Rheumatoid Nodule

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Image of Rheumatoid Nodule

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ICD Codes

ICD-9-CM:
714.0 – Rheumatoid arthritis

ICD-10-CM:
M06.30 – Rheumatoid nodule, unspecified site

Synopsis

Rheumatoid nodules occur as the most common cutaneous manifestation of rheumatoid arthritis. The characteristic rheumatoid nodule occurs in 20% of patients with rheumatoid arthritis and may be an indication of a more severe form of the disease. Etiology of rheumatoid nodules remains unclear, but both vascular and external trauma, combined with pooling of rheumatoid immune complexes, likely lead to the formation of the nodule. Rheumatoid nodules may also occur within internal organs such as the heart, lungs, and muscle. Visceral nodules may clinically mimic infection, malignancy, or other inflammatory processes such as Wegener's granulomatosis. Very rarely, nodules occur in the sclera, causing it to atrophy and perforate.

These patients will have a moderate to high titer of rheumatoid factor. Sometimes, however, patients with mild rheumatoid arthritis may also develop nodules, as may patients who have rheumatoid disease without joint involvement. Nodules can also precede the onset of arthritis by a number of years. 

Nodules on pressure areas such as the sacrum have a tendency to ulcerate. Subsequent secondary infection can lead to septicemia and septic arthritis. More complications of nodule formation are pain, reduced joint mobility, and neuropathy.

Nodules are composed of fibrous tissue with areas of fibrinoid necrosis, typically with palisaded granulomas in the deep dermis and subcutis. Nodules may stay the same size or grow larger. They may persist indefinitely or resolve spontaneously. Neuropathy and fistula formation are also known to occur.

Rheumatoid Nodulosis
This is a variant of rheumatoid disease in which nodules appear in the absence of synovitis. These nodules tend to be smaller than rheumatoid nodules and occur mostly on the hands and feet. After a number of years, rheumatoid nodulosis may convert to rheumatoid disease in which the joints are affected. Initiation of methotrexate therapy is a known trigger of nodulosis, especially on the hands.

Benign Rheumatoid Nodules
Nodules may sometimes be present in healthy young children in the absence of rheumatoid disease. The location of these nodules is different from those of typical rheumatoid nodules in that these occur mainly on the pretibial areas, feet, and scalp.

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