Subcutaneous nodules in rheumatoid arthritis.

A 29 year old male with rheumatoid arthritis (RA) of 10 years duration presented with multiple subcutaneous nodules of one month duration while on methotrexate (7.5 mg once a week), salazopyrine (1000 mg/day) and methyl prednisolone (4 mg/day). The nodules involved tendons of metacarpophalangeal joints (Figure 1) and base of left great toe (Figure 2), were painless and did not interfere with his daily activities. There was mild synovitis of left ankle. No other extra-articular manifestations were present. ESR was 17mm at 1hr. Methotrexate induced accelerated nodulosis (MIAN) was diagnosed. Methotrexate (MTX) was continued at the same dose. There was no change in number and size of nodules at three months follow-up.