Conjunctival Nodules Associated with Rheumatoid Arthritis ("Rheumatoid Nodulosis"): A Clinicopathologic Study of Two Cases

Abstract

Abstract: : Purpose: To describe the clinical and histopathologic features of rheumatoid nodules in the conjunctiva. Methods: Biopsies were taken from large conjunctival nodules in two patients with rheumatoid arthritis being treated with methotrexate. One of these patients had a history of chronic follicular conjunctivitis. Histopathologic features of these lesions were compared with those of classic, subcutaneous rheumatoid nodules and ocular rheumatoid nodules, including the one previous case report of conjunctival rheumatoid nodules. Results: Biopsies of the lesions showed chronic inflammation in the conjunctiva composed mainly of plasma cells surrounded by foci of granulomatous inflammation. The granulomas exhibit areas of central necrobiosis of collagen surrounded by a palisade of epithelioid histiocytes and fibroblasts. The collective findings are consistent with rheumatoid nodules of the conjunctiva. Interestingly, both patients were receiving methotrexate treatment for control of their rheumatoid arthritis. Accelerated rheumatoid nodulosis is a well known complication of methotrexate use. Methotrexate-induced accelerated nodulosis most commonly involves the fingers. Involvement of the elbows, knees, feet, lungs, larynx and heart also has been documented. Methotrexate-induced accelerated nodulosis of the ocular surface has not been previously reported. Conclusions: Rheumatoid nodules can develop in the conjunctiva of patients with rheumatoid arthritis and have the appearance of a chronic follicular conjunctivitis. Methotrexate therapy may be a risk factor for this condition.

Keywords: conjunctiva • autoimmune disease • pathology: human