An Interesting An Interesting case of Arthritiscase of Arthritis

S.Karthikeyan.S.Karthikeyan.

Prof. P. VIJAYARAGHAVAN’s Prof. P. VIJAYARAGHAVAN’s unit,M5unit,M5

20/F Ms.Vani presented with20/F Ms.Vani presented with c/o pain and swelling of joints of upper & c/o pain and swelling of joints of upper &

lower lower

limbs – 15 dayslimbs – 15 days

On elaborating :On elaborating : pain and swelling involved both pain and swelling involved both

knee,ankle & wristknee,ankle & wrist Started with pain, lead to swellingStarted with pain, lead to swelling Involvement of joints was simultaneousInvolvement of joints was simultaneous difficulty in using the above joints +difficulty in using the above joints + other joints not involvedother joints not involved

h/o fever-6 days +h/o fever-6 days + Low grade, intermittent, in Low grade, intermittent, in

eveningevening no rigors & chillsno rigors & chills No h/o rash,sore throat,No h/o rash,sore throat, burning micturition,diarrhea burning micturition,diarrhea oral ulcers,photosensitivityoral ulcers,photosensitivity early morning stiffnessearly morning stiffness chest pain,palpitation,syncopechest pain,palpitation,syncope cough,breathlessnesscough,breathlessness abdominal pain/distension,jaundiceabdominal pain/distension,jaundice involuntary movementsinvoluntary movements loss of weight loss of weight

Past history: Past history:

No similar illness in pastNo similar illness in past

No h/o recurrent URIs No h/o recurrent URIs

No h/o TB,RHDNo h/o TB,RHD Personal h/o:Personal h/o:

Mixed dietMixed diet Family h/o:Family h/o:

No similar illness in familyNo similar illness in family

Grandfather had PTB Grandfather had PTB

& died 6 months back& died 6 months back

O/EO/E Conscious,Oriented,Febrile,Conscious,Oriented,Febrile, No Pallor, Icterus, Cyanosis,No Pallor, Icterus, Cyanosis, Clubbing,Pedal edemaClubbing,Pedal edema rashes,generalised rashes,generalised

lymphadenopathylymphadenopathy Hydrated, JVP Hydrated, JVP Oral cavity – normalOral cavity – normal VITALS:VITALS: Pulse 92/mtPulse 92/mt B.P.120/80B.P.120/80 Temp. - 99 FTemp. - 99 F

CVS:CVS: S1 S2+, no murmurS1 S2+, no murmur

RS:RS: NVBSNVBS

ABDOMEN:ABDOMEN: Soft,no organomegalySoft,no organomegaly

CNS:CNS: NFNDNFND

Musculoskeletal System:Musculoskeletal System:

Wrist, Ankle,Knee -Wrist, Ankle,Knee -

Symmetrical involvement+ Symmetrical involvement+

Swelling+,Swelling+,

Warm,tenderWarm,tender

Active&passive movements- Active&passive movements-

painful&restricted painful&restricted

Other joints not involved Other joints not involved

Provisional Diagnosis:Provisional Diagnosis:

Symmetrical Polyarthritis for Symmetrical Polyarthritis for evaluationevaluation

INITIAL TREATMENT:INITIAL TREATMENT:

Bed restBed rest

T.Brufen 400 mg tidT.Brufen 400 mg tid

T.Ranitidine 150 mg bdT.Ranitidine 150 mg bd

T.Bct 1 bdT.Bct 1 bd

Investigations Investigations CBC: RFT:CBC: RFT: Hb – 10.2g B.urea: 30Hb – 10.2g B.urea: 30 TC -- 7200 Sr. creatinine : 0.8TC -- 7200 Sr. creatinine : 0.8 DC – P60 L38 E2 B.sugar : 90DC – P60 L38 E2 B.sugar : 90 Plt -- 1.5 lakhs Sr. Sodium: 142 Plt -- 1.5 lakhs Sr. Sodium: 142 PCV -- 31 Sr. Potassium: 4.5PCV -- 31 Sr. Potassium: 4.5 Sr. Calcium: 10 Sr. Calcium: 10 ESR 20/40mm ESR 20/40mm Sr.Uricacid: 4.5 Sr.Uricacid: 4.5

mg/dlmg/dl

Contd……….Contd………. Urine Routine:Urine Routine: sugar: nilsugar: nil albumin: nilalbumin: nil deposits: 1-2 pus cellsdeposits: 1-2 pus cells LFT: LFT: T.Bilurubin: 1 mg T.Protein: 7 g/dlT.Bilurubin: 1 mg T.Protein: 7 g/dl D.bilurubin: 0.3 mg D.bilurubin: 0.3 mg

Sr.albumin:4.5g/dlSr.albumin:4.5g/dl SGOT : 28 IU/L SGOT : 28 IU/L

Sr.globulin:3.5g/dlSr.globulin:3.5g/dl SGPT : 32 IU/LSGPT : 32 IU/L ALK.PHOSPHATASE: 80 IU/LALK.PHOSPHATASE: 80 IU/L

Fever profileFever profile Smear Mp/Mf : negativeSmear Mp/Mf : negative

Blood widal : negativeBlood widal : negative

Dengue IgM/G:negativeDengue IgM/G:negative

MSAT: negativeMSAT: negative

Blood c/s:Blood c/s: Urine c/s: no growthUrine c/s: no growth Throat swab c/s:Throat swab c/s:

Rheumatology Rheumatology work upwork up ASO : 1:100 dilASO : 1:100 dil

CRP : 20 mg/lCRP : 20 mg/l

ANA: negativeANA: negative

RF : negativeRF : negative

Anti CCP:0.57 U/ml (negative)Anti CCP:0.57 U/ml (negative)

P.smear : normocytic normochromic P.smear : normocytic normochromic anaemia anaemia

Imaging Imaging

Xray chest: Xray chest:

X ray knee,ankle,wrist: normal X ray knee,ankle,wrist: normal studystudy

USG Abd:USG Abd:

Cardio work upCardio work up

ECG: wnlECG: wnl ECHO:ECHO:

EF:65%EF:65%

Normal valvesNormal valves

Normal chambersNormal chambers

Normal LV Systolic functionNormal LV Systolic function

Synovial fluid aspiration: dry tapSynovial fluid aspiration: dry tap

DIFFERENTIAL DIFFERENTIAL DIAGNOSISDIAGNOSIS

DDsDDs VIRAL ARTHRITIS:VIRAL ARTHRITIS: Arthropod borne:Arthropod borne:

chikungunya,onyong-chikungunya,onyong-yong,Rossriveryong,Rossriver

fever with itchy rash+fever with itchy rash+

symmetric arthritissymmetric arthritis

small joints of hands & feet small joints of hands & feet most most

commonly involvedcommonly involved

large joints may be involvedlarge joints may be involved

resolves in 7--- 10 daysresolves in 7--- 10 days

Other viruses:Other viruses: Rubella ---- Rubella ---- small joints involvedsmall joints involved

Parvo virus B19 ---Parvo virus B19 ---adults arthralgia +adults arthralgia +

Hepatitis B ---Hepatitis B ---symptoms resolve with symptoms resolve with jaundicejaundice

abnormal LFTabnormal LFT

BACTERIAL ARTHRITIS:BACTERIAL ARTHRITIS: Gonococcal Arthritis:Gonococcal Arthritis: colonisation of colonisation of

throat,cervix,urethra+throat,cervix,urethra+ gonococcal bactrermia+gonococcal bactrermia+ fever, chills,papules pustulesfever, chills,papules pustules migratory arthritismigratory arthritis Non-gonococcal Arthritis:Non-gonococcal Arthritis: S.aureus,S.pyogenes,H.influenzaeS.aureus,S.pyogenes,H.influenzae monoarthritis usuallymonoarthritis usually poly articular in Rheumatoid poly articular in Rheumatoid

Arthritis pts Arthritis pts

Reactive polyarthritis :Reactive polyarthritis :

occurs 1—4 weeks after non gonococcaloccurs 1—4 weeks after non gonococcal

urethritis/enteric urethritis/enteric infectionsinfections

caused by caused by yersinia,shigella,campylobacteryersinia,shigella,campylobacter

salmonellasalmonella

asymmetric oligoarthritis +asymmetric oligoarthritis +

associated with associated with uveitis,conjunctivitis,rashesuveitis,conjunctivitis,rashes

GOUT:GOUT: occurs in elderly men/post menopausaloccurs in elderly men/post menopausal womenwomen

premenopausal gout rarepremenopausal gout rare

initially mono articular initially mono articular polyarticularpolyarticular

metatorsophalanaeal of 1metatorsophalanaeal of 1stst toe involved toe involved

attacks subside attacks subside in 3—10 daysin 3—10 days

Acute rheumatic fever: Acute rheumatic fever: criteria not criteria not fulfilledfulfilled

Arthritis associated with BacterialArthritis associated with Bacterial

endocarditis:endocarditis: criteria not fulfilled criteria not fulfilled

Chronic ArthritisChronic Arthritisinitial presentationinitial presentation

SLE:SLE:

CRITERIA NOT CRITERIA NOT FULFILLEDFULFILLED

RA: RA:

“ “CLINCHING CLINCHING INESTIGATION”INESTIGATION”

“ “MANTOUX”MANTOUX”

“ “20 mm “20 mm “

Background of TB contact Background of TB contact

Acute symmetric polyarthritisAcute symmetric polyarthritis

ESR/CRP/ Other ESR/CRP/ Other Rheumatological Rheumatological

work up -- negativework up -- negative

other likely diagnosis excluded other likely diagnosis excluded

MANTOUX --- “20 mm” positiveMANTOUX --- “20 mm” positive

““PONCET” diseasePONCET” disease

FOLLOW UPFOLLOW UP

Patient became symptom free 14 Patient became symptom free 14 DAYS after DAYS after

Starting CAT 1 ATTStarting CAT 1 ATT

ORIGINAL DEFINITION ORIGINAL DEFINITION by PONCETby PONCET

DEFINED AS “the association of DEFINED AS “the association of polyarthritis with polyarthritis with (i) active or inactive visceral tuberculosis or (i) active or inactive visceral tuberculosis or (ii) a family history of tuberculosis or (ii) a family history of tuberculosis or (iii) the presence of a true tuberculous joint in (iii) the presence of a true tuberculous joint in

any patient before, coincident with, or any patient before, coincident with, or following a polyarthitis of any type” .following a polyarthitis of any type” .

This definition This definition lacked diagnostic precision lacked diagnostic precision

and led to the inclusion by Poncet of and led to the inclusion by Poncet of patients who clearly had other rheumatic patients who clearly had other rheumatic diseases like rheumatoid arthritis.diseases like rheumatoid arthritis.

Poncet’s disease Poncet’s disease (Tuberculous Rheumatism)(Tuberculous Rheumatism)

DEFNITION: DEFNITION: ““polyarthritis associated polyarthritis associated with visceral tuberculosis in which with visceral tuberculosis in which there is no evidence of bacteriologic there is no evidence of bacteriologic involvement of the joints themselves.” involvement of the joints themselves.”

It It may precede may precede underlying active TB underlying active TB

The diagnosis is largely clinical and is The diagnosis is largely clinical and is made by made by excluding excluding other causes of other causes of polyarthritis polyarthritis

Poncet’s pathogensisPoncet’s pathogensis Despite the difference in clinical presentation, Despite the difference in clinical presentation,

the pathogenetic mechanism is considered to be the pathogenetic mechanism is considered to be similar to other reactive arthritis. similar to other reactive arthritis.

It has been hypothesized “It has been hypothesized “that after infection, as that after infection, as a result of systemic immunization, sensitized a result of systemic immunization, sensitized CD4+ cells together with bacterial antigens CD4+ cells together with bacterial antigens migrate to the joints and cause arthritis”. migrate to the joints and cause arthritis”.

Clinical featuresClinical features polyarticular, symmetrical, arthritis of polyarticular, symmetrical, arthritis of

predominantly the large joints.predominantly the large joints. Knee Knee is the most frequently involved is the most frequently involved

jointjoint.. Case reports describe patients ranging Case reports describe patients ranging

from from 2 years to 40 years 2 years to 40 years indicating that indicating that Poncet’s disease predominantly occurs in Poncet’s disease predominantly occurs in young adults and children.young adults and children.

Arthritis in Poncet’s disease is Arthritis in Poncet’s disease is usually usually acute or subacute acute or subacute in onset and duration. in onset and duration.

A strongly A strongly positive reaction to tuberculinpositive reaction to tuberculin, , frequently observed in the literature.frequently observed in the literature.

Contd…Contd…

Associated with Associated with extrapulmonary TB extrapulmonary TB more often than PTBmore often than PTB

Under lying Under lying lymph node TB lymph node TB commoncommon

Erythema nodosum Erythema nodosum --- 6%--- 6%

Para infective Vs Reactive Para infective Vs Reactive arthritisarthritis

Poncet’s disease has been now called a Poncet’s disease has been now called a para-infective arthritis para-infective arthritis

A para-infective arthritis is A para-infective arthritis is likelike reactive reactive arthritis, an aseptic arthritis triggered arthritis, an aseptic arthritis triggered by an infection outside the joint. by an infection outside the joint.

However, in para-infective arthritis, However, in para-infective arthritis, treatment of the infection treatment of the infection leads to cure leads to cure of the arthritis unlike true reactive of the arthritis unlike true reactive arthritis where this does not always arthritis where this does not always lead to resolution of the arthritislead to resolution of the arthritis. .

Contd…….Contd…….

Chronic arthritis Chronic arthritis has never been has never been

reported in Poncet's disease. reported in Poncet's disease.

Poncet's disease is generally, except Poncet's disease is generally, except in two reports, in two reports, not associated with not associated with sacroiliitis.sacroiliitis.

Carry home points…..Carry home points….. Poncet disease is Poncet disease is rare rare ““ a para-infective a para-infective

symmetrical polyarthritis involving symmetrical polyarthritis involving predominantly large joints”predominantly large joints”

Can Can precede,follow or manifest concomitantlyprecede,follow or manifest concomitantly

with features of active TB…..mostly with features of active TB…..mostly extrapulmonaryextrapulmonary

Diagnosis is Diagnosis is largely clinical and by exclusion largely clinical and by exclusion of of other potential possibilitiesother potential possibilities

Strongly Strongly positive tuberculin reaction+positive tuberculin reaction+ Complete resolution of arthritis of Poncet’s Complete resolution of arthritis of Poncet’s

disease on anti-tuberculosis therapy disease on anti-tuberculosis therapy within within days days also furnishes further proof of the also furnishes further proof of the diagnosis.diagnosis.

References References

Harrison’s Principles of internal Harrison’s Principles of internal medicinemedicine

1717thth edition edition Kelly’s text book of RheumatologyKelly’s text book of Rheumatology eMedicineeMedicine Ind. J. Tub., 1988, 35, 28Ind. J. Tub., 1988, 35, 28 Oxford journal of RheumatologyOxford journal of Rheumatology

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