Rheumatoid nodules: causes, symptoms, diagnosis, treatment

In 20% of patients with rheumatoid arthritis, nodular rashes are detected - rheumatoid nodules. Rheumatoid nodules are subcutaneous or periosteal nodules with a diameter of several millimeters to 2 cm. Most often, the rashes are multiple, they are painless. They are located near bone structures, often next to joints, especially elbows, can be fused with underlying tissues, and ulcerate in case of injury. These nodules are clinically indistinguishable from rheumatic nodules, but are not accompanied by rheumatic disease, usually occur in children, rarely in adults. They are considered specific for rheumatoid arthritis and are considered one of the diagnostic criteria. Similar nodules were described in systemic lupus erythematosus, they are similar to a deep form of annular granuloma; WF Lever et al. (1975) suggest calling them pseudorheumatoid nodules. Nodes most often appear in severe cases of the disease, when the blood serum often has positive antiulcer and rheumatoid factors. Sometimes rashes occur in patients with a moderate severity of the process.

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Histopathology

The nodes consist of fibrous tissue, which contains foci of fibrinoside necrosis, around which there are many fibroblasts and histiocytes. In addition, the presence of young granulation tissue, amorphous material, nuclear remnants and vasculitis in the nodes is noted.

Pathomorphology

The lesion contains several clearly defined areas of fibrinoid necrosis of collagen, surrounded by palisade-like histiocytes, including lymphocytes, neutrophils, mast cells, and foreign body-type giant multinucleated cells. There may be structures resembling sarcoid granulomas. In the stroma of the nodule, there is an inflammatory infiltrate consisting of lymphoid elements, proliferation of blood vessels, and fibrosis.

Histogenesis is not sufficiently dense. It is believed that nodules arise as a result of deposition of immune complexes in vessels. Direct immunofluorescence reaction reveals deposits of IgG and IgM in the vessel walls.

Symptoms of Rheumatoid Nodules

The nodes are often located in the area of the radius, rarely - the knees, on the auricle, the back of the hands, the lower back and, possibly, in other areas subject to pressure. In these areas, nodes several centimeters in diameter, single or multiple, purple in color appear. Under the influence of trauma, the nodes quickly ulcerate. The addition of staphylococcal infection can lead to staphylococcal sepsis and septic arthritis, sometimes rheumatic nodes can be localized on the sclera (scleromalacia), while the sclera can atrophy and ulcerate, and blindness occurs.

Differential diagnosis

The disease should be distinguished from annular granuloma, nodules in erythema nodosum, leprosy, sarcoidosis, etc.

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Treatment of rheumatoid nodules

The underlying disease is treated. Corticosteroid ointments and creams are used locally. Epithelializing agents are used for ulcers.