Journal of General Internal Medicine

, Volume 32, Issue 8, pp 955–956 | Cite as

Painful Plantar Lesions: An Unusual Presentation for Rheumatoid Nodules

  • Pablo Del Barrio-Díaz
  • Sergio González
  • Cristián Vera-Kellet
Clinical Practice: Clinical Images

KEY WORDS

rheumatoid nodules rheumatoid arthritis plantar nodule painful 
A 59-year-old man with rheumatoid arthritis on long-term methotrexate presented with 6 months of multiple painful lesions on his heels that impaired his gait. He denied any trauma to his foot or new medications. Physical examination revealed multiple painful papules and nodules on his heels (Fig.1). A skin biopsy of a nodule showed diffuse interstitial and granulomatous infiltration throughout the dermis, with a central area of necrosis surrounded by palisading epithelioid macrophages (Fig.2), findings consistent with rheumatoid nodules (RN).
Figure 1

Nodules on the heels.

Figure 2

Granuloma with a central area of necrosis (black arrow) surrounded by palisading epithelioid macrophages (yellow arrow) enclosed by granulation tissue (blue arrow).

He received infliximab and direct injection of intralesional betamethasone. After 6 months of treatment, there was a little improvement, although no new lesions developed.

RN typically appears on extensor surfaces and areas of pressure or repetitive trauma, particularly adjacent to the olecranon and the dorsal aspect of the hand.1 Occurrence in the feet is rare, and only sparsely reported in the literature.2 Asymptomatic lesions do not require treatment unless they become ulcerated or infected or limit mobility.3 Clinicians should be aware of this presentation and differentiate it from conditions with similar appearance including fibromas caused by chronic trauma from shoes, subcutaneous granuloma annulare. and sarcoidosis.

Notes

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.

References

  1. 1.
    Tilstra JS, Lienesch DW. Rheumatoid Nodules. Dermatol Clin. 2015;33(3):361–71.CrossRefPubMedGoogle Scholar
  2. 2.
    McMurrich W, Thomson C, McKay ND, McRorie E, Salter D, McKinley J. Soft tissue swellings in the foot: rheumatoid nodulosis. Foot (Edinb). 2014;24(1):37–41.CrossRefGoogle Scholar
  3. 3.
    Gale M, Gilbert E, Blumenthal D. Isolated rheumatoid nodules: a diagnostic dilemma. Case Rep Med. 2015;2015:352352.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Society of General Internal Medicine 2017

Authors and Affiliations

  • Pablo Del Barrio-Díaz
    • 1
  • Sergio González
    • 2
  • Cristián Vera-Kellet
    • 1
    • 3
  1. 1.Facultad de Medicina, Department of DermatologyPontificia Universidad Católica de ChileSantiagoChile
  2. 2.Facultad de Medicina, Department of PathologyPontificia Universidad Católica de ChileSantiagoChile
  3. 3.Facultad de Medicina, Department of Dermatology, Connective Tissue Diseases UnitPontificia Universidad Católica de ChileSantiagoChile

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