Disseminated subcutaneous nodules and destructive polyarthritis

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 …