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CASE REPORT
Year : 2021  |  Volume : 14  |  Issue : 1  |  Page : 97-99  

Tubercular rheumatism - Poncet's disease


1 Department of Medicine, Lady Hardinge Medical College, SSK Hospital, New Delhi, India
2 Department of Medicine, PGIMER, Dr. RML Hospital, New Delhi, India

Date of Submission19-Nov-2019
Date of Decision06-Feb-2020
Date of Acceptance30-Apr-2020
Date of Web Publication22-Jan-2021

Correspondence Address:
Rohit Bansal
R-4/44 Raj Nagar, Ghaziabad - 201 002, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_313_19

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  Abstract 


Poncet's disease is a rare form of tuberculosis (TB). It is described as a hypersensitivity reaction of extra-articular TB, which manifests as acute-onset non-destructive polyarthritis of large joints. It resolves completely on anti-tubercular therapy. We describe a case of a young female patient who presented with symmetrical polyarthritis on a background of tubercular lymphadenitis. The workup for rheumatological diseases was negative. A diagnosis of Poncet's disease or tubercular rheumatism was made by exclusion. There was complete resolution of symptoms of joint disease following anti-tubercular therapy. Poncet's disease should be kept under suspicion in TB endemic areas while investigating patients of arthritis. In a resource-limited setting, in patients with TB, the response of coincident inflammatory arthritis to anti-tubercular therapy may be first observed, before subjecting them to further investigations and/or empirical therapy.

Keywords: Polyarthritis, Poncet disease, tuberculosis, Tubercular rheumatism


How to cite this article:
Kumar A, Singh AK, Bansal P, Bansal R. Tubercular rheumatism - Poncet's disease. Med J DY Patil Vidyapeeth 2021;14:97-9

How to cite this URL:
Kumar A, Singh AK, Bansal P, Bansal R. Tubercular rheumatism - Poncet's disease. Med J DY Patil Vidyapeeth [serial online] 2021 [cited 2021 Mar 3];14:97-9. Available from: https://www.mjdrdypv.org/text.asp?2021/14/1/97/307678




  Introduction Top


Poncet's disease is a non-destructive arthritis involving one or more large joints seen in patients with active visceral or disseminated tuberculosis (TB). There is no evidence of bacteriological involvement of joint themselves, nor any other known cause of polyarthritis detected. The symptoms resolve completely with anti-tubercular chemotherapy.[1] We report a case of acute tubercular disease with rheumatism as it is an underdiagnosed clinical condition. The patient presented with joint pains and was incidentally detected to have tubercular lymphadenopathy, thereby reaffirming the character of TB as “the great masquerader.”


  Case Report Top


A 18-year-old non-pregnant female, presented with complaint of pain involving multiple joints of 2 months duration. Joint involvement was asymmetric, involving large joints of the lower limb. Initially, it started from the right knee joint, which was associated with swelling, which resolved after immobilization over 15 days followed by involvement of left knee joint, and then, bilateral ankle joint, which was milder in intensity and resolved on its own with some residual pain. It was not associated with early morning stiffness; there was no involvement of the spine or small joints of hands. It was associated with a history of fever, which was low grade and associated with evening rise of temperature. The patient complained of significant weight loss and loss of appetite, which gradually increased in intensity to high grade with chills documented to be 100°–102°F. There was no history of any trauma, conjunctivitis, bladder, or bowel symptoms, any autoimmune disease, or family history of TB.

The vital parameters were within the normal limits. There was tenderness present over the left knee joint, and both the ankle join, associated with the swelling but no deformity. The rest of the examination was within the normal limits. The patient was evaluated in view of fever with migratory oligoarthritis. She had anemia with hemoglobin of 9.2 g/dl, erythrocyte sedimentation rate of 100 at the end of the 1st h, anti-nuclear antibody, rheumatoid arthritis factor, and anti-streptolysin O titers was negative, C-reactive protein was positive, anti-cyclic citrullinated peptide was negative (<0.5 U/ml), human leukocyte antigen (HLA)-B27 was negative, and throat swab showed no pus cells or any growth. Urine microscopy and cultures, as well as blood cultures, revealed no growth.

Viral markers, including HIV 1 and 2, were negative. X-rays of the ankle and knee were unremarkable. The Mantoux test (intradermal skin test) for TB was positive, with a reading of 16 mm. The radiograph of the chest was normal. Contrast-enhanced computed tomography of the chest showed multiple enlarged necrotic mediastinal and cervical lymph nodes, and thus, the patient was diagnosed with pulmonary TB.

The patient was started on oral anti-tubercular drugs (isoniazid, rifampicin, pyrazinamide, and ethambutol). While treatment with nonsteroidal anti-inflammatory drugs gave only temporary relief of joint pains, fever, and arthralgia completely subsided within 2 weeks of anti-tubercular chemotherapy. There was no recurrence of arthritis. Joint aspiration could not be done because the patient did not provide consent for the same. However, a diagnosis of reactive tuberculous arthritis, or Poncet's disease, was made due to joint involvement in the presence of active TB and in the absence of any deformities or erosions. The rheumatism responded to anti-tubercular therapy, which confirmed our diagnosis. The patient continued to remain symptom-free in the follow-up after 2 months at the time of reporting this case.


  Discussion Top


Musculoskeletal involvement is one of the most common forms of extrapulmonary TB. Along with septic TB arthritis, a nonsuppurative reactive arthritis (ReA) has also been seen in association with TB, a condition known as Poncet's disease.[1] Although Poncet's disease has conentionally been described as a polyarthritis, it often presents as pauciarticular, symmetrical arthritis predominantly involving the large joints. There is no axial involvement.[2] Ankles, knees, wrist, and elbows are most frequently affected in Poncet's disease.[3] Other symptoms that may be associated are included enlargement of axillary or cervical lymph nodes, fever, and skin involvement such as erythema nodosum.[4] The diagnosis is made by excluding other rheumatological disease and connective tissue disorders. It should be under suspicion in TB prevalent regions in patients presenting with a symmetrical arthritis. Criteria for the diagnosis of Poncet's disease have been suggested by Rueda et al. and are summarized in [Table 1].[2] Extrapulmonary TB, especially TB lymphadenitis, is most commonly implicated, as was the case in our patient. The rapidity of the response of arthritic symptoms to anti-tubercular multidrug therapy confirms the diagnosis of PD.
Table 1: Suggested criteria for diagnosis of Poncet's disease[2]

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The presentation of Poncet's disease is distinct from the better defined ReA seen with other systemic infections. The gross differentiating features are summarized in [Table 2]. The pathogenic mechanism is, however, similar to ReA. A vigorous immune reaction to TB infection within the joints has been described, where activation of T-cells leads to cross-reactivity with cartilage proteoglycans.[5] This hypersensitivity to mycobacterial antigens may be associated with HLA DR3 and/or HLA DR4 haplotypes. Poncet's disease also differs from the more common TB monoarthritis, which is a septic arthritis caused by mycobacteria associated with joint destruction.[6] As discussed before, Poncet's arthritis is non-destructive and resolves completely following TB treatment, while septic TB arthritis heals more slowly. PD is not associated with chronicity. It has a much better prognosis than septic arthritis, which may be complicated by erosive arthropathy and osteomyelitis.
Table 2: Reactive arthritis versus Poncet's disease

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In conclusion, Poncet's disease is a poorly recognized manifestation of TB. Given the debilitating nature of the illness and the ease with which it is controlled, tubercular etiology deserves strong clinical suspicion in the work-up of polyarthritis, particularly in regions where the prevalence of TB is high. A consensus on clinical criteria that allow early diagnosis and treatment of this disease should be reached at the earliest.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Garg P, Gupta N, Arora M. Monoarticular poncet disease after pulmonary tuberculosis: A Rare case report and review of literature. Perm J 2016;20:15-99.  Back to cited text no. 1
    
2.
Rueda JC, Crepy MF, Mantilla RD. Clinical features of Poncet's disease. From the description of 198 cases found in the literature. Clin Rheumatol 2013;32:929-35.  Back to cited text no. 2
    
3.
Es-Souiri J, Mounir A, Kona I, Abourazzak FE, Harzy T. Poncet's disease: A challenging cause of polyarthritis in a Moroccan patient. Egypt Rheumatol 2017;39:183-5.  Back to cited text no. 3
    
4.
Segula D, Mahmood N, Allain TJ. Ward round: A 43-year-old diabetic man with multiple joint pains. Malawi Med J 2012;24:84-6.  Back to cited text no. 4
    
5.
Adhi F, Hasan R, Adhi M, Hamid SA, Iqbal N, Khan JA. Poncet's disease: Two case reports. J Med Case Rep 2017;11:93.  Back to cited text no. 5
    
6.
Chakraborty PP, Ray S, Selvan C, Bhattacharjee R, Mandal SK. Poncet's disease: An unusual presentation of tuberculosis in a diabetic lady. World J Clin Cases 2015;3:385-8.6.  Back to cited text no. 6
    



 
 
    Tables

  [Table 1], [Table 2]



 

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