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 Dr Sampurna Roy MD

http://www.histopathology-india.net/ dermpath.htm

Subcutaneous rheumatoid nodules occur in about 20-25% patients with rheumatoid arthritis.

The presence of these extra-articular lesions correlates with the extent of joint involvement and they are an index of disease severity.

They may also occur in rheumatic fever or rarely in systemic lupus erythematosus.

Rheumatoid nodules have also been reported in patients with no previous history of rheumatoid arthritis or any other systemic disease.

'Accelerated rheumatoid nodulosis' is a condition in which small nodules develop  on the hand, feet and ears during methotrexate therapy.

Age and sex : Rheumatoid nodules may develop in adults and in children and is slightly more common in females.

Location: These are usually situated near bony structures close to a joint. The lesions are primarily located in the subcutaneous tissue and may involve deep and superficial dermis.   

Images (JHU)   

Gross: Fibrous white masses with creamy yellow irregular areas of necrobiosis. The size varies from a few millimeters to centimeters.

Microscopic features:  Image Link1 ; Image Link2 ; Image Link3 ; Image Link4.

Sharp irregular areas of necrobiosis (huge deposits of fibrin)
Located in the subcutis and deep reticular dermis.
Surrounded by a palisade of elongated  histiocytes.
Stroma surrounding the nodules show perivascular lymphocytic infiltrate including plasma cells.
Some neutrophils and nuclear dusts of neutrophils may be present. Acute or chronic thrombotic endoarteritis is observed in some cases around rheumatoid nodules.
Old lesions show dense fibrosis, clefts and cystic degeneration.

Differential diagnosis:
Deep variant of granuloma annulare: click
Contains abundant mucin (appears pale and basophilic) surrounded by palisades of histiocytes. Clinical information is very useful.
Necrobiosis Lipoidica: click
There is degeneration of collagen in early lesion. Thickened collagen bundles are present in old lesions.
Tiers of inflammatory cells (lymphocytes, histiocytes, plasma cells) are present throughout the reticularis dermis.
Inflammatory cells & histiocytes are present in the septa of subcutaneous fat.

Collagenolytic (necrobiotic) granulomas: part II--the 'red' granulomas.J Cutan Pathol. 2004;31(6):409-18.

The spectrum of cutaneous lesions in rheumatoid arthritis: a clinical and pathological study of 43 patients.J Cutan Pathol. 2003 Jan;30(1):1-10.

Cytokine profile of the rheumatoid nodule suggests that it is a Th1 granuloma.Arthritis Rheum. 2003 Feb;48(2):334-8.

Fine-needle aspiration of rheumatoid nodule: a case report with review of diagnostic features and difficulties.Diagn Cytopathol. 2003 Jun;28(6):322-4.

Expression of the histiocytic marker PG-M1 in granuloma annulare and rheumatoid nodules of the skin.J Cutan Pathol. 2002 Nov;29(10):590-5.

Complement mediated vascular endothelial injury in rheumatoid nodules: a histopathological and immunohistochemical study.J Rheumatol. 2000;27(8):1839-47.

The histopathologic spectrum of palisaded neutrophilic and granulomatous dermatitis in patients with collagen vascular disease.Arch Dermatol. 1994;130(10):1278-83.

Subcutaneous palisading granuloma of the scalp in childhood.Pediatr Neurosurg. 1994;21(2):113-6.

The subcutaneous rheumatoid nodule.Hand Clin. 1989 May;5(2):127-35.

Rheumatoid nodules. A lightmicroscopical study with special reference to fibrin and fibronectin.Histochemistry. 1984;80(5):463-7.

Histopathological analysis of sixteen subcutaneous rheumatoid nodules.Acta Pathol Jpn. 1980;30(6):871-82.

  

Soft Tissue Pathology: Myxoid Tumours of Soft Tissue ;  Classification of Soft Tissue Tumour;  Gross examination of soft tissue specimen ;  A practical approach to histopathological reporting of soft tissue tumours ;  Grading of soft tissue tumours ; Lipomatous tumours ;Neural tumours ; Myogenic tumours ;Vascular tumours ; Fibroblastic/Myofibroblastic tumours ; Myofibroblastic tumours ;  Fibrohistiocytic tumours ; ChondroOsseous tumours ; Soft TissueTumours of Uncertain Differentiation ; Notochordal Tumour -Chordoma ;Extra-adrenal Paraganglioma ; Gastrointestinal Stromal Tumour ;