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Nodules on the Hands: Challenge.

CASE REPORT A 56-year-old woman presented with a 6-month history of subcutaneous nodules on the fingers of both her hands (Fig. 1). These lesions caused mild discomfort with flexion and extension movements. Neither nail involvement nor presence of lesions on other locations of the skin could be detected. There was no significant personal or family history of any connective tissue or rheumatic disorders. Complete blood cell count, complete metabolic panel, C-reactive protein, and erythrocyte sedimentation rate were within normal ranges. Antinuclear antibody, rheumatoid factor, and anti-cyclic citrullinated peptide were negative. Radiography of the hands did not show erosive changes or other rheumatological disorders. A biopsy specimen was obtained from one of the nodules. On histopathological examination, there was a nodular fibroblastic proliferation characterized by long fascicles of fibroblasts in a densely collagenous stroma (Figs. 2A, B). An immunohistochemical stain for alpha-smooth muscle actin demonstrated a membranous pattern of staining consistent with myofibroblastic differentiation (Fig. 2C). An absence of elastic fibers in the myofibroblastic proliferation was observed with orcein stain, but elastic fibers appeared normal in the uninvolved reticular dermis (Fig. 2D). Immunohistochemical stains for S100 protein and CD34 were performed and were negative in the myofibroblastic proliferation.