[Pre-iliac tumor mass syndrome: An atypical rheumatoid nodule]

Rheumatoid arthritis (RA) is a polymorphous chronic inflammatory disease that is common in general population and is responsible for the occurrence of subcutaneous or visceral rheumatoid nodules. Their typical clinical presentations and localizations do not generally pose any diagnostic or therapeutic problem. We report here an atypical fistulized presentation of an unusual iliac rheumatoid nodule in a 65-year-old female patient. The evolution was favorable without recurrence at 6 months after complete surgical resection and appropriate antibiotherapy.

Bamboo nodes associated with mixed connective tissue disease as a cause of hoarseness

Vocal fold lesions related to autoimmune diseases are rheumatoid nodules and, to a lesser extent, bamboo nodes. Mostly transverse, they are located in the middle third of the vocal cord and exhibit a yellowish appearance. The characteristic shape of these lesions led to their name. These vocal fold deposits may interfere with the normal vibratory cycle during phonation and thus may be an unusual cause of hoarseness. We present a 43-year-old woman with known mixed connective tissue disease and a dysphonia. Laryngostroboscopy showed bamboo nodes as described above. We applied several laryngeal injections of cortisone as described previously in the literature. Since this treatment did not lead to a sufficient voice improvement, we attempted to surgically remove the deposits. After the surgery, the voice improved considerably. In all patients with rheumatic diseases who suffer from a rough, breathy, or unstable voice, a laryngostroboscopic examination should be done. If, however, a bamboo node lesion of the vocal folds is found by the laryngologists, an associated autoimmune disorder must be assumed, and adequate diagnostic procedures have to be initiated. Local laryngeal injections (1–3 times) with steroids should be the first line of therapy. In unsuccessful cases, subsequent surgery can be a useful treatment of bamboo nodes to stabilize and improve voice quality.

Extradural spinal cord compression by rheumatoid nodule

Rheumatoid disease is a systemic disorder affecting multiple organs. It is known to affect the nervous system in a variety of ways, but its presentation with spinal cord compression by a rheumatoid nodule is rare. We report two cases presenting with cord compression by a rheumatoid nodule who underwent surgical decompression with good recovery.

Lumbar radiculopathy caused by extradural rheumatoid nodules

✓The authors report on a 51-year-old woman with a 9-year history of rheumatoid arthritis (RA) who presented with symptomatic rheumatoid nodules in the lumbar extradural region with compression on the L-5 nerve roots bilaterally. She had also suffered from dysesthesia in the right lower leg and intermittent claudication. Magnetic resonance imaging revealed masses compressing the dural sac, and on lumbar myelography and computed tomography myelography a filling defect at L4–5 was revealed, which was compressing the dural sac posterolaterally on both sides. The masses were surgically removed. On histological examination the typical characteristics of rheumatoid nodules were found. Soon after the operation all of the patient's symptoms disappeared.

There have been few reports on extradural rheumatoid nodules. Patients with RA usually complain of articular symptoms, and in fact the patient in the present study had been referred to the authors' institution for total hip arthroplasty. However, various symptoms other than those arising from articular lesions were found clinically. The authors believe that if patients with RA are also examined for extraarticular lesions, it is likely that these will be more frequently detected.

MRI bone oedema predicts eight year tendon function at the wrist but not the requirement for orthopaedic surgery in rheumatoid arthritis

OBJECTIVE

To investigate the role of early magnetic resonance imaging (MRI) of the wrist in predicting functional outcome in rheumatoid arthritis.

METHODS

MRI scans of the dominant wrist were scored for synovitis, tendon inflammation, bone oedema, and erosion at first presentation (n = 42), at 1 year (n = 42), and at 6 years (n = 31). At 8 years, clinical reassessment (n = 28) was undertaken. Tendon function was graded 0-3 for movement, tendon sheath swelling, and pain on resistance at nine flexor and extensor tendons of the hand. Hand function was also assessed using the Sollerman grip test. The requirement for joint or tendon surgery by 8 years was determined by telephone survey in 39 of the original 42 patients.

RESULTS

At 8 years, tendon function was highly correlated with hand function (Sollerman score, R = -0.51, p = 0.005) and global function (health assessment questionnaire score, R = 0.53, p = 0.004). Using a model incorporating baseline and 1 year MRI scores, the MRI bone oedema score was strongly predictive of tendon function at 8 years (chi(2)(2) = 15.3, p = 0.0005), as was the MRI bone erosion score (chi(2)(2) = 9.23, p = 0.01). Hand function was also predicted by the baseline MRI erosion score (p = 0.02). MRI variables did not predict the requirement for surgery, but patients who had surgery were more likely to show progression of MRI bone erosion scores between baseline and 1 year (p = 0.008).

CONCLUSIONS

Extensive MRI bone oedema and erosions at the wrist in early rheumatoid arthritis predict tendon dysfunction and impaired hand function in the medium term but not the requirement for joint or tendon surgery.

Rheumatoid nodulosis. Two cases with destructive polyarthritis after 20 years

The term "rheumatoid nodulosis" was coined by Ginsberg in 1975 to designate a rare and distinctive form of rheumatoid disease. Anecdotal case reports suggest a benign nondestructive course, although prolonged follow-up data are usually unavailable. We describe two cases of typical rheumatoid nodulosis with follow-ups exceeding 25 years. Onset occurred at 14 and 22 years of age, respectively. Both patients presented with palindromic rheumatism, positive tests for rheumatoid factors, negative tests for other biological markers, and normal radiographs. Multiple subcutaneous nodules developed after 4 and 6 years with palindromic flares, respectively. Functional impairments and disfigurement required several surgical procedures to remove nodules. Histology was typical for rheumatoid nodules. Neither patient responded to disease-modifying anti-rheumatic drugs (gold, antimalarials, and D-penicillamine). Treatment consisted of nonsteroidal anti-inflammatory drugs combined with prednisone as needed. After 20 and 22 years of follow-up, respectively, both patients had typical rheumatoid arthritis with deformities and radiological joint destruction. In conclusion, these two cases establish that rheumatoid nodulosis can occur as a presentation of rheumatoid arthritis with a potential for severe joint damage after many years.

A case of rheumatoid nodulosis successfully treated with surgery

We report the case of a 76 year-old male with multiple subcutaneous nodules, but without joint symptoms or deformities, who was diagnosed histopathologically with rheumatoid nodulosis after resection of the nodules. Rheumatoid nodulosis is a disease characterized by multiple subcutaneous nodules that are histopathologically similar to rheumatoid nodules, a high titer of rheumatoid factor, and radiologically detectable cystic bone lesions, but with none or few of the systemic manifestations orjoint activity of rheumatoid arthritis (RA). It is considered to be a benign variant of RA. This rare disease must be considered when a case of multiple subcutaneous nodules is encountered, even in aged males withoutjoint symptoms or deformities.

A giant rheumatoid nodule

Subcutaneous rheumatoid nodules occur commonly in advanced cases of rheumatoid arthritis and are the most common extra-articular lesion of this disease. We present a case of a very unusual giant rheumatoid nodule that developed on the lateral side of a knee. The case was devoid of systemic symptoms of arthritis and the lesion was limited to a rheumatoid nodule. The nodule was successfully treated by surgical excision. However, other new nodules developed in her hand. Her clinical course has not been satisfactory.

Embolic complications of a mitral valve rheumatoid nodule

We describe a patient with a rheumatoid nodule on the mitral valve who developed embolic phenomena from an overlying thrombus. It is important to recognize that thrombus can develop on intracardiac rheumatoid nodules and that these patients may require anticoagulation.

Rheumatoid nodule of the nasal septum

Necrotizing granulomatous nodules are a common feature in patients with rheumatoid disease, affecting 20 per cent of seropositive patients. Although most commonly found subcutaneously at points of pressure, these nodules may occur in the connective tissues elsewhere in the body. In the upper aerodigestive tract, nodules have been described in diverse locations, but commonly in the trachea, larynx and the ear. We present the first reported case of a rheumatoid nodule affecting the nasal septum.

Intraarticular rheumatoid nodule detection in the knee joint using ultrasonography

Rheumatoid nodules represent a classic diagnostic sign of rheumatoid arthritis. They can be found in 20-25% of patients and are localized to the extensor surface of the proximal ulna and other friction areas such as the back of the head, the sacrum, the digits and the Achilles tendon. They can also develop in some internal organs such as the lungs, kidneys and the heart. Rheumatoid nodules are a characteristic extra-articular feature of RA. Intraarticular rheumatoid nodules are rare and their detection is a diagnostic challenge. There are few reports in the medical literature on their ultrasonographic detection. We report our results from a retrospective study on 9 patients (5 with gait problems and 4 - asymptomatic) with intraarticular rheumatoid nodules in the knee joint. Ultrasonography was most important in their detection. The diagnosis was confirmed histologically in two of our patients following surgical removal of the nodules.

Aortic valve rheumatoid nodules producing clinical aortic regurgitation and a review of the literature

The majority of cardiac involvement in rheumatoid arthritis (RA) is an incidental finding at postmortem, as less than 3% of patients with RA have clinical cardiac signs or symptoms. Most cardiac involvement in RA involves the pericardium and has been known since Charcot first described an RA patient with pericarditis in 1881. Cardiac involvement takes two different forms: non-specific inflammatory changes and specific granuloma formation. Specific rheumatoid nodules in the heart are an infrequent complication of RA. This is the first case report of a surgically excised heart valve with rheumatoid nodules. A 74-year-old RA patient with a high seropositive rheumatoid factor presented with severe aortic regurgitation and underwent a valve replacement. The native aortic valve showed significant stenosis with multiple, classic rheumatoid nodules.

Painful snapping in rheumatoid knees

Painful snapping caused by a solitary intra-articular nodular mass was found in 11 knee joints of 8 patients with rheumatoid arthritis. The masses were characteristically situated in the anterolateral aspect of the lateral femoral condyle of each joint, and appeared to jump and slip in and out of the patellofemoral articulation during flexion and extension. The snapping caused by the solitary mass was noticed as the joint flexed from 15 degrees to 30 degrees in 9 knees and from 50 degrees to 60 degrees in 3. Histopathological examination of the masses revealed typical findings of a rheumatoid nodule in 4 knee joints and myxomatous degeneration and collagen necrosis in 7.

A rare case of embolizing cardiac tumor: rheumatoid nodule of the mitral valve

We report the case of a 65-year-old woman with rheumatoid arthritis who was admitted with a stroke. Echocardiographic examination revealed a multilobule, highly mobile tumor on the posterior leaflet of the mitral valve. Surgical exploration showed a tumor infiltrating the valve, the annulus, and the adjacent left ventricular wall, which required complete valve resection. Histologic study demonstrated typical characteristics of a rheumatoid nodule.

The management of rheumatoid nodules

Rheumatoid nodules are present in approximately 25% of patients with seropositive rheumatoid arthritis (RA) and are the most common extra-articular lesions of this disease. Current methods of treatment include a variety of antirheumatic agents, surgical excision, or observation. Treatment options for the rheumatoid nodule are limited, due in part to the highly variable nature of the nodule. This series describes 4 seropositive RA patients, all with extensive rheumatoid nodules. Three were successfully treated by surgical excision, and 1 was successfully treated with conservative management. Surgical treatment is effective. Indications include local pain, nerve compression, limited range of motion, erosion, and infection.

Rheumatoid nodules affecting both heels with surgical debulking: a case report*

The presence of subcutaneous nodules in association with rheumatoid arthritis is well documented. In most cases, these nodules occur in association with severe rheumatoid disease. Treatment should be initiated with conservative measures such as custom-molded shoes, nonweightbearing, and oral antibiotic therapy to control infection. The goals of surgery were to alleviate pain, improve function and cosmesis, remove infected bone, and prevent further infection. The surgical sites are completely healed without complications 2 years postoperatively.

Rheumatoid Nodules of the Larynx

Two unique cases of rheumatoid nodules affecting the larynx are reported. These subcutaneous nodules represent localized laryngeal involvement from autoimmune disorders. The otolaryngologist should be aware of these possibilities as part of the differential diagnosis in the workup of dysphonia.

Rheumatoid nodules on amputation stumps: report of three cases

We describe three patients, all of them lower limb amputees who also had seropositive, nodular rheumatoid arthritis. In each case, rheumatoid nodules developed on the amputation stump, causing difficulties with prosthesis fit and comfort and impairment of ambulation. Nodules were successfully excised in two cases and the prosthesis modified in the third. The patients were able to resume walking or transferring with their prostheses.

Trigger wrist induced by finger movement. Pathogenesis and differential diagnosis

Four cases of trigger wrist induced by finger motion are reported. The cause of trigger wrist induced by finger motion was a rheumatoid nodule in one case, giant cell tumor of the flexor tendon sheath in one case, partial laceration of the flexor digitorium superficialis tendon in one case, and lipofibroma in one case. Triggering or snapping at the wrist is also induced by motion of the wrist and forearm. Reported cases were also analyzed and the clinical entity of the true trigger wrist and differential diagnosis were discussed.

Subcutaneous palisading granuloma of the scalp in childhood

Subcutaneous palisading granulomas, lesions characterized by collagen necrosis and chronic inflammatory changes, may present as ill-defined, immobile, nontender masses of the scalp. They are frequently multiple and may vary in size over time. Imaging studies rarely show involvement of the calvarium. The histological pattern of palisading histiocytes around necrobiotic granulomas is seen in association with a variety of systemic illnesses but more commonly occurs as an isolated entity in childhood. They are unlikely to herald rheumatological disease unless the erythrocyte sedimentation rate is elevated. In the presence of juvenile rheumatoid arthritis, histological confirmation is usually not indicated. If the lesions are not associated with any other clinical symptoms excisional biopsy may be indicated to establish a diagnosis. The nodules need not be removed as they will spontaneously regress.

Surgical treatment of arthritis in the elderly

Arthritis in the elderly can be very effectively treated by a combination of careful orthopaedic and rheumatological assessment. The overall functional assessment, and definition of the aims and likely results of surgical treatment by the team approach, involving occupational therapists, physiotherapists and social workers, are important for success. There are many worthwhile surgical procedures available to relieve pain, and restore mobility and independence to those affected by osteoarthritis and rheumatoid arthritis.

Rheumatoid nodulosis in the foot: a variant of rheumatoid disease

Rheumatoid nodulosis is a relatively benign variant of rheumatoid disease. This entity has been previously ignored in the medical literature. Confusion with other diseases that can produce nodules is not infrequent. A discussion of this entity, as well as a case report, will be presented.

Rheumatoid nodulosis of the hand

Rheumatoid nodulosis is an uncommon variant of rheumatoid disease with distinctive clinical and radiographic characteristics and a favorable prognosis. This is in contrast to the poor prognosis for the severe form of rheumatoid disease with which rheumatoid nodules are often associated. A case of rheumatoid nodulosis of the hand treated with complete resection of the nodules is presented with a 2.5-year follow-up. Fourteen cases of documented rheumatoid nodulosis are reviewed and surgical treatment is recommended for both functional and cosmetic reasons.

Surgery of the elbow joint in rheumatoid arthritis

A review is made of the literature of the mechanics of the elbow joint and the types of operations available. It is clear that the elbow is a complex joint and that in patients with rheumatoid arthritis destruction and disability occurs relatively late in the disease. Of the operations available, synovectomy and excision of the radial head are best done early in order to obtain the movement of supination and pronation. Total elbow replacement, particularly the unconstrained type is producing encouraging results and seems rational in view of the structure of the elbow. However it is early days in the design of these prostheses and the clear message is that the patients need full assessment in the light of their other joints involved.

Trigger wrist phenomenon in rheumatoid arthritis

Flexor tendon synovitis in patients with rheumatoid arthritis commonly presents with a carpal tunnel syndrome and a concomitant trigger finger. Triggering at the wrist joint is in this disease an uncommon additional feature. In the two cases reported, histological examination of the tissue has indicated that, as well as chronic synovitis, there was a true rheumatoid nodule present at the wrist joint, either pedunculated or fusiform. The passage of the nodule, with a 'Click' from the proximal side of the transverse carpal ligament to the distal aspect, when the fingers are flexed, creates the sensation, signs and symptoms of a trigger wrist.

Intra-articular rheumatoid nodule of the knee joint

A 44-year-old woman with a long-standing history of classical rheumatoid arthritis had an intra-articular rheumatoid nodule of the knee joint. The history, symptoms, and signs of this case were, however, almost identical to those cases previously reported. This entity has a classic presentation and distinct findings on examination which distinguish it from other intra-articular lesions of the knee.

[Multiple pseudoxanthomatour rheumatoid nodules]

2 cases of Rheumatoid arthritis associated with multiple subcutaneous nodules were presented, which resembled "pseudoxanthomatour rheumatoid nodules" as before reported. In the first case, the asymmetrical joint involvement has been preceded by the formation of subcutaneous nodules since 5 years; In the second case, arthritis appeared long before the nodules were formed. In both cases, circumscript vasculitis and high titer of rheumatoid factor were noticed and cystic activities were found in several nodules.

Rheumatoid changes in the metacarpophalangeal region as a cause of Bunnell's sign

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Rheumatoid-like nodules presenting as Haglund's deformity in an adult, nonarthritic patient

The authors present the case of an adult female patient with bilateral posterior heel masses. These were removed and histologically found to be rheumatoid-like nodules. There was no clinical or laboratory evidence of rheumatoid disease. A review of the literature is presented.

Benign rheumatoid nodule versus subcutaneous granuloma annulare: a diagnostic dilemma--are they the same entity?

The authors differentiate benign rheumatoid nodules from similar subcutaneous lesions based on location and pathologic characteristics. Although many of these lesions spontaneously resolve, recurrence rates may be high. Various therapeutic modalities are therefore suggested. An illustrative case study is presented.