Case for diagnosis. Subcutaneous nodules in the plantar region,

AnBrasDermatol.2020;95(5):649---651

Anais

Brasileiros

de

Dermatologia

WHAT

IS

YOUR

DIAGNOSIS?

Case

for

diagnosis.

Subcutaneous

nodules

in

the

plantar

region

夽,夽夽

Diego

Henrique

Morais

Silva

,

Isaura

Azevedo

Fasciani

,

Neusa

Yuriko

Sakai

Valente

,

Bethânia

Cabral

Cavalli

Swiczar

DepartmentofDermatology,HospitaldoServidorPúblicoEstadualdeSãoPaulo,SãoPaulo,SP,Brazil

Received18October2019;accepted9February2020

Availableonline26June2020

KEYWORDS

Arthritis,rheumatoid; Granuloma;

Rheumatoidnodule

Abstract Theauthorsreportacaseofmobileandpainfulnodulesonthebilateralplantar

sur-faceofafemalepatientreferredbytherheumatologyservice,whereshewasbeingfollowed-up

forrheumatoidarthritis.Anoduleexcisionwasperformedfordifferentialdiagnosisand

symp-tomrelief;thehistopathologicalanalysiswascompatiblewitharheumatoidnodule.Although

rheumatoid nodules areacommon manifestationofrheumatoid arthritis,exclusive plantar

involvementisseldomdescribedintheliterature.

©2020SociedadeBrasileira deDermatologia.PublishedbyElsevierEspa˜na,S.L.U.Thisisan

openaccessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

Case

report

A60-year-oldcaucasianwomanwasreferredtothe derma-tologyoutpatientclinicbytherheumatologyservice,where shewasfollowed-upduetoa20-yearhistoryofrheumatoid arthritis.Thepatientreportedatwo-yearhistoryofpainful nodulesonthesoles ofherfeet,withslowgrowth,which hindered walking (Figs. 1 and 2). The ultrasound report

夽 _{Howtocitethisarticle:SilvaDHM, FascianiIA,ValenteNYS,}

SwiczarBCC.Casefordiagnosis.Subcutaneousnodulesinthe plan-tarregion.AnBrasDermatol.2020;95:649---51.

夽夽_{StudyconductedattheHospitaldoServidorPúblicoEstadual}

deSãoPaulo,SãoPaulo,SP,Brazil.

∗_{Correspondingauthor.}

E-mail:[email protected](D.H.Silva).

showednonspecificnodulesinthesubcutaneoustissue.The appearanceofthenoduleswasaccompaniedbya progres-siveworseningofjointsymptoms.Oneof thenoduleswas excised(Fig.3).

What

is

your

diagnosis?

a) Fibroma

b) Rheumatoidnodule c) Lipoma

d) Calcinosis

Discussion

Rheumatoid arthritis is a systemic inflammatory dis-ease, primarily articular, that affects about 0.8% of the https://doi.org/10.1016/j.abd.2020.02.006

0365-0596/©2020SociedadeBrasileiradeDermatologia.PublishedbyElsevierEspa˜na,S.L.U.ThisisanopenaccessarticleundertheCC BYlicense(http://creativecommons.org/licenses/by/4.0/).

650 SilvaDHMetal.

Figure1 Nodulesontheleftplantarsurface.

Figure2 Detailofnodulesinpressureareas oftheplantar region.

worldpopulation.1_{Amongthecutaneousmanifestationsof}

rheumatoidarthritis,rheumatoidnodulesarethemost com-mon,beingobservedinapproximately30%ofthesepatients. They typically consist of subcutaneous, painless nodules locatedin extensorandrepetitivetrauma regions suchas thebackofthehands,ankles,knees,elbows,andthe occip-italregion.2_{Rheumatoidnodulesaremorecommoninmen,}

Figure3 Granulomawith centralnecrosissurroundedby a

palisadeofepithelioidcells(Hematoxylin&eosin,×100).

especiallyCaucasians.1_{Plantarinvolvementisrareand}

sel-domdescribedintheliterature;itisgenerallyobservedin thecontextofmultiplelesionsinotherlocations.3

There are a variety of differential diagnoses, includ-ing subcutaneous granuloma annulare, calcinosis, lipoma, andgoutytophi;however,thehistoryofrheumatoid arthri-tis,especiallyinacontextofexacerbationofthearticular condition,favorstheclinicaldiagnosisof rheumatoid nod-ule.Indoubtfulcases,thedefinitivediagnosisisestablished by histopathological findings of a granulomatous process characterized by a focus of fibrinoid necrosis surrounded by a palisade of histiocytes.2 _{Most patients have}

asymp-tomatic nodules and do not require treatment; however, whenthesenodulesbecomepainful,infected,orulcerated, treatment is imperative.1,2,4 _{The intralesional application}

of corticosteroidstoreduce thesizeof thenodulesis the treatment of choice in most symptomatic cases. Surgical resection is generally not necessary, except in cases of nervecompression orthosewithrangeof jointmovement limitation.1,4

After excision and confirmation of the diagnosis of rheumatoidnodule,thepatientiscurrentlybeing followed-up by the rheumatology team, with improvement of joint symptoms after the introduction of certolizumab, which inhibits tumor necrosis factor-␣ (TNF-␣). As the jointsymptomswerecontrolled,thepatientpresentedan improvementinsymptomsandareductioninthedimensions oftheplantarnodules.

Financial

support

Nonedeclared.

Authors’

contributions

DiegoHenriqueMoraisSilva:Conceptionandplanningofthe study;elaborationandwritingofthemanuscript.

IsauraAzevedoFasciani:Conceptionandplanningofthe study;criticalreviewoftheliterature.

Casefordiagnosis.Subcutaneousnodulesintheplantarregion 651 NeusaYurikoSakaiValente:Conceptionandplanningof

thestudy;obtaining,analyzing,andinterpretingthedata; effectiveparticipationinresearchorientation;intellectual participationinpropaedeuticand/ortherapeuticconductof studiedcases.

Bethânia Cabral Cavalli Swiczar: Effective participa-tion in research orientation; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases.

Conflicts

of

interest

Nonedeclared.

References

1.HaltaT,KavanaughA.Rheumatoidarthritisindermatology.Clin Dermatol.2006;24:430---7.

2.XueY,CohenJM,WrightNA,MerolaJF.Skinsignsofrheumatoid arthritisand itstherapy-inducedcutaneousside effects.AmJ ClinDermatol.2016;17:147---62.

3.McMurrichW,ThomsonC,McKayND,McRorieE,SalterD, McKin-leyJ.Soft tissueswellingsinthefoot: Rheumatoidnodulosis. Foot(Edinb).2014;24:37---41.

4.Tilstra JS, Lienesch DW. Rheumatoid nodules. Dermatol Clin. 2015;33:361---71.