560
Correspondence
Poncet's Disease: Case Report
Correspondence: Dr. Del J. Dellart, Department of Medicine. Saginaw Cooperative Hospitals, 1000 Houghton Avenue. Saginaw, Michigan 48602.
Clinical Infectious Diseases 1992;15:560 © 1992 by The University of Chicago. All rights reserved. 1058-4838/92/1503-0032$02.00
The patient received isoniazid (300 mg/d) and rifampin (600 mg/d) for 6 months, as well as pyrazinamide (1.5 gld) for the first 2 months and tolerated therapy well. Her arthralgias resolved over the first 3-months of treatment in the absence of continued nonsteriodal antiinflammatory therapy, and results of her urinalysis and serum chemistries normalized. She remains well after therapy. In 1989 Dall and colleagues [4] reported a case in support of Poncet's disease and reviewed 13 cases in the recent Englishlanguage literature. Six of 10 patients for whom findings ofchest films were reported had unremarkable examinations. For 10 of II patients who received antituberculous drugs, arthralgias resolved during therapy; Mantoux tests for all 10 were positive. Maricic and Alepa [ I] recently reported a case of reactive arthritis complicating Mycobacterium avium-Mycobacterium intracellulare complex infection that would suggest that the syndrome may not be limited to Mycobacterium tuberculosis infection. In a review of 50 cases, Summers and Jayson [5] failed to find support for tuberculous rheumatism, but this small study may have missed a true but infrequent relationship. Continued case reports, perhaps stimulated by heightened awareness, support the association. In summary, we describe a patient with reactive arthritis whose Mantoux test converted to positive with onset during pregnancy. The patient responded to antituberculous therapy alone, and we believe that this case represents Poncet's disease. Though cultures of sputum and urine were negative, a Mantoux reaction of a 30-mm induration is considered by many to document infection [6], and the results of her test clearly showed recent conversion. Clinicians may consider this diagnosis for seronegative patients with arthritis, particularly with the incidence of tuberculosis in developed countries again on the rise.
Del J. DeHart Department of Internal Medicine. College of Human Medicine, Michigan State University, and Saginaw Cooperative Hospital. Saginaw, Michigan
References I. Maricic MJ. Alepa FP. Reactive arthritis after Mycobacterium aviuni-intracellulare infection: Poncet's disease revisited. Am J Med 1990;88:549-50. 2. Ames PRJ. Capasso G. Testa V, Maffulli N, Tortora M, Gaeta GB. Chronic tuberculous rheumatism (Poncet's disease) in a gymnast. Br J RheumatoI1990;29:72-4. 3. Southwood TR, Hancock EJ. Petty RE, Malleson PN, Theissen PN. Tuberculous rheumatism (Poncet's disease) in a child. Arthritis Rheum 1988;31:1311-13. 4. Dall L. Long L, Stanford J. Poncet's disease: tuberculous rheumatism. Rev Infect Dis 1989; I I: 105-7. 5. Summers GD, Jayson MIV. Does Poncet's disease exist? Rheumatol Rehabil 1980; 19:149-50. 6. Des Prez RM, Heim CR. Mycobacterium tuberculosis. In: Mandell GL, Douglas RG Jr, Bennett JE, eds. Principles and practice of infectious diseases. 3rd ed. New York: Churchill Livingstone, 1990: 1877-906.
Downloaded from http://cid.oxfordjournals.org/ at Michigan State University on March 23, 2015
SIR-Despite recent debate about the very existence ofPoncet's disease, or tuberculous rheumatism, case reports continue to appear in the English-language literature [1-3]. We report a case ofa woman with polyarthralgias who responded to specific antituberculous therapy; we believe that this case represents Poncet's disease. A 37-year-old woman was evaluated because of arthralgias and a positive Mantoux test. During a routine pregnancy evaluation, a tine test for tuberculosis was positive. A spontaneous miscarriage occurred at the 16th week of gestation, and 2 months later a Mantoux test with 5 tuberculin units of purified protein derivative was positive at 30 mm ofinduration. Multiple tine tests were negative during her six previous pregnancies. She complained ofa 4- to 5-month history of progressive arthralgias involving the wrists, shoulders, knees, and ankles, which decreased partially over the first hours of the day. Nonsteroidal antiinflammatory drugs provided little relief She also reported a 6-lb weight loss over the last year, progressive malaise and fatigue of 4 months' duration, and night sweats for the previous 2 weeks. She denied fevers, rashes, cough, or dysuria. Her history was significant for colonic interposition to the esophagus for refractory diffuse esophageal spasm and incidental splenectomy 15 years earlier. There was no family history of tuberculosis, and there was no unusual travel. She lived in an urban area and denied exposure to unprocessed farm products. Her job did involve extensive interactions with migrant farm workers. Mantoux tests taken by her family remained negative. Physical examination revealed mild discomfort upon palpation of the affected joints, but no effusions were noted. Laboratory evaluation revealed an aspartate aminotransferase level of83 U/L (normal level, 0-58 U/L) and an alanine aminotransferase level of 148 U/L (normal level, 0-50 U/L); the results of the remainder of the serum chemistry profile were normal. Her total leukocyte count was 6 X 109/L, and the differential blood cell count was normal. The platelet count was 432 X 109/L. The erythrocyte sedimentation rate was II mm/h (determined by the Westergren method). Results of tests for antinuclear antibodies, rheumatoid factor, antistreptolysin 0, and thyroid function were normal, as were those of the Monospot test, rapid plasma reagin tests, and hepatitis A and B screens. A test for antibody to human immunodeficiency virus type I was negative. Urinalysis initially revealed 5-10 erythrocytes per high-power field and a trace of protein. Cultures of sputum and urine were negative for acid-fast bacilli. Her chest film demonstrated scarring of the left base and right apical pleural thickening, but no active process was noted.
CID 1992; 15 (September)
Correspondence
Poncet's Disease: Case Report
Correspondence: Dr. Del J. Dellart, Department of Medicine. Saginaw Cooperative Hospitals, 1000 Houghton Avenue. Saginaw, Michigan 48602.
Clinical Infectious Diseases 1992;15:560 © 1992 by The University of Chicago. All rights reserved. 1058-4838/92/1503-0032$02.00
The patient received isoniazid (300 mg/d) and rifampin (600 mg/d) for 6 months, as well as pyrazinamide (1.5 gld) for the first 2 months and tolerated therapy well. Her arthralgias resolved over the first 3-months of treatment in the absence of continued nonsteriodal antiinflammatory therapy, and results of her urinalysis and serum chemistries normalized. She remains well after therapy. In 1989 Dall and colleagues [4] reported a case in support of Poncet's disease and reviewed 13 cases in the recent Englishlanguage literature. Six of 10 patients for whom findings ofchest films were reported had unremarkable examinations. For 10 of II patients who received antituberculous drugs, arthralgias resolved during therapy; Mantoux tests for all 10 were positive. Maricic and Alepa [ I] recently reported a case of reactive arthritis complicating Mycobacterium avium-Mycobacterium intracellulare complex infection that would suggest that the syndrome may not be limited to Mycobacterium tuberculosis infection. In a review of 50 cases, Summers and Jayson [5] failed to find support for tuberculous rheumatism, but this small study may have missed a true but infrequent relationship. Continued case reports, perhaps stimulated by heightened awareness, support the association. In summary, we describe a patient with reactive arthritis whose Mantoux test converted to positive with onset during pregnancy. The patient responded to antituberculous therapy alone, and we believe that this case represents Poncet's disease. Though cultures of sputum and urine were negative, a Mantoux reaction of a 30-mm induration is considered by many to document infection [6], and the results of her test clearly showed recent conversion. Clinicians may consider this diagnosis for seronegative patients with arthritis, particularly with the incidence of tuberculosis in developed countries again on the rise.
Del J. DeHart Department of Internal Medicine. College of Human Medicine, Michigan State University, and Saginaw Cooperative Hospital. Saginaw, Michigan
References I. Maricic MJ. Alepa FP. Reactive arthritis after Mycobacterium aviuni-intracellulare infection: Poncet's disease revisited. Am J Med 1990;88:549-50. 2. Ames PRJ. Capasso G. Testa V, Maffulli N, Tortora M, Gaeta GB. Chronic tuberculous rheumatism (Poncet's disease) in a gymnast. Br J RheumatoI1990;29:72-4. 3. Southwood TR, Hancock EJ. Petty RE, Malleson PN, Theissen PN. Tuberculous rheumatism (Poncet's disease) in a child. Arthritis Rheum 1988;31:1311-13. 4. Dall L. Long L, Stanford J. Poncet's disease: tuberculous rheumatism. Rev Infect Dis 1989; I I: 105-7. 5. Summers GD, Jayson MIV. Does Poncet's disease exist? Rheumatol Rehabil 1980; 19:149-50. 6. Des Prez RM, Heim CR. Mycobacterium tuberculosis. In: Mandell GL, Douglas RG Jr, Bennett JE, eds. Principles and practice of infectious diseases. 3rd ed. New York: Churchill Livingstone, 1990: 1877-906.
Downloaded from http://cid.oxfordjournals.org/ at Michigan State University on March 23, 2015
SIR-Despite recent debate about the very existence ofPoncet's disease, or tuberculous rheumatism, case reports continue to appear in the English-language literature [1-3]. We report a case ofa woman with polyarthralgias who responded to specific antituberculous therapy; we believe that this case represents Poncet's disease. A 37-year-old woman was evaluated because of arthralgias and a positive Mantoux test. During a routine pregnancy evaluation, a tine test for tuberculosis was positive. A spontaneous miscarriage occurred at the 16th week of gestation, and 2 months later a Mantoux test with 5 tuberculin units of purified protein derivative was positive at 30 mm ofinduration. Multiple tine tests were negative during her six previous pregnancies. She complained ofa 4- to 5-month history of progressive arthralgias involving the wrists, shoulders, knees, and ankles, which decreased partially over the first hours of the day. Nonsteroidal antiinflammatory drugs provided little relief She also reported a 6-lb weight loss over the last year, progressive malaise and fatigue of 4 months' duration, and night sweats for the previous 2 weeks. She denied fevers, rashes, cough, or dysuria. Her history was significant for colonic interposition to the esophagus for refractory diffuse esophageal spasm and incidental splenectomy 15 years earlier. There was no family history of tuberculosis, and there was no unusual travel. She lived in an urban area and denied exposure to unprocessed farm products. Her job did involve extensive interactions with migrant farm workers. Mantoux tests taken by her family remained negative. Physical examination revealed mild discomfort upon palpation of the affected joints, but no effusions were noted. Laboratory evaluation revealed an aspartate aminotransferase level of83 U/L (normal level, 0-58 U/L) and an alanine aminotransferase level of 148 U/L (normal level, 0-50 U/L); the results of the remainder of the serum chemistry profile were normal. Her total leukocyte count was 6 X 109/L, and the differential blood cell count was normal. The platelet count was 432 X 109/L. The erythrocyte sedimentation rate was II mm/h (determined by the Westergren method). Results of tests for antinuclear antibodies, rheumatoid factor, antistreptolysin 0, and thyroid function were normal, as were those of the Monospot test, rapid plasma reagin tests, and hepatitis A and B screens. A test for antibody to human immunodeficiency virus type I was negative. Urinalysis initially revealed 5-10 erythrocytes per high-power field and a trace of protein. Cultures of sputum and urine were negative for acid-fast bacilli. Her chest film demonstrated scarring of the left base and right apical pleural thickening, but no active process was noted.
CID 1992; 15 (September)
