Poncet’s Disease – A Commonly Missed Diagnosis

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.

Expanding the spectrum of reactive arthritis (ReA): classic ReA and infection-related arthritis including poststreptococcal ReA, Poncet’s disease, and iBCG-induced ReA

Reactive arthritis (ReA) is a form of sterile arthritis that occurs secondary to an extra-articular infection in genetically predisposed individuals. The extra-articular infection is typically an infection of the gastrointestinal tract or genitourinary tract. Infection-related arthritis is a sterile arthritis associated with streptococcal tonsillitis, extra-articular tuberculosis, or intravesical instillation of bacillus Calmette–Guérin (iBCG) therapy for bladder cancer. These infection-related arthritis diagnoses are often grouped with ReA based on the pathogenic mechanism. However, the unique characteristics of these entities may be masked by a group classification. Therefore, we reviewed the clinical characteristics of classic ReA, poststreptococcal ReA, Poncet’s disease, and iBCG-induced ReA. Considering the diversity in triggering microbes, infection sites, and frequency of HLA-B27, these are different disorders. However, the clinical symptoms and intracellular parasitism pathogenic mechanism among classic ReA and infection-related arthritis entities are similar. Therefore, poststreptococcal ReA, Poncet’s disease, and iBCG-induced ReA could be included in the expanding spectrum of ReA, especially based on the pathogenic mechanism.

Poncet’s disease (tuberculous rheumatism) in a Nigerian male: a frequently overlooked diagnosis

Poncet’s disease is an uncommon syndrome and a reactive polyarthritis associated with active tuberculosis with no evidence of mycobacterial infection of the joint. The condition is different from tuberculous arthritis which is usually monoarticular and caused by direct tubercular involvement of the joint. There has been a paucity of case reports on Poncet’s disease in Nigeria despite the high incidence of tuberculosis. We report a case of a 45-year male who presented with inflammatory polyarthritis involving the knees, wrists, ankles, small joints of the hands bilaterally of four weeks duration. This was preceded by three week’s history of productive cough. Chest radiograph and sputum Gene Xpert revealed features consistent with tuberculosis. Synovial fluid from knee joint effusion showed no evidence of mycobacterium tuberculosis. He was diagnosed to have Poncet’s disease based on the clinical findings and investigation results. He was commenced on antituberculous medications with complete resolution of symptoms after two months. Poncet’s disease is a rare manifestation of tuberculosis and should be considered a differential in any case of active tuberculosis presenting with arthritis. The correct and prompt identification of this condition by clinicians is important with the aim of instituting the appropriate therapy.

Poncet’s Disease Revisited

Tuberculosis (TB) is one of the most dreaded diseases prevalent in developing countries. Though primarily affecting the lungs, TB can affect almost any part of the body. The musculoskeletal system is the fourth most common extra-pulmonary target, after pleural, lymphatic and genitourinary system. Poncet’s Disease aka Tuberculous Rheumatism is a rare rheumatologic association of active Extra Pulmonary TB (EPTB) which may be easily missed/misdiagnosed even though TB is frequently encountered in medical practice. The authors present the case of an adolescent who presented with subacute symmetrical inflammatory arthritis of lower extremities. Investigations ruled out other rheumatological conditions. He recovered completely after receiving Antitubercular Treatment (ATT) for abdominal TB, which was diagnosed during workup.

Poncet’s Disease: A Case Report

Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis (MTB). It spreads from one person to the another through the air while coughing, spitting, speaking or sneezing. TB most commonly affects lungs but it can affect any organ system. Diagnosis of TB is made on the basis of microbiological evidence of MTB on microscopic examination, cultures and chest X-rays. Poncet’s disease is a separate entity in which joints are involved in the form of joint pain and swelling without any microbiological evidence of MTB. It usually occurs in the background setting of pulmonary TB. This case focuses on importance of considering Poncet’s disease in the differential diagnosis of paediatric polyarticular arthritis in TB endemic regions or if there is a history suggestive of TB exposure and infection.

THU0605 AN ATYPICAL CASE OF PONCET DISEASE

Background:Poncet disease (PD) is defined as an inflammatory rheumatism associated with visceral tuberculosis without direct bacteriological involvement of the joints [1]. It is classified as a parainfectious rather than a reactive arthritis [2].Objectives:Here by a first case of PD who presented with sterile arthritis and tuberculous spondylodiscitis.Methods:We report a case of a 40-year-old women who presented with polyarthritis in 2014. On physical examination, she had synovitis in both wrists, the metacarpophalangeal joints and the fifth proximal interphalangeal joint of the right hand. Her serum was negative for Rheumatoid Factor (RF) and anti-cyclic citrullinated peptide (anti-CCP) antibody. Her C-reactive protein (CRP) was 24,5mg/l. Ultrasound revealed tenosynovitis of the superficial and deep flexor tendons on both hands with Doppler signal. The Magnetic resonance imaging (MRI) of the hands showed active synovitis in the wrists mainly in the distal radioulnar joint, erosions in the ulnar styloid as well as edematous infiltration of the soft tissue of the hands. Since she fulfilled the new ACR/EULAR 2010 criteria for RA, a diagnosis of rheumatoid arthritis (RA) was made and the patient was put on Methotrexate (MTX) 15 mg/week/po in January 2015. Eight months later, the patient developed high temperature 38°c and lumbar stiffness. A chest CT performed as part of the etiologic investigation didn’t show pulmonary manifestations but revealed a lytic vertebrae lesion. Lumbar spine MRI showed prevertebral edema and soft tissue enhancement with abnormal marrow signal in L2 and L3 which was concerning for infectious etiology. MTX was stopped. A CT-guided core needle biopsy concluded to a tuberculous spondylodiscitis. The patient was initiated on an antituberculous-therapy (ATT) for 15 months. The course was marked by the reoccurrence of low back pain. MRI of the spine was then performed and revealed persistence of spondylodiscitis and multiple abscesses at the levels of L2-L3. The ATT was resumed.Results:The patient received four drugs for 4 months, followed by isoniazid and rifampicin for 1 year. At follow up, the patient responded well to treatment with complete resolution of symptoms without sequelae. She did not present neither polyarthritis nor synovitis. Moreover, she sustained a negative CRP (2mg/dl). Ultrasound control of the wrists did not show synovitis or tenosynovitis Doppler signal. Similarly, a disappearance of effusion as well as synovitis was noted on the MRI at follow up.Conclusion:We report a unique case of Poncet disease with tubercular spondylodiscitis. It is important to recognize PD in a patient presenting with polyarthritis in order to avoid unnecessary long-term disease-modifying antirheumatic treatment. Future research is indicated to understand the etiopathogenesis of Poncet’s disease and to educate clinicians as to the importance of maintaining a high index of suspicion about this rare, yet potentially easily treatable disease.References:[1]Sood R, Wali JP, Handa R. Poncet’s disease in a north Indian hospital. Trop Doctor. 1999; 29: 33-6.[2]Bloxham CA, Addy DP. Poncet’s disease: parainfective tuberculous polyarthropathy. Br Med J. 1978; 1: 1590.Disclosure of Interests:None declared

Poncet’s disease diagnostic criteria decodes conundrum: Poncet’s vs pseudo Poncet’s

Poncet’s disease is very important and yet a challenging diagnosis of importance in countries with high TB endemicity (e.g. India). In this case series, we present 5 patients with diagnosed as Poncet’s disease and in our tertiary health care center over 12 months and examine the performance of the diagnostic criteria suggested by Sharma and Pinto. The majority (4/5) of the patients were subsequently diagnosed and responded to anti-tuberculous therapy. In the other patient, a diagnosis of atypical seropositive rheumatoid arthritis or Pseudo Poncet’s disease was established on follow up.