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| Year : 2002 | Volume
: 36
| Issue : 1 | Page : 53-54 |
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| Tuberculous rheumatism (Poncet's disease) A case report |
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H Rao, LR Sharma, N Rao
Departments of Orthopaedics and Medicine, Krishna Institute of Medical Sciences, Karad, India
Click here for correspondence address and email
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How to cite this article:
Rao H, Sharma L R, Rao N. Tuberculous rheumatism (Poncet's disease) A case report. Indian J Orthop 2002;36:53-4 |
 Introduction | |  |
Tubercular rheumatism (Poncet's Disease) is a non-destructive parainfective symmetric polyarthritis occurring in patients with active visceral or disseminated tuberculosis, in which there is neither evidence of bacteriological involvement of joint themselves nor any other known cause of polyarthritis detected. [1] The symptoms resolve completely with anti-tuberculosis chemotherapy. [2] The condition is different from tubercular arthritis which is usually mono-articular and is caused by direct tubercular infection of the joint. This is an unusual and rare condition. Since 1974, about 29 cases have been reported in Western and Indian literature. Considering the incidence of tuberculosis in our country the number of reported cases of Poncet's disease reported are few. The diagnosis needs strong clinical suspicion. We decided to report this case of active tubercular polydactylitis with rheumatism as this has not been reported previously.
| Case Report | | |
A 16-year female reported with pain in multiple asymmetric small joints of the hands since 2 months, swelling over the same joints since 1 1/2 months. There was pain and swelling in symmetric large joints of the upper and lower limbs since 1 1/2 months without diurnal variation. There was also history of low-grade evening rise of temperature and loss of appetite and weight during the same period.
Initially the patient developed pain in her left ring finger PIP joint which was followed by gradually increasing swelling. After a few days PIP and DIP joints of right middle finger, both knees, both ankles and elbows developed painful swelling. The intensity of pain in the larger joints increased over passage of time and was aggravated by movement, relieved by rest and NSAIDs. There was also morning stiffness lasting for half an hour.
There was no history of trauma, conjunctivitis, bowel or bladder symptoms, or similar episodes in the past. There was neither family history of pulmonary tuberculosis rheumatic or autoimmune disease.
The vital parameters were within normal limits. The left ring finger had a diffuse spindle shaped swelling with slight increase in local temperature and tenderness over proximal and middle phalanges with terminal restriction of movement at the PIP joint. The right hand had similar findings over middle and proximal phalanges of ring finger and middle finger and the large joints (Knees, Ankles and elbows) had similar swelling, with mild tenderness bilaterally across the joint line with mild synovial hypertrophy. Effusion in the joints was minimal and the movements were terminally restricted and painful.
The patient had anemia (Hb 9.5gm), with leukocytosis (12900) 94% x 6% and ESR of 110 at the end of the first hour. RA factor, LE cell, ASO titre (1:200 dilution) were negative, serum uric acid was 2.6 mg% was normal, X-rays of hands showed findings of dactylitis of 4 th metacarpal left and proximal phalanges of left and right ring fingers and middle phalanx of right middle finger [Figure 1]. X-rays of knees, ankle, and elbows were normal.
Based on radiological evidence of polydactylitis we decided to take histopathogical specimen of synovial tissue from PIP joint left ring finger, the report revealed caseating granulomatous lesion suggestive of active tuberculosis.
The patient was treated with four-drug oral anti-tuberculosis treatment (INH, Rifampicin, PZA and Ethambutol) for 2 months thereafter INH and Rifampicin for 1 year. Within 2 weeks her arthralgia and swelling over large joints abated completely. However in her small joints marked regression of swelling was noted at 3 months after starting treatment and it regressed completely towards the end of treatment.
| Discussion | | |
Poncet first described the occurrence of polyarthritis in patients with active tuberculosis. [3] The initial concept of tubercular rheumatism was based on association of polyarthritis with:
- Active or inactive visceral tuberculosis, or
- Family history of tuberculosis, or
- Presence of a true tubercular joint in any patient before, coincident with, or following a polyarthritis of any type. [4]
The above criterion was met with many controversies, as it was very broad based and led to diagnostic inaccuracies. The very existence of such an entity was questioned by some. [4],[5] In this case histopathologically proven tubercular dactylitis with exclusion by radiological, serological and clinical means of other causes suggested the diagnosis of Poncet's disease. Further improvement of polyarthritis on starting antitubercular treatment within 2 weeks substantiated the diagnosis.
Symmetric involvement of large joints and asymmetric involvement of small joints of hands in this series were consistent with other series. [2] Lymphadenopathy was strikingly absent in contrast with other series. [2],[6] The age of our patient was 16 which is well within the age range 2-40 years reported in literature and further confirms the predilection of affection in children.
There are various hypothesis put forward to explain the pathogenesis of tubercular rheumatism. Genetic theory has been put forward ascribing a HLA linked hyper responsiveness to Mycobacterium antigen. [7] Immunological explanation has been given on the basis of finding a hypersensitive immune response to tuberculoprotein; [8] cross reactive immune response has also been thought of on the basis of finding antigenic similarity between human cartilage and fraction of Mycobacterium tuberculosis. [9] The tubercular bacilli have been found to be arthritogenic. This fact is based on observing chronic synovitis in animals injected with heat killed dessicated TB bacilli. [10] The mechanism of pain has been attributed to rapid accumulation of periarticular fluid possibly due to exaggerated hypersensitivity reaction. [11]
The severity of joint involvement may vary from arthralgia to acute or sub-acute rheumatism or could become chronic and deforming. In one case report the symptoms lasted for 18 months. [12] The joint symptoms may precede other manifestations of tuberculosis or there could be simultaneously involvement of joints with pulmonary tuberculosis.
Poncet's disease is essentially a diagnosis of exclusion and requires a high degree of clinical suspicion. Known cases of primary active tuberculosis should be suspected for Poncet's and also non-specific polyarthritis should be screened for primary active pulmonary or extra pulmonary lesions.
| References | | |
| 1. | Allen SC. A case in favour of Poncet's disease. Br Med J 1981; 283:952.  |
| 2. | Bhargava AD, Malviya AN. Tuberculous rheumatism (Poncet's disease) - A case series. Ind J Tub 1998; 45:215-219. |
| 3. | Poncet A. De la polyarthrites tuberculeuse deformante ou pseudorheumatisme chronique tuberculeux. Congres Francaise de chirurgerie 1897; 1:732. |
| 4. | Issacs AJ, Sturrock RD. Poncet's disease; fact or fiction? Tubercle 1974; 55:135. |
| 5. | Summers SD, Jayson MVIV. Does Poncet's disease exist? Rheumatol Rehab 1980; 19:149. |
| 6. | Ku FS, Li CL. Differential diagnosis of rheumatic fever and allergic arthritis due to tuberculosis. Chin Med J (Eng) 1966; 85:477. |
| 7. | Ottenhof THM, Torres P. HLA-DRA associated immune response gene for Mycobacteriumtuberculosis: a clue to the pathogenesis of rheumatoid arthritis. Lancet 1989; II: 310. |
| 8. | Dall L, Long L. Poncet's disease: Tuberculous rheumatism. Rev Inf Diseases 1989; 2(1): 105. |
| 9. | Holoshitz J, Drucker I. T lymphocytes of patients with rheumatoid arthritis patients show augumented reactivity to a fraction of mycobacteria cross reactive with cartilage. Lancet 1986;II: 305. |
| 10. | Pearson CM. Development of arthritis, periarthritis and periostitis in rats given adjuvants. Proc Soc Exp Biol Med 1956; 91:95. |
| 11. | Gupta SK, Singh KP. Tuberculous rheumatism. J Ind Med Assoc 1996; 94(9): 358-9. |
| 12. | Wilkinson AG, Roy S. Two cases of Poncet's disease. Tubercle 1984; 65(4): 301. |
Correspondence Address:
H Rao
KIMS, Karad, District Satara - 415110.
India
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