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Necrobiotic nodules

Case contributed by Stefan Tigges
Diagnosis probable

Presentation

Cough, chronic joint pain.

Patient Data

Age: 45
Gender: Female

Initial Chest X-ray.

x-ray

Multiple pulmonary nodules, some cavitary. Findings are otherwise normal.

CT chest one month later.

ct

CT chest confirms pulmonary nodules, some cavitary. Findings are otherwise normal.

Right hand 10 years prior.

x-ray

There is diffuse osteopenia and uniform narrowing of the second and third metacarpophalangeal joints and the carpus. Probable distal radial erosion. The left hand (not shown) had similar findings.

C-spine 10 years prior.

x-ray

Lateral views of the cervical spine obtained in the neutral position and extension are normal, but with flexion, the atlanto-dens interval is abnormally wide, indicating that the transverse ligament is torn.

Case Discussion

Cavitary lung nodules are most often due to lung metastases (commonly squamous cell primaries) or infections (septic emboli or fungal infections). This patient has characteristic hand (osteopenia and unform MCP/carpal joint space narrowing) and cervical spine (increased atlanto-dens interval with flexion) findings of rheumatoid arthritis, suggesting that the lung nodules are necrobiotic nodules.

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