Annals ofthe Rheumatic Diseases 1992; 51: 1005-1006 1005 Ann Rheum Dis: first published as 10.1136/ard.51.8.1005 on 1 August 1992. Downloaded from Palmar rheumatoid nodulosis associated with local pressure Eldad Ben-Chetrit, Claes Enk, Alan Rubinow Abstract Rheumatoid nodulosis is a term used to describe adult patients with rheumatoid arthritis with little or no clinical joint inflam- mation who have numerous subcutaneous nodules indistinguishable from those of patients with active rheumatoid arthritis. This paper reports the case of a woman with quiescent rheumatoid arthritis who developed palmar nodulosis three weeks after the strenuous activity of painting her gpartment. This case illustrates the direct association between the appearance of nodulosis and physical pressure despite inactive disease. (Ann Rheum Dis 1992; 51: 1005-1006) Figure I Rheumatoid nodulosis on both palms ofthe patient. Rheumatoid nodules are common extra-articular manifestations of rheumatoid arthritis. Their incidence is 20-25% in adults with a greater (Westergren). Rheumatoid factor (latex fixation percentage (90%) in severely ill patients who test) was positive in a titre of 1/32. A fluorescent are positive for rheumatoid factor.' Although antinuclear factor test was positive (+2/+4). generally associated with more severe articular Liver and kidney functions were normal. A and disease massive occur a was systemic nodules may biopsy sample from palmar nodule http://ard.bmj.com/ in patients with little or no detectable synovitis.2 characteristic of a rheumatoid nodule (fig 2). When the nodules are numerous and not The patient reported that during preparations associated with active articular or systemic for Passover three weeks previously she had disease, the term rheumatoid nodulosis is used.3 painted the walls and doors of her apartment. The nodules are most commonly found on The sites of the nodule formation conformed to extensor surfaces and on areas subject to areas of pressure related to use of the paint pressure such as the elbow, occiput, or sacrum. brush or roller. This paper reports the case of a woman with on September 29, 2021 by guest. Protected copyright. quiescent rheumatoid arthritis who developed palmar nodulosis three weeks after the strenuous Discussion activity of painting her apartment. Rheumatoid nodules are granulomatous lesions which are still a key finding in patients with rheumatoid arthritis. Generally such nodules Case report are associated with more severe articular and A 41 year old woman who had had seropositive systemic disease and high titres of rheumatoid rheumatoid arthritis for eight years presented to factor. In 1949 Bywaters described a particular kheumatology Unit, our outpatient clinic with multiple palmar variant of rheumatoid arthritis characterised by Department of Medicine, nodules. She had been treated beneficially with transient digital pad nodules and palmar Hebrew University- gold injections and non-steroidal anti-inflam- contractures resembling palindromic rheu- Hadassah Hospital, and for the last Jerusalem, Israel matory drugs for five years matism.2 In 1975 the term rheumatoid nodulosis E Ben-Chetrit three years was asymptomatic while receiving was used for adult patients with little or no A Rubinow 200 mg/day hydroxychloroquine (Plaquenil). clinical joint inflammation but with numerous Department of She reported that three weeks previously no subcutaneous nodules with a histopathology Dermatology, nodule was apparent on her palms and she felt indistinguishable from seropositive rheumatoid Hebrew University- Hadassah Hospital, well. Physical examination showed a thin arthritis.3 The criteria for the diagnosis of Jerusalem, Israel woman with mild deformities of her hands and rheumatoid nodulosis are not clear. Some C Enk multiple non-tender nodules located to the workers have described subchondral cysts as Correspondence to: flexor surfaces of her palms (fig 1). No sign of necessary for the diagnosis,45 whereas others Dr E Ben-Chetrit, Department of Medicine, active arthritis was noted. have reported patients with rheumatoid Hadassah University Laboratory tests gave the following results: nodulosis without radiological lesions.6 7 Couret Hospital, POB 12000, count 8 Jerusalem 91120, Israel. haemoglobin of 120 g/l; white blood cell et al suggested that the diagnosis of rheuma- Accepted for publication 7 5x 109/l; and thrombocytes 250x lO9/l. The toid nodulosis should be based on the following 8 November 1991 erythrocyte sedimentation rate was 30 mm/hour four criteria: (a) no or mild systemic mani- 1006 Ben-Chetrit, Enk, Rubinow A i36S :1.B. '.ve X jS f}s#% Ann Rheum Dis: first published as 10.1136/ard.51.8.1005 on 1 August 1992. Downloaded from ,..<*# :. .J . e. \ X ,<. &x>2. 6- & Xl; x i .^Y ,|,; :. .' t _ > t A ub x > > - w £ .......... t w > >42> *;;*SS.s *t !1 W ;. S Figure 2 (A)Biopsy samplefrom palmar nodule showing typical necroticfocus surrounded by pallisades ofproliferating histiocytes. (B) Higher magnification ofthe nodule. festations of rheumatoid arthritis; (b) benign rheumatoid arthritis, regardless of disease clinical course; (c) recurrent joint symptoms activity, should avoid the kind of activities that with minimal clinically or radiologically detect- require strenuous repetitive movement or local able disease; and (d) multiple rheumatoid pressure on body surfaces. nodules identified by taking biopsy samples. Typically the nodules appear on the extensor http://ard.bmj.com/ surfaces of the forearm below the elbow and are presumably associated with mild repetitive traumatic pressure. Subcutaneous nodules may 1 Schumacher H R, Gall E P, eds. Rheumatoid arthritis. Philadelphia: Lippincott, 1988. be confused clinically with joint xanthomas, 2 Bywaters E G. A variant of rheumatoid arthritis characterized granuloma annulare, and tophi or multicentric by recurrent digital pad nodules and palmar fasciitis, closely resembling palindromic rheumatism. Ann Rheum histiocytosis.' Dis 1949; 8: 2-30. The appearance of nodules in this patient 3 Ginsburg M H, Genant H U, Yu T F, McCarty D J. on September 29, 2021 by guest. Protected copyright. Rheumatoid nodulosis: an unusual variant of rheumatoid deserves comment. First, the number ofnodules disease. Arthritis Rheun 1975; 18: 49. and their appearance during a quiescent period 4 Wisnieski J J, Askarii Ad. Rheumatoid nodulosis. Arch Intern Med 1981; 141: 515-9. suggest the diagnosis of rheumatoid nodulosis. 5 Morales-Pip A, Elena-Ibanez A, Zea-Mendoza A C, Second, the temporal relation between the Rocamora-Ripoll A, Beltran-Gutierez J. Rheumatoid nodulosis: report of a case with evidence of intraosseous strenuous effort of decorating with repetitive rheumatoid granuloma. Arthritis Rheum 1986; 29: 1278-83. pressure over the palms of her hands and the 6 Schreiber S, Schumacher H R, Cherian P V. Palindromic rheumatism with rheumatoid nodules: a case report with appearance of the nodules support the part ultrastructural studies. Ann Rhewn Dis 1986; 45: 78-81. played by trauma in the pathogenesis of these 7 Brown M M, Hadler N M, Sams W M, Wilson J, Snyderman R. Rheumatoid nodulosis, sporadic and familial diseases. lesions. J Rhewnatol 1979; 6: 282-92. Each year many Israeli patients suffer trauma 8 Couret M, Combe B, Chicong V T, Leroux J L, Blotman F, Sany J. Rheumatoid nodulosis: report of two new cases and related to the traditional intensive preparations discussion of diagnostic criteria. J Rhewmatol 1988; 15: for Passover or spring cleaning. Patients with 1427-30..