What Are Rheumatoid Nodules?

Appearance and Significance of Rheumatoid Nodules

185076826.jpg
Richard Rudisill/E+/Getty Images

As part of the disease process, firm, non-tender, subcutaneous nodules develop in up to 35% of rheumatoid arthritis patients. The nodules can be subtle, painless masses that tend to develop over the extensor surface of joints or over pressure points. They are considered the most common cutaneous (skin) manifestation of rheumatoid arthritis and generally measure between 2 mm and 5 cm.. At initial presentation, when patients first are evaluated for rheumatoid arthritis by a doctor, about 7% of patients have palpable, subcutaneous rheumatoid nodules.

Common sites for rheumatoid nodules include the elbow, back of the forearm, metacarpophalangeal joints (knuckles), Achilles, and extensor tendons. Rheumatoid nodules are rarely found over the sacrum, occiput (back of the head), vocal cords, pulmonary parenchyma, pleura, pericardium, myocardium, or the leptomeninges of the central nervous system—but it is possible, as it is for them to develop within internal organs.  

Rheumatoid nodules, which may appear as a single mass or as a cluster of nodules, usually develop when rheumatoid arthritis is active. The subcutaneous nodules are typically moveable and have a rubbery feel. Some are bound to the periosteum (bone) and then feel firm or hard to the touch.

Nodular masses are not exclusive to rheumatoid arthritis. Nodular masses can occur with gout (called gout tophi), rheumatic fever, xanthomatosis, and sarcoidosis, among other conditions. One distinguishing feature between rheumatoid nodules and gout tophi is that rheumatoid nodules rarely ulcerate or come through the overlying skin.

There is also a well-known correlation between rheumatoid nodules and a high level of rheumatoid factor.

Rheumatoid nodules are commonly associated with joint deformity and serious extra-articular manifestations of rheumatoid arthritis, which may include involvement of the lungs or eyes Rheumatoid nodules may vary in size during the course of the disease process.

Rheumatoid nodules may be associated with complications, including limited joint mobility, neuropathy, fistula formation, and infection.

About 75% of patients with Felty's syndrome have rheumatoid nodules. Rheumatoid arthritis patients with nodules are more likely to develop vasculitis. Generally, it is thought that patients with rheumatoid nodules have a more severe disease course with rheumatoid arthritis and more rapidly progressive joint damage.  

Intranodular steroid injections may reduce the size of a nodule. Treatment with DMARDs or TNF blockers may or may not eliminate rheumatoid nodules as rheumatoid arthritis is brought under control. Interestingly, some patients treated with methotrexate experience worsening nodules, even if other aspects of the disease seem well-controlled. Surgical removal is an option, but nodules tend to recur in as little as a few months, especially when they are present over an area of repeated trauma. Usually, for that reason, surgery is discouraged.

Photos of Actual Rheumatoid Nodules

  • Arthritis Hand Photo Gallery
    Hand damage and deformity caused by arthritis can include nodules, swelling, stiffness, ulnar drift, contractures, and other problems.

    Sources:

    Rheumatoid Nodules. UpToDate. John M. Davis, M.D., M.S. December 2015.
    http://www.uptodate.com/contents/rheumatoid-nodules

    Kelley's Textbook of Rheumatology. Ninth edition. Chapter 70 - Clinical Features of Rheumatology. Rheumatoid Nodules. Sweeney, Harris, and Firestein.

    Rheumatoid Arthritis: Early Diagnosis and Treatment. Third edition. Cush, Weinblatt, and Kavanaugh. Professional Communications, Inc. Rheumatoid Nodules. Page 41.

    Continue Reading