Extensive Subcutaneous Rheumatoid Nodules Reflecting High Burden of Disease Activity

Rheumatoid arthritis (RA) is a chronic autoimmune systemic disease affecting mostly the small joints of the hands and feet. Extra-articular manifestations (EAMs) comprise the involvement of the skin, eyes, heart and lung. Among them, subcutaneous rheumatoid nodules (RN) are a common manifestation of systemic disease. However, disorders such as rheumatoid nodulosis, multicentric reticulohistocytosis (MRH) and others present subcutaneous nodules, similar to those seen in RA patients. A 41-year-old woman with a 10-year history of untreated RA, presented complaining of pain and tenderness in the small joints of the hands and feet. Past medical and family history were unremarkable. She presented swelling and tenderness on all metacarpophalangeal joints (MCPs) bilaterally and had multiple widespread subcutaneous RN affecting almost all the fingers of the hands, as well as, the Achille's tendons in a symmetrical manner. She had elevated levels of acute phase reactants and high titres of autoantibodies. Hand x-rays revealed severe erosive changes affecting all MCPs joints bilaterally. Thus, in this review we discuss the differential diagnosis of subcutaneous RN and their role in RA disease activity. This is an educational case of a patient with RA and extensive subcutaneous RN affecting the upper and lower extremities. To this end, physicians must be familiar and recognise early these signs which reflect RA disease activity and treat appropriately.