Poncet’s Disease in a Tuberculosis Endemic Country


Aman Sharma

Clinical Immunology and Rheumatology Services,

Department of Internal Medicine,

PGIMER, Chandigarh

Tuberculosis continues to be an important public health problem in India. Despite advances in the diagnostic armamentarium, including imaging and molecular techniques, tuberculosis with its myriad clinical manifestations still continues to challenge even the most astute physicians. Approximately 10%–11% of extrapulmonary tuberculosis cases have bones and joints involvement. Tuberculosis can also cause a form of reactive arthritis called Poncet’s disease. Although many physicians dispute the existence of this entity, it is now a well-reported phenomenon. This entity was first described by Antonin Poncet in 1897. Although initial descriptions included all cases of polyarthritis associated with tuberculosis, the term is now restricted to reactive arthritis associated with tuberculosis without the direct bacteriological involvement of the joints. Over 200 cases have now been described in literature, with as many as 35% of the reported cases being from India. However, it is likely that many of these cases are missed. Lack of awareness as well as the absence of standard diagnostic criteria may contribute to these small numbers. A few recent reports have attempted to describe this disease better. The authors have recently proposed new criteria to aid in the diagnosis of Poncet’s disease.

Poncet’s disease occurs with both pulmonary and extrapulmonary tuberculosis; however, it seems to be more common with extrapulmonary tuberculosis, especially tubercular lymphadenitis. The clinical presentation of Poncet’s disease may vary from acute to chronic oligoarthritis or polyarthritis.In a recent review of 198 cases, oligoarthritis was found to be more common. The ankle is the most common joint involved, followed by the knees. Poncet’s disease can also involve the small joints; however, axial involvement has not been reported. In addition, enthesitis has only rarely been reported. Poncet’s disease may also present as bilateral ankle arthritis, with or without erythema nodosum, closely mimicking Lofgren’s disease. Joint symptoms usually occur at presentation; however, arthritis may occur while the patient is on antitubercular therapy. Poncet’s disease is non-erosive and non-deforming, even in patients with long standing disease.

Associated clinical features, depending on the site of tuberculosis, usually suggest the diagnosis of tuberculosis. However, systemic symptoms may not be observed in most patients, thus, a high index of suspicion is very essential to make the correct diagnosis. Examination may reveal enlarged lymph nodes and chest X-ray may reveal hilar lymphadenopathy. This again underlines the need for detailed physical examination and basic investigations in every patient with arthritis. Poncet’s disease may occur along with other hypersensitivity manifestations like erythema nodosum, tuberculids, phlyctenular conjunctivitis, oral aphthae, and granulomatous uveitis, leading to interesting clinical presentations. A patient with Poncet’s disease who presented with oral and genital ulcers, skin rash, and polyarthritis mimicking Behçet’s disease has also been reported. The involvement of the glans penis instead of the scrotum or peno-scrotal junction along with positive raised the suspicion of Poncet’s disease and positive TB PCR from skin lesions confirmed the diagnosis. The patient also responded to the anti-tubercular therapy. Tuberculin skin test is positive in most cases; however, in this trial series, it was negative in 19% patients. Thus, Poncet’s disease should not be excluded merely based on Mantoux negativity and an attempt for microbiological diagnosis should always be made. Previous authors have suggested performing a synovial biopsy to rule out tubercular arthritis in every case of Poncet’s disease. However, the authors of this study believe that this is neither feasible nor essential as the two diseases have entirely different clinical presentations. TB arthritis is usually monoarticular and erosive, with the hip and knee being most commonly involved.

The authors have recently proposed diagnostic criteria forPoncet’s disease based on their experience of 23 patients. The presence of non-erosive non-deforming arthritis is an essential criterion. Major criteria include concurrent diagnosis of extra-articular tuberculosis and complete response to ATT without sequelae. Mantoux positivity, presence of other hypersensitivity phenomenon such as tuberculids, and absence of axial involvement are taken as minor criteria. Cases can be graded as definite, probable, or possible Poncet’s disease based on these criteria. Patients can only be classified as a definite case of Poncet’s disease after an adequate trial of ATT, hence, the authors suggest that cases should be classified as probable or possible initially and upgraded to definite after response to ATT. This criterion should be validated in different Poncet’s disease cohort.

The pathogenesis of Poncet’s disease is likely to be immune-mediated. A vigorous Th1 helper T cell response to mycobacterial antigens may localize to the joints and trigger the arthritic process. The importance of CD4 cells is also underlined by the rare occurrence of this disease in HIV positive patients despite the increased incidence of tuberculosis in this population.

Patients with Poncet’s disease respond very well to the antitubercular therapy. The articular symptoms resolve in 2–4 weeks without any sequelae. Treatment with steroids and DMARDs must be avoided, as they may lead to the dissemination of tuberculosis. This is unlike the treatment of reactive arthritis where antibiotics have no proven role. Hence, Poncet’s disease is considered to be a parainfective arthritis rather than true reactive arthritis.

In conclusion, Poncet’s disease is a form of reactive arthritis associated with tuberculosis away from the joints. A high index of suspicion is required for making the diagnosis. Once the diagnosis has been established, the treatment is not difficult, with the condition being completely curable with the anti-tuberculosis therapy. More research is needed to understand the pathogenesis of this disease.

Suggested Reading

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3. Sharma A, Pinto B, Dogra S,et al.A case series and review of Poncet's disease, and the utility of currentdiagnostic criteria.Int J Rheum Dis. 2016;19(10):1010–1017.
4. Kroot EJ, Hazes JM, Colin EM, et al. Poncet's disease: Reactive arthritis accompanying tuberculosis. Two case reports and a review of the literature. Rheumatology (Oxford).2007;46:484–489.
5. Sharma A, Dogra S, Pinto B,et al.Poncet's disease presenting as Pseudo-Behçet's disease.Int J Rheum Dis. 2013;16(4):483–485.