Rheumatoid Necrobiotic Nodules

Rheumatoid Necrobiotic Nodules

Helen T. Winer-Muram, MD

Axial NECT shows multiple solid image and cavitary image pulmonary nodules from rheumatoid arthritis.

Axial NECT in the same patient shows large peripheral cavitary nodules with variable wall thickness image from rheumatoid necrobiotic nodules.


Abbreviations and Synonyms

  • Rheumatoid arthritis (RA)

  • Caplan syndrome, rheumatoid pneumoconiosis


  • Subacute or chronic inflammatory polyarthropathy of unknown cause


General Features

  • Best diagnostic clue: Chronic pleural effusion and lung nodules in patient with rheumatoid arthritis

  • Patient position/location: Peripheral subpleural

  • Size: Variable, usually < 1 cm diameter

  • Morphology: Solid or cavitary nodules

CT Findings

  • Rheumatoid nodules (seen in < 5%)

    • Morphology

      • Solitary or multiple, 0.5-7 cm, few in number

      • Usually well circumscribed

      • Resemble neoplasm, discrete, rounded, or lobulated

      • May rarely calcify

      • Identical to subcutaneous nodules (usually seen around elbows)

    • Cavitation (50%)

      • Thick or thin smooth wall

      • May contain necrotic lung ball or rarely mycetoma

      • May result in pneumothorax (may be refractory to therapy)

    • Distribution

      • Peripheral (subpleural)

    • Evolution

      • Wax & wane

  • Caplan syndrome: Rare

    • Hypersensitivity reaction to dust

    • Associated with coal miner’s pneumoconiosis

    • Redefined to include silica, asbestos, dolomite, carbon

    • Large rounded nodules (0.5-5 cm), may cavitate

    • Indistinguishable from silicate pneumoconiotic nodules or tuberculous nodules

    • Nodules have peripheral distribution

    • Serologic but not clinical rheumatoid arthritis

  • Other associated pleuropulmonary abnormalities

    • Pleural disease

      • Most common abnormality in RA

      • Pleural effusions or thickening from fibrothorax

      • Effusions small to large

      • Effusions usually unilateral, transient, persistent, or relapsing

      • May be associated with rheumatoid nodules and subcutaneous nodules

      • Pleural abnormalities and pulmonary nodules, if present, help distinguish RA-related interstitial lung disease

  • Interstitial pneumonitis & fibrosis

    • Most common pulmonary abnormality (30-40%)

    • Nonspecific interstitial pneumonia or usual interstitial pneumonia

  • Cryptogenic organizing pneumonia pattern

    • Ground-glass opacities, nodules, bronchovascular distribution

  • Airways disease

    • Bronchiectasis, follicular bronchiolitis, constrictive bronchiolitis

Radiographic Findings

  • Nodules may appear in crops, persist or resolve spontaneously, wax & wane

  • Serial radiography for surveillance

    • Development of new nodules

    • Stability or resolution of nodules

    • Progression: Increasing size and number of nodules, development of cavitation

    • Development of pleuropulmonary complications

Imaging Recommendations

Sep 20, 2016 | Posted by in RESPIRATORY IMAGING | Comments Off on Rheumatoid Necrobiotic Nodules
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