A 76-year-old woman had a 40-year history of rheumatoid arthritis (RA). She had repeatedly refused treatment with disease-modifying drugs, including methotrexate(Drug information on methotrexate). Nodules began to develop 15 years after the initial diagnosis; they recurred after surgical removal. Drs Ildiko Lingvay and KoKo Aung of Texas Tech University, Odessa, write that rheumatoid nodules, a major diagnostic criterion for RA, are one of the most common extra-articular manifestations of the disease. The incidence of nodules among patients with RA has been reported to be 20% to 30%.1,2 Nodules can be subcutaneous or may form on any body surface, such as heart valves, lungs, and vocal cords. Subcutaneous nodules tend to develop on pressure points. The extensor surface of the elbows is the most common site. When they arise along tendon sheaths, range of motion may be limited and tendon rupture, particularly at proximal interphalangeal joints, can occur. Rheumatoid nodules can develop in bedridden patients on the occiput and ischium. The nodules’ necrotic center is encompassed by palisading fibroblasts, which are surrounded by lymphocytes that can produce IgG and IgM rheumatoid factor. Most patients who have rheumatoid nodules are seropositive for rheumatoid factor. Rheumatoid nodules can obliterate the right ventricular cavity, which leads to right-sided heart failure.3 The possibility that these nodules may be a paraneoplastic syndrome was suggested by the report of their development before the onset of B-cell lymphoma.4 Accelerated rheumatoid nodulosis, especially involving the hands and feet, has been described in patients who are taking methotrexate for RA and in children with juvenile RA.5,6 Surgical removal of the nodules is reserved for patients with local pain, nerve compression, limited range of motion, infection, or erosion.7 Surgically removed nodules may recur.