Rheumatoid nodules in a patient with primary antiphospholipid (Hughes) syndrome

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.

Antiphospholipid syndrome and palindromic rheumatism: a new possible association

OBJECTIVE

The aim of this study was to report six patients with palindromic rheumatism (PR) in whom signs, symptoms, and/or serologic evidence of antiphospholipid syndrome (APS) developed.

METHODS

The medical histories of the patients were reviewed with special emphasis on age, gender, duration of PR, and lapse of time until antiphospholipid antibodies were detected or APS was diagnosed. Three representative cases are described.

RESULTS

Two patients were women and four were men. Their mean age was 49.3 years (range 36-80), and the mean duration of PR was 5.5 years (range 3-8). In all patients, raised titers of antiphospholipid antibodies were found on two or more occasions. Two patients developed clinical pictures compatible with APS, two showed symptoms which may be attributable for APS, and raised titers of antiphospholipid antibodies were found in only two.

CONCLUSION

It seems that the appearance of these two uncommon conditions together is more than coincidental and may point to a previously unreported clinical association.

Collagenolytic (necrobiotic) granulomas: part II - the ‘red’ granulomas

A collagenolytic or necrobiotic non-infectious granuloma is one in which a granulomatous infiltrate develops around a central area of altered collagen and elastic fibers. The altered fibers lose their distinct boundaries and exhibit new staining patterns, becoming either more basophilic or eosinophilic. Within the area of altered collagen, there may be deposition of acellular substances such as mucin (blue) or fibrin (red), or there may be neutrophils with nuclear dust (blue), eosinophils (red), or flame figures (red). These color distinctions can be used as a simple algorithm for the diagnosis of collagenolytic granulomas, i.e. 'blue' granulomas vs. 'red' granulomas. Eight diagnoses are included within these two groupings, which are discussed in this two-part article. In the previously published first part, the clinical presentation, pathogenesis and histologic features of the 'blue' collagenolytic granulomas were discussed. These are the lesions of granuloma annulare, Wegener's granulomatosis, and rheumatoid vasculitis. In this second half of the series, the 'red' collagenolytic granulomas are discussed; these are the lesions of necrobiosis lipoidica, necrobiotic xanthogranuloma, rheumatoid nodules, Churg-Strauss syndrome, and eosinophilic cellulitis (Well's Syndrome).

The spectrum of cutaneous lesions in rheumatoid arthritis: a clinical and pathological study of 43 patients

INTRODUCTION

Rheumatoid arthritis (RA) is an idiopathic arthropathy syndrome that has a propensity to affect the small joints of the hands and feet with extra-articular manifestations comprising skin lesions, neuropathy, pericarditis, pleuritis, interstitial pulmonary fibrosis and a systemic polyarteritis nodosa (PAN)-like vasculitic syndrome. The most widely recognized skin lesion is the rheumatoid nodule. Other skin manifestations are poorly defined.

MATERIALS AND METHODS

Using a natural language search of the authors' outpatient dermatopathology databases, skin biopsies from 43 patients with RA were selected for retrospective analysis in an attempt to define the dermatopathological spectrum of RA and its clinical correlates.

RESULTS

The biopsies were categorized by the dominant histologic pattern, recognizing that in most cases there were additional minor reaction patterns. Palisading and/or diffuse interstitial granulomatous inflammation was the dominant pattern seen in 21 patients; the lesions included nodules, plaques and papules with a predilection to involve skin over joints. Besides interstitial histiocytic infiltrates and variable collagen necrobiosis, these cases also showed interstitial neutrophilia, vasculitis and pauci-inflammatory vascular thrombosis. The dominant morphology in 11 other patients was vasculopathic in nature: pauci-inflammatory vascular thrombosis, glomeruloid neovascularization, a neutrophilic vasculitis of pustular, folliculocentric, leukocytoclastic or benign cutaneous PAN types, granulomatous vasculitis, and lymphocytic vasculitis and finally occlusive intravascular histiocytic foci for which the designation of "RA-associated intravascular histiocytopathy" is proposed. Rheumatoid factor (RF) positivity and active arthritis were common in this group, with anti-Ro and anticardiolipin antibodies being co-factors contributing to vascular injury in some cases. Immunofluorescent testing in three patients revealed dominant vascular IgA deposition. In nine patients, the main pattern was one of neutrophilic dermal and/or subcuticular infiltrates manifested clinically as urticarial plaques, pyoderma gangrenosum and panniculitis.

CONCLUSIONS

The cutaneous manifestations of RA are varied and encompass a number of entities, some of which define the dominant clinical features, such as the rheumatoid papule or subcutaneous cords, while others allude to the histopathology, i.e. rheumatoid neutrophilic dermatosis. We propose a more simplified classification scheme using the adjectival modifiers of "rheumatoid-associated" and then further categorizing the lesion according to the dominant reaction pattern. Three principal reaction patterns are recognized, namely extravascular palisading granulomatous inflammation, interstitial and/or subcuticular neutrophilia and active vasculopathy encompassing lymphocyte-dominant, neutrophil-rich and granulomatous vasculitis. In most cases, an overlap of the three reaction patterns is seen. Co-factors for the vascular injury that we believe are integral to the skin lesions of RA include RF, anti-endothelial antibodies of IgA class, anti-Ro and anticardiolipin antibodies.