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Pathology of Subcutaneous Rheumatoid Nodule

Dr Sampurna Roy MD  


Path Quiz Case 53: Case history and images

Diagnosis : Rheumatoid Nodule




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.   

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

Microscopic features:

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:

Contains abundant mucin (appears pale and basophilic) surrounded by palisades of histiocytes. 

Clinical information is very useful.

Necrobiosis Lipoidica: 

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.


Further reading:

Cutaneous necrobiotic conditions associated with rheumatoid arthritis: important extra-articular involvement.

Fine-needle aspiration of rheumatoid nodule: a case report with review of diagnostic features and difficulties.

Expression of the histiocytic marker PG-M1 in granuloma annulare and rheumatoid nodules of the skin

Complement mediated vascular endothelial injury in rheumatoid nodules: a histopathological and immunohistochemical study.

The histopathologic spectrum of palisaded neutrophilic and granulomatous dermatitis in patients with collagen vascular disease.




Dr Sampurna Roy  MD

Consultant  Histopathologist (Kolkata - India)  ; Dermpath-India  ;  Soft Tissue Tumour Online ;Cardiac Path Online ;

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