Case and Research Letters
Rheumatoid Nodulosis in an Adult Patient Negative for Rheumatoid Factor
Nodulosis reumatoideos en una paciente adulta con factor reumatoide negativo
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Nódulos eritematovioláceos con distribución centrofacial sobre la frente y las mejillas. B. Varios nódulos en forma de cúpula de consistencia firme y parches en el tronco. C. Histiocitos fusiformes con tendencia a la nodularidad (H-E x40). D. Bacilos ácido-alcohol resistentes intracitoplasmáticos en macrófagos (Ziehl-Neelsen X100).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "J.J. Dávila-Rodríguez, C Rosero, S Tello, S Yanchapaxi" "autores" => array:4 [ 0 => array:2 [ "nombre" => "J.J." 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Álvarez-Chinchilla, I. Poveda Montoyo, F. Illán, J. Bañuls Roca" "autores" => array:4 [ 0 => array:4 [ "nombre" => "P.J." "apellidos" => "Álvarez-Chinchilla" "email" => array:1 [ 0 => "pedroalvarezchinchilla@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "I." "apellidos" => "Poveda Montoyo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "F." "apellidos" => "Illán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "J." "apellidos" => "Bañuls Roca" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital General Universitario de Alicante, Alicante, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital General Universitario de Alicante, Alicante, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Medicina Clínica, Universidad Miguel Hernández, Sant Joan D’Alacant, Alicante, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nodulosis reumatoideos en una paciente adulta con factor reumatoide negativo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 850 "Ancho" => 1506 "Tamanyo" => 363126 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Panoramic image showing granulomas located in the deep dermis (hematoxylin-eosin, original magnification ×20). B, Detail of the same image showing granulomas composed of palisaded histiocytes (arrow) arranged around a central eosinophilic zone corresponding to fibrin (asterisk) (hematoxylin-eosin, original magnification ×100).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 56-year-old woman was seen for asymptomatic nodules that had appeared several months earlier and were located on the elbows and the backs of the hands at the metacarpophalangeal joints. She reported no local or systemic symptoms apart from mild, periodic, nondisabling pain of the finger joints that did not require regular use of medication. Physical examination revealed painless, skin-colored or slightly erythematous subcutaneous nodules that were attached to deep planes (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A). The lesions did not compromise joint function. Dermoscopy findings were nonspecific, and included a lesion with a flesh-colored background and white, mainly crystalline structures, as well as poorly focused irregular vascular structures (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Ultrasound revealed a well defined nodule with hypoechoic content and no power Doppler activity that was in contact with the extensor tendon of the fourth finger (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>C and D). In laboratory tests C-reactive protein levels and the erythrocyte sedimentation rate were consistently within the normal range in successive analyses. Rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP) antibody were negative. An X-ray of the hands revealed no joint alterations. The X-ray was evaluated by staff at the rheumatology department of our hospital, who found that no criteria for any specific arthropathy were fulfilled.</p><p id="par0015" class="elsevierStylePara elsevierViewall">An excisional biopsy of one of the nodules on the hands showed granulomas with an eosinophilic center surrounded by palisaded histiocytes, with absence of mucin (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A and B). The histological diagnosis was compatible with a rheumatoid nodule. Because the patient did not meet the criteria for rheumatoid arthritis, a diagnosis of rheumatoid nodulosis has been established after more than 5 years of follow-up.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Rheumatoid nodulosis is characterized by the presence of histologically confirmed rheumatoid nodules with absent or mild joint pain. The lesions have a benign course, and the systemic findings characteristic of rheumatoid arthritis are absent.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The nodules usually appear in the fifth decade of life, are more common in men, and are preferentially located on extensor surfaces such as the elbows and the backs of the fingers, although any area can be affected.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The literature describes certain cases triggered by treatment with drugs, in particular methotrexate and anti-tumor necrosis factor biological therapies. These cases usually correspond to palindromic rheumatoid arthritis, which precedes the joint pain.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Our patient had at no time received treatment with any of these drugs.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The nodules are usually skin colored, and can be solitary or multiple. They can be mobile or attached to the periosteum, bursa, or tendons,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> but rarely result in compression of adjacent structures. Neither dermoscopy nor ultrasound reveal findings specific to this entity, but both techniques can help characterize the relationship with nearby structures.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The clinical differential diagnosis should include subcutaneous granuloma annulare, tophi, xanthomas, and sarcoidosis, among other entities, and histological differentiation from other processes that involve necrobiotic granulomas is required.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> The main differential diagnosis is granuloma annulare, deeper forms of which can be difficult to distinguish from rheumatoid nodulosis. In rheumatoid nodules the area of necrobiosis is more homogeneous and eosinophilic owing to the presence of fibrin and the absence of mucin. By contrast, granuloma annulare has a basophilic appearance owing to the presence of mucin and the absence of fibrin. Joint involvement is either absent or mild, and laboratory test results are generally positive for rheumatoid factor<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–5</span></a> and negative for anti-CCP antibody. However, rheumatoid nodulosis patients can test negative for rheumatoid factor, as occurred in our patient. In rare cases progression to erosive arthritis has been described, in some cases fulfilling the criteria for rheumatoid arthritis over time.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3,6–9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The lesions do not usually require treatment, although occasionally treatment with nonsteroidal anti-inflammatory drugs or intralesional corticosteroids may be required. Resection can be performed to alleviate severe local discomfort in highly symptomatic patients.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,6</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">We wish to stress the importance of considering a potential diagnosis of rheumatoid nodulosis in cases of rheumatoid nodules without a diagnosis of rheumatoid arthritis, bearing in mind that progression towards rheumatoid arthritis has been reported in rare cases.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Discussion" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-02-16" "fechaAceptado" => "2018-06-03" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Álvarez-Chinchilla PJ, Poveda Montoyo I, Illán F, Bañuls Roca J. Nodulosis reumatoideos en una paciente adulta con factor reumatoide negativo. Actas Dermosifiliogr. 2019;110:865–867.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 850 "Ancho" => 1506 "Tamanyo" => 160764 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, Skin-colored nodule located on the back of the hand at the metacarpophalangeal joint. B, Dermoscopic image of the lesion shown in A, showing a skin-colored background and nonspecific crystalline structures, as well as poorly focused irregular vascular structures. C, Ultrasound image of the lesion shown in A, showing a well-defined hypoechoic nodule located deep in the dermis. D, Ultrasound image of the lesion showing no power Doppler activity.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 850 "Ancho" => 1506 "Tamanyo" => 363126 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, Panoramic image showing granulomas located in the deep dermis (hematoxylin-eosin, original magnification ×20). B, Detail of the same image showing granulomas composed of palisaded histiocytes (arrow) arranged around a central eosinophilic zone corresponding to fibrin (asterisk) (hematoxylin-eosin, original magnification ×100).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rheumatoid nodulosis: report of two new cases and discussion of diagnostic criteria" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. Couret" 1 => "B. Combe" 2 => "V.T. Chuong" 3 => "J.L. Leroux" 4 => "F. Blotman" 5 => "J. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 5 | 14 | 19 |
| 2024 Octubre | 112 | 52 | 164 |
| 2024 Septiembre | 127 | 30 | 157 |
| 2024 Agosto | 148 | 75 | 223 |
| 2024 Julio | 133 | 35 | 168 |
| 2024 Junio | 137 | 72 | 209 |
| 2024 Mayo | 135 | 44 | 179 |
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| 2024 Marzo | 118 | 29 | 147 |
| 2024 Febrero | 86 | 43 | 129 |
| 2024 Enero | 113 | 42 | 155 |
| 2023 Diciembre | 93 | 24 | 117 |
| 2023 Noviembre | 123 | 36 | 159 |
| 2023 Octubre | 113 | 51 | 164 |
| 2023 Septiembre | 95 | 31 | 126 |
| 2023 Agosto | 76 | 14 | 90 |
| 2023 Julio | 101 | 38 | 139 |
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| 2023 Marzo | 105 | 34 | 139 |
| 2023 Febrero | 114 | 25 | 139 |
| 2023 Enero | 98 | 19 | 117 |
| 2022 Diciembre | 78 | 34 | 112 |
| 2022 Noviembre | 49 | 27 | 76 |
| 2022 Octubre | 76 | 23 | 99 |
| 2022 Septiembre | 64 | 44 | 108 |
| 2022 Agosto | 67 | 37 | 104 |
| 2022 Julio | 41 | 44 | 85 |
| 2022 Junio | 35 | 27 | 62 |
| 2022 Mayo | 119 | 65 | 184 |
| 2022 Abril | 178 | 35 | 213 |
| 2022 Marzo | 173 | 51 | 224 |
| 2022 Febrero | 165 | 38 | 203 |
| 2022 Enero | 123 | 33 | 156 |
| 2021 Diciembre | 86 | 43 | 129 |
| 2021 Noviembre | 95 | 45 | 140 |
| 2021 Octubre | 98 | 54 | 152 |
| 2021 Septiembre | 82 | 50 | 132 |
| 2021 Agosto | 66 | 26 | 92 |
| 2021 Julio | 51 | 29 | 80 |
| 2021 Junio | 63 | 37 | 100 |
| 2021 Mayo | 68 | 55 | 123 |
| 2021 Abril | 127 | 105 | 232 |
| 2021 Marzo | 58 | 39 | 97 |
| 2021 Febrero | 40 | 28 | 68 |
| 2021 Enero | 30 | 26 | 56 |
| 2020 Diciembre | 34 | 13 | 47 |
| 2020 Noviembre | 22 | 19 | 41 |
| 2020 Octubre | 23 | 28 | 51 |
| 2020 Septiembre | 21 | 15 | 36 |
| 2020 Agosto | 25 | 20 | 45 |
| 2020 Julio | 11 | 12 | 23 |
| 2020 Junio | 15 | 19 | 34 |
| 2020 Mayo | 12 | 15 | 27 |
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| 2020 Marzo | 37 | 4 | 41 |
| 2020 Febrero | 7 | 7 | 14 |
| 2020 Enero | 1 | 2 | 3 |
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