Nodules, rheumatoid

Extra-articular involvement may include rheumatoid nodules, vasculitis, pleural effusions, pulmonary fibrosis, ocular manifestations, pericarditis, cardiac conduction abnormalities, bone marrow suppression, and lym-phadenopathy. 

Rheumatoid nodules Subcutaneous nodules over bony prominences or extensor surfaces, or in jux-... 

Patients with rheumatoid arthritis may also suffer from wide range of symptoms which affect other parts of the body. These symptoms may include anaemia, dry eyes, osteoporosis and nodules, among other things. 

Rheumatoid Subcutaneous nodules, over bony prominences, or extensor sudaces, or in... 

Kekow J, Welte T, Kellner U, Pap T. Development of rheumatoid nodules during anti-tumor necrosis factor alpha therapy with etanercept. Arthritis Rheum 2002 46(3) 843. ... 

Hubscher O, Re R, lotti R. Pulmonary rheumatoid nodules in an etanercept-treated patient. Arthritis Rheum 2003 48(7) 2077-8. 

Since the first descriptions of the rapid development of a large number of nodules, also termed accelerated nodu-losis, in methotrexate-treated patients, a number of such reports have accumulated in patients with rheumatoid arthritis or, more rarely, psoriatic arthritis (66-68). Nodulosis is characterized by the development of small, painful, multiple nodules, sometimes disseminated pulmonary, meningeal, or pericardial nodulosis has also been... 

The nodules can appear at any time during treatment, with or without concomitant cutaneous vasculitis, and are usually found in patients with erosive disease and a high titer of rheumatoid factor. This has raised the question as to whether they are a reason to modify treatment, and whether they are rheumatic or represent a true adverse effect of methotrexate certainly, methotrexate-associated nodulosis is very similar to idiopathic rheumatoid arthritis nodulosis and sometimes disappears despite continuation of methotrexate. However, prompt regression on methotrexate withdrawal and recurrence on rechallenge in several patients strongly argue for a causal drug-related effect. 

Falcini F, Taccetti G, Ermini M, Trapani S, Calzolari A, Franchi A, Cerinic MM. Methotrexate-associated appearance and rapid progression of rheumatoid nodules in systemic-onset juvenile rheumatoid arthritis. Arthritis Rheum 1997 40(l) 175-8. 

Goffe B +, ]Am Acad Dermatol 49(2), S105 Rheumatoid nodules... 

Rheumatoid arthritis is the most common systemic inflammatory disease, and is characterized by symmetrical joint involvement. Extra-articular involvement including rheumatoid nodules, vasculitis, eye inflammation, neurologic dysfunction, cardiopulmonary disease, lymphadenopathy, and splenomegaly are manifestations of the disease. Although the usual disease course is chronic, some patients will enter a remission spontaneously. 

Tenderness with warmth and swel ling over affected joints usually involving hands and feet. Distribution of joint involvement is frequently symmetrical. Rheumatoid nodules may also be present. 

Rheumatoid nodules occur in 20% of patients with rheumatoid arthritis. These nodules are seen most commonly on the extensor surfaces of the elbows, forearms, and hands, but also may be seen on the feet and at other pressure points. They also may develop in the lung or pleural lining of the lung, and rarely in the meninges. Rheumatoid nodules usually are asymptomatic and do not require any special intervention. Nodules are observed more commonly in patients with erosive disease. ... 

Rheumatoid arthritis may involve the pleura of the lung, which is often asymptomatic, although pleural effusions may result. Pulmonary fibrosis also may develop as a result of rheumatoid involvement smoking appears to increase the risk of this complication. Rheumatoid nodules may develop in lung tissue and appear similar to neoplasms on chest x-ray films. Interstitial pneumonitis and arteritis are rare, potentially life-threatening complications of rheumatoid arthritis. 

Ocular manifestations include keratoconjunctivitis sicca and inflammation of the sclera, episclera, and cornea. Atrophy of the lacrimal duct may result in a decrease in tear formation, causing dry and itchy eyes, termed keratoconjunctivitis sicca. When this is observed in association with rheumatoid arthritis, it is referred to as Sjogren s syndrome. Artificial tears may be used to relieve symptoms. Inflammation of the superficial layers of the sclera (episcleritis) is generally self-limiting. Involvement of deeper tissues (scleritis) usually results in a more serious, painful, and chronic inflammation. Rheumatoid nodules may develop on the sclera. 

Wear and tear Systemic autoimmune disease (+) Rheumatoid factor (+) Rheumatoid nodules... 

HRCT often discloses a complex admixture of lesions, termed rheumatoid lung. Bronchiectasis is present in 8% to 75% of patients, but the distinction between primary bronchiectasis and traction bronchiectasis due to pulmonary fibrosis is often difficult (139,140,149,151,152,155,166,177). Bronchiolitis is also frequent, manifesting as centrilobular nodules, tree-in-bud sign, mosaic perfusion, or air trapping (139,149,151,152,155,166,177). Emphysema is present in 5% to 43% of patients (13,139,140,149,151,152,155,166,174,177) and is widely viewed as a trait of RA-ILD, unlike findings in other CTDs. Emphysema is more frequent with an HRCT pattern of UIP, as opposed to NSIP (155). Other features include pulmonary rheumatoid nodules and pleural effusion or thickening can be observed. Pulmonary artery enlargement has been observed in nearly half of patients with RA-ILD, in spite of the fact that overt PH is rare in RA (155). 

The most common CTD throughout the world is rheumatoid arthritis (RA). Thoracic manifestations of RA are numerous (Table 1) including forms of ILD. The thoracic disease manifestations independent of ILD include pleural effusions, bronchiolitis obliterans (BO) without an organizing pneumonia, rheumatoid nodules, upper airway obstruction, and acute rheumatoid pneumonitis. 

Rheumatoid (necrobiotic) nodules Pneumoconiotic nodules (Caplan s syndrome)... 

Necrobiotic rheumatoid nodules associated with bronchopleural fistula Pyopneumothorax Thoracic cage immobihty... 

Rupture of necrobiotic nodule into pleural space Pleural fibrosis from previous rheumatoid effusion... 

Figure 1 Chest computed tomography demonstrating multiple pulmonary nodules from rheumatoid arthritis. Note that nodules are of different sizes and may he scattered randomly throughout the lung parenchyma. Cavitation can occur as seen in the largest nodule on this cut from chest computed tomography.

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