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http://www.uptodate.com/contents/rheumatoid-nodules?topicKey=RHEUM%2F7523&elapsedTimeMs=2&source=search_result&searchTerm=nodulo+reumatoid 1/9
Official reprint from UpToDate
www.uptodate.com 2014 UpToDate
Authors
Peter H Schur, MD
Carl Turesson, MD, PhD
Section Editor
RN Maini, BA, MB BChir, FRCP,
FMedSci, FRS
Deputy Editor
Paul L Romain, MD
Rheumatoid nodules
Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Feb 2014. | This topic last updated: jul 24, 2012.
INTRODUCTION The rheumatoid nodule is the most common cutaneous manifestation of rheumatoid arthritis
(RA) [1,2]. Although nodules commonly are found on pressure points (such as the olecranon process), they may
occur at other sites, including ones within internal organs of the body. Thus, bedridden patients can develop
nodules on the occiput and ischial areas, and nodules occasionally form on the Achilles tendon and vocal cords [3].
Rheumatoid "nodulosis" is characterized by multiple nodules on the hands and multiple subchondral bone cysts
known as "geodes" [4]. These nodules tend to occur on extensor surfaces adjacent to joints, elbows, and fingers,
as well as the forearm, metacarpophalangeal and proximal interphalangeal joints, occiput, back, heel, and other
areas [5].
The clinical and histopathologic features, diagnosis, and treatment of rheumatoid nodules will be reviewed here. The
articular features and an overview of the systemic and nonarticular manifestations of RA are presented separately.
(See "Clinical features of rheumatoid arthritis" and "Overview of the systemic and nonarticular manifestations of
rheumatoid arthritis".)
PREVALENCE AND CLINICAL SIGNIFICANCE
Subcutaneous nodules Palpable nodules in the subcutaneous tissues have been reported at initial
presentation in 7 percent of patients with RA [6] and are found at some time during the disease course in 30 to 40
percent of patients [7]. The vast majority of nodule formers have positive tests for rheumatoid factor [1]. Nodules are
found in 75 percent of patients with RA-associated Feltys syndrome [5]. RA patients with nodules are also more
likely to develop vasculitis [8]. Limited data suggest that many patients with rheumatoid nodules have a positive
test for antibodies to citrulline containing peptides (eg, anti-CCP) [9]. In general, patients with rheumatoid nodules
tend to have a severe RA phenotype, with more rapid progression of joint destruction than other patients with RA
[10]. Rheumatoid nodules have also been noted in occasional patients with systemic lupus erythematosus,
ankylosing spondylitis, granuloma annulare, and chronic active hepatitis, and they have been associated with
antiphospholipid antibodies in patients with RA, as well as in healthy children and adults [5].
The size of the nodules varies from 2 mm to 5 cm; they are firm, nontender, and moveable in subcutaneous tissue
(picture 1) [5].
In many cases, the nodules are neither symptomatic nor a cosmetic concern. However, rheumatoid nodules can be
painful and/or disfiguring, can interfere with function, and can cause compressive neuropathies. Some patients find
the nodules more distressing than the arthritis. The nodules may also ulcerate and thus serve as a site for local
infection or other distant infectious complications by hematogenous spread of bacteria.
A poorly understood phenomenon is that some patients treated for RA with methotrexate have a noticeable
increase in the size and number of rheumatoid nodules. This is referred to as accelerated nodulosis and is
discussed in more detail elsewhere. (See "Major side effects of low-dose methotrexate", section on 'Nodulosis'.)