“Rheumatoid nodules” and lymphoma!

A 63 year old woman presented with painful, stiff hands. There was swelling of the hands, ankles and feet but no systemic upset. On examination there was soft tissue thickening of the proximal interphalangeal (PIP) and metacarpal phalangeal (MCP) joints of the hands with pitting oedema of the hands, feet and lower legs. The remainder of the examination was unremarkable. The following investigations were negative or normal. Full blood count and differential, erythrocyte sedimentation rate (ESR), C reactive protein (CRP), rheumatoid factor, nuclear antibody profile, thyroid function. Serological investigation for parvovirus B19 was negative. Radiographs of the hands revealed soft tissue swelling but no erosions. During the following six months the patient developed synovitis of PIP joints and wrists (fig 1) with bilateral dorsal sheath effusions (fig2). Multiple firm nodules were noted on both elbows and forearms measuring up to 1 cm (fig 2) and she developed symptoms …