What is your diagnosis?
Case for diagnosis. Subcutaneous nodules in the plantar region
Diego Henrique Morais Silva
, Isaura Azevedo Fasciani, Neusa Yuriko Sakai Valente, Bethânia Cabral Cavalli Swiczar
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Department of Dermatology, Hospital do Servidor Público Estadual de São Paulo, São Paulo, SP, Brazil
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Subcutaneous nodules in the plantar region" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "649" "paginaFinal" => "651" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Diego Henrique Morais Silva, Isaura Azevedo Fasciani, Neusa Yuriko Sakai Valente, Bethânia Cabral Cavalli Swiczar" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Diego Henrique Morais" "apellidos" => "Silva" "email" => array:1 [ 0 => "dhenriquems@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Isaura Azevedo" "apellidos" => "Fasciani" ] 2 => array:2 [ "nombre" => "Neusa Yuriko Sakai" "apellidos" => "Valente" ] 3 => array:2 [ "nombre" => "Bethânia Cabral Cavalli" "apellidos" => "Swiczar" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Dermatology, Hospital do Servidor Público Estadual de São Paulo, São Paulo, SP, Brazil" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 679 "Ancho" => 905 "Tamanyo" => 204790 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Granuloma with central necrosis surrounded by a palisade of epithelioid cells (Hematoxylin & eosin, ×100).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 60-year-old caucasian woman was referred to the dermatology outpatient clinic by the rheumatology service, where she was followed-up due to a 20-year history of rheumatoid arthritis. The patient reported a two-year history of painful nodules on the soles of her feet, with slow growth, which hindered walking (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). The ultrasound report showed nonspecific nodules in the subcutaneous tissue. The appearance of the nodules was accompanied by a progressive worsening of joint symptoms. One of the nodules was excised (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec9005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect9015">What is your diagnosis?</span><p id="par0010" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">a)</span></span><p id="par0015" class="elsevierStylePara elsevierViewall">Fibroma</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">b)</span></span><p id="par0020" class="elsevierStylePara elsevierViewall">Rheumatoid nodule</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">c)</span></span><p id="par0025" class="elsevierStylePara elsevierViewall">Lipoma</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel"><span class="elsevierStyleBold">d)</span></span><p id="par0030" class="elsevierStylePara elsevierViewall">Calcinosis</p></li></ul></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">Rheumatoid arthritis is a systemic inflammatory disease, primarily articular, that affects about 0.8% of the world population.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> Among the cutaneous manifestations of rheumatoid arthritis, rheumatoid nodules are the most common, being observed in approximately 30% of these patients. They typically consist of subcutaneous, painless nodules located in extensor and repetitive trauma regions such as the back of the hands, ankles, knees, elbows, and the occipital region.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> Rheumatoid nodules are more common in men, especially Caucasians.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> Plantar involvement is rare and seldom described in the literature; it is generally observed in the context of multiple lesions in other locations.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">There are a variety of differential diagnoses, including subcutaneous granuloma annulare, calcinosis, lipoma, and gouty tophi; however, the history of rheumatoid arthritis, especially in a context of exacerbation of the articular condition, favors the clinical diagnosis of rheumatoid nodule. In doubtful cases, the definitive diagnosis is established by histopathological findings of a granulomatous process characterized by a focus of fibrinoid necrosis surrounded by a palisade of histiocytes.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> Most patients have asymptomatic nodules and do not require treatment; however, when these nodules become painful, infected, or ulcerated, treatment is imperative.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">1,2,4</span></a> The intralesional application of corticosteroids to reduce the size of the nodules is the treatment of choice in most symptomatic cases. Surgical resection is generally not necessary, except in cases of nerve compression or those with range of joint movement limitation.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">1,4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">After excision and confirmation of the diagnosis of rheumatoid nodule, the patient is currently being followed-up by the rheumatology team, with improvement of joint symptoms after the introduction of certolizumab, which inhibits tumor necrosis factor-α (TNF-α). As the joint symptoms were controlled, the patient presented an improvement in symptoms and a reduction in the dimensions of the plantar nodules.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Financial support</span><p id="par0050" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Authors' contributions</span><p id="par0055" class="elsevierStylePara elsevierViewall">Diego Henrique Morais Silva: Conception and planning of the study; elaboration and writing of the manuscript.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Isaura Azevedo Fasciani: Conception and planning of the study; critical review of the literature.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Neusa Yuriko Sakai Valente: Conception and planning of the study; obtaining, analyzing, and interpreting the data; effective participation in research orientation; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Bethânia Cabral Cavalli Swiczar: Effective participation in research orientation; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1410360" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1290409" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 3 => array:2 [ "identificador" => "sec9005" "titulo" => "What is your diagnosis?" ] 4 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 5 => array:2 [ "identificador" => "sec0015" "titulo" => "Financial support" ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Authors' contributions" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-10-18" "fechaAceptado" => "2020-02-09" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1290409" "palabras" => array:3 [ 0 => "Arthritis, rheumatoid" 1 => "Granuloma" 2 => "Rheumatoid nodule" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The authors report a case of mobile and painful nodules on the bilateral plantar surface of a female patient referred by the rheumatology service, where she was being followed-up for rheumatoid arthritis. A nodule excision was performed for differential diagnosis and symptom relief; the histopathological analysis was compatible with a rheumatoid nodule. Although rheumatoid nodules are a common manifestation of rheumatoid arthritis, exclusive plantar involvement is seldom described in the literature.</p></span>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Silva DHM, Fasciani IA, Valente NYS, Swiczar BCC. Case for diagnosis. Subcutaneous nodules in the plantar region. An Bras Dermatol. 2020;95:649–51.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Hospital do Servidor Público Estadual de São Paulo, São Paulo, SP, Brazil.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1354 "Ancho" => 905 "Tamanyo" => 113897 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Nodules on the left plantar surface.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 809 "Ancho" => 905 "Tamanyo" => 84839 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Detail of nodules in pressure areas of the plantar region.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 679 "Ancho" => 905 "Tamanyo" => 204790 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Granuloma with central necrosis surrounded by a palisade of epithelioid cells (Hematoxylin & eosin, ×100).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0025" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rheumatoid arthritis in dermatology" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "T. 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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 16 | 7 | 23 |
| 2024 Outubro | 100 | 76 | 176 |
| 2024 Setembro | 157 | 75 | 232 |
| 2024 Agosto | 148 | 95 | 243 |
| 2024 Julho | 146 | 124 | 270 |
| 2024 Junho | 106 | 70 | 176 |
| 2024 Maio | 76 | 75 | 151 |
| 2024 Abril | 104 | 86 | 190 |
| 2024 Março | 82 | 68 | 150 |
| 2024 Fevereiro | 105 | 81 | 186 |
| 2024 Janeiro | 71 | 50 | 121 |
| 2023 Dezembro | 62 | 75 | 137 |
| 2023 Novembro | 80 | 64 | 144 |
| 2023 Outubro | 83 | 89 | 172 |
| 2023 Setembro | 78 | 68 | 146 |
| 2023 Agosto | 73 | 41 | 114 |
| 2023 Julho | 58 | 26 | 84 |
| 2023 Junho | 81 | 49 | 130 |
| 2023 Maio | 73 | 27 | 100 |
| 2023 Abril | 61 | 16 | 77 |
| 2023 Março | 55 | 47 | 102 |
| 2023 Fevereiro | 42 | 40 | 82 |
| 2023 Janeiro | 35 | 39 | 74 |
| 2022 Dezembro | 54 | 23 | 77 |
| 2022 Novembro | 60 | 56 | 116 |
| 2022 Outubro | 58 | 52 | 110 |
| 2022 Setembro | 52 | 60 | 112 |
| 2022 Agosto | 47 | 43 | 90 |
| 2022 Julho | 40 | 42 | 82 |
| 2022 Junho | 52 | 54 | 106 |
| 2022 Maio | 31 | 51 | 82 |
| 2022 Abril | 29 | 47 | 76 |
| 2022 Março | 43 | 52 | 95 |
| 2022 Fevereiro | 27 | 48 | 75 |
| 2022 Janeiro | 39 | 81 | 120 |
| 2021 Dezembro | 35 | 61 | 96 |
| 2021 Novembro | 37 | 55 | 92 |
| 2021 Outubro | 52 | 83 | 135 |
| 2021 Setembro | 32 | 39 | 71 |
| 2021 Agosto | 37 | 59 | 96 |
| 2021 Julho | 47 | 52 | 99 |
| 2021 Junho | 39 | 49 | 88 |
| 2021 Maio | 47 | 110 | 157 |
| 2021 Abril | 104 | 263 | 367 |
| 2021 Março | 75 | 66 | 141 |
| 2021 Fevereiro | 35 | 23 | 58 |
| 2021 Janeiro | 40 | 23 | 63 |
| 2020 Dezembro | 32 | 14 | 46 |
| 2020 Novembro | 83 | 10 | 93 |
| 2020 Outubro | 28 | 8 | 36 |
| 2020 Setembro | 20 | 10 | 30 |
| 2020 Agosto | 10 | 9 | 19 |
| 2020 Julho | 24 | 13 | 37 |
| 2020 Junho | 3 | 3 | 6 |
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