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Rheumatoid Arthritis — SCE Rheumatology MCQ

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HardRheumatoid ArthritisRheumatoid ArthritisSCE Rheumatology

A 65-year-old woman with seropositive rheumatoid arthritis has received methotrexate 20 mg once weekly for 18 months. Her synovitis remains in sustained clinical remission. Over 6 weeks, she develops a crop of firm, painless, 3–6 mm subcutaneous nodules over several finger pulps and the extensor surface of one elbow. Biopsy shows palisading histiocytes surrounding fibrinoid necrosis. What is the most likely explanation?

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Correct answer: A — Methotrexate-induced accelerated nodulosis

The answer is **D, methotrexate-induced accelerated nodulosis**. This paradoxical adverse effect is characterised by the rapid appearance or proliferation of small nodules during methotrexate treatment, often on the fingers and sometimes at other pressure sites, despite good control of articular rheumatoid arthritis. Histologically, these lesions are indistinguishable from conventional rheumatoid nodules, showing palisading granulomatous inflammation around fibrinoid necrosis. Conventional rheumatoid nodules are therefore the principal distractor, but their usual evolution is less abrupt and is not defined by this characteristic temporal pattern during otherwise effective methotrexate therapy. Infection would generally produce inflammatory or systemic features, while gouty tophi and xanthomata have different histopathological appearances. Management is individualised because standardised treatment guidance is lacking.

Reference: Palmeiro AG et al. Drug-induced accelerated nodulosis: review of the literature. International Journal of Dermatology. 2023;62(3):432–440. https://pubmed.ncbi.nlm.nih.gov/36512719/