylprednisolone, with complete resolution, but he continued to develop new nodules. Nonsteroidal antiinflammatory drugs (NSAID) helped his occasional pain from draining nodules, but did not change the shape or size of the nodules. Accompanying the nodules, he experienced intermittent joint pain and swelling that involved proximal interphalangeal joints, wrists, shoulders, and elbows. The joint pain improved under treatment with hydroxychloroquine but the nodules persisted. Due to anxiety over side effects he stopped hydroxychloroquine after 6 months. … Address correspondence to Dr. Schumacher; E-mail: schumacr{at}mail.med.upenn.edu

Large elbow nodules in a patient with rheumatoid nodulosis

Rheumatoid nodulosis is an uncommon pathology considered as a particular variant of rheumatoid arthritis associated with subcutaneous rheumatoid nodules, palindromic rheumatism, and mild or no systemic manifest­ation, usually with positive rheumatoid factor and radiological subchondral bone cysts. We describe a 58-year-old man with the diagnosis of seropositive but nondestructive, nondeforming rheumatoid arthritis, who exhibits multiple subcutaneous rheumatoid nodules associated with episodes of intermittent arthralgias and subchondral cystic lesions of the small bones of the hands and feet. Large nodules were surgically removed from the two elbows. They were histologically typical of rheumatoid nodules. All these findings were consistent with the diagnosis of rheumatoid nodulosis.

Non-Infectious Granulomatous Diseases of the Skin and their Associated Systemic Diseases

Non-infectious granulomatous diseases of the skin are a broad group of distinct reactive inflammatory conditions that share important similarities. As a group, they are relatively difficult to diagnose and distinguish both clinically as well as histologically. Many of these disorders have significant associations with systemic diseases that impact the patient's overall prognosis. In this update, we offer a discussion of emerging concepts and controversies in this field, as presented through evidence-based answers to seven important clinical questions regarding palisading and epithelioid granulomata. These questions offer an opportunity to review ten non-infectious granulomatous conditions that have implications for systemic disease: granuloma annulare, annular elastolytic giant cell granuloma, necrobiosis lipoidica, methotrexate-induced accelerated rheumatoid nodulosis, necrobiotic xanthogranuloma, interstitial granulomatous dermatitis, interstitial granulomatous drug reaction, palisaded neutrophilic granulomatous dermatitis, sarcoidosis, and metastatic Crohn disease. Recent clinical, epidemiologic, and laboratory studies have shed some light on these diseases, the association of these conditions with systemic disorders, and their overall prognoses.

Leishmaniasis and Rheumatoid Nodulosis in a Patient With HIV Infection

We describe the case of a 44-year-old homosexual man diagnosed with HIV infection and visceral leishmaniasis. He presented nodules on the dorsum of the hands. Histological study of one of the nodules revealed necrobiotic palisading granulomas with abundant Leishmania amastigotes within the histiocytes and in the adjacent extracellular space. Tissue and peripheral blood cultures were positive for Leishmania infantum, zymodeme MON-24. A biopsy of healthy skin did not reveal the presence of Leishmania. A diagnosis of rheumatoid nodulosis with Leishmania was made and treatment was started with intravenous liposomal amphotericin, leading to slight improvement. We believe that the presence of the parasite within the nodules was the result of its dissemination during visceral leishmaniasis in an immunocompromised patient with HIV infection, and that the Leishmania did not have an etiological role in the appearance of the nodules. We present the first case of the association between Leishmania and rheumatoid nodulosis.

Leishmaniasis y nodulosis reumatoide en paciente con infección por el virus de la inmunodeficiencia humana

We describe the case of a 44-year-old homosexual man diagnosed with HIV infection and visceral leishmaniasis. He presented nodules on the dorsum of the hands. Histological study of one of the nodules revealed necrobiotic palisading granulomas with abundant Leishmania amastigotes within the histiocytes and in the adjacent extracellular space. Tissue and peripheral blood cultures were positive for Leishmania infantum, zymodeme MON-24. A biopsy of healthy skin did not reveal the presence of Leishmania. A diagnosis of rheumatoid nodulosis with Leishmania was made and treatment was started with intravenous liposomal amphotericin, leading to slight improvement. We believe that the presence of the parasite within the nodules was the result of its dissemination during visceral leishmaniasis in an immunocompromised patient with HIV infection, and that the Leishmania did not have an etiological role in the appearance of the nodules. We present the first case of the association between Leishmania and rheumatoid nodulosis.

Rheumatoid nodulosis: successful response to topical tacrolimus

Rheumatoid nodulosis is considered a benign variant of rheumatoid arthritis. Several therapies have been used with variable results. We report a 63-year-old man who presented with nodular lesions on the metacarpophalangeal joints and knees which were diagnosed of rheumatoid nodulosis. Topical tacrolimus was started with good response on the following months.

Rheumatoid Nodule

Rheumatoid nodules are the most common extra-articular manifestation of rheumatoid arthritis. Dermatologist may be concerned with the diagnosis and management of rheumatoid nodules, although most patients will probably be under the care of a rheumatologist. This article focuses in clinical, pathogenic, diagnostic, and therapeutic aspects of rheumatoid nodules. Classic rheumatoid nodules commonly occur in genetically predisposed patients with severe, seropositive arthritis. However, they may appear in other clinical settings. Accelerated rheumatoid nodulosis, especially involving the hands, has been reported in patients receiving methotrexate, antitumor necrosis factor alpha biologic drugs or leflunomide therapy for rheumatoid arthritis. Rheumatoid nodulosis is characterized by multiple rheumatoid nodules, recurrent joint symptoms with minimal clinical or radiologic involvement, and a benign clinical course. Pseudorheumatoid nodules have been reported in healthy children. Although histologically almost indistinguishable from true rheumatoid nodules, some consider these lesions to be a form of deep granuloma annulare.