Meningeal rheumatoid nodules in a 55-year-old man presenting with chronic headaches and oculomotor nerve palsy: an uncommon extra-articular manifestation of rheumatoid arthritis.

Rheumatoid arthritis (RA) is a multisystem inflammatory disease which can involve many organ systems including the central nervous system (CNS). Though not very common, the results can be severely debilitating. The spectrum of the CNS involvement includes meningitis, encephalitis and occasionally rheumatoid nodules. Its presentation is variable, though very rarely it can present as focal neurological deficits. Imaging can be suggestive, but diagnosis usually requires tissue biopsy. Treatment consists of high-dose steroids and immunosuppressants. We describe the case of a 55-year-old male patient with a history of RA presenting with a third nerve palsy and headache who was found to have rheumatoid nodules on biopsy. CNS involvement in RA should be considered in anyone with rheumatoid arthritis who presents with focal neurological deficits, though infections and space-occupying lesions should also be ruled out.

Rheumatoid nodules in thyroid gland parenchyma as an expression of rheumatoid arthritis: a case report.

BACKGROUND: The rheumatoid nodule is the most common extra-articular manifestation of rheumatoid arthritis. When present, it is readily identified in conventional hematoxylin and eosin sections. CASE PRESENTATION: We report a case with several rheumatoid nodules in a thyroid gland of a 33-year-old Greek woman with a 3-year history of rheumatoid arthritis treated with methotrexate, after having total thyroidectomy for hypothyroidism. CONCLUSION: To the best of our knowledge, this is the first time that rheumatoid nodules have been encountered in the thyroid gland.

Nodulosis reumatoidea pulmonar durante el tratamiento con fármacos anti-TNF / Rheumatoid lung nodulosis during anti-TNF therapy

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Rheumatoid nodules and quality of life in rheumatoid arthritis females - complex assessment.

Rheumatoid arthritis (RA) represents the most commonly diagnosed arthropathy that affect many tissue types and organs, characterized by a clinical, functional and therapeutic pathogenic complexity and it affects especially diarthroidal joints. Rheumatoid nodules (RNs) are one of the most frequent extra-articular manifestations of RA, and usually reflect an advanced stage of the disease and a poor prognosis. The complexity of histological, clinical and functional aspects in RA has a real impact on the quality of life in all patients diagnosed with this disorder. Our prospective study presents the RNs involvement in the rehabilitation program performed in order to enhance the quality of life in the 25 RA female patients. We made a complex assessment and realized a correlation between pain, disability and histological aspect of RN, before and after the rehabilitation program. Also, we evaluated the clinical and functional effectiveness of a complex rehabilitation program and changes in impairment and activity limitation in women with RA and RNs. The immunohistological complexity of RNs reflects the intensity of the inflammatory-immune process and completes the assessment of RA patients with RNs. It allows for medical assistance quantification, even for patients that have a poor evolution prognosis.

Nódulos pulmonares reumatoides, forma de presentación, métodos diagnósticos y evolución, a propósito de 5 casos / Pulmonary rheumatoid nodules, presentation, methods, diagnosis and progression in reference to 5 cases

Los nódulos reumatoides son una manifestación rara de las enfermedades pulmonares relacionadas con la artritis reumatoide. Su aparición y evolución en el curso de la artropatía es variable. El diagnóstico de nódulo reumatoide pulmonar se puede sugerir si tienen una apariencia típica y en un contexto clínico adecuado, pero no se puede hacer un diagnóstico de certeza basándonos solo en las pruebas de imagen. Se recomienda el control de los nódulos y puede ser necesario el estudio histológico para diferenciarlos de lesiones tumorales (AU)

Rheumatoid nodules are a rare manifestation of lung disease associated with rheumatoid arthritis. Their emergence and evolution in the course of the disease is variable. The diagnosis of pulmonary rheumatoid nodules may be suggested if they have a typical appearance in an appropriate clinical context, but an accurate diagnosis cannot be made based only on imaging tests. It is recommended to follow nodules and may be necessary to histologically differentiate them from tumors (AU)

Extraarticular manifestations in Turkish patients with rheumatoid arthritis: impact of EAMs on the health-related quality of life in terms of disease activity, functional status, severity of pain, and social and emotional functioning.

The aim of our study was to investigate extraarticular manifestations (EAMs) in Turkish patients with rheumatoid arthritis (RA) and also assess the impact of EAMs on various health-related quality of life (HRQoL) domains, including physical, social, emotional, mental functioning, and bodily pain. A total of 150 patients were included in the study. EAMs were identified clinically. Pulmonary involvement was confirmed by using pulmonary function tests (PFT) and high-resolution computed tomography (HRCT), atlantoaxial subluxation by cervical spine X-rays. Peripheral neuropathy, rheumatoid nodules, and Sicca symptoms were picked up on clinical examination. Peripheral neuropathy was also confirmed by electroneurophysiologic studies. Patients were evaluated by Rheumatoid Arthritis Quality of Life (RAQoL), and Short form-36 (SF36). The quadrivariate Disease Activity Score- 28 (DAS28) was used for measuring disease activity. Functional status was evaluated by using the Stanford Health Assessment Questionnaire (HAQ). The severity of pain was documented by using 10-cm Visual Analog Scale-Pain (VAS-pain). EAMs were observed in 50 patients (33.3%). These were pulmonary involvement (28.7%), rheumatoid nodules (14.7%), Sicca Syndrome (8%), peripheral neuropathy (2.7%), and atlantoaxial subluxation (0.7%), respectively. It was not recorded any statistically significant difference in HAQ, DAS28, VAS-pain, and RAQoL scores between the patient groups with and without EAMs. Patients with EAMs scored significantly lower in physical functioning, role-physical, and role-emotional subgroups of SF36 (P < 0.01). Presence of EAMs is not directly associated with disease activity and functional status, but influences negatively HRQoL including physical and emotional functioning.

MRI and pathological findings of rheumatoid meningitis.

Rheumatoid meningitis (RM) is one of the most severe complications of rheumatoid arthritis. The mortality rate of RM is relatively high and diagnosis can be difficult. We present an 80-year-old woman who was diagnosed with microscopic findings of RM after analysis of biopsy specimens taken from a brain lesion. MRI scanning revealed meningeal enhancement in the brain, and the pathological findings were those of meningeal lymphocytic infiltration, vasculitis and rheumatoid nodules. RM is a treatable disease and in this patient RM was diagnosed on the basis of biopsy findings.

Matrix metalloproteinase gene polymorphisms in patients with rheumatoid arthritis.

Several genetic factors seem to be involved in the pathogenesis of rheumatoid arthritis (RA). The aim of this study was to analyze whether functional polymorphisms in the promoter region of the MMP-1, -3 and -9 genes were associated with RA. The study population comprises 110 RA patients and 100 healthy controls. The -1607 1G/2G MMP-1, -1171 5A/6A MMP-3, and -1562 C/T MMP-9 polymorphisms were analyzed. The frequency of the 5A allele of MMP-3 gene was significantly higher in the controls when compared with the RA patients (0.45 vs. 0.32, P < 0.01). No significant differences were observed in the allele frequencies for the MMP-1 and -9 polymorphisms between RA patients and controls. Individuals carrying MMP-3 5A allele have significant higher frequency of extra-articular manifestations and rheumatoid nodules than individuals homozygous for 6A allele (P < 0.05). The results presented in this study provide evidence of an association between the MMP-3 gene polymorphism and RA.

Microvascular dysfunction in rheumatoid arthritis assessed by laser Doppler anemometry: relationship to soluble adhesion molecules and extraarticular manifestations.

In search of a noninvasive diagnostic test for rheumatoid vasculitis (RV), this study addressed the questions whether changes in capillary blood cell velocity (CBV) detected by laser Doppler anemometry in patients with rheumatoid arthritis (RA) were correlated with the levels of soluble adhesion molecules and whether cutaneous flow abnormalities may reflect extraarticular manifestations in RA. In 31 RA patients and 20 patients with osteoarthritis (OA), CBV was measured in the skin above the left ring finger at rest and after 3-min arterial occlusion. Serum levels of soluble intercellular adhesion molecule-1 (sICAM-1), soluble vascular cell adhesion molecule-1 (sVCAM-1), soluble E-selectin (sE-selectin), and soluble P-selectin (sP-selectin) were assessed by enzyme linked immunosorbent assay. Peak CBV was reduced in RA patients compared to OA patients (0.42 +/- 0.07 mm/s vs. 0.70 +/- 0.13 mm/s; P = 0.013). Both CBV during rest and reactive hyperemia were not correlated with the levels of soluble adhesion molecules. There were no significant differences in resting or peak CBV between RA patients with or without extraarticular manifestations. The lack of an inverse correlation between the levels of soluble adhesion molecules and CBV during rest and reactive hyperemia contradicts the assumption that inflammatory vascular damage indicated by increased levels of soluble adhesion molecules was the main reason for the impairment of microcirculation. The present results do not suggest that cutaneous flow abnormalities may reflect extraarticular manifestations in RA.

Corticosteroid injections reduce size of rheumatoid nodules.

BACKGROUND: Symptomatic rheumatoid nodules are frequently surgically treated. Injection with steroids might be an alternative treatment. PATIENTS AND METHODS: To determine whether injection with triamcinolon acetonide reduces the size of rheumatoid nodules, we randomized twenty patients with symptomatic nodules to either triamcinolon acetonide 40 mg/ml plus lidocaine 2% or lidocaine 1% (placebo). We measured the nodules before injection and 2, 4, 8, and 12 weeks after injection. Possible side effects were recorded. RESULTS: We found that the volume of the nodules injected with triamcinolon acetonide reduced significantly (p = 0.011), from 130 to 8 mm(3) (median calculated size) at 12 weeks, compared with baseline. Furthermore, at 12 weeks, the difference between the groups was significant (p = 0.03). The median size of the placebo nodules diminished as well, from 358 to 237 mm(3), but this was not significant. Pain at injection was the only side effect, equally distributed in both treatment groups. CONCLUSION: Injection with triamcinolon acetonide seems to be an alternative for surgery of rheumatoid nodules. No adverse events occurred but the limited sample does not allow definitive conclusions.

MRI bone oedema predicts eight year tendon function at the wrist but not the requirement for orthopaedic surgery in rheumatoid arthritis.

OBJECTIVE: To investigate the role of early magnetic resonance imaging (MRI) of the wrist in predicting functional outcome in rheumatoid arthritis. METHODS: MRI scans of the dominant wrist were scored for synovitis, tendon inflammation, bone oedema, and erosion at first presentation (n = 42), at 1 year (n = 42), and at 6 years (n = 31). At 8 years, clinical reassessment (n = 28) was undertaken. Tendon function was graded 0-3 for movement, tendon sheath swelling, and pain on resistance at nine flexor and extensor tendons of the hand. Hand function was also assessed using the Sollerman grip test. The requirement for joint or tendon surgery by 8 years was determined by telephone survey in 39 of the original 42 patients. RESULTS: At 8 years, tendon function was highly correlated with hand function (Sollerman score, R = -0.51, p = 0.005) and global function (health assessment questionnaire score, R = 0.53, p = 0.004). Using a model incorporating baseline and 1 year MRI scores, the MRI bone oedema score was strongly predictive of tendon function at 8 years (chi(2)(2) = 15.3, p = 0.0005), as was the MRI bone erosion score (chi(2)(2) = 9.23, p = 0.01). Hand function was also predicted by the baseline MRI erosion score (p = 0.02). MRI variables did not predict the requirement for surgery, but patients who had surgery were more likely to show progression of MRI bone erosion scores between baseline and 1 year (p = 0.008). CONCLUSIONS: Extensive MRI bone oedema and erosions at the wrist in early rheumatoid arthritis predict tendon dysfunction and impaired hand function in the medium term but not the requirement for joint or tendon surgery.

[The functional condition of the left ventricle in patients suffering from rheumatoid arthritis with subcutaneous rheumatoid nodules].

The purpose of the study was to evaluate the systolic and diastolic left ventricular (LV) function in patients with the system form of rheumatoid arthritis (RA) with subcutaneous rheumatoid nodules (SRN). The subjects, 105 patients with proved RA, were divided into two groups. The main group consisted of 40 patients suffering from system RA with SRN. The comparison groups included 40 patients suffering from the articular-and-visceral form of RA without SRN, and 25 patients with the articular form of RA. The systolic LV function was evaluated in all the 105 RA patients using M-mode Echo CG. In 20 patients with SRN systolic and diastolic LV function was evaluated with radionuclide ventriculography (RVG). The hemodynamic parameters obtained with Echo CG and RVG were processed according to variation statistics rules, presenting the data in groups as a mean and the standard error (M +/- m); the results were compared between the patients and between the patients and healthy controls. The significance was estimated using Student criterion (p < 0.05). In the group of RA patients with SRN, Echo CG and RVG found a significant decrease in LV systolic function parameters vs. patients without SRN and healthy controls. RVG revealed LV diastolic dysfunction in RA patients with SRN. Systolodiastolic LV dysfunction in these patients suggests myocardial involvement. Present-day instrumental methods of the evaluation of functional heart condition may be used to evaluate systolic and diastolic LV function in RA patients, especially during the dynamic observation of the effectiveness of RA treatment with modern anti-rheumatic preparations.

Nódulo reumatóide intermetatarsal com sintomas de neuroma de Morton: diagnóstico diferencial / Intermetatarsal rheumatoid node with Morton's neuroma signs: differential diagnosis

Paciente do sexo feminino, com 38 anos de idade, portadora de artrite reumatóide (AR), com dor intermetarsal no 3º espaco, em ambos os pés, com parestesia dos 3º e 4º dedos. Operada para resseccão de massas hipoecóicas evidenciadas por ecografia. O exame anátomo-patológico definiu degeneracão fibrinóide e mixóide (nódulo reumatóide).

Rheumatoid necroses in the forefoot.

BACKGROUND: The incidence and morphological features of rheumatoid necroses (RN) in the forefoot are unknown. METHODS: Biopsy material from 223 patients with seropositive rheumatoid arthritis (RA) was examined morphologically. The incidence and morphological features of RN in the forefoot were evaluated. RESULTS: RN was found in 65% of cases, which had not been suspected clinically. It was correlated with pain in 69% of cases. CONCLUSIONS: Rheumatoid necrosis contributes to the development of pain and foot deformation. It can be a significant factor worsening the clinical behavior in seropositive RA patients.

Vocal fold deposits in autoimmune disease--an unusual cause of hoarseness.

The objective of this study was to evaluate the symptoms and clinical characteristics in patients with autoimmune vocal fold deposits. Fourteen patients underwent videolaryngostroboscopic examination and voice recording. Eleven of the 14 patients underwent rheumatological examination. In all cases, endoscopic examination showed transverse white-yellow band lesions in the middle of the membranous portion of the vocal folds. In most cases, the lesions were bilateral but not exactly opposing each other. The most common voice characteristics were instability and intermittent aphonia. Inflammatory disease was present in 10 patients; five of these had rheumatoid arthritis (RA). No immunological signs common for all patients could be found. The histological examination was consistent with rheumatoid nodules. Vocal fold deposits, occurring most often in patients with RA, is an uncommon cause of hoarseness. Because the patients may have hoarseness as their primary symptom, it is important for otolaryngologists to be familiar with this disorder.

Extra-articular manifestations in 587 Italian patients with rheumatoid arthritis.

The aim of the study was to evaluate the frequency of extra-articular manifestations (EAMs) of rheumatoid arthritis (RA) in a series of patients from nine Italian rheumatology clinics. A total of 587 patients underwent direct questioning, complete physical evaluation, and review of medical records and laboratory data. The relationships between EAMs and the eosinophilic count, IgM rheumatoid factor (RF), and antinuclear antibodies (ANA) were studied. EAMs were present in 240/587 (40.9%) patients. The most common features were sicca syndrome (17.5%) and rheumatoid nodules (16.7%). EAMs were significantly more frequent in male patients (OR = 1.68), patients with ANA positivity (OR = 2.82), high anatomical class (OR = 2.3), and rheumatoid factor seropositivity (OR = 2.22). EAMs were more common in patients from southern Italy than in those from northern Italy (P < 0.001). EAMs seem to be rarer in Italy than in the Anglo-Saxon populations of northern Europe and the USA. Differences in prevalence of EAMs can exist even within the same country.