Poncet's Disease Research Articles

Poncet\'s Arthritis in a Patient with Multidrug-Resistant Tuberculosis

A 17-year-old female diagnosed to have multidrug-resistant pulmonary tuberculosis (MDR-TB), presented with Poncet's arthritis which responded to second-line anti-TB treatment. Poncet's disease is more commonly present in association with extra-pulmonary TB and involves large and small joints. However, our patient had pulmonary MDR-TB and small joint involvement.

Infectious mimics of rheumatoid arthritis.

Rheumatoid arthritis (RA) can have various infectious mimics. As immunosuppressive agents used in treatment can aggravate the underlying infections, correct diagnosis of RA and ruling out infections is important. Numerous viral infections (Parvovirus B19, Hepatitis B, Hepatitis C, Chikungunya and other alphaviruses, human immunodeficiency virus (HIV) and various other viruses), mycobacterial infections (Poncet's disease, tubercular septic arthritis, and leprosy), bacterial arthritis, brucellosis and Lyme disease are among common infections that mimic RA. Widespread travel and tourism, especially to exotic areas, high risk sexual behavior and widespread use of immunosuppressive and chemotherapeutic agents has led to numerous outbreaks of infections in areas where these infections were never reported before. Hence, rheumatologists all over the world should be familiar with musculoskeletal manifestations of infections. History of travel, comorbid fever, skin rash, genital ulcers, urethral discharge, the consumption of unpasteurized milk, lymphadenopathy, tenosynovitis, low platelet count, and positive Mantoux test can offer potential diagnostic clues. Serological testing, cultures, specific radiological signs and deoxyribonucleic Acid (DNA) amplification techniques often aid in diagnosis. Treatment mainly consists of antimicrobial agents, analgesics, and nonsteroidal anti-inflammatory drugs (NSAIDs). However, immunosuppressive agents including steroids and disease modifying anti-rheumatic drugs (DMARDs) are needed occasionally in different refractory and prolonged illnesses. Most of the times, episodes of arthritis are self-limiting and respond to treatment of underlying cause. However, few infections like Chikungunya and Lyme's disease can lead to chronic arthritis as well.

Poncet's disease: a reactive arthritis secondary to pulmonary tuberculosis.

Poncet's disease: a reactive arthritis secondary to pulmonary tuberculosis.

English

Tuberculosis (TB) is the leading cause of mortality among infectious diseases with estimated 1.5 million deaths from TB in 2018 -19 and presented as a public health concern. In 1897, the Frenchman Antonin Poncet first described Poncet's disease (PD) as a rare syndrome, where polyarthritis in an acute stage of TB, resolved without joint damage. Similar reports on patients of tuberculosis and joint pain led authors to improve the definition, and in 1978, PD was described as a para infective arthritis by Bloxham and Addy. Regardless of its doubtful existence, cases have been continued to be reported over the years. Poncet's disease is a form of reactive arthritis which is characterized by articular affection in patients diagnosed with TB where there is immune reaction to the tuberculous protein but there is no direct invasion by the micro-organism.1,2 PD is to be differentiated from tuberculous arthritis where there is monoarticular and direct tubercular involvement of the joint. Before more obvious features develop, the sole manifestation of the disease is joint involvement. Crippling pain is experienced during polyarthritis which limits the mobility and activities of patients. Polyarthritis can also occur in common causes such as rheumatological diseases as a symptom and thus can be easily misdiagnosed. Polyarthropathy, that is multiple large and small joints involvement in the body, is the one of the rarest presentations in both active pulmonary and extrapulmonary tuberculosis. This polyarticular impairment observed in patients with active TB, a form of reactive arthritis is known as Poncet’s disease. Since there is no direct bacillary invasion of the joints, it is an aseptic form of arthritis. It is not to be confused with tuberculous arthritis, which is usually monoarticular and where there is direct tuberculin infection. Poncet's disease remains a diagnosis of exclusion. Since case reports are very rare even in countries where tuberculosis is common thus no accepted diagnostic criteria is set for Poncet's disease. This diagnostic possibility becomes increasingly important as the use of corticosteroids, immune suppressants or biologicals can risk further dissemination of the disease. We describe the case of a 50-year-old woman, who presented with active tuberculosis where polyarthralgia was the first and only symptom for four months. Polyarthritis patients were being treated with both non-steroidal anti-inflammatory drugs and antitubercular therapy and to the surprise patients with antitubercular treatment had complete resolution of symptoms after 6-week therapy whereas non-steroidal anti-inflammatory drugs (NSAIDS) offer no benefit. The total duration of therapy was 6 months.

Clinical Images: Papulonecrotic tuberculid and Poncet disease.

Clinical Images: Papulonecrotic tuberculid and Poncet disease.

Tubercular rheumatism - Poncet's disease

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.

Poncet′s disease (tubercular rheumatism): a narrative review

Poncet's disease or tubercular rheumatism is uncommon, and there are not many related studies. No consensus has been achieved with respect to its etiopathogenesis. The low prevalence of this Poncet's disease even in endemic regions suggests hidden mechanisms that require further research to fully comprehend this enigmatic disorder. Careful identification of primary focus of tubercular infection, clinical suspicion and knowledge of this disorder is crucial for prompt identification and treatment. This article aims to provide an overview of the recently published articles about Poncet's disease. The article attempts to highlight key features of the disease for better understanding of this peculiar disorder.

Poncet Disease: A Case-based Review of an Uncommon Extrapulmonary Manifestation of Tuberculosis

Background: Tuberculosis (TB), an ancient infectious disease caused by the bacteria Mycobacterium tuberculosis, still remains a leading cause of morbidity and mortality in our modern world, causing ∼1.3 million deaths worldwide in 2017 alone. Because it disproportionately impacts the developing world, the unique manifestations of TB may be less encountered and therefore less known to many physicians in developed countries. Case: A 63-year-old woman, with a past medical history of ulcerative colitis, who was on tumor necrosis factor-α inhibitor therapy, presented with fevers, lymphadenopathy, erythema nodosum, and diffuse joint pains. The differential diagnosis included sarcoidosis manifesting as Lofgren syndrome and TB. A tissue biopsy of her right supraclavicular lymph node confirmed the diagnosis of tuberculous lymphadenitis, reactivated in the setting of her adalimumab therapy. Given the patient’s arthritic symptoms, we were also suspicious for Poncet disease (PD), a lesser-known entity defined by reactive arthritis in the setting of TB. Discussion: This case of an immunocompromised woman with fevers, lymphadenopathy, polyarthritis, and erythema nodosum demonstrates a unique presentation of TB. PD is defined as reactive arthritis due to infection with TB elsewhere in the body. Although PD was first described in 1897, it stills remains a disputed and lesser-known entity. This case highlights the importance of recognizing this unique manifestation of TB to prevent misdiagnosis and delay. It also demonstrates the diagnostic challenge in distinguishing the overlapping features of sarcoidosis manifesting as Lofgren syndrome and PD.

A commonly missed diagnosis: Poncet's disease

Tuberculosis (TB) is on the rise particularly in developing countries like India. The lung happens to be the most common site for the occurrence of the same, but extra pulmonary manifestation is not that uncommon. Joint involvement in TB is usually monoarticular, rarely may present as polyarthritis. Reactive arthritis in TB is known as Poncet's disease, a rare aseptic form of arthritis characterized by polyarticular impairment observed in patients with active TB, with no evidence of direct bacillary invasion of the joints. The condition is different from tuberculous arthritis which is usually monoarticular and is caused by direct tubercular involvement of the joint. A 40 year female patient reported with gradually enlarging swelling of left preauricular region and painful joints based on clinical history and investigations she was diagnosed with Poncet's disease.

Musculoskeletal Tuberculosis: A Multifaceted Foe

AbstractTuberculosis (TB) still remains a global epidemic, and India accounts for one-fourth of the world's TB burden. The incidence of extrapulmonary TB has relatively remained constant, but with the introduction of antitumor necrosis factor, there has been a surge in pulmonary and extrapulmonary TB cases presenting to rheumatologists. Musculoskeletal TB accounts for 10 to 30% of all cases of extrapulmonary TB, with spondylitis (Pott's spine) being the most common manifestation. Manifestations mimicking autoimmune spondylitis are seen in 10% of cases. Tubercular arthritis most commonly presents with large joint monoarthritis, but oligo- or polyarticular involvement is also seen. Poncet's disease is a form of reactive arthritis occurring in patients with pulmonary or extrapulmonary TB, which is rarely seen with good response to antitubercular treatment. Quite often, there is delay in the diagnosis of musculoskeletal TB due to absence of constitutional symptoms. Treatment of musculoskeletal TB involves prolonged course of antitubercular treatment, and surgical interventions are limited to special cases.

Tuberculous rheumatism: A great mimic of juvenile idiopathic arthritis

Tuberculosis (TB) is an underreported epidemic. Musculoskeletal TB is a relatively rare extrapulmonary complication of Mycobacterium tuberculosis involving just 1%–3% of patients. It commonly affects the spine and osteoarticular joints such as hip and knee, and it is mostly monoarticular. Oligo and polyarticular involvement, also called tuberculous rheumatism or Poncet's disease (PD), is an extremely rare occurrence due to a vigorous immune response to mycobacteria which contributes to the arthritic process. Here, we report a case of PD in a 3-year-old girl, who presented with complaints of insidious onset polyarthritis, mimicking juvenile arthritis. Cervical lymph node aspirate isolated acid-fast bacilli. The child was diagnosed as a case of PD, and after starting antituberculous therapy, her symptoms dramatically resolved. This patient illustrates the need to consider the possibility of TB in high-risk pediatric populations in countries like India as one of the causes of nonresolving chronic arthritis.

Poncet's disease: Uncommon musculoskeletal manifestation of tuberculosis.

Poncet's disease: Uncommon musculoskeletal manifestation of tuberculosis.

Features of extra-spinal musculoskeletal tuberculosis: A retrospective study from an North Indian Tertiary Care Institute

Background: The aim is to study the clinical features and diagnosis of primary extra-spinal musculoskeletal manifestations of tuberculosis (TB) in otherwise healthy individuals. Methods: In this retrospective study of 10 years duration electronic database and case records of patients with musculoskeletal TB were analyzed. Patient's positive for HIV and rheumatic diseases with or without immunosuppressive drugs or biological agents were excluded from the study. Results: Fifty-one patients were identified with the mean age at presentation of 33.35 years (range 4–72), male: female ratio of 1.1:1 and mean duration of disease was 14.65 months (range, 0.25–120). The most frequent manifestation was articular (arthritis/arthralgia n = 40, monoarthritis n = 28, oligoarthritis n = 10, polyarthralgia n = 2) followed by tenosynovitis (n = 6), tuberculous osteomyelitis (n = 5), isolated bursitis (n = 1), and pyomyositis (n = 1). Poncet's disease was diagnosed in five patients. Disseminated TB was detected in four patients. Pain (n = 50) followed by swelling of the involved site (n = 37) were the most common presenting symptoms. Fever was present in 15 (29.4%) patients. Nine patients had a previous history of TB. Concurrent pulmonary TB was present in two patients. Lymph node enlargement was present in 12 (23.5%) patients. A definite diagnosis of musculoskeletal TB was made in 31 (61%) patients and probable TB in 20 (39%) patients. Conclusion: Musculoskeletal manifestations of TB can occur at any age. Chronic monoarthritis is the most common presentation; however, oligoarthritis and/or tenosynovitis may be a presenting manifestation. The absence of fever should not discourage the diagnosis of musculoskeletal TB.

Poncet disease, tuberculosis-arthritis: a case report in upper Egypt and a review of the literature

Reactive arthritis in tuberculosis (TB) is known as Poncet’s disease, a rare aseptic form of arthritis characterized by polyarticular impairment observed in patients with active TB, with no evidence of direct bacillary invasion of the joints. The literature related to this syndrome is scarce and restricted to case reports, which contributes to its underdiagnosis. This study aimed at reporting a case of Poncet’s arthritis diagnosed at our hospital, and at reviewing the diagnostic and therapeutic aspects involved; hence, we describe a case of Poncet’s disease in a 13-year-old girl whose reactive arthritis overshadowed other clinical symptoms of TB, resulting in delayed diagnosis and treatment. Anti-TB treatment was initiated. Clinical remission occurred after 2 weeks and the diagnosis of Poncet’s arthritis was established, concluding that taking a thorough medical history and performing relevant examinations and investigations for possible TB, especially in endemic areas, will help expedite the diagnostic process even in the absence of TB symptoms.

Monoarticular Poncet Disease after Pulmonary Tuberculosis: A Rare Case Report and Review of Literature

Tuberculosis is a major health problem worldwide, more so in Asian countries and especially India. Being a communicable disease, it can affect the lives of many people. Tuberculosis has varied manifestations and can affect almost every part of the human body. Pulmonary tuberculosis is the most common form. Poncet disease (tuberculous rheumatism) is a polyarticular arthritis that occurs during acute tuberculosis infection in which no mycobacterial involvement can be found or no other known cause of polyarthritis is detected. We describe an atypical presentation of active pulmonary tuberculosis with monoarticular Poncet disease of the right knee in a 24-year-old woman. The diagnosis of Poncet disease is mainly clinical with exclusion of other causes. It generally presents as an acute or subacute form; however, chronic forms have been described in the literature.

Poncet Disease, TB Reactive Arthritis, a Case Report in Upper Egypt and Review of the Literature

Reactive arthritis in tuberculosis (TB) is known as Poncet’s disease (PD), a rare aseptic form of arthritis characterized by polyarticular impairment observed in patients with active TB, with no evidence of direct bacillary invasion of the joints. The literature related to that syndrome is scarce and restricted to case reports, which contributes to it’s under diagnosis. This study aimed at reporting a case of Poncet’s arthritis diagnosed at our hospital, and at reviewing the diagnostic and therapeutic aspects involved, so, we describe a case of Poncet’s disease in a 13-year old girl whose reactive arthritis overshadowed other clinical symptoms of TB resulting in delayed diagnosis and treatment. Anti TB treatment was initiated. Clinical remission occurred after two weeks and the diagnosis of Poncet’s arthritis was established concluding that taking a thorough medical history as well as performing relevant examinations and investigations for possible TB especially in endemic areas will help expedite the diagnostic process even in absence of TB symptoms.

Tuberculous rheumatism “Poncet's disease”. Case report

Abstract Background Deaths due to tuberculosis have reached 2.5 million cases per year worldwide. Poncet's disease is an infrequent form of tuberculosis characterised by a clinical picture of polyarthritis. Clinical case A 24-year-old male presented with morning stiffness, arthralgias, bilateral symmetric arthritis of the proximal interphalangeal joints, wrists, knees, ankles, and shoulders, and adenomegalies at the cervical, submandibular, left supraclavicular, axillary and inguinal levels, without fever. Laboratory results were as follows: ESR 44 mm/h, C-reactive protein 4.35, normal levels of complement C3 and C4, negative rheumatoid factor and anticyclic citrullinated peptide antibodies, positive antinuclear antibodies with fine speckled pattern (1:320) and cytoplasm (1:160) pattern and negative anti-Smith, -double-stranded DNA, Sjogren's syndrome-antigen A and Sjogren's syndrome-antigen B. Histological report of cervical node tissue revealed granulomatous lesions compatible with tuberculosis. Rheumatoid arthritis and systemic lupus erythematosus were ruled out. Anti-tuberculosis agents were initiated that resolved the clinical picture. Diagnosis of Poncet's disease was confirmed. Conclusion The differential diagnosis between tuberculosis and autoimmune inflammatory joint diseases is a clinical challenge.

Tuberculosis and Poncet's disease: the many faces of an old enemy

1 describe a patient with constitutional symptoms, bilateral pulmonary infi ltrates, cervical lymphadenopathy, skin nodules, and symmetrical large joint polyarthritis. The multisystem involvement suggests an underlying cause such as tuberculosis, sarcoidosis, vasculitis, HIV, or possibly multiple origins. Lymph node and skin biopsy samples were pathognomonic of tuberculosis. No information about tuberculosis culture is provided and it is assumed that drug susceptibility testing was not done. This case reminds us that tuberculosis is common in individuals from resource poor settings (an estimated 9 million cases occurring annually) and should be looked for in any encounter with the health-care system or practitioner. 2

Poncet's disease mimicking rheumatoid arthritis in a patient with suspected Crohn's disease

Poncet's disease is a rarely reported entity with an unknown pathogenesis. However, because it has a very favorable prognosis with antituberculosis drugs, we believe it should be considered as a differential diagnosis for patients with fever and polyarthritis of unknown cause, particularly if active tuberculosis is suspected.

A case series and review of Poncet's disease, and the utility of current diagnostic criteria.

Poncet's disease is a well recognized form of reactive arthritis in the presence of extra-articular tuberculosis. There are very limited case reports even from countries where tuberculosis is common and there are no accepted diagnostic criteria for Poncet's disease. In the present study we are describing clinical features of Poncet's disease from a tuberculosis-endemic region along with a proposal of a new diagnostic criteria. All patients diagnosed as having Poncet's disease were included. The clinical details, demographic features, pattern of joint involvement, investigation findings, treatment details and clinical outcomes were recorded on a structured pro forma. Twenty-three patients with Poncet's disease were identified during the study period. Thirteen patients had oligoarthritis and the rest had polyarthritis with ankle joint involvement being most common. The duration of joint symptoms varied from 3days to 6years. All patients had non-erosive and non-deforming arthritis. Systemic symptoms were absent in 48% of patients. Mantoux was positive in most cases (81%). Tuberculosis was extrapulmonary in most cases, lymph node tuberculosis being most common. All patients had complete resolution of joint symptoms with anti-tubercular treatment. All the factors contributing to eventual diagnosis of Poncet's disease were carefully analyzed and diagnostic criteria are proposed. In the proposed criteria, there are two essential, two major and three minor criteria. According to these criteria 19 patients had definite and three had probable Poncet's disease. The most common presentation of Poncet's is in the form of oligoarthritis. The proposed criteria can be used for diagnosing Poncet's disease.