Table of Contents  
Year : 2020  |  Volume : 5  |  Issue : 4  |  Page : 23-27

Poncet's disease (tubercular rheumatism): a narrative review

Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand, India

Date of Web Publication29-Dec-2020

Correspondence Address:
Ganesh Singh Dharmshaktu
Department of Orthopaedics, Government Medical College, Haldwani, Uttarakhand
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2542-4157.305396

Rights and Permissions

Poncet's disease or tubercular rheumatism is uncommon, and there are not many related studies. No consensus has been achieved with respect to its etiopathogenesis. The low prevalence of this Poncet's disease even in endemic regions suggests hidden mechanisms that require further research to fully comprehend this enigmatic disorder. Careful identification of primary focus of tubercular infection, clinical suspicion and knowledge of this disorder is crucial for prompt identification and treatment. This article aims to provide an overview of the recently published articles about Poncet's disease. The article attempts to highlight key features of the disease for better understanding of this peculiar disorder.

Keywords: mycobacterium tuberculosis; Poncet′s disease; review; synovitis; tubercular rheumatism; tuberculous arthritis

How to cite this article:
Dharmshaktu GS. Poncet's disease (tubercular rheumatism): a narrative review . Clin Trials Orthop Disord 2020;5:23-7

How to cite this URL:
Dharmshaktu GS. Poncet's disease (tubercular rheumatism): a narrative review . Clin Trials Orthop Disord [serial online] 2020 [cited 2022 Oct 7];5:23-7. Available from:

  Introduction Top

Poncet's disease (PD) or tubercular rheumatism is an uncommon presentation in patients of primary visceral or disseminated tuberculosis. [1] The entity, first described by Antonin Poncet as polyarthritis associated with tuberculosis, currently is used to describe only cases with reactive arthritis associated with tuberculosis without direct bacteriological confirmation. [2],[3] It usually presents as nondestructive arthritis where evidences of bacterial presence are negative following exclusion of other differentials. In contrast to tubercular arthritis directly affecting the joint, PD is usually polyarticular and is found to respond well to anti-tubercular treatment (ATT). Few other important features that may help differentiate PD from rheumatoid arthritis and other rheumatic conditions (as rheumatoid factor [RA] factor and anti-cyclic citrullinated protein [CCP] can be positive in both cases) and go in favor of PD are reactive arthritis at younger age, arthritic symptoms at initial phase of infection (not weeks after or after infection subsides), dramatic response to ATT (improvements noted in weeks or few months). [3] Very few cases of PD have been reported in the medical literature and many cases, experts believe, might be underreported even from endemic countries. Severe form of PD may result in protracted course with varying morbidity and deformities. These cases require high index of suspicion for diagnosis and careful exclusion of other probable conditions.

A search in the PubMed central ( and Google Scholar database for full text articles with search query "Poncet's disease" the year from 2005 to 2020 was done. Only the articles concerning PD, after going through full-texts, were included. The objective of the review was to provide readers a quick overview of recent updates on PD for better acknowledgement and identification of this uncommon condition.

  Pathogenesis Top

As the exact pathogenesis is not clear, various theories try to explain the probable etiopathogenesis of PD. Genetic theory is suggested by some due to its selective and rare affliction in an otherwise common disease of high prevalence. Human leukocyte antigen (HLA-DR3 and 4 haplotype) links have been associated with its causation. [4] Case control study of cases of PD against normal subject also highlights linkage of HLA (HLA-B27, DQB*0301) with PD and further research is advocated for more comprehensive information. [5],[6]

Immunological theory suggests hypersensitivity response to tubercular proteins as another mechanism. [7] There seems to exist cross reactivity and immune response due to antigenic similarity between human cartilage and mycobacteria. [8] Besides, intra-articular injection of heat dessicated tuberculosis (TB) bacilli in animals is shown to promote synovitis response substantiating previous theories. [9] It has been observed that in cases of bladder carcinoma receiving attenuated Bacillus Calmette-Guerin (BCG) intra-vesical instillation, 0.55% of these develop reactive polyarthritis. [10] This fact also supports link between mycobacterial antigen response and PD and should be investigated further. Reactive arthritis has been associated with HLA-B27 and association between HLA-B27 and DQB* 0301 alleles was also noted in PD. [11] Cell mediated immune response to tubercular antigen and probable molecular mimicry between mycobacteria heat shock protein 65 and human heat shock protein has been implicated as another theory. [12] Mycobacterial degradation products and overt mycobacterial DNA are found to be present in affected joint synovium. [13] Experts also believe the presence of mycobacterial sequences in normal and inflamed joint relates to trafficking of antigens from BCG vaccination. [14] The linking of PD with rheumatoid arthritis has also been substantiated. [15]

  Clinical Presentations Top

The presentation of PD is reactive, aseptic, non-destrcutive arthritis of large joints. Other common presentation may be pauci-articular arthritis, whereas axial joints are usually spared. [16] Lymphadenopathy, fever, and erythema nodosum are other notable associations. [17],[18] In an extensive review of literature, Kroot et al. [19] noted most cases were male and most common locations were knee, ankle and wrist. Septic arthritis was ruled out by culture in very few cases and only one case had septic tubercular arthritis along with the joint PD. A large study including 23 cases of PD described most cases presenting with oligoarthritis followed by polyarthritis. [20] Ankle joint was commonest affected site and systemic symptoms were absent in 48% cases, while Mantoux test was positive in 81% cases. A recent systematic review of the cases in medical literature included 199 patients with PD including author's case. Mean age was 33.7 years (range 2-78 years) and most cases (42.2%) were males. Most number of cases (35%, n=70) were reported from India followed by Brazil. In 96.5% cases, specific site of tuberculosis was mentioned, 56.8% had extrapulmonary TB and lymph node involvement was found in 42% cases. Ankle joint was common involvement followed by knee and wrist and lung was common associated involvement. Usually first line ATT works in most cases, but second line can be used in multi-drug resistant TB as was used in pulmonary multi-drug resistant case with small joint involvement. [21] The cases with other disorders closely associated with TB such as human immunodeficiency virus have also presented with painful inflammatory arthritis, finally diagnosed as PD. [22] Localized immune phenomena without organism isolation is common in two tubercular forms- tuberculids (cutaneous immune reactions in high cell mediated immunity patients) and PD. A delayed type hypersensitivity reaction in from of papulonecrotic tuberculid and PD was reported in a recent case. [23] The other epiphenomena associated with tuberculosis such as erythema induratum of Bazin or livedo reticularis in conjunction with an extraskeletal tubercular focus and polyarthritis may suggest PD and require ATT trial. [24] The diagnosis of PD, when presented with history of watery diarrhea and symmetrical multiple joint (including small joints of hand) arthritis, may be difficult and requires careful exclusion of reactive and rheumatoid arthritis. [25] Paediatric cases are another underrepresented groups with few reports. In a large case pool of 462 cases of pediatric rheumatologic disorders from South Africa, only four cases of PD were described. [26] Some of the described and notable cases have also been included in tabulated form in the article [Table 1].
Table 1: A few notable cases described with key details from year 2007 onwards

Click here to view

  Recent Updates In Diagnosis Top

No accepted diagnostic criteria exist for PD that invariably presents as reactive arthritis in the presence of extra-articular tuberculosis. Recent studies have attempted to form a diagnostic criteria following study of all known factors contributing to diagnosis of PD. The criteria by Sharma et al. had two essential, two major and two minor criteria and are simple in practical application. [19],[20],[27] Probable cases are called definitive only following positive response to ATT. The previous criteria given by Novaes et al. are also there but little used nowadays. [28] Diagnostic criteria were suggested to improve and strengthen another criteria used to diagnose PD. Utility of criteria by Sharma was used in a subsequent series of five cases and concluded that if the case does not fit into "definite" category, the case should be kept in close observation with regular reconsideration by using the criteria. [29] One case of atypical seropositive RA was found and was termed "pseudo Poncet's disease" by authors. [30]

High titers of rheumatoid factor and anti-CCP have been found in handful of cases that might be confusing as they mimic RA. Describing their case with high rheumatoid factor and anti-CCP in the setting of positive sample for TB monoarthritis have been found to respond to ATT. Occasional reports of positive anti-CCP in cases of tuberculosis are found and this fact should be remembered in these contexts. [31] The differentiation of PD from another uncommon disorder called Löfgren's syndrome (acute presentation of sarcoidosis) is challenging and an algorithm was advised by Garg et al. [32] in this regard. They distinguished 10 cases as Löfgren syndrome and 8 cases as PD out of 18 cases of acute ankle inflammatory arthritis. This is important as the treatment is entirely different for two conditions - glucocorticoid, methotrexate, hydroxychloroquin in Löfgren's syndrome and ATT in PD. Equally important is careful exclusion of differential diagnosis such as other causes of arthritis of viral, bacterial, arthropod-borne etiology, reactive arthritis, gout and chronic arthritis. [33] In absence of conclusive diagnosis, presence of surrogate findings such as reactive immunologic reactions, arthritis and erythema nodosum, may be suspected for tubercular infection as respiratory symptoms may be absent at presentation or may follow later. [34] In a case, presence of erythema nodosum and polyarthritis with mediastinal widening due to lymphadenopathy on CT was later diagnosed as PD. [35] Lymph node biopsy, in presence of lymphadenopathy is important and has been found to reveal epitheloid granuloma or acid fast bacillus in many cases. [36] Synovial biopsy, either surgical (open or arthroscopic) or ultrasound based, is a critical step to rule out many joint pathologies and should be more widely available and hurdles regarding this should be remedied. [37]

  Treatment Top

The fortunate fact is that PD is a non-destructive, transient and migratory mono or polyarthritis without organism isolation that resolves without any structural articular damage. Anti-tubercular treatment is the mainstay of treatment. Resolution of symptoms was usually noted with 1 week to 4 months of initiation of ATT and no case developes irreversible arthritis. [38],[39],[40] In presence of chronic inflammation with no relief on prolonged course of treatment, the diagnosis of PD requires reevaluation. Defaulter to ATT treatment may also develop PD and restart of ATT may be done in such cases. Cases once treated as PD, may rarely be diagnosed as RA in future and for which disease modifying drugs might be used then. [41] In another case of PD treated with ATT for relief in polyarthralgia and low back pain, adalimumab was administered for remaining enthesitis and tendinitis. [42] Development of PD after BCG instillation for urogenital malignancy is also reported in the literature with final diagnosis of PD and subsequent improvement on BCG discontinuation and ATT. [43]

PD cases are less in number despite high tuberculosis incidence in developing countries may signify either underreporting, as the total reported cases are in hundreds only, or the unclear pathogenesis that makes it a selective disorder. Most cases, however, are managed well conservatively without long-term morbidity or arthritis. [44] Occasionally, ATT defaulters can also present with polyarthalgia like symptoms and careful history and previous investigations should be checked and new ones advised to rule out tuberculosis and in worst case scenario a drug-resistant one. [45] In one case on tumor necrosis factor alpha therapy for ulcerative colitis and later presenting with diffuse joint pain along with fever, erythema nodosum and lymphadenopathy, the biopsy of which was positive for TB. Adalimumab probably reactivated the tubercular lymphadenitis in that case. [46] The polyarthralgia may mimic rheumatoid arthritis and may complicate the things as tubercular cases may also show positivity to rheumatoid factor (8-60%) and anti-CCP (7-39%). [47] The other benefit of early diagnosis of PD is prevention of further complication such as pulmonary TB or pleural effusion in late stages as described in a previous report. [48] Occult abdominal TB with hyper-ferritenmia mimicking adult onset Still's disease underlines importance of looking beyond joints and careful exclusion of PD. [49] Death has been rare complication in healthy patient soon after the diagnosis of disseminated tuberculosis and bone marrow examination showing haemophagcytic lymphohistiocytosis in the setting of PD. [50]

  Conclusion Top

Acknowledgement of this condition and anticipation in known cases of tuberculosis in the endemic region shall be important for early diagnosis. Cases with arthritis and negative culture may also be looked for systemic tuberculosis and PD should be kept as an uncommon differential diagnosis.

Author contributions

GSD contributed to the conception, design, manuscript preparation and manuscript review and approved the final version of the manuscript.

Conflicts of interest

None declared.

Financial support


Copyright license agreement

The Copyright License Agreement has been signed by the author before publication.

Data sharing statement

No data is reported in the article.

Plagiarism check

Checked twice by iThenticate.

Peer review

Externally peer reviewed.

Open access statement

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

C-Editor: Zhao M; S-Editor: Li CH; L-Editors: Qiu Y, Wang L;

T-Editor: Jia Y

  References Top

Allen SC. A case in favour of Poncet's disease. Br Med J (Clin Res Ed). 1981;283:952.  Back to cited text no. 1
Poncet A. De la polyarthrite tuberculeuse deformante ou pseudo-rheumatisme chronique tuberculeux. Congr Fr Chir. 1887;1:732-739.  Back to cited text no. 2
Calado JOA, 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.  Back to cited text no. 3
Ariza-Prota M, Pando-Sandoval A, Garcia-Clemente M, Casan P. Poncet's disease mimicking rheumatoid arthritis in a patient with suspected Crohn's disease. Clin Case Rep. 2016;4:72-75.  Back to cited text no. 4
Ottenhoff TH, Torres P, de las Aguas JT, et al. Evidence for an HLA-DR4-associated immune-response gene for Mycobacterium tuberculosis. A clue to the pathogenesis of rheumatoid arthritis? Lancet. 1986;2:310-313.  Back to cited text no. 5
Southwood TR, Gaston JS. The molecular basis of Poncet's disease? Br J Rheumatol. 1990;29:491.  Back to cited text no. 6
Lugo-Zamudio G, Yamamoto-Furusho J, Delgado-Ochoa D, Nunez-Farfan RM, Vargas-Alarcon G, Brbosa-Cobos RE. Human leukocyte antigen typing in tuberculous rheumatism: Poncet's disease. Int J Tuberc Lung Dis. 2010;14:916-920.  Back to cited text no. 7
Dall L, Long L. Poncet's disease: Tuberculous rheumatism. Rev Inf Diseases. 1989;11:105-107.  Back to cited text no. 8
Holoshitz J, Klajman A, Drucker I, et al. T lymphocytes of rheumatoid arthritis patients show augmented reactivity to a fraction of mycobacteria cross-reactive with cartilage. Lancet. 1986;2:305-309.  Back to cited text no. 9
Pearson CM. Development of arthritis, periarthritis and periostitis in rats given adjuvants. Proc Soc Exp Biol Med. 1956;91:95-101.  Back to cited text no. 10
Lugo-Zamudio GE, Yamamoto-Furusho JK, Delgado-Ochoa D, et al. Human leukocyte antigen typing in tuberculous rheumatism: Poncet's disease. Int J Tuberc Lung Dis. 2010;14;916-920.  Back to cited text no. 11
Iwata H, Kinoshita M, Sumiya M. Emergence of erosive polyarethritis coincident with Mycobacterium kansasii pulmonary infection in a patient with systemic sclerosis-rheumatoid arthritis overlap syndrome. Clin Exp Rheumatol. 1999;17:757-758.  Back to cited text no. 12
Tivanen P. From reactive arthritis to rheumatoid arthritis. J Autoimmun. 2001;16:369-371.  Back to cited text no. 13
Kempsell KE, Cox CJ, McColm AA, et al. Detection of mycobacterium tuberculosis group organisms in human and mouse joint tissue by reverse transcriptase PCR prevalence in diseased synovial tissue suggests lack of specific association with rheumatoid arthritis. Infect Immun. 2001;69:1821-1831.  Back to cited text no. 14
Albert LJ. Infection and rheumatoid arthritis guilty by association. J Rheumatol. 2000;27:564-566.  Back to cited text no. 15
Malaviya AN, Kotwal PP. Arthritis associated with tuberculosis. Best Pract Res Clin Rheumatol. 2003;17:319-343.  Back to cited text no. 16
Chakraborty PP, Ray S, Selvan C, Bhattacharjee R, Mandal SK. Poncet's disease: An unusual presentation of tuberculosis in a diabetic lady. World J Clin Cases. 2015;3:385-388.  Back to cited text no. 17
Segula D, Mahmood N, Allian TJ. Ward round: A 43-year-old diabetic man with multiple joint pains. Malawi Med J. 2012;24:84-86.  Back to cited text no. 18
Kroot EJ, Hazes JM, Colin EM, Dolhain RJ. Poncet's disease: reactive arthritis accompanying tuberculosis. Two case reports and a review of the literature. Rheumatology (Oxford). 2007;46:484-489.  Back to cited text no. 19
Sharma A, Pinto B, Dogra S, et al. A case series and review of Poncet's disease, and the utility of current diagnostic criteria. Int J Rheum Dis. 2016;19:1010-1017.  Back to cited text no. 20
Rueda JC, Crepy MF, Mantilla RD. Clinical fewatures of Pioncet'd disease: From the description of 198 cases fund in the literature. Clin Rheumatol. 2013;32:929-935.  Back to cited text no. 21
Biraris PR, Rathi VM, Udwadia F. Poncet's arthritis in a patient with multi-drug resistant tuberculosis. Indian J Chest Dis Alied Sci. 2015;57:195-198.  Back to cited text no. 22
Omonge E, Otieno F, Kubo M, Shiruli B. Poncet's disease in human immunodeficiency virus: a case report. BMC Res Notes. 2017;10:203.  Back to cited text no. 23
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.  Back to cited text no. 24
Ribeiro R, Patrício C, Pais da Silva F, Silva PE. Erythema induratum of Bazin and Ponçet's arthropathy as epiphenomena of hepatic tuberculosis. BMJ Case Rep. 2016;2016:bcr2015213585.  Back to cited text no. 25
Segula D, Mahmood N, Allain TJ. Ward round: A 43-year-old diabetic man with multiple joint pain. Malawi Med J. 2012;24:84-86.  Back to cited text no. 26
Okong'o LO, Scott C. The spectrum of paediatric rheumatic diseases in two tertiary centres in Cape Town, South Africa. Pediatr Rheumatol Online J. 2014;12(Suppl 1):P155.  Back to cited text no. 27
Novaes GS, Kalil G, Borrelli FE. Criteria for diagnosis for Poncet's disease. Rev Bras Rheumatol. 1992;32:20-26.  Back to cited text no. 28
Yushiro E, Shin-Ya K, Tomohiro K, et al. Reactive arthritis induced by active extra-articular tuberculosis A case report. Medicine (Baltimore). 2019;98:e18008.  Back to cited text no. 29
Shobha V, Desai AM. Poncet's disease diagnostic criteria decodes conundrum: Poncet's versus pseudo Poncet's. Rheumatismo. 2019;71:46-50.  Back to cited text no. 30
Sasaki H, Inagaki M, Shioda M, Nagasaka K. Poncet's disease with high titers of rheumatoid factor and anti-citrullinated peptide antibodies mimicking rheumatoid arthritis. J Infect Chemother. 2015;21:65-69.  Back to cited text no. 31
Garg S, Malaviya AN, Kapoor S, Rawat R, Agarwal D, Sharma A. Acute inflammatory ankle arthritis in Northern India- Löfgren's syndrome or Poncet's disease. J Assoc Physicians India. 2011;59:87-90.  Back to cited text no. 32
Fehr A, El-Nouby F, Eltony AA, Abdelkareem Y, Bogdady S. Poncet disease, tuberculosis-arthritis: a case report in upper Egypt and a review of the literature. Egypt Rheumatol Rehabil. 2017;44:39-42.  Back to cited text no. 33
Irmi, Zaiton A, Faezah H. Reactive arthritis in tuberculosis: A case of Poncet's disease. Malays Fam Physician. 2013;8:24-27.  Back to cited text no. 34
Singh H, Pannu AK, Suri V, Bhalla A, Kumari S. Poncet's disease: Uncommon musculoskeletal manifestation of tuberculosis. J Family Med Prim Care. 2018;7:1589-1590.  Back to cited text no. 35
Garg P, Gupta N, Arora M. Monoarticular Poncet disease after pulmonary tuberculosis: A rare case report and review of literature. Perm J. 2016;20:15-199.  Back to cited text no. 36
Smits M, van de Groes, Thurlings RM. Synovial tissue biopsy collection by rheumatologists: Ready for clinical implementation? Front Med (Lausanne). 2019;6:138.  Back to cited text no. 37
Es-Souiri J, Mounir A, Kona I, Abourazak FA, Harzy T. Poncet's disease: A challenging cause of polyarthritis in a Moroccan patient. Egyptian Rheumatol. 2017;39:183-185.  Back to cited text no. 38
Mehrotra V, Garg K, Devi P, Chauhan S. A commonly missed diagnosis: Poncet's disease. J Indian Acd Oral Med Radiol. 2019;31:176-180.  Back to cited text no. 39
Adhi F, Hasan R, Adhi M, Hamid SA, Iqbal N, Khan JA. Poncet's disease: two case reports. J Med Case Rep. 2017;11:93.  Back to cited text no. 40
Nyo MTL, Ally MMTM, Van Duuren EM, Arendse R. Poncet's Disease in the Preclinical Phase of Rheumatoid Arthritis. Case Rep Rheumatol. 2018;2018:3571247.  Back to cited text no. 41
Endo Y, Kawashiri S, Koga T, et al. Reactive arthritis inducded by active extra-articular tuberculosis. A case report. Medicine (Baltimore). 2019;98:e18008.  Back to cited text no. 42
Sampaio PCM, Lira YG, Ribeiro HYU, de Paula Moreira F, Gadelha MSM, da Cruz SFS. Poncet's disease after the intravesical instillation of Bacillus Calmette-Guérin (BCG): a case report. BMC Res Notes. 2017;10:416.  Back to cited text no. 43
Godinez-Baca LE, Lugo-Zamudio GE. Poncet's disease: unusual manifestation of tuberculosis. Med Int Mex. 2019;35:268-272.  Back to cited text no. 44
Simcock DE, Mukherjee D, Gendi NS. Poncet's disease--a novel cause of non-compliance with anti-tuberculous drugs. Respir Med. 2004;98:795-797.  Back to cited text no. 45
Hale S, Speigel P, See S, Cheema B. Poncet disease: A case based review of an uncommon extrapulmonary manifestation of tuberculosis. Clin Pulm Med. 2019;26:173-177.  Back to cited text no. 46
Shimmerling RH, Delbanco TL. The rheumatoid factor: an analysis of clinical utility. Am J Med. 1991;91:528-534.  Back to cited text no. 47
Adhi F, Hasan R, Adhi M, Hamid SA, Iqbal N, Khan JA. Poncet's disease: two case reports. J Med Case Rep. 2017;11:93.  Back to cited text no. 48
Sood I, Kasundra GM, Supriya PS, Gupta A, Bhushan B. A rare case of occult abdominal tuberculosis with Poncet;s disease mimicking adult onset Still's disease. J Midlife Health. 2016;6:125-128.  Back to cited text no. 49
Naha K, Dasari S, Vivek G, Prabhu M. Disseminated tuberculosis presenting with secondary haemophagocytic lymphohistiocytosis and Poncet's disease in an immunocompetent individual. BMJ Case Rep. 2013;2013:bcr2012008265.  Back to cited text no. 50


  [Table 1]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Clinical Present...
Recent Updates I...
Article Tables

 Article Access Statistics
    PDF Downloaded495    
    Comments [Add]    

Recommend this journal