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A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
A Case of Poncet's Disease
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  • Saw an 8 yr old girl today, who presented with high grade fever, swelling , warmth and tenderness of both knees. On performing ultrasound of the Knees, I saw synovial effusion with synovitis as manifested by increased blood flow on colour doppler. I though of JRA. On examining the other large joints, including the anjles, elbows, shoulder and hips, if found features of synovitis. Then I examined the chest and abdomen and found thickening of the ileocolic region with extensive abdominal nodes. On asking her father, he gave a history of the mother having TB 3 years back. Could it be a case of Poncet's disease ?
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  • DEAR SIR,
    VERY GOOD CASE FOR ACADEMICALLY VERY NICE AND RARE VARIETY .
    BEST WISH FOR YOU
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  • 1. An Interesting case of Arthritis S.Karthikeyan. Prof. P. VIJAYARAGHAVAN’s unit,M5
  • 2.
    • 20/F Ms.Vani presented with
    • c/o pain and swelling of joints of upper & lower
    • limbs – 15 days
    • On elaborating :
    • pain and swelling involved both knee,ankle & wrist
    • Started with pain, lead to swelling
    • Involvement of joints was simultaneous
    • difficulty in using the above joints +
    • other joints not involved
  • 3.
    • h/o fever-6 days +
    • Low grade, intermittent, in evening
    • no rigors & chills
    • No h/o rash,sore throat,
    • burning micturition,diarrhea
    • oral ulcers,photosensitivity
    • early morning stiffness
    • chest pain,palpitation,syncope
    • cough,breathlessness
    • abdominal pain/distension,jaundice
    • involuntary movements
    • loss of weight
  • 4.
    • Past history:
    • No similar illness in past
    • No h/o recurrent URIs
    • No h/o TB,RHD
    • Personal h/o:
    • Mixed diet
    • Family h/o:
    • No similar illness in family
    • Grandfather had PTB
    • & died 6 months back
  • 5.
    • O/E
    • Conscious,Oriented,Febrile,
    • No Pallor, Icterus, Cyanosis,
    • Clubbing,Pedal edema
    • rashes,generalised lymphadenopathy
    • Hydrated, JVP
    • Oral cavity – normal
    • VITALS:
    • Pulse 92/mt
    • B.P.120/80
    • Temp. - 99 F
  • 6.
    • CVS:
    • S1 S2+, no murmur
    • RS:
    • NVBS
    • ABDOMEN:
    • Soft,no organomegaly
    • CNS:
    • NFND
  • 7.
    • Musculoskeletal System:
    • Wrist, Ankle,Knee -
    • Symmetrical involvement+
    • Swelling+,
    • Warm,tender
    • Active&passive movements-
    • painful&restricted
    • Other joints not involved
  • 8.
    • Provisional Diagnosis:
    • Symmetrical Polyarthritis for evaluation
  • 9.  
  • 10.
    • INITIAL TREATMENT:
    • Bed rest
    • T.Brufen 400 mg tid
    • T.Ranitidine 150 mg bd
    • T.Bct 1 bd
  • 11. Investigations
    • CBC: RFT:
    • Hb – 10.2g B.urea: 30
    • TC -- 7200 Sr. creatinine : 0.8
    • DC – P60 L38 E2 B.sugar : 90
    • Plt -- 1.5 lakhs Sr. Sodium: 142
    • PCV -- 31 Sr. Potassium: 4.5
    • Sr. Calcium: 10
    • ESR 20/40mm Sr.Uricacid: 4.5 mg/dl
  • 12. Contd……….
    • Urine Routine:
    • sugar: nil
    • albumin: nil
    • deposits: 1-2 pus cells
    • LFT:
    • T.Bilurubin: 1 mg T.Protein: 7 g/dl
    • D.bilurubin: 0.3 mg Sr.albumin:4.5g/dl
    • SGOT : 28 IU/L Sr.globulin:3.5g/dl
    • SGPT : 32 IU/L
    • ALK.PHOSPHATASE: 80 IU/L
  • 13. Fever profile
    • Smear Mp/Mf : negative
    • Blood widal : negative
    • Dengue IgM/G:negative
    • MSAT: negative
    • Blood c/s:
    • Urine c/s: no growth
    • Throat swab c/s:
  • 14. Rheumatology work up
    • ASO : 1:100 dil
    • CRP : 20 mg/l
    • ANA: negative
    • RF : negative
    • Anti CCP:0.57 U/ml (negative)
    • P.smear : normocytic normochromic anaemia
  • 15. Imaging
    • Xray chest:
    • X ray knee,ankle,wrist: normal study
    • USG Abd:
  • 16.  
  • 17.  
  • 18.  
  • 19.  
  • 20. Cardio work up
    • ECG: wnl
    • ECHO:
    • EF:65%
    • Normal valves
    • Normal chambers
    • Normal LV Systolic function
  • 21.
    • Synovial fluid aspiration: dry tap
  • 22.
    • DIFFERENTIAL DIAGNOSIS
  • 23. DDs
    • VIRAL ARTHRITIS:
    • Arthropod borne:
    • chikungunya,onyong-yong,Rossriver
    • fever with itchy rash+
    • symmetric arthritis
    • small joints of hands & feet most
    • commonly involved
    • large joints may be involved
    • resolves in 7--- 10 days
  • 24.
    • Other viruses:
    • Rubella ---- small joints involved
    • Parvo virus B19 --- adults arthralgia +
    • Hepatitis B --- symptoms resolve with jaundice
    • abnormal LFT
  • 25.
    • BACTERIAL ARTHRITIS:
    • Gonococcal Arthritis:
    • colonisation of throat,cervix,urethra+
    • gonococcal bactrermia+
    • fever, chills,papules pustules
    • migratory arthritis
    • Non-gonococcal Arthritis:
    • S.aureus,S.pyogenes,H.influenzae
    • monoarthritis usually
    • poly articular in Rheumatoid Arthritis pts
  • 26.
    • Reactive polyarthritis :
    • occurs 1—4 weeks after non gonococcal
    • urethritis/enteric infections
    • caused by yersinia,shigella,campylobacter
    • salmonella
    • asymmetric oligoarthritis +
    • associated with uveitis,conjunctivitis,rashes
  • 27.
    • GOUT:
    • occurs in elderly men/post menopausal
    • women
    • premenopausal gout rare
    • initially mono articular polyarticular
    • metatorsophalanaeal of 1 st toe involved
    • attacks subside in 3—10 days
  • 28.
    • Acute rheumatic fever: criteria not fulfilled
    • Arthritis associated with Bacterial
    • endocarditis: criteria not fulfilled
  • 29. Chronic Arthritis initial presentation
    • SLE:
    • CRITERIA NOT FULFILLED
    • RA:
  • 30.  
  • 31.
    • “CLINCHING INESTIGATION”
    • “MANTOUX”
    • “ 20 mm “
  • 32.
    • Background of TB contact
    • Acute symmetric polyarthritis
    • ESR/CRP/ Other Rheumatological
    • work up -- negative
    • other likely diagnosis excluded
    • MANTOUX --- “20 mm” positive
    • “ PONCET” disease
  • 33. FOLLOW UP
    • Patient became symptom free 14 DAYS after
    • Starting CAT 1 ATT
  • 34. ORIGINAL DEFINITION by PONCET
    • DEFINED AS “the association of polyarthritis with
      • (i) active or inactive visceral tuberculosis or
      • (ii) a family history of tuberculosis or
      • (iii) the presence of a true tuberculous joint in any patient before, coincident with, or following a polyarthitis of any type” .
    • This definition lacked diagnostic precision and led to the inclusion by Poncet of patients who clearly had other rheumatic diseases like rheumatoid arthritis.
  • 35. Poncet’s disease (Tuberculous Rheumatism)
    • DEFNITION: “ polyarthritis associated with visceral tuberculosis in which there is no evidence of bacteriologic involvement of the joints themselves.”
    • It may precede underlying active TB
    • The diagnosis is largely clinical and is made by excluding other causes of polyarthritis
  • 36. Poncet’s pathogensis
    • Despite the difference in clinical presentation, the pathogenetic mechanism is considered to be similar to other reactive arthritis.
    • It has been hypothesized “ that after infection, as a result of systemic immunization, sensitized CD4+ cells together with bacterial antigens migrate to the joints and cause arthritis”.
  • 37. Clinical features
    • polyarticular, symmetrical, arthritis of predominantly the large joints.
    • Knee is the most frequently involved joint .
    • Case reports describe patients ranging from 2 years to 40 years indicating that Poncet’s disease predominantly occurs in young adults and children.
    • Arthritis in Poncet’s disease is usually acute or subacute in onset and duration.
    • A strongly positive reaction to tuberculin , frequently observed in the literature.
  • 38. Contd…
    • Associated with extrapulmonary TB more often than PTB
    • Under lying lymph node TB common
    • Erythema nodosum --- 6%
  • 39. Para infective Vs Reactive arthritis
    • Poncet’s disease has been now called a para-infective arthritis
    • A para-infective arthritis is like reactive arthritis, an aseptic arthritis triggered by an infection outside the joint.
    • However, in para-infective arthritis, treatment of the infection leads to cure of the arthritis unlike true reactive arthritis where this does not always lead to resolution of the arthritis .
  • 40. Contd…….
    • Chronic arthritis has never been reported in Poncet's disease.
    • Poncet's disease is generally, except in two reports, not associated with sacroiliitis.
  • 41. Carry home points…..
    • Poncet disease is rare “ a para-infective symmetrical polyarthritis involving predominantly large joints”
    • Can precede,follow or manifest concomitantly
    • with features of active TB…..mostly extrapulmonary
    • Diagnosis is largely clinical and by exclusion of other potential possibilities
    • Strongly positive tuberculin reaction+
    • Complete resolution of arthritis of Poncet’s disease on anti-tuberculosis therapy within days also furnishes further proof of the diagnosis.
  • 42. References
    • Harrison’s Principles of internal medicine
    • 17 th edition
    • Kelly’s text book of Rheumatology
    • eMedicine
    • Ind. J. Tub., 1988, 35, 28
    • Oxford journal of Rheumatology
  • 43. THANK YOU

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