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Ooi PS, Ismail H, Meganathan G, Nabila Saidi N, Dhamotharan Y, Chua HH. Poncet disease in a patient with smear-negative pulmonary tuberculosis: A case report. MALAYSIAN FAMILY PHYSICIAN : THE OFFICIAL JOURNAL OF THE ACADEMY OF FAMILY PHYSICIANS OF MALAYSIA 2024; 19:49. [PMID: 39220238 PMCID: PMC11366276 DOI: 10.51866/cr.581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Pulmonary tuberculosis poses a diagnostic dilemma to clinicians especially in the absence of typical presentation. The hypersensitivity to tuberculosis infection in other parts of the body can lead to nondestructive, para-infectious arthritis. This is known as Poncet disease, one of the clinical syndromes of musculoskeletal tuberculosis. Herein, we report a case of smear-negative pulmonary tuberculosis presenting with atypical features. It started with multiple joint pain, followed by the presence of multiple tender nodular skin lesions over the bilateral shins and wrist. Subsequent investigations led to the diagnosis of smear-negative pulmonary tuberculosis. Joint pain and erythema nodosum disappeared soon after antituberculosis therapy, supporting the diagnosis of Poncet disease.
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Affiliation(s)
- Poh Siang Ooi
- MD, MMed (Family Medicine), Klinik Kesihatan Kepala Batas, Lot 1466, Mukim 6, Kepala Batas, Penang, Malaysia.
| | - Hartini Ismail
- MBBS, Klinik Kesihatan Kepala Batas, Lot 1466, Mukim 6, Kepala Batas, Ministry of Health Malaysia, Penang, Malaysia
| | - Gayatherri Meganathan
- MBBS, Klinik Kesihatan Kepala Batas, Lot 1466, Mukim 6, Kepala Batas, Ministry of Health Malaysia, Penang, Malaysia
| | - Nurfathehatul Nabila Saidi
- MBBS, Klinik Kesihatan Kepala Batas, Lot 1466, Mukim 6, Kepala Batas, Ministry of Health Malaysia, Penang, Malaysia
| | - Yeogeashweary Dhamotharan
- MBBS, Klinik Kesihatan Kepala Batas, Lot 1466, Mukim 6, Kepala Batas, Ministry of Health Malaysia, Penang, Malaysia
| | - Hui Heng Chua
- MD, MPath (Anatomic Pathology), Hospital Pulau Pinang, Jalan Residensi, George Town, Ministry of Health Malaysia, Penang, Malaysia
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Minotti C, Costenaro P, Donà D, Zuliani M, Bosa L, Leon A, Perilongo G, Gaio P, Martini G, Cananzi M. Disseminated Mycobacterial Infection With Reactive Polyarthritis (Poncet's Disease) During Immune-suppressive Treatment Including Ustekinumab for Pediatric Crohn's Disease. Pediatr Infect Dis J 2024; 43:543-549. [PMID: 38377462 DOI: 10.1097/inf.0000000000004277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
BACKGROUND The incidence of pediatric inflammatory bowel disease is increasing. tumor necrosis factor alpha inhibitors medicines improved the prognosis of affected subjects. Nonetheless, a proportion of patients do not respond or lose response to treatment. Newer biologics, like ustekinumab, have been approved for adults. The pediatric off-label use of these drugs is increasing, despite limited safety evidence. We report a case of disseminated mycobacterial infection (MI) presenting with reactive polyarthritis (Poncet's disease, PD) in a girl with Crohn's disease receiving various immunosuppressants, including ustekinumab. CASE REPORT A 12-year-old girl with Crohn's disease was admitted for acute-onset migratory polyarthritis of large and small joints and opioid-resistant pain. She had recently received adalimumab and methotrexate and was currently under treatment with ustekinumab. She was vaccinated with Bacillus Calmette-Guérin and screened for tuberculosis before starting immunosuppressants. Interferon-gamma release assay, Mantoux test and chest computed tomography scan were negative. Disseminated MI with PD was diagnosed following positive cultures for Mycobacterium tuberculosis complex in blood and intestinal biopsies (with negative in synovial fluid and gastric aspirate). Whole-exome sequencing did not identify any genetic susceptibility to MI. Antituberculosis treatment eradicated MI. CONCLUSIONS Children with inflammatory bowel disease receiving combination immunosuppressive treatments including tumor necrosis factor alpha inhibitors and anti-IL-12/23 agents are at higher risk for MI. Disseminated MI should be considered and ruled out in these patients when presenting with pulmonary, extrapulmonary or unusual clinical manifestations, like PD. The collection of multiple specimens (including intestinal biopsies) for mycobacterial culture is recommended when mycobacterial disease is suspected.
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Affiliation(s)
- Chiara Minotti
- From the Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
- PhD Program in Clinical Research, Pediatric Research Center, University Children's Hospital Basel, Basel, Switzerland
| | - Paola Costenaro
- From the Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Daniele Donà
- From the Division of Pediatric Infectious Diseases, Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Monica Zuliani
- Pediatric Radiology, Department for Integrated Diagnostic Services
| | - Luca Bosa
- Pediatric Gastroenterology, Digestive Endoscopy, Hepatology and Care of the Child with Liver Transplantation, Department of Women's and Children's Health, University Hospital of Padova
| | | | | | - Paola Gaio
- Pediatric Gastroenterology, Digestive Endoscopy, Hepatology and Care of the Child with Liver Transplantation, Department of Women's and Children's Health, University Hospital of Padova
| | - Giorgia Martini
- Pediatric Rheumatology, Department of Women's and Children's Health, University Hospital of Padova, Padova, Italy
| | - Mara Cananzi
- Pediatric Gastroenterology, Digestive Endoscopy, Hepatology and Care of the Child with Liver Transplantation, Department of Women's and Children's Health, University Hospital of Padova
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Baker H, Amaral JK, Schoen RT. Management of postinfectious inflammatory arthritis. Curr Opin Rheumatol 2024; 36:155-162. [PMID: 38411201 DOI: 10.1097/bor.0000000000001009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
PURPOSE OF REVIEW Postinfectious inflammatory arthritis can result from various pathogens, including bacteria, viruses, fungi, and parasites. Prompt identification and treatment of acute infection is vital, but some cases progress to chronic arthritis despite successful treatment of infection. Postinfectious inflammatory arthritis varies from mild, self-limited arthralgia to severe, refractory arthritis, necessitating ongoing disease-modifying treatment. This review explores the spectrum of postinfectious inflammatory arthritis to provide insights into effective management. RECENT FINDINGS Research continues regarding the benefit of antimicrobial therapy, beyond treatment of the acute infection, to diminish the severity of postinfectious inflammatory arthritis. Following treatment of acute infection, most cases are self-limited so treatment is symptomatic. However, a difficult-to-predict fraction of cases develop chronic postinfectious inflammatory arthritis that can be challenging to manage. Recently, as more biologic, and targeted synthetic DMARDs have become available, treatment options have expanded. SUMMARY In this article, we use the term 'postinfectious inflammatory arthritis' rather than 'reactive arthritis' because it describes a broader spectrum of diseases and emphasizes the common pathogenesis of a postinfectious inflammatory process. We summarize the conventional therapies and recent management developments for the most frequently encountered postinfectious inflammatory arthritides.
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Affiliation(s)
- Hailey Baker
- Section of Rheumatology, Allergy, and Immunology, Yale School of Medicine
| | - J Kennedy Amaral
- Institute of Diagnostic Medicine of Cariri, Juazeiro do Norte, Ceará, Brazil
| | - Robert T Schoen
- Section of Rheumatology, Allergy, and Immunology, Yale School of Medicine
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Zengin O, Göre B, Sağlar Y, Şahiner ES, İnan O, Ateş İ. Poncet's disease and tubal tuberculosis: A case report. Int J Rheum Dis 2024; 27:e14883. [PMID: 37602566 DOI: 10.1111/1756-185x.14883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/06/2023] [Accepted: 08/09/2023] [Indexed: 08/22/2023]
Abstract
A 25-year-old female patient was admitted to the hospital with abdominal pain, loss of appetite, and weight loss for the last 5 months. The patient underwent paracentesis five times and was referred to our clinic after peritonitis findings were detected. Tubal tuberculosis was detected during her hospitalization. The patient, who also developed joint pain, was diagnosed with Poncet's disease. She was given quadruple antituberculosis treatment. After the treatment, the patient's joint pain regressed, and the adnexal mass due to tubal tuberculosis disappeared. In this case report, we wanted to present a rare case of Poncet's disease with tubal tuberculosis.
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Affiliation(s)
- Oğuzhan Zengin
- Department of Internal Medicine, Ankara City Hospital, Ankara, Turkey
| | - Burak Göre
- Department of Internal Medicine, Ankara City Hospital, Ankara, Turkey
| | - Yunus Sağlar
- Department of Internal Medicine, Ankara City Hospital, Ankara, Turkey
| | | | - Osman İnan
- Department of Internal Medicine, Ankara City Hospital, Ankara, Turkey
| | - İhsan Ateş
- Department of Internal Medicine, Ankara City Hospital, Ankara, Turkey
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Higashiguchi M, Matsumoto T, Kitamura T, Nakajima T, Nishioka K, Kimura H, Yamamoto T, Komuta K. Poncet's Disease (Reactive Arthritis Associated with Tuberculosis). Intern Med 2022; 61:3245-3249. [PMID: 35342140 PMCID: PMC9683800 DOI: 10.2169/internalmedicine.9241-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
An 82-year-old man with miliary tuberculosis was admitted to our hospital. Approximately six weeks after starting anti-tuberculosis treatment, he complained of pain in the fingers, wrists, and ankles. A histopathological examination of the synovial biopsy revealed nonspecific chronic inflammation with no granulomas. Culture of the biopsy specimen yielded no acid-fast bacilli. Poncet's disease was diagnosed based on the clinical presentation, with no findings suggestive of other diseases. His joint pain rapidly improved with steroid therapy. Tuberculosis can cause arthritis through immune-mediated mechanisms without direct invasion in an entity known as Poncet's disease.
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Affiliation(s)
- Masayoshi Higashiguchi
- Department of Internal Medicine, Osaka Anti-Tuberculosis Association Osaka Fukujuji Hospital, Japan
| | - Tomoshige Matsumoto
- Department of Internal Medicine, Osaka Anti-Tuberculosis Association Osaka Fukujuji Hospital, Japan
| | - Takashi Kitamura
- Department of Orthopedic Surgery, Osaka Anti-Tuberculosis Association Osaka Fukujuji Hospital, Japan
| | - Takako Nakajima
- Department of Orthopedic Surgery, Osaka Anti-Tuberculosis Association Osaka Fukujuji Hospital, Japan
| | - Koji Nishioka
- Department of Internal Medicine, Osaka Anti-Tuberculosis Association Osaka Fukujuji Hospital, Japan
| | - Hiromi Kimura
- Department of Internal Medicine, Osaka Anti-Tuberculosis Association Osaka Fukujuji Hospital, Japan
| | - Takafumi Yamamoto
- Department of Orthopedic Surgery, Osaka Anti-Tuberculosis Association Osaka Fukujuji Hospital, Japan
| | - Kiyoshi Komuta
- Department of Internal Medicine, Osaka Anti-Tuberculosis Association Osaka Fukujuji Hospital, Japan
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Ding Y, Xue L. HLA-B27 negative reactive arthritis versus HLA-B27 positive reactive arthritis: A retrospective study. Medicine (Baltimore) 2022; 101:e30383. [PMID: 36107557 PMCID: PMC9439772 DOI: 10.1097/md.0000000000030383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Reactive arthritis (ReA) is defined as inflammatory arthritis secondary to an extra-articular infection with a key genetic background, HLA-B27. However, to date, the diagnosis and classification remain incomplete. The study focused on the similarities and differences in clinical manifestation, imaging features, and laboratory inspection between HLA-B27 negative patients and HLA-B27 positive patients in order to provide a reference for future development of diagnostic and classification criteria. Twenty-five ReA (19 HLA-B27 negative patients and 6 HLA-B27 positive patients) were included in this retrospective study. Clinical data, including demographics, clinical symptoms, imaging features, and laboratory inspection, were collected. The chi-square test and Mann-Whitney U test were used in the analysis. HLA-B27 negative group showed more involvement of upper extremities and small joints, while HLA-B27 positive group performed more axial symptoms. No significant difference was found in imaging features (ultrasound and magnetic resonance imaging) or laboratory inspection (microbes culture and infection-related indicators) between the 2 groups. ReA patients with different genetic backgrounds show various manifestations, although they encounter similar infections.
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Affiliation(s)
- Yimei Ding
- Department of Rheumatology and Immunology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Luan Xue
- Department of Rheumatology and Immunology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
- *Correspondence: Luan Xue, Department of Rheumatology and Immunology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai 200437, China (e-mail: )
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Jung Y, Choi BY. Differential Diagnosis of Inflammatory Arthropathy Accompanying Active Tuberculosis Infection. JOURNAL OF RHEUMATIC DISEASES 2022; 29:108-115. [PMID: 37475896 PMCID: PMC10327614 DOI: 10.4078/jrd.2022.29.2.108] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/14/2022] [Accepted: 02/15/2022] [Indexed: 07/22/2023]
Abstract
Objective The study aimed to ascertain the clinical manifestations of inflammatory arthritis accompanying tuberculosis (TB) for the differential diagnosis. Methods We retrospectively reviewed patients with active TB who presented with inflammatory arthropathy at Seoul Medical Center. Among 2,872 patients with active TB infection, 47 had inflammatory arthropathy 14 had crystal-induced arthropathy; 12, TB arthritis; 12, Poncet's disease (PD); 8, Rheumatoid arthritis (RA); and 1, septic arthritis. The clinical characteristics and laboratory and radiographic findings of each group were analyzed. Results In TB arthritis, weight-bearing joints were more commonly affected than the elbow and wrist joints. When compared to TB arthritis, PD demonstrated a significantly higher proportion of polyarthritis and involved both large and small-to-medium-sized joints. The duration of arthritis symptoms after anti-TB treatment was significantly shorter in patients with PD (56 days vs. 90 days, p=0.028). When compared to PD, RA flares during active TB infection involved only small-to-medium-sized joints rather than a mixed distribution (62.5% vs. 16.7%, p=0.035). Patients with PD more commonly had fever at onset and showed a good response to nonsteroidal anti-inflammatory drugs alone or were in remission within 3 months after anti-TB treatment. The presence of rheumatoid factor or anti-cyclic citrullinated peptide and radiographic progression after 12 months was frequently observed in patients with RA flares. Conclusion The differential diagnosis of inflammatory arthritis accompanying active tuberculosis infection is challenging. Comprehensive history taking and physical examination, synovial fluid analysis, and a high level of clinical suspicion are essential to avoid delayed diagnosis and to reduce the significant morbidity involved.
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Affiliation(s)
| | - Byoong Yong Choi
- Division of Rheumatology, Department of Internal Medicine, Seoul Medical Center, Seoul, Korea
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8
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Poncet's disease: a reactive arthritis secondary to pulmonary tuberculosis. Clin Rheumatol 2022; 41:1615-1616. [PMID: 35112194 DOI: 10.1007/s10067-022-06088-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 11/03/2022]
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Abstract
Rheumatoid arthritis (RA) can have various infectious mimics. As immunosuppressive agents used in treatment can aggravate the underlying infections, correct diagnosis of RA and ruling out infections is important. Numerous viral infections (Parvovirus B19, Hepatitis B, Hepatitis C, Chikungunya and other alphaviruses, human immunodeficiency virus (HIV) and various other viruses), mycobacterial infections (Poncet's disease, tubercular septic arthritis, and leprosy), bacterial arthritis, brucellosis and Lyme disease are among common infections that mimic RA. Widespread travel and tourism, especially to exotic areas, high risk sexual behavior and widespread use of immunosuppressive and chemotherapeutic agents has led to numerous outbreaks of infections in areas where these infections were never reported before. Hence, rheumatologists all over the world should be familiar with musculoskeletal manifestations of infections. History of travel, comorbid fever, skin rash, genital ulcers, urethral discharge, the consumption of unpasteurized milk, lymphadenopathy, tenosynovitis, low platelet count, and positive Mantoux test can offer potential diagnostic clues. Serological testing, cultures, specific radiological signs and deoxyribonucleic Acid (DNA) amplification techniques often aid in diagnosis. Treatment mainly consists of antimicrobial agents, analgesics, and nonsteroidal anti-inflammatory drugs (NSAIDs). However, immunosuppressive agents including steroids and disease modifying anti-rheumatic drugs (DMARDs) are needed occasionally in different refractory and prolonged illnesses. Most of the times, episodes of arthritis are self-limiting and respond to treatment of underlying cause. However, few infections like Chikungunya and Lyme's disease can lead to chronic arthritis as well.
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Affiliation(s)
- Vikas Sharma
- Rheumatology Superspeciality Cell, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India.
| | - Aman Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
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10
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Abstract
Reactive arthritis (ReA) is a form of inflammatory arthritis triggered by a remote antecedent infection, usually in the genitourinary or gastrointestinal tract. It is part of the spondyloarthropathy (SpA) spectrum, an umbrella term for a group of distinct conditions with shared clinical features. Typically, it presents with an asymmetric oligoarthritis of the lower limb joints, and patients may also have sacroiliitis, enthesitis and dactylitis. Other features often seen include anterior uveitis, urethritis and skin manifestations such as pustular lesions on the plantar areas. Although ReA was characterised initially as a sterile arthritis, the detection of metabolically active Chlamydia species in the joint fluid of some affected patients has generated further questions on the pathophysiology of this condition. There are no formal diagnostic criteria, and the diagnosis is mainly clinical. HLA-B27 can support the diagnosis in the correct clinical context, and serves as a prognostic indicator. The majority of patients have a self-limiting course, but some develop chronic SpA and require immunomodulatory therapy.
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Affiliation(s)
- Ameen Jubber
- Department of Rheumatology, University Hospitals of Leicester NHS Trust, Leicester, LE1 5WW, UK,
| | - Arumugam Moorthy
- Department of Rheumatology, University Hospitals of Leicester NHS Trust, Leicester; College of Life Sciences, University of Leicester, Leicester
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Dasgupta S, Kumar RR, Suman SK, Kumar U. Tuberculosis: A Rare Cause of Polyarthritis. J Clin Rheumatol 2021; 27:e179-e180. [PMID: 31977657 DOI: 10.1097/rhu.0000000000001309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Sauvik Dasgupta
- From the Department of Rheumatology, All India Institute of Medical Science, New Delhi, India
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12
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Taniguchi Y, Nishikawa H, Yoshida T, Terada Y, Tada K, Tamura N, Kobayashi S. Expanding the spectrum of reactive arthritis (ReA): classic ReA and infection-related arthritis including poststreptococcal ReA, Poncet's disease, and iBCG-induced ReA. Rheumatol Int 2021; 41:1387-1398. [PMID: 33939015 PMCID: PMC8091991 DOI: 10.1007/s00296-021-04879-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 04/24/2021] [Indexed: 01/06/2023]
Abstract
Reactive arthritis (ReA) is a form of sterile arthritis that occurs secondary to an extra-articular infection in genetically predisposed individuals. The extra-articular infection is typically an infection of the gastrointestinal tract or genitourinary tract. Infection-related arthritis is a sterile arthritis associated with streptococcal tonsillitis, extra-articular tuberculosis, or intravesical instillation of bacillus Calmette–Guérin (iBCG) therapy for bladder cancer. These infection-related arthritis diagnoses are often grouped with ReA based on the pathogenic mechanism. However, the unique characteristics of these entities may be masked by a group classification. Therefore, we reviewed the clinical characteristics of classic ReA, poststreptococcal ReA, Poncet’s disease, and iBCG-induced ReA. Considering the diversity in triggering microbes, infection sites, and frequency of HLA-B27, these are different disorders. However, the clinical symptoms and intracellular parasitism pathogenic mechanism among classic ReA and infection-related arthritis entities are similar. Therefore, poststreptococcal ReA, Poncet’s disease, and iBCG-induced ReA could be included in the expanding spectrum of ReA, especially based on the pathogenic mechanism.
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Affiliation(s)
- Yoshinori Taniguchi
- Department of Endocrinology, Metabolism, Nephrology and Rheumatology, Kochi Medical School Hospital, Nankoku, 783-8505, Japan.
| | - Hirofumi Nishikawa
- Department of Endocrinology, Metabolism, Nephrology and Rheumatology, Kochi Medical School Hospital, Nankoku, 783-8505, Japan
| | - Takeshi Yoshida
- Department of Internal Medicine, Chikamori Hospital, Kochi, Japan
| | - Yoshio Terada
- Department of Endocrinology, Metabolism, Nephrology and Rheumatology, Kochi Medical School Hospital, Nankoku, 783-8505, Japan
| | - Kurisu Tada
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Naoto Tamura
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Shigeto Kobayashi
- Department of Internal Medicine and Rheumatology, Juntendo University Koshigaya Hospital, Saitama, Japan.
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Basu S, Elkington P, Rao NA. Pathogenesis of ocular tuberculosis: New observations and future directions. Tuberculosis (Edinb) 2020; 124:101961. [PMID: 33010848 DOI: 10.1016/j.tube.2020.101961] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 04/22/2020] [Accepted: 06/03/2020] [Indexed: 01/01/2023]
Abstract
Ocular tuberculosis (OTB) encompasses all forms of intra- and extra-ocular inflammation associated with Mycobacterium tuberculosis (Mtb) infection. However, the organism is rarely found in ocular fluid samples of diseased eyes, rendering the pathomechanisms of the disease unclear. This confounds clinical decision-making in diagnosis and treatment of OTB. Here, we critically review existing human and animal data related to ocular inflammation and TB pathogenesis to unravel likely pathomechanisms of OTB. Broadly there appear to be two fundamental mechanisms that may underlie the development of TB-associated ocular inflammation: a. inflammatory response to live/replicating Mtb in the eye, and b. immune mediated ocular inflammation induced by non-viable Mtb or its components in the eye. This distinction is significant as in direct Mtb-driven mechanisms, diagnosis and treatment would be aimed at detection of Mtb-infection and its elimination; while indirect mechanisms would primarily require anti-inflammatory therapy with adjunctive anti-TB therapy. Further, we discuss how that most clinical phenotypes of OTB likely represent a combination of both mechanisms, with one being predominant than the other.
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Affiliation(s)
- Soumyava Basu
- Retina and Uveitis Service, L V Prasad Eye Institute (Mithu Tulsi Chanrai Campus), Bhubaneswar, India.
| | - Paul Elkington
- NIHR Biomedical Research Centre, School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, UK
| | - Narsing A Rao
- USC-Roski Eye Institute, Department of Ophthalmology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Calado JDOA, Miola AC, Silvares MRC, Marques SA. Disseminated tuberculosis associated with reactive arthritis of Poncet in an immunocompetent patient. An Bras Dermatol 2020; 95:343-346. [PMID: 32303434 PMCID: PMC7253921 DOI: 10.1016/j.abd.2019.08.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 08/30/2019] [Indexed: 11/25/2022] Open
Abstract
Cutaneous tuberculosis is a rare extrapulmonary manifestation of tuberculosis which, like disseminated tuberculosis, commonly occurs in immunocompromised patients. Poncet reactive arthritis is a seronegative arthritis affecting patients with extrapulmonary tuberculosis, which is uncommon even in endemic countries. We report a previously healthy 23-year-old male patient with watery diarrhea associated with erythematous ulcers on the lower limbs and oligoarthritis of the hands. Histopathological examination of the skin showed epithelioid granulomatous process with palisade granulomas and central caseous necrosis. AFB screening by Ziehl-Neelsen staining showed intact bacilli, the culture was positive for Mycobacterium tuberculosis, and colonoscopy revealed multiple shallow ulcers. Disseminated tuberculosis associated with reactive Poncet arthritis was diagnosed, with an improvement of the clinical and skin condition after appropriate treatment.
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Affiliation(s)
- Juliana de Oliveira Alves Calado
- Department of Dermatology and Radiotherapy, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista, Botucatu, SP, Brazil
| | - Anna Carolina Miola
- Department of Dermatology and Radiotherapy, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista, Botucatu, SP, Brazil.
| | - Maria Regina Cavariani Silvares
- Department of Dermatology and Radiotherapy, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista, Botucatu, SP, Brazil
| | - Silvio Alencar Marques
- Department of Dermatology and Radiotherapy, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista, Botucatu, SP, Brazil
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Endo Y, Kawashiri SY, Koga T, Okamoto M, Tsuji S, Takatani A, Shimizu T, Sumiyoshi R, Igawa T, Iwamoto N, Ichinose K, Tamai M, Nakamura H, Origuchi T, Kawakami A. Reactive arthritis induced by active extra-articular tuberculosis: A case report. Medicine (Baltimore) 2019; 98:e18008. [PMID: 31804308 PMCID: PMC6919392 DOI: 10.1097/md.0000000000018008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
RATIONALE Rare cases of reactive arthritis induced by active extra-articular tuberculosis (Poncet disease) have been reported. Complete response to antitubercular treatment and evidence of active extra-articular tuberculosis are the most important clinical features of Poncet disease. We report the case of successfully treated a patient with reactive arthritis induced by active extra-articular tuberculosis with a TNF inhibitor after sufficient antitubercular treatment. PATIENT CONCERNS A 56-year-old Japanese man was admitted to our department with polyarthralgia, low back pain, and high fever. The results of rheumatoid factor, anti-citrullinated protein antibody, human leukocyte antigen B27, and the assays for the detection of infections (with an exception of T-SPOT.TB) were all negative. Fluoro-deoxy-D-glucose-positron emission tomography with CT (PET/CT) showed moderate uptake in the right cervical, right supraclavicular, mediastinal, and abdominal lymph nodes. As magnetic resonance imaging and power Doppler ultrasonography showed peripheral inflammation (tendinitis, tenosynovitis, ligamentitis, and enthesitis in the limbs). DIAGNOSIS A diagnosis of tuberculous lymphadenitis was eventually established on the basis of lymph node biopsy results. There was no evidence of a bacterial infection including acid-fast bacteria in his joints, and the symptoms of polyarthralgia and low back pain were improved but not completely resolved with NSAID therapy; in addition, a diagnosis of reactive arthritis induced by active extraarticular tuberculosis was made. INTERVENTIONS The patient experienced persistent peripheral inflammation despite antitubercular treatment for more than nine months and was then successfully treated with a tumor necrosis factor inhibitor (adalimumab 40 mg every 2 weeks). OUTCOMES Finally, the patient responded to the treatment and has been in remission for over 4 months as of this writing. LESSONS In patients who present with symptoms associated with spondyloarthritis, it is important to distinguish between classic reactive arthritis and reactive arthritis induced by extra-articular tuberculosis infection. Introduction of biological agents should be carefully considered in settings where reactive arthritis induced by active extra-articular tuberculosis shows progression to chronicity despite sufficient antitubercular treatment.
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Abstract
Poncet disease is a rare, acute-onset polyarthritis associated with active extra-articular tuberculosis (TB) without evidence of active infection in the affected joint and resolves without residual joint damage or long-term complications. Most cases are reported at the commencement of anti-tuberculous therapy (ATT). A 13-year-old girl with Poncet disease is reported which, despite almost 6 months of treatment for abdominal TB, manifested with bilateral knee joint involvement which resolved only with continuation of ATT. A synovial biopsy was sterile.
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Affiliation(s)
- Ira Shah
- Department of Paediatrics, Paediatric TB Clinic, B. J. Wadia Hospital for Children , Mumbai , India.,Department of Infectious Diseases, Nanavati Hospital , Mumbai , India
| | - Radhika Kalelkar
- Department of Paediatrics, Paediatric TB Clinic, B. J. Wadia Hospital for Children , Mumbai , India
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17
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Whitley MJ, Stout JE, Kapila A, Selim MA, Mansoori P, Marano AL. Papulonecrotic tuberculid and Poncet disease: A case of multisystem delayed-type hypersensitivity in a patient with Mycobacterium tuberculosis infection. JAAD Case Rep 2019; 5:794-797. [PMID: 31517000 PMCID: PMC6728731 DOI: 10.1016/j.jdcr.2019.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Affiliation(s)
- Melodi Javid Whitley
- Department of Dermatology, Duke University Medical Center, Durham, North Carolina
| | - Jason E Stout
- Division of Infectious Diseases and International Health, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Atul Kapila
- Division of Rheumatology and Immunology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - M Angelica Selim
- Department of Dermatology, Duke University Medical Center, Durham, North Carolina.,Department of Pathology, Duke University Medical Center, Durham, North Carolina
| | - Parisa Mansoori
- Department of Pathology, Duke University Medical Center, Durham, North Carolina
| | - Anne L Marano
- Department of Dermatology, Duke University Medical Center, Durham, North Carolina
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18
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Stephenson L, Byard RW. An atlas overview of characteristic features of tuberculosis that may be encountered at autopsy. Forensic Sci Med Pathol 2019; 16:143-151. [PMID: 31471869 DOI: 10.1007/s12024-019-00161-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2019] [Indexed: 11/29/2022]
Abstract
Tuberculosis (TB) is a bacterial infection caused by Mycobacterium tuberculosis. Although primarily a disease of the respiratory system it may be found in any organ or tissue. Global population movements and the emergence of resistant strains are contributing to increasing numbers of cases in certain populations. Subtlety of symptoms and signs, chronicity of disease and failure to seek medical assistance may result in the diagnosis only being made at the time of autopsy. For this reason forensic pathologists need to understand the protean manifestations of the disease and the variable mechanisms by which TB may cause death. This atlas overview provides descriptions of the pathological manifestations of TB in a variety of organs with accompanying illustrations. It serves as a summary of conditions that should be checked for at autopsy in suspected or confirmed cases.
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Affiliation(s)
- Lilli Stephenson
- Forensic Science South Australia (FSSA) and the School of Medicine, The University of Adelaide, Level 2 Medical School North Building, Frome Road, Adelaide, South Australia, 5000, Australia
| | - Roger W Byard
- Forensic Science South Australia (FSSA) and the School of Medicine, The University of Adelaide, Level 2 Medical School North Building, Frome Road, Adelaide, South Australia, 5000, Australia.
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Heath K, Byard RW. Tuberculosis-related stigma contributing to a 'hidden' disease at autopsy. MEDICINE, SCIENCE, AND THE LAW 2019; 59:135-138. [PMID: 31081464 DOI: 10.1177/0025802419849350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
A 29-year-old African immigrant to Australia was found dead in bed. She had no known medical history, except for recent weight loss and hip/leg pain. Autopsy examination revealed extensive tuberculous consolidation with widespread cavitation of the lungs, with multiple caseating granulomas containing large numbers of acid fast bacilli on histology. Similar granulomas were also present in lymph nodes of the porta hepatis, mediastinum and pulmonary hilum, and within the liver, spleen and mesentery. Mycobacterial polymerase chain reaction analysis confirmed tuberculous infection. Her serum was negative for human immunodeficiency virus infection. Death was due to disseminated tuberculosis. In many parts of Africa, there are negative cultural associations attached to tuberculosis, which often leads to a delay in diagnosis. The case demonstrates the extent of active disease that may be uncovered at autopsy in decedents from societies where tuberculosis is stigmatised and therefore concealed. It also emphasises the risk of infection for forensic workers.
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Affiliation(s)
- Karen Heath
- Forensic Science South Australia (FSSA) and the School of Medicine, The University of Adelaide, Australia
| | - Roger W Byard
- Forensic Science South Australia (FSSA) and the School of Medicine, The University of Adelaide, Australia
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20
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Erre GL, Colombo E, Bibbò S, Dore MP. Reactive arthritis secondary to Hafnia alvei enterocolitis. BMJ Case Rep 2019; 12:12/5/e228513. [PMID: 31142484 DOI: 10.1136/bcr-2018-228513] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Diagnosis of postenteritic reactive arthritis (ReA) is a challenge and might have a broad range of differential diagnoses. A 50-year-old man was referred to our attention because of persistent inflammatory low back pain and asymmetric oligoarthritis. The clinical history was positive for diarrhoea in the previous 3 months. Inflammatory bowel disease, Whipple and celiac diseases were carefully excluded. In addition, serology, stool cultures, biopsies from the upper gastrointestinal tract yielded negative results for infections. A presumptive diagnosis of ReA was done and a non-steroidal anti-inflammatory drug trial prescribed. Persistence of symptoms prompted us for a second look of the colon. Biopsy collected from the terminal ileum were cultured and surprisingly colonies of Hafnia alvei, a rod-shaped Enterobacteriaceae, were detected. Treatment with ciprofloxacin leads to fast symptoms resolution. Although enterocolitis from H. alvei has been rarely reported, the culture of intestinal specimens might be recommended in the work-up of patients with suspected postenteritic ReA.
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Affiliation(s)
- Gian Luca Erre
- Specialità Mediche, Azienda Ospedaliero Universitaria di Sassari, Sassari, Italy
| | | | - Stefano Bibbò
- Gastroenterology and Liver Unit, Catholic University of Rome, Rome, Italy
| | - Maria Pina Dore
- Dipartimento di Medicina Clinica e Sperimentale, Università degli Studi di Sassari, Sassari, Italy
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21
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Singh H, Pannu AK, Suri V, Bhalla A, Kumari S. Poncet's disease: Uncommon musculoskeletal manifestation of tuberculosis. J Family Med Prim Care 2019; 7:1589-1590. [PMID: 30613568 PMCID: PMC6293919 DOI: 10.4103/jfmpc.jfmpc_288_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Harpreet Singh
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashok K Pannu
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Suri
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashish Bhalla
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Savita Kumari
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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22
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Do pulmonary findings of granulomatosis with polyangiitis respond to anti-tuberculosis treatment? Rheumatol Int 2018; 38:1131-1138. [PMID: 29632976 DOI: 10.1007/s00296-018-4027-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 04/06/2018] [Indexed: 10/17/2022]
Abstract
Granulomatosis with polyangiitis (GPA) involves upper and lower respiratory tracts and kidneys. Lung involvement is among the most important organ involvements in GPA. GPA's lung involvement might be confused with other granulomatous conditions with lung involvement. In this report, we presented clinical features of two cases with GPA who had been diagnosed as tuberculosis (TBC) and well treated with anti-tuberculosis (anti-TBC) drugs. However, one of two cases had ear-nose-throat (ENT) manifestations before the diagnosis of TBC and her extrapulmonary findings related with GPA have added to clinical features in the following years. In the second case, the manifestations of GPA appeared after 13 months of anti-TBC treatment. We speculated that lung involvement in these cases may be due to GPA rather than TBC. Our aim was to highlight difficulties in the differential diagnosis between GPA and TBC and suggest the possible beneficial effect of anti-TBC drugs on the lung involvement due to GPA in light of the literature data.
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Poncet’s Disease in the Preclinical Phase of Rheumatoid Arthritis. Case Rep Rheumatol 2018; 2018:3571247. [PMID: 29854537 PMCID: PMC5964554 DOI: 10.1155/2018/3571247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 04/12/2018] [Accepted: 04/17/2018] [Indexed: 11/17/2022] Open
Abstract
We report on a patient with seropositive polyarthritis retrospectively diagnosed as Poncet’s disease in the preclinical phase of seropositive rheumatoid arthritis. Our patient developed rheumatoid arthritis more than 2 years after being successfully treated for pulmonary tuberculosis and an initial inflammatory polyarthritis consistent with the diagnosis of Poncet’s disease. This case illustrates the importance of recognizing Poncet’s disease in a patient presenting with polyarthritis in order to avoid inappropriate long-term disease modifying antirheumatic treatment. It also illustrates the need for adequate follow-up of patients with Poncet’s disease after treatment with antituberculosis treatment so that progression to a primary inflammatory arthritis such as rheumatoid arthritis may be identified timeously. Although seropositivity for rheumatoid arthritis has been reported in Poncet’s disease as well as in tuberculosis, it is rather uncommon, and long-term follow-up of patients with Poncet’s disease is essential particularly if they have positive serological tests for rheumatoid arthritis. In this case report, we describe the first reported case of Poncet’s disease in the preclinical phase of rheumatoid arthritis and review the literature related to this rare disease presentation.
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24
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Akselrod H, Modak RM, Cushing L, Seemungal I, Simon GL. Difficult to Discern: Tuberculous Myositis with Poncet's Arthritis. Am J Med 2017; 130:1376-1378. [PMID: 28821375 DOI: 10.1016/j.amjmed.2017.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 07/31/2017] [Accepted: 08/01/2017] [Indexed: 11/18/2022]
Affiliation(s)
- Hana Akselrod
- Division of Infectious Diseases, Department of Medicine, George Washington University School of Medicine & Health Sciences, Washington, DC.
| | - Rohit M Modak
- Department of Medicine, Virginia Hospital Center, Arlington
| | - Laurel Cushing
- Department of Medicine, Virginia Hospital Center, Arlington
| | - Ian Seemungal
- Department of Medicine, Virginia Hospital Center, Arlington
| | - Gary L Simon
- Division of Infectious Diseases, Department of Medicine, George Washington University School of Medicine & Health Sciences, Washington, DC
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25
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Sait S, Mubashir M, Anwar R, Khan N. Poncet's disease (tubercular rheumatism) with primary involvement of the foot - A case report. Foot Ankle Surg 2016; 22:e17-e20. [PMID: 27502237 DOI: 10.1016/j.fas.2016.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 12/24/2015] [Accepted: 01/15/2016] [Indexed: 02/04/2023]
Abstract
We present a rare case with primary tubercular involvement of the foot, accomapanied by a reactionary (aseptic) effusion in the knee. The diagnosis was delayed due to unusual presentation and also because of failure to elicit a detailed history. Incision and drainage of the foot abscess and antitubercular drug therapy resulted in satisfactory control of tubercular infection. Polyarticular presentation may not always signify active tubercular focus in every joint; it may reflect reactive synovitis known as Poncet's disease, which resolves with multidrug antitubercular therapy.A multidispilinary approach should be adopted and chest physicians, rheumatologists and orthopaedic surgeons should work in close association to correctly diagnose and treatthis condition.
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Affiliation(s)
- Saif Sait
- Trauma & Orthopaedics, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Mohd Mubashir
- Department of General Surgery, Mayo Institute of Medical Sciences, Safedabad, Lucknow, India
| | - Rahij Anwar
- Department of Orthopaedic Surgeon, Pilgrim Hospital, Boston, Lincolnshire, United Kingdom.
| | - Nissa Khan
- Emergency Department, Holbaek Hospital Denmark
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26
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Lugo-Zamudio GE, Barbosa-Cobos RE, González-Ramírez LV, Delgado-Ochoa D. Reumatismo tuberculoso «enfermedad de Poncet». Reporte de caso. CIR CIR 2016; 84:169-72. [DOI: 10.1016/j.circir.2015.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Accepted: 11/19/2014] [Indexed: 10/22/2022]
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Affiliation(s)
- Keertan Dheda
- Lung Infection and Immunity Unit, Division of Pulmonology and UCT Lung Institute, Department of Medicine, University of Cape Town, Cape Town, South Africa.
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28
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Affiliation(s)
- Shalabh Arora
- Department of Internal Medicine, Christian Medical College Hospital, Vellore, Tamil Nadu, India.
| | - Turaka Vijay Prakash
- Department of Internal Medicine, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Ronald Albert Carey
- Department of Internal Medicine, Christian Medical College Hospital, Vellore, Tamil Nadu, India
| | - Samuel George Hansdak
- Department of Internal Medicine, Christian Medical College Hospital, Vellore, Tamil Nadu, India
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Sharma A, Pinto B, Dogra S, Sharma K, Goyal P, Sagar V, Dhir V, Sharma S, Singh S. A case series and review of Poncet's disease, and the utility of current diagnostic criteria. Int J Rheum Dis 2015; 19:1010-1017. [PMID: 26354099 DOI: 10.1111/1756-185x.12726] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Aman Sharma
- Department of Internal Medicine; Post Graduate Institute of Medical Education and Research; Chandigarh India
| | - Benzeeta Pinto
- Department of Internal Medicine; Post Graduate Institute of Medical Education and Research; Chandigarh India
| | - Sunil Dogra
- Department of Dermatology; Post Graduate Institute of Medical Education and Research; Chandigarh India
| | - Kusum Sharma
- Department of Medical Microbiology; Post Graduate Institute of Medical Education and Research; Chandigarh India
| | - Palvi Goyal
- Department of Internal Medicine; Post Graduate Institute of Medical Education and Research; Chandigarh India
| | - Vinay Sagar
- Department of Internal Medicine; Post Graduate Institute of Medical Education and Research; Chandigarh India
| | - Varun Dhir
- Department of Internal Medicine; Post Graduate Institute of Medical Education and Research; Chandigarh India
| | - Shefali Sharma
- Department of Internal Medicine; Post Graduate Institute of Medical Education and Research; Chandigarh India
| | - Surjit Singh
- Department of Internal Medicine; Post Graduate Institute of Medical Education and Research; Chandigarh India
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Poncet's disease with high titers of rheumatoid factor and anti-citrullinated peptide antibodies mimicking rheumatoid arthritis. J Infect Chemother 2015; 21:65-9. [DOI: 10.1016/j.jiac.2014.07.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 07/17/2014] [Accepted: 07/22/2014] [Indexed: 12/18/2022]
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31
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Pseudo-Behçet’s disease associated with tuberculosis: a case report and review of the literature. Rheumatol Int 2014; 34:1471-4. [DOI: 10.1007/s00296-014-2998-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Accepted: 03/18/2014] [Indexed: 11/27/2022]
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