Intended for healthcare professionals

Endgames Case Review

Disseminated subcutaneous nodules and destructive polyarthritis

BMJ 2019; 365 doi: (Published 17 April 2019) Cite this as: BMJ 2019;365:l1344
  1. Nobuya Abe, senior resident,
  2. Yuichiro Fujieda, assistant professor (post CCT),
  3. Olga Amengual, assistant professor, (consultant),
  4. Tatsuya Atsumi, professor
  1. Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
  1. Correspondence to Y Fujieda edaichi{at}

A 56 year old man presented with multiple subcutaneous nodules over his body and deformities of both hands and feet. He had a seven year history of chronic peripheral polyarthritis (suspected to be rheumatoid arthritis) but had been reluctant to take antirheumatic therapy and did not attend clinic appointments. He consumed 40-60 g (5-7 units) of alcohol a day.

Examination revealed asymmetrical elastic, hard, painless, and partly ulcerated subcutaneous nodules around articular structures, tendons, and bursas (fig 1). The nodules restricted extension of the left forefinger and left knee.

Fig 1

Multiple subcutaneous nodules and deformities of both hands

Plain joint radiography of the fingers and toes showed widespread destructive arthritis with joint dislocation, ankylosis, and well defined, punched …

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