Rice body synovitis is an uncommon manifestation of chronic synovial inflammation, most frequently associated with rheumatoid arthritis and less commonly with infectious etiologies such as tuberculosis. Massive involvement of the subacromial–subdeltoid bursa may cause significant functional limitation and is often managed surgically. However, evidence supporting effective medical management remains limited. This study aims to describe the clinical, radiological, and therapeutic features of a patient with rheumatoid arthritis–associated massive shoulder rice body synovitis successfully treated with targeted synthetic disease-modifying antirheumatic drug therapy and to evaluate the feasibility of a non-surgical approach.

A 54-year-old female with seropositive rheumatoid arthritis presented with progressive swelling of the left shoulder and restricted motion. Prior treatment with methotrexate and nonsteroidal anti-inflammatory drugs was inadequate. Baseline assessment included Disease Activity Score in 28 joints with erythrocyte sedimentation rate together with erythrocyte sedimentation rate C-reactive protein and anti-cyclic citrullinated peptide antibody testing. Tuberculosis was excluded using T-SPOT.TB. Magnetic resonance imaging was performed to characterize the lesion. Because surgery was declined methotrexate was continued at 10 mg weekly and upadacitinib 15 mg daily was initiated. Clinical laboratory and imaging outcomes were followed for six months.

At baseline the patient had active disease with a Disease Activity Score of 5.15, elevated erythrocyte sedimentation rate 55 mm/h mildly increased C-reactive protein and strongly positive anti-cyclic citrullinated peptide antibodies. Magnetic resonance imaging showed marked distension of the subacromial–subdeltoid bursa containing numerous small hypointense nodules within fluid, consistent with rice bodies. After treatment initiation symptoms improved rapidly. Within one month swelling decreased and mobility improved. Continued therapy led to sustained recovery. At six months swelling resolved completely and full range of motion returned. Disease activity decreased with improvement in inflammatory markers. Follow-up imaging demonstrated near-complete resolution with disappearance of rice bodies and minimal residual fluid. No surgery was required and no serious adverse events occurred.

In this patient with active seropositive RA, non-surgical treatment with upadacitinib plus methotrexate was associated with near-complete clinical and MRI resolution of massive shoulder rice body synovitis. The case supports the concept that aggressive suppression of synovial inflammation may, in selected circumstances, offer an alternative to surgery after tuberculosis has been reasonably excluded.