Two cases of polyarthritis in young people with extra-articular tuberculosis are described. The clinical features were consistent with the concept of Poncet\u27s disease. After synovial biopsy one patient proved to have tuberculous peripheral arthritis. This observation raised doubts about the diagnosis in the other patient. Multiple joints may be simultaneously infected with Mycobacterium tuberculosis and Poncet\u27s disease, if it exists, should not be entertained in the absence of synovial biopsy

Gibson, T

Hameed, K

Islam, N

Karim, M

English

eCommons@AKU

eCommons@AKUSection of Internal Medicine Department of MedicineSeptember 1993The diagnosis of Poncet's diseaseK HameedAga Khan UniversityM KarimAga Khan UniversityN IslamAga Khan University, najmul.islam@aku.eduT GibsonFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_med_intern_medPart of the Internal Medicine CommonsRecommended CitationHameed, K., Karim, M., Islam, N., Gibson, T. (1993). The diagnosis of Poncet's disease. British Journal of Rheumatology, 32(9),824-826.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_med_intern_med/100British Journal of Rheumatology 1993;32:824-826CASE REPORTSTHE DIAGNOSIS OF PONCET'S DISEASEK. HAMEED, M. KARIM, N. ISLAM and T. GIBSONDepartment of Medicine, Aga Khan University Hospital, Stadium Road, P.O.Box 3500, Karachi-74800,PakistanSUMMARYTwo cases of polyarthritis in young people with extra-articular tuberculosis are described. The clinical features were con-sistent with the concept of Poncet's disease. After synovial biopsy one patient proved to have tuberculous peripheralarthritis. This observation raised doubts about the diagnosis in the other patient. Multiple joints may be simultaneouslyinfected with Mycobacterium tuberculosis and Poncet's disease, if it exists, should not be entertained in the absence ofsynovial biopsy.KEY WORDS: Polyarthritis, Tuberculosis, Synovial biopsy.THERE is persistent scepticism about the existence ofPoncet's disease, a sterile polyarthritis associated withnon-articular tuberculosis [1]. There is even doubtabout whether Poncet intended such an interpretationof his observations. His principal hypothesis implicatedtuberculous infection (TB) in the aetiology of RA[2, 3]. We describe two patients with arthritis and TBwho illustrate the uncertainties of Poncet's disease.CASE REPORTSCase 1A 15-yr-old girl presented at our hospital with a 4-monthhistory of neck swelling, joint pain and fever. She was other-wise well. Examination revealed bilateral cervical lymphnode enlargement especially on the right (Fig. 1). The nodeswere discrete and were not tender. There were no otherabnormal findings apart from tender and warm swelling ofthe left wrist and fingers (Fig. 2), right elbow and ankle andthe left knee. There was no demonstrable knee joint effusion.Investigations were Hb 11.1 g/dl, WBC 6.0 x 10"9/l, neutro-phils 79%, ESR 95 mm/h, RF and anti-DNA negative. Bru-cella antibodies were negative and X-rays of involved jointswere normal. A biopsy of one cervical lymph node confirmedthe clinical suspicion of TB lymphadenitis by revealing typi-cal granulomata. Culture did not yield mycobacteria. A rheu-matologist suggested that the arthritis was due to Poncet'sdisease. A synovial biopsy was not performed and quadrupleanti-tuberculous treatment was implemented. Within 4months the lymph node enlargement and synovitis hadresolved. Six months after commencing treatment she waswell.Case 2An 18-yr-old male student was admitted to the hospitalwith an 8-month history of fever, neck, sternal and peripheraljoint pain affecting the right shoulder, left wrist and ankle.His presentation coincided with that of case 1. There was noantecedent medical history. He was afebrile and there waspronounced restriction of head rotation. Right shouldermovement was limited by pain and the left wrist and ankleSubmitted 1 February: revised version accepted 5 May 1993.Correspondence to T. Gibson, Department of Rheumatology,Guys Hospital, London SE1 9RT.0263-7103/93/090824 + 03 $08.00/0were warm, swollen and tender. There was no neurologicaldeficit. Investigations revealed: Hb 12.1 g/dl, WBC7.0 x 10"9/l, neutrophils 70%, ESR 95 mm/h. Brucella anti-bodies were negative. X-rays of involved peripheral jointswere normal but views of the spine demonstrated destructionof C3, 5, 7, Dl and L5 vertebrae with little loss of interver-tebral disc spaces (Fig. 3). Computerized tomography wasused to obtain a needle biopsy of the involved lumbar ver-tebra. This yielded tissue containing granulomata typical ofTB infection. A diagnosis of TB osteomyelitis was made andquadruple anti-tuberculous treatment commenced. A rheu-matologist suggested that the peripheral arthritis was due toPoncet's disease. An open synovial biopsy of the left wristwas obtained 5 days after treatment was started when thesynovitis appeared to be receding. This revealed multiplecaseating granulomata. The patient remained in hospital forseveral weeks, during which time the arthritis resolved andhis neck pain improved sufficiently for him to be dischargedwearing a collar.DISCUSSIONSince 1974, there have been at least 11 English lan-guage reports of Poncet's disease describing a total of19 cases [3-13]. Seven of these have derived from west-ern countries where TB is now uncommon. In Pakistan,the infection is endemic but as elsewhere, skeletal andjoint involvement is the least common manifestation[14]. A recent survey spanning 10 yr described 52 casesof peripheral TB arthritis [15]. None was ascribed toPoncet's disease even though 10% had at least twojoints involved simultaneously. The report confirmedthat young patients are especially susceptible to artic-ular disease and that oligoarthritis with involvement ofthe upper limbs is more common than is supposed. Thenotion that TB arthritis is exclusively monarticular is amisconception. Emphasis of this characteristic hasbeen deployed to support the diagnosis of Poncet'sdisease in polyarticular presentations [5]. In two suchinstances, an affected joint subsequently proved to be afocus of infection [3, 7].Critical examination of most reports of Poncet'sdisease reveals anomalies that raise doubts about theattribution of arthritis. The acceptance of polyarthra-© 1993 British Society for Rheumatology824Downloaded from https://academic.oup.com/rheumatology/article-abstract/32/9/824/1782149 by Francesca Farr on 10 October 2018HAMEED ETAL.: PONCET'S DISEASE 825FIG. 1.—Case 1 showing right sided cervical lymph node enlargement.lgia without objective evidence of synovitis has been anact of faith by some authors [2, 9]. Of the 19 casesdescribed, synovial biopsy was undertaken in only four[3, 7, 8, 13]. All failed to reveal evidence of TB butbiopsy of one joint was followed by subsequent iso-lation of mycobacteria [3] indicating that even biopsymay be inconclusive of TB arthritis. In our case 2, theclinical diagnosis of Poncet's disease was revised afteropen biopsy revealed the true nature of the arthritis.The patient also had infection of several vertebral sites,further evidence of the disseminating proclivity of theorganism. It is of interest that two previous reports ofPoncet's disease also had spinal osteomyelitis [8, 13].These, like both our patients were young. Of all thequoted cases, only three were aged more than 40 yr[11, 12]. It is noteworthy that it is the younger agegroups which appear more likely to develop TB infec-tive arthritis [15].Our Case 1 resembled examples of Poncet's diseasedescribed by some others in as much as she had objec-tive involvement of more than three joints [8, 13]. Thetender swelling of the fingers was probably secondaryto wrist synovitis. She did not undergo synovial biopsyin deference to her age and the rheumatologist's diag-nosis. However, Case 2 manifestly confirmed thatmultiple joints may be infected simultaneously byMycobacterium tuberculosis and the experience madethe diagnosis of Poncet's disease in Case 1 less secure.The arthritis of both patients responded to anti-TBtreatment and it is therefore likely that the arthritis wasFIG. 2.—Swollen left wrist and fingers in Case 1.Downloaded from https://academic.oup.com/rheumatology/article-abstract/32/9/824/1782149 by Francesca Farr on 10 October 2018826 BRITISH JOURNAL OF RHEUMATOLOGY VOL. 32 NO. 9FIG. 3.—Cervical spine X-ray of Case 2 revealing tubercularosteomyelitis at C3 and C5 vertebrae.not coincidental to tuberculosis. This is the usual thera-peutic outcome described for Poncet's disease whichunlike reactive arthritis has been associated only withcontinuing active infection at extra-articular sites.The possibility of Poncet's disease representing animmune response to mycobacterial antigens has,despite the apparent rarity of the disorder, promptedspeculation about the relationship between arthritis,65 kD heat shock protein, T cell responsiveness andimmunogenetic susceptibility [16, 17]. Although suchspeculation is of interest it would be advisable if futuredescriptions of Poncet's disease offered for publicationwere scrutinized with exceptional care. No case shouldbe accepted as further proof of such an entity withoutevidence of rigorous exclusion of TB joint infectionincluding synovial biopsy. The apparent paucity of thecondition in areas of the world where TB is commonand recognition that the organism may occasionallyinfect several joints makes us sceptical about the con-cept of Poncet's disease as a polyarticular immuneresponse to Mycobacterium tuberculosis.REFERENCES1. Summers G, Jayson M. Does Poncet's disease exist?Rheum Rehab 1980;19:149-50.2. Wilkinson MC. A note on Poncet's tuberculous rheu-matism. Tubercle 1967;48:297-306.3. Isaacs AJ, Sturrock RD. Poncet's disease—fact or fic-tion? Tubercle 1974;55:135^*2.4. Malik S, Khatri G, Deodhar S. Tuberculous rheuma-tism (Poncet's disease). J Indian Med Ass 1977;69:201-2.5. Bloxham C, Addy D. Poncet's disease: para-infectivetuberculous arthropathy. BMJ 1978;i:1590.6. Allen S. A case in favour of Poncet's disease. BMJ1981;283:952.7. Wilkinson A, Roy S. Two cases of Poncet's disease.Tubercle 1984;65L301-3.8. Southwood T, Hancock E, Petty R, Malleson P, Thies-sen P. Tuberculous rheumatism (Poncet's disease) ina child. Arthritis Rheum 1988;31:1311-13.9. Pande D, Dubey A, Choudhury P. Poncet's disease.Indian Pediat 1988;26:828-30.10. Dall L, Long L, Stanford J. Poncet's disease: tubercu-lous rheumatism. Rev Infectious Dis 1989,2:105-7.11. Khoury M. Does reactive arthritis to tuberculosis(Poncet's disease) exist? J Rheum 1989;16:1162.12. Maricic M, Alepa F. Reactive arthritis after mycobac-terium avium intracellulare infection: <• Poncet'sdisease revisited. Am J Med 1990;88:549-50.13. Ames P, Capasso G, Testa V, Maffulli N, Tortora M,Gaeta G. Chronic tuberculous rheumatism (Pon-cet's disease) in a gymnast. BrJ Rheumatol 1990^29:72-4.14. Alvarez S, McCabe W. Extra-pulmonary tuberculosisrevisited: a review of experience at Boston City andother hospitals. Medicine 1984;63:25-55.15. Garrido G, Gomez-Reino J, Fernandez-Dapica P, Pal-enque E, Prieto S. A review of peripheral tubercu-lous arthritis. Semin Arthritis Rheum 1988;18:142-9.16. Situnayake R, McConkey B. Does reactive arthritis totuberculosis (Poncet's disease) exist? J Rheumatol1989;16:1163-4.17. Southwood T, Gaston JSH. The molecular basis ofPoncet's disease? BrJ Rheumatol 1990;29:491.Downloaded from https://academic.oup.com/rheumatology/article-abstract/32/9/824/1782149 by Francesca Farr on 10 October 2018

The diagnosis of Poncet\u27s disease

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The diagnosis of Poncet\u27s disease

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