Cutaneous mucinous nodules associated with proliferating synovitis of rheumatoid arthritis

Review of Primary Cutaneous Mucinoses in Nonlupus Connective Tissue Diseases

Lichen myxedematosus is an idiopathic, cutaneous mucinosis with 2 clinicopathologic subsets. There is the generalised papular and sclerodermoid form, more properly termed scleromyxedema, and the localised papular form. We report the first case, to our knowledge, of lichen myxedematosus in association with rheumatoid arthritis as well as a case in association with dermatomyositis. An up-to-date literature review on cutaneous mucinoses and connective tissue diseases, excluding the common association of primary and secondary mucinoses with systemic lupus erythematosus, was also performed.

Cutaneous manifestations associated with rheumatoid arthritis

Rheumatoid arthritis presents various cutaneous manifestations, either specific or nonspecific skin features, which are induced by the activation of inflammatory cells (neutrophils, lymphocytes, macrophages), vasculopathy, vasculitis, acral deformity, drugs, and so on. These include (1) specific findings, (2) findings due to vascular impairment, (3) findings due to immune dysfunction, (4) characteristic neutrophilic conditions, and (5) miscellaneous conditions. On the other hand, some of the specific manifestations show common histopathological features such as palisading granulomas with necrobiosis. It is important to recognize the common and/or uncommon skin conditions of RA for all clinicians associated with RA therapy.

Cutaneous mucinous nodule in a patient with rheumatoid arthritis

We report a cutaneous mucinous nodule on the inflamed elbow joint in a patient with rheumatoid arthritis (RA). The lesion is clinically characterized by a continuous flow of mucinous exudates from the nodule, and histologically by an extensive mucin deposition and proliferations of the fibroblastic cells and mononuclear cells. The histological findings suggest the histogenesis of this unique nodule is related to extralesional proliferation of synovial lining cells consisting of monocyte-macrophage lineage cells and fibroblast-like cells which potentially produce synovial fluid. Four patients have been hitherto reported in the published work and all of them have been associated with RA. The condition may be one of the characteristic skin manifestations of RA.

Rheumatoid Nodule

Rheumatoid nodules are the most common extra-articular manifestation of rheumatoid arthritis. Dermatologist may be concerned with the diagnosis and management of rheumatoid nodules, although most patients will probably be under the care of a rheumatologist. This article focuses in clinical, pathogenic, diagnostic, and therapeutic aspects of rheumatoid nodules. Classic rheumatoid nodules commonly occur in genetically predisposed patients with severe, seropositive arthritis. However, they may appear in other clinical settings. Accelerated rheumatoid nodulosis, especially involving the hands, has been reported in patients receiving methotrexate, antitumor necrosis factor alpha biologic drugs or leflunomide therapy for rheumatoid arthritis. Rheumatoid nodulosis is characterized by multiple rheumatoid nodules, recurrent joint symptoms with minimal clinical or radiologic involvement, and a benign clinical course. Pseudorheumatoid nodules have been reported in healthy children. Although histologically almost indistinguishable from true rheumatoid nodules, some consider these lesions to be a form of deep granuloma annulare.

Rheumatoid arthritis: a review of the cutaneous manifestations

Rheumatoid arthritis is a chronic inflammatory arthritis with significant extra-articular manifestations. Of note are unique cutaneous manifestations that the dermatologist may encounter. This article will make the dermatologist more cognizant of these skin findings in patients with this systemic inflammatory disorder. It examines rheumatoid arthritis, focusing on the general nonspecific and disease-specific rheumatoid arthritic skin changes. Classic rheumatoid nodules, accelerated rheumatoid nodulosis, rheumatoid nodulosis, rheumatoid vasculitis, Felty syndrome, pyoderma gangrenosum, interstitial granulomatosus dermatitis with arthritis, palisaded neutrophilic and granulomatosis dermatitis, rheumatoid neutrophilic dermatitis, juvenile rheumatoid arthritis, and adult-onset Still disease are reviewed. Understanding the cutaneous expressions of rheumatoid arthritis may lead to early diagnosis, prompt treatment, and lower morbidity and mortality for the affected persons. Learning objective At the completion of this learning activity, participants should be able to describe rheumatoid arthritis in terms of its epidemiology, etiology, pathogenesis, and general and specific cutaneous manifestations.

Mucinous nodules on the skin overlying a rheumatoid arthritic joint

A rare case of mucinous nodules on the skin overlying rheumatoid synovitis in a 79-year-old man is described. The patient had a five year history of RA. The patient had complained of arthralgia in the left elbow joint, and X-ray demonstrated narrowing of thejoint space along with bone destruction. He underwent an intraarticular injection of dexamethazone and lidocaine. Three weeks later, he noticed two dome-shaped nodules about 5 mm in size developing on the elbow. Histopathological examination demonstrated poorly defined mucinous nodules in the upper dermis. The mucinous material positively stained with alcian blue and colloid iron, and was metachromatic with toluidine blue. These positive stainings disappeared after hyaluronidase digestion. Five to six weeks after being resected, both nodules recurred. Lesional injections of triamcinolone were effective. The intraarticular injections preceding the appearance of the nodules might have created channels from the joint space to the skin. Leakage of activated synovial cells, which produced hyaluronic acid, through the channels might have caused the mucinous stroma of the nodules.

Dermatomyositis and mucinosis

BACKGROUND

Mucin deposition is a common feature in autoimmune collagen diseases including dermatomyositis. Nevertheless, clinical manifestations of mucinosis are uncommon in patients with dermatomyositis. Two cases of mucinosis associated with dermatomyositis are reported.

PATIENTS

A 53-year-old woman presented with symmetrical plaques on the upper limbs formed by the coalescence of small, violaceous papules. In addition, she showed the typical cutaneous and muscle features of dermatomyositis. A 44-year-old woman with dermatomyositis of 5 years' evolution developed linear, flesh-colored papules across the flexural creases of her palms and fingers.

RESULTS

Skin biopsy of the upper limb lesions in the first patient showed epidermal changes compatible with dermatomyositis and dermal mucin deposition. Histopathologic examination of the palmar lesions of the second patient showed less intense epidermal changes of dermatomyositis and dermal mucin deposition.

CONCLUSIONS

Mucin deposition in patients with dermatomyositis may have an unusual clinical presentation, and it should be considered in the differential diagnosis of atypical cutaneous lesions in these patients.

Cutaneous histiocytic lymphangitis: an unusual manifestation of rheumatoid arthritis

Two cases are presented of unusual cutaneous lesions associated with rheumatoid arthritis in underlying joints. The lesions were evanescent, erythematous and violaceous partly macular and partly indurated plaques, with a livedo-like pattern of erythema at the edge in one case. Histological changes were identical in the two cases. The major features were dilated, dermal lymphatics containing aggregates of inflammatory cells, mainly histiocytes, with adjacent perivascular lymphoid aggregates. An appropriate name for this reaction would appear to be cutaneous histiocytic lymphangitis.