Re: Thinking caps on then !!

September 30, 2005

They are painless and do not interfere with finger

movement. No other abnormalities of the hands are

noted.

Any ideas ??

,

How about this ...

http://www.cfpc.ca/cfp/2005/Jan/vol51-jan-clinical-2.asp

A 37-year-old man presented with faintly pink subcutaneous nodules over

the extensor surfaces of the proximal interphalangeal joints of his

fourth and fifth fingers. These nodules were firm, mobile, and

nontender.

Rheumatoid nodules

Rheumatoid nodules are the most common extra-articular manifestation of

rheumatoid arthritis (RA); about 25% of adult patients with RA have

them.1,2 About 90% of patients with RA and subcutaneous nodules test

positive for rheumatoid factor, and 40% of all seropositive patients

with RA have subcutaneous nodules.3 Rheumatoid nodules are clinical

predictors of more severe arthritis, seropositivity, joint erosions, and

rheumatoid vasculitis.2 The presence of rheumatoid nodules often

suggests a need for more aggressive treatment of the underlying RA to

prevent sequelae.

Rheumatoid nodules are firm, nontender, and movable within the

subcutaneous tissue; however, they could also be attached to underlying

structures such as the periosteum, fascia, and tendons.3 The lesions

range from 2 mm to >5 cm,4 and can enlarge or regress, recur, or persist

indefinitely.3 Most subcutaneous nodules are found on bony prominences,

extensor surfaces, or adjacent to joints. They are most frequently found

on extensor surfaces of the proximal ulna and olecranon,

metacarpophalangeal and proximal interphalangeal joints, ischial

tuberosities, joints in the foot, and sacrum.4 Occasionally, they

manifest on the sclera, pinna of ears, heart, vocal cords, lungs,

nervous system, abdominal wall, and muscle.4,5 Histologically,

rheumatoid nodules present as a palisading granulomatous reaction, and

mature nodules have a classic three-layer structure.1

The exact etiology of rheumatoid nodules is unknown. Experts speculate

that a series of events beginning with local vascular trauma and pooling

of rheumatoid factor immune complexes, followed by activation and

mobilization of local monocytes or macrophages; fibrinoid deposition by

procoagulants; tissue necrosis by cytotoxins, proteinases and

collagenase secretion from macrophages; and chemotactic attraction of

macrophages to the necrotic zone is responsible for formation of

rheumatoid nodules.1,6 This hypothesis is consistent with the clinical

findings of higher titres of rheumatoid factor and vasculitis often

reported in patients with RA who have rheumatoid nodules.2 Since

rheumatoid nodules most commonly arise in areas prone to trauma, a local

tissue reaction that creates a focus of granulation tissue might also

contribute to initial formation of these lesions.1

Rheumatoid nodules are not exclusive to RA. Histologically identical

nodules are sometimes a feature of systemic lupus erythematosus (SLE),

subcutaneous granuloma annulare, necrobiosis lipoidica diabeticorum,

rheumatic fever, and foreign body granulomas.2,3,7,8 Subcutaneous

nodules have also been reported in 5% to 10% of children with juvenile

rheumatoid arthritis,3 and benign rheumatoid nodules have been described

in children and adults with no evidence of RA.2,7 Rheumatoid nodulosis

syndrome, which presents with numerous rheumatoid nodules, a high titre

of rheumatoid factor, but mild or no RA, has been reported in a few

patients.3,7,8

Diagnosis

A diagnosis of rheumatoid nodules is made in the clinical context of the

disease. Symmetric inflammatory polyarthritis, seropositivity for

rheumatoid factor, and other associated symptoms, such as vasculitis,

are highly suggestive of RA. Subcutaneous nodules with a history of gout

or current podagra could lead to a diagnosis of tophaceous gout.

Violaceous papules or nodules (Gottron’s papules) with muscle weakness

and heliotrope rash are characteristic of dermatomyositis. Lichen planus

is a pruritic, papular eruption characterized by its violaceous-purple

colour, flat-topped polygonal shape, and sometimes, fine scale. It is

most commonly found on the flexor surfaces of the upper extremities

(especially wrists), genitalia, and mucous membranes (called Wickham

striae in the mouth).

Although biopsies of subcutaneous nodules are occasionally done, they

are not useful for diagnosis since many different types of subcutaneous

nodules are histologically identical to rheumatoid nodules. Many

rheumatoid nodules occur in areas difficult to biopsy, such as over

extensor tendons. A complete history and physical examination, focusing

on cutaneous and rheumatologic aspects, and occasionally laboratory

testing (eg, rheumatoid factor, serum urate) are sufficient to diagnose

rheumatoid nodules.

Management

Rheumatoid nodules typically present asymptomatically as a cosmetic

complaint. Indications for treatment include areas exposed to repetitive

trauma and nodules on weight-bearing prominences that might cause

progressive erosions and severe pain, neuropathy, limitation of motion,

or deformity, and damage to underlying structures.8 Some nodules rupture

and lead to deep infections.4

There are very few treatment options for rheumatoid nodules. Large

nodules can be excised, but they frequently recur within scar tissue,

especially if subjected to repetitive trauma. Injecting corticosteroids

directly into the lesion sometimes reduces its size. While this

procedure is most effective for deep lesions in the olecranon bursa,

nodules on the buttocks and feet tend to ulcerate and are likely to

become infected. Once they are infected, surgical excision or drainage

is required.8 Oral corticosteroids and hydroxychloroquine can also be

used,3,8 but their effects on rheumatoid nodules vary, as most patients

with RA already receive these medications for the chronic condition.

Rheumatoid nodules occasionally resolve without medical or surgical

intervention.

Dave

September 30, 2005

I vote for ganglia cysts

Dave Olley <olley@...> wrote:They are painless and do not interfere with

finger