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.