This is the first description of the development of rheumatoid nodules in 3 rheumatoid arthritis patients following leflunomide therapy. The nodules were localized at typical sites with preference of the extensor side of hands and elbow. One nodule examined histologically revealed the typical architecture of RA nodules. In all 3 patients the time of onset of nodulosis was about 6 months after initiating the leflunomide therapy. In all 3 patients leflunomide was clinically efficacious concerning RA: remission or near remission was achieved. Due to the extent of nodulosis, the leflunomide therapy had to be stopped in 2 patients. Progression and acceleration of nodulosis is well known following MTX therapy in RA patients. It is caused by adenosine A1 receptor promotion of multinucleated giant cell formation by human monocytes. Leflunomide has no known influence on adenosine metabolism, so different pathogenetic mechanisms must be assumed for the induction of nodulosis by leflunomide.

We report about a patient with polyarticular rheumatoid arthritis taking methotrexat and 5 mg prednisolone who developed in the course of a RA flare a septic arthritis in the right shoulder. Listeria monocytogenes could be identified as the causative bacteria. Clinically, the Listeria-induced septic arthritis could not be differentiated from rheumatoid arthritis; fever was not present. The synovial analysis showed a granulocytic effusion with 19,000 cells/ml; there was no microbiological growth within the first 24 hours. Only the low glucose level indicated a possible septic arthritis. After 48 hours, gram-positive bacterial growth was evident and Listeria monocytogenes could be isolated after 72 hours. Therapy was initiated by antibiotic treatment and arthrotomy with synovectomy followed by extensive irrigation which proved effective in bacterial elimination but joint destruction resulted. During the whole course, Listeria antibodies were negative and proved to be too insensitive. The incidence of Listeria-induced arthritis is very low; a review of the literature revealed only 24 reported cases. It occurs primarily in patients with rheumatic diseases under immunosuppression and in prosthetic joints. The diagnosis is based on cultural detection. It is important to cultivate synovial effusions for longer than 24 hours in order to identify Listeria. This is of relevance since Listeria serology is not sensitive.

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Limited resources in our health system require fast action to maintain sufficient health care. Improvements in the quality of standards and the processes involved are overcome more easily by the industry compared to human medicine. Can the heterogenous group of rheumatic patients be compared? Can the demands of the individual groups be satisfied concerning their health care? Coordination centers for rheumatic diseases can improve the quality of health care in conjunction with the infrastructure created by the patient support groups. These projects should not fail due to the financial crisis in our social system. It is about time to think about alternative financial models, such as foundations.

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