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Nodules on the Hands.

ANSWER Fibroblastic rheumatism. Fibroblastic rheumatism (FR) is a rare condition characterized by cutaneous nodules associated with rheumatologic symptoms such as polyarthritis. Other clinical findings include sclerodactyly, joint contractures, thickened palmar fascia, Raynaud phenomenon, and in some cases, progressive erosive arthropathy. Nodules seem to have a predilection for the hands and periarticular areas. Microscopically, the nodules of FR are characterized by a proliferation of bland fibroblasts within a densely collagenous stroma. An absence of elastic fibers within the lesion is a characteristic finding in FR. Although musculoskeletal symptoms are commonly associated with this condition and a rheumatologic workup is usually positive, some cases presented exclusively with cutaneous lesions have been reported. Since it was described in 1980 by Chaouat et al, publications on this condition have been very scant. Pathogenesis is unknown, and there does not appear to be a particular age of onset or gender predilection. Diagnosis is based on clinicopathologic correlation. Imaging examinations can show erosions in the articular surface, depending on the stage of the disease. Differential diagnosis includes rheumatoid nodules, erythema elevatum diutinum, multicentric reticulohistiocytosis, fibromatosis, and nodular scleroderma. The prognosis is usually favorable. FR nodules tend to resolve in 6–24 months and heal without residual lesions, but in advanced cases, contractures of the flexor muscles of the fingers and rapidly progressive joint involvement may be present. Many therapies have been described with variable responses, including aspirin, nonsteroidal anti-inflammatory agents, prednisone, colchicine, hydroxychloroquine, penicillamine, physical therapy, methotrexate, interferon alpha, and TNF-alpha inhibitors (infliximab). However, these therapeutic options are limited and derived from observational data reported in isolated cases. More information regarding the origin and the pathogenesis of this condition is needed to identify additional targeted therapies. According to the mild symptoms in this case, the patient is on regular follow-up without treatment. In conclusion, we would like to highlight that it is important to consider the diagnosis of FR in patients with cutaneous nodules and joint symptoms and to be aware of the histological findings of this entity. The increasing number of reported cases of FR will hopefully raise clinical awareness of the disorder for correct diagnosis and treatment.