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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A Case of Poncet's Disease

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

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