Sulfasalazine's potential in managing rheumatoid nodules: Insights from a case report

Abstract

Rationale: Rheumatoid arthritis (RA) is a systemic inflammatory disease characterized by joint inflammation and various extra-articular manifestations, including rheumatoid nodules (RNs). This case study aims to explore the effectiveness of alternative treatments for RNs, particularly highlighting the therapeutic potential of sulfasalazine.

Patient concerns: A 52-year-old male with established RA presented with worsening joint pain and firm nodules on his elbows, feet, and fingers.

Diagnoses: The patient fulfilled the diagnostic criteria for RA and was diagnosed with methotrexate-induced RNs based on their temporal association with methotrexate initiation.

Interventions: Methotrexate was discontinued and a combination of leflunomide and sulfasalazine was initiated. Sulfasalazine led to improvement in both joint pain and nodule size. However, due to cost concerns, the patient discontinued sulfasalazine, resulting in a resurgence of both symptoms and nodule enlargement. Reintroduction of methotrexate resulted in significant improvement in joint inflammation, and notably, no new nodules developed at 6 months follow-up.

Outcomes: Sulfasalazine demonstrated efficacy in managing RA nodules, suggesting a potential alternative therapy.

Lessons: The case highlights the complex etiology of nodules in RA and emphasizes the importance of individualized treatment approaches and close monitoring for optimal management.

Figure 1.

Rheumatoid nodules.

Figure 2.

Chest X-rays show normal findings with no evidence of rheumatoid nodules.

Figure 3.

X-rays of the hands reveal bilateral and symmetrical involvement, proximal interphalangeal joint space narrowing, metacarpophalangeal joint space narrowing, and metacarpophalangeal joint osteopenia (red circles).