Nodular rheumatoid arthritis resembling gout

A 57-year-old man presented for review in the rheumatology outpatients clinic. He had a 30-year history of rheumatoid arthritis and was known to be positive for rheumatoid factor and anticitrullinated protein antibodies (anti-CCP antibodies). He had been treated over the past 30 years with various immunosuppression regimens, including long-term methotrexate, leflunomide and sulfasalazine. His disease had been stable for the past 2 years with no recent increase in nodules or episodes of acute synovitis. Several times in the past 15 years his diagnosis of rheumatoid arthritis had come into question due to the atypical appearance of his hands which closely resembled gout (figures 1 and 2). On two occasions, excision of rheumatoid nodules was sent for histology to exclude other diagnoses such as gout and multicentric reticulohistiocytosis