Poncet's disease and papulonecrotic tuberculid in a patient infected with the human immunodeficiency virus

Poncet's disease: two case reports

BACKGROUND

One of the rare presentations of active pulmonary or even extrapulmonary tuberculosis is polyarthropathy which is the involvement of multiple large and small joints in the body; a reactive constellation known as Poncet's disease. This may sometimes be the sole manifestation of the disease before more obvious features develop. The pain experienced during polyarthritis can be crippling thereby limiting the mobility and activities of patients. Polyarthritis as a symptom of active tuberculosis can be easily misinterpreted for more common causes of polyarthritis such as rheumatological diseases that present similarly.

CASE PRESENTATION

We describe the case of a 25-year-old Asian woman and a 45-year-old Asian man who presented with active tuberculosis where polyarthralgia was the first and only symptom for many months followed by pulmonary and pleural manifestations. Both patients showed dramatic improvement with anti-tuberculous therapy. The total duration of therapy was 6 months.

CONCLUSIONS

Based on our observations, we propose that tuberculosis be included among the differentials for patients with unusual presentation of joint pains, especially in endemic regions and/or susceptible populations.

Clinical features of Poncet's disease. From the description of 198 cases found in the literature

Poncet's disease (PD) is an entity described as a reactive arthritis due to tuberculous infection elsewhere from the joints. PD existence has been questioned; however, more cases have been reported over the years. Due to its rare nature, little is known about the clinical picture of this disease and no prospective studies had been made to address this issue. We performed a systematic review of the written literature on PD in different databases using the key words "Poncet's disease," "tuberculous rheumatism," and "tuberculous reactive arthritis." Out of 78 articles, 198 patients were included in the analysis, plus our patient. Several characteristic patterns were found. Also, a review of the pathogenesis and some hypotheses are made. PD is a well-defined entity, which should be taken as a reactive arthritis for future studies given the increase in TB incidence and prevalence around the world, especially in high-burden countries.

Cutaneous Tuberculosis : A Clinico-morphological Study

BACKGROUND

Cutaneous tuberculosis forms a small subset of extrapulmonary tuberculosis. The present study is an attempt to observe the clinico morphological pattern seen in cases of cutaneous tuberculosis over a period of 5 years, and to correlate them with mantoux reactivity and human immunodeficiency virus (HIV) status.

METHODS

All cases of cutaneous tuberculosis observed among the dermatology in patients and those attending out patient department were included in the study. The basis of diagnosis was clinical, histopathological and microbiological. Intradermal mantoux test and serological test in the form of enzyme-linked immunosorbent assay (ELISA) for tuberculosis was done. HIV screening was carried out in 32 cases. CD4 counts were done in all HIV positive cases.

RESULTS

A total 0.02% patient attending the dermatology centre had cutaneous tuberculosis. The spectrum of infection included 19 (51%) cases of lupus vulgaris, 7 (19%) cases of papulonecrotic tuberculids, six cases each of tuberculosis verrucosa cutis and scrofuloderma. One case had scrofuloderma and lupus vulgaris and another both scrofuloderma and papulonecrotic tuberculide. One case of lichen scrofulosorum was seen in a seven year old boy. 11 cases revealed evidence of systemic tuberculosis. Seven cases of HIV with CD4 counts between 50-500 cells/μl were observed in this study.

CC chemokine receptor (CCR)-2 prevents arthritis development following infection by Mycobacterium avium

The host factors that influence autoimmune arthritides such as rheumatoid arthritis have not been fully elucidated. We previously found that genetic inactivation of CC chemokine receptor 2 (CCR2) in the arthritis-prone DBA/1j mouse strain significantly increases the susceptibility of this strain to autoimmune arthritis induced by immunization with collagen type II (CII) and complete Freund's adjuvant (CFA). Here, we show that following intradermal infection with Mycobacterium avium, a similar arthritis phenotype was detected in Ccr2-null mice in the DBA/1j, but not in the BALB/c background. The failure to develop arthritis in Ccr2-null BALB/c mice occurred in the face of high bacterial burdens and low interferon gamma (IFNgamma) production. By contrast, Ccr2-null DBA/1j mice had low bacterial burdens, produced normal amounts of IFNgamma, and had high titers of autoantibodies against CII. Thus, the Ccr2-null state in an arthritic-prone genetic background leads to increased arthritis susceptibility following infectious (M. avium) and noninfectious (CII/CFA) challenges. Because CCR2 serves as a negative regulator of murine arthritis, caution might need to be exercised while testing CCR2 blockers in human arthritis or other diseases. These findings also indicate that Ccr2-null DBA/1j mice might serve as a valuable model system to uncover the immunological determinants of arthritis and to test novel antiarthritic agents.