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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 21  |  Issue : 1  |  Page : 97-100

Tuberculous rheumatism: A great mimic of juvenile idiopathic arthritis


1 Department of Pediatrics, INHS Dhanvantari, Port Blair, Andaman and Nicobar Islands, India
2 Department of Pediatrics, Armed Forces Medical College, Mumbai, Maharashtra, India
3 Department of Pediatrics, INHS Asvini, Mumbai, Maharashtra, India
4 Department of Microbiology, BJGMC, Pune, India

Date of Submission09-Nov-2018
Date of Acceptance08-Feb-2019
Date of Web Publication19-Jun-2019

Correspondence Address:
Surg Lt Cdr Manas Ranjan Mishra
Department of Pediatrics, INHS Dhanvantari, Minnie Bay, Port Blair, Andaman and Nicobar Islands
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmms.jmms_74_18

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  Abstract 


Tuberculosis (TB) is an underreported epidemic. Musculoskeletal TB is a relatively rare extrapulmonary complication of Mycobacterium tuberculosis involving just 1%–3% of patients. It commonly affects the spine and osteoarticular joints such as hip and knee, and it is mostly monoarticular. Oligo and polyarticular involvement, also called tuberculous rheumatism or Poncet's disease (PD), is an extremely rare occurrence due to a vigorous immune response to mycobacteria which contributes to the arthritic process. Here, we report a case of PD in a 3-year-old girl, who presented with complaints of insidious onset polyarthritis, mimicking juvenile arthritis. Cervical lymph node aspirate isolated acid-fast bacilli. The child was diagnosed as a case of PD, and after starting antituberculous therapy, her symptoms dramatically resolved. This patient illustrates the need to consider the possibility of TB in high-risk pediatric populations in countries like India as one of the causes of nonresolving chronic arthritis.

Keywords: Extrapulmonary tuberculosis, juvenile idiopathic arthritis, polyarthritis, Poncet's disease, tuberculous rheumatism


How to cite this article:
Mishra MR, Joshi D, Adhikari K M, Dharmshale S. Tuberculous rheumatism: A great mimic of juvenile idiopathic arthritis. J Mar Med Soc 2019;21:97-100

How to cite this URL:
Mishra MR, Joshi D, Adhikari K M, Dharmshale S. Tuberculous rheumatism: A great mimic of juvenile idiopathic arthritis. J Mar Med Soc [serial online] 2019 [cited 2019 Sep 22];21:97-100. Available from: http://www.marinemedicalsociety.in/text.asp?2019/21/1/97/260674




  Introduction Top


History of tuberculosis (TB) dates back to the history of civilization, with evidence of TB infections discovered from human remains dating 9000 years ago. In the era of increasing human immunodeficiency virus (HIV) infections and immunodeficiency states such as chronic kidney diseases and long-term steroid therapy, an increased incidence has been observed globally.[1] According to the Global TB Report 2018, TB caused an estimated 1.6 million deaths, and 10.0 million new TB cases were detected worldwide in 2017.[2]

Among extrapulmonary complications of TB, musculoskeletal involvement is seen in merely 1%–3% of patients.[3] Most commonly affected joints are the spine, hip, and knee joint, respectively.[1]

Poncet's disease (PD) or tuberculous rheumatism is not a very well-known entity. Diagnosis is established only after exclusion of other etiologies of polyarthritis and tuberculous arthritis itself.[4] This case is reported because of its rarity, and in a TB endemic country like India, one should keep this possibility in mind, as early recognition of this complication can avoid delay in initiation of appropriate treatment.


  Case Report Top


A 3-year-old female child presented with swelling of knees, ankles, and elbow joints of 1½-year duration. The swelling was insidious in onset, first involving right knee joint with pain and mild restriction of movement. It progressed over 3–4 months involving both knee and ankle joints. She was unable to bear weight in the lower limbs and had only partial relief with nonsteroidal anti-inflammatory drugs (NSAIDs), which she took off and on. There was no significant medical history, no family history of rheumatic or autoimmune disease, no history of fever with rash, no chronic cough, no significant loss of appetite or weight, and no contact with a known case of TB. The child was immunized for age.

Initial evaluation was done in a peripheral hospital. Serological workup including antistreptolysin O, rheumatoid factor, antinuclear antibodies, and anti-cyclic citrullinated peptide was negative. The child was diagnosed as a probable case of seronegative juvenile rheumatoid arthritis and advised NSAIDs. However, when her complaints did not subside, she was referred to a higher center.

At our center, clinical examination revealed that the child had failure to thrive. Weight was 9.44 kg (<−3 Z-score); height was 91 cm (median to −2 Z-scores); pallor was present; and the child had arthritis of both knees [Figure 1], right knee more than left, and both ankle joints. She was unable to bear weight on her legs and had to be supported by her parents even to attend her daily needs. She had a single 1-cm left cervical lymph node. There were no skin lesions. Other systemic examinations were normal.
Figure 1: Initial presentation with joint swelling and inability to bear weight

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On laboratory investigations, there was low hemoglobin 8.6 g/dL, with microcytic hypochromic picture on peripheral smear, high erythrocyte sedimentation rate of 30 mm in the 1st h, and C-reactive protein was positive. Antinuclear antibody and rheumatoid factor were negative. X-ray of the knee joint revealed soft-tissue swelling with diffuse osteopenia with valgus deformity [Figure 2]. Ultrasonography right knee joint revealed fluid collection in the suprapatellar bursa with multiple septa. Magnetic resonance imaging of the right knee joint revealed bilateral synovitis with moderate effusion [Figure 3]. Chest X-ray and gastric aspirate for acid-fast bacilli (AFB) and cartridge-based nucleic acid amplification (CB-NAAT) were done to evaluate for pulmonary tuberculosis and were found to be normal. Serum calcium, phosphorus, and 25-OH Vitamin D were also within normal limits. However, serum alkaline phosphatase was raised (670 IU/L), and Mantoux test was strongly positive (15 mm). Synovial fluid analysis of the right knee revealed clear fluid with a total cell count of 380/mm3 with lymphocytic predominance (96%) and adenosine deaminase 18 U/L (>31 is a marker for TB arthritis).[3],[5] Aspirate from the left knee was also sterile. Fine-needle aspiration cytology of cervical lymph node revealed a necrotic center with epitheloid granulomas; Ziehl–Neelsen staining was positive for AFB. HIV ELISA was negative.
Figure 2: Initial X-ray showing diffuse osteopenia and valgus deformity

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Figure 3: Magnetic resonance imaging of the right knee joint showing bilateral synovitis with moderate effusion

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Based on the above findings, a diagnosis of tubercular lymphadenitis with tuberculous rheumatism was made, and the child was started on 6-month antituberculous therapy (ATT) with 2 months of intensive phase (H + R + Z + E) and 4 months of continuation phase (H + R + E) as per the RNTCP protocol. There was dramatic improvement in her with relief of pain and swelling in both knees and ankle joints. There was no palpable lymphadenopathy. On follow-up after 2 months, she was active and playful with a weight gain of 1 kg. There was no residual deformity in the knees [Figure 4].
Figure 4: Marked improvement noticed at follow-up

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  Discussion Top


TB is endemic in developing countries. Of the global burden of TB, largest numbers (45%) are detected in Asia with overcrowding, poor sanitation, and malnutrition being attributed as the main culprits.[2] Familiarity with the protean and rare manifestations of the disease is thus essential.

Musculoskeletal TB is a rare entity seen only in 1%–3% of patients.[3] Spinal TB amounts to half of these cases and the rest affect appendicular joints such as hip and knee.[6] Peripheral joint involvement by tubercular bacilli is predominantly monoarticular. Rarely, oligoarticular or polyarticular affliction is seen.[7] Common conditions presenting with chronic polyarthritis in children are JIA, Reiter's disease, psoriatic arthropathy, hemophilic arthropathy, sarcoidosis, etc.

Arthritic process in PD can be attributed to the vigorous immune response to mycobacteria.[8] T-cell-mediated cross-reactivity between mycobacterial antigens and host cartilage is accepted as the main pathogenesis in those who are genetically predisposed.[9] Most common presentation is acute-onset arthritis with acute onset of TB.[10] It is often pauciarticular predominantly affecting large joints.[4],[11] In a review, six out of seven patients developed arthritis after initiation of antituberculous treatment.[11] However, in our case, the child presented with polyarthritis which was refractory to NSAIDS and symptoms abated dramatically after starting ATT.

Our case had no symptoms suggestive of TB other than failure to thrive. Polyarthritis without a clear primary site for TB may be misdiagnosed as rheumatologic diseases, as happened in our case. This highlights the importance of good clinical examination in all patients, as in this case, lymph node examination was a vital pivot in the diagnosis. The common differences between PD and tuberculous arthritis are enumerated in [Table 1].[12] Rapid resolution of arthritis is generally expected once ATT is initiated.[11] Signs and symptoms of our patient were relieved within 2 weeks of starting antituberculous treatment.
Table 1: The common differences between Poncet's disease and tuberculous arthritis are enumerated below[12]

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India, being an endemic country for TB, mandates a much higher suspicion and low threshold for investigations. Symptoms like weight loss or not gaining weight should always be documented with appropriate and proper weighing. Smear microscopy, culture, and nucleic acid amplification tests are the primary diagnostic tools for TB. Where CB-NAAT is doable, it forms the first line of investigations and has the following sensitivity, namely sputum (89%), gastric aspirate (66%), induced sputum (88%), lymph node aspirate (87.6%), CSF (71.1%), joint aspirate (97.2%), peritoneal fluid (59.2%), and pleural fluid (50.9%). Other modalities such as Mantoux, chest X-ray, and interferon-gamma release assay are other diagnostic tools and aid in diagnosis. However, liquid culture remains the gold standard for diagnosis.[13],[14],[15] In children who cannot expectorate sputum spontaneously, gastric aspirate forms a mainstay for CB-NAAT.


  Conclusion Top


PD is a rare clinical diagnosis, and other causes of arthritis such as infective, rheumatic, and systemic causes must be excluded. In countries with a high prevalence of TB, diagnostic workup of arthritis should also include workup for TB because signs and symptoms of arthritis may develop before signs and symptoms of disease itself, as was in our case. The mainstay of treatment is a complete course of ATT for 12–18 months and nonweight-bearing exercises. Surgical interventions such as synovectomy and debridement are required if no response is seen after 4–5 months of ATT.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

The authors would like to thank the Department of Pediatrics, CH (SC), Pune and Armed Forces Medical College, Pune.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mah EL, Bux S. Tuberculous synovitis of the knee with unusually thick synovial granulation tissue: A case report. Internet J Orthopedic Surg 2006;6. Available form: https://print.ispub.com/api/0/ispub-article/12162. [Last accessed on 2019 Mar 05].  Back to cited text no. 1
    
2.
World Health Organization. Global Tuberculosis Report 2018. Geneva: World Health Organization; 2018.  Back to cited text no. 2
    
3.
Malaviya AN, Kotwal PP. Arthritis associated with tuberculosis. Best Pract Res Clin Rheumatol 2003;17:319-43.  Back to cited text no. 3
    
4.
Dall L, Long L, Stanford J. Poncet's disease: Tuberculous rheumatism. Rev Infect Dis 1989;11:105-7.  Back to cited text no. 4
    
5.
Foocharoen C, Sarntipipattana C, Foocharoen T, Mahakkanukrauh A, Paupairoj A, Teerajetgul Y, et al. Synovial fluid adenosine deaminase activity to diagnose tuberculous septic arthritis. Southeast Asian J Trop Med Public Health 2011;42:331-7.  Back to cited text no. 5
    
6.
St. Clair Strange FG. Current concepts review. Tuberculosis of bones and joints (78-A: 288-298, Feb 1996) by Watts and Lifeso. J Bone Joint Surg Am 1998;80:604.  Back to cited text no. 6
    
7.
Spiegel DA, Singh GK, Banskota AK. Tuberculosis of the musculoskeletal system. Tech Orthop 2005;20:167-78.  Back to cited text no. 7
    
8.
Southwood TR, Gaston JS. The molecular basis of Poncet's disease? Br J Rheumatol 1990;29:491.  Back to cited text no. 8
    
9.
Rueda JC, Crepy MF, Mantilla RD. Clinical features of Poncet's disease. From the description of 198 cases found in the literature. Clin Rheumatol 2013;32:929-35.  Back to cited text no. 9
    
10.
Valleala H, Tuuminen T, Repo H, Eklund KK, Leirisalo-Repo M. A case of Poncet disease diagnosed with interferon-gamma-release assays. Nat Rev Rheumatol 2009;5:643-7.  Back to cited text no. 10
    
11.
Abdulaziz S, Almoallim H, Ibrahim A, Samannodi M, Shabrawishi M, Meeralam Y, et al. Poncet's disease (reactive arthritis associated with tuberculosis): Retrospective case series and review of literature. Clin Rheumatol 2012;31:1521-8.  Back to cited text no. 11
    
12.
Rueda JC, Crepy MF, Mantilla RD. Clinical features of Poncet's disease. From the description of 198 cases found in the literature. Clin Rheumatol 2013;32:929-35.  Back to cited text no. 12
    
13.
Revised National TB Control Programme, Technical and Operational Guidelines for Tuberculosis Control in India; 2016.  Back to cited text no. 13
    
14.
Zar HJ, Hanslo D, Apolles P, Swingler G, Hussey G. Induced sputum versus gastric lavage for microbiological confirmation of pulmonary tuberculosis in infants and young children: A prospective study. Lancet 2005;365:130-4.  Back to cited text no. 14
    
15.
Kohli M, Schiller I, Dendukuri N, Dheda K, Denkinger CM, Schumacher SG, et al. Xpert® MTB/RIF assay for extrapulmonary tuberculosis and rifampicin resistance. Cochrane Database Syst Rev 2018;8:CD012768. Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012768.pub2/full. [Last accessed on 2019 Mar 05].  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
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