A good clinical examination clinched the diagnosis : Poncet’s disease revisited
This case was contributed by
Dr.Vipul Agarwal
MBBS, MD (Internal Medicine), FAGE
Assistant Professor, Department of Internal Medicine
Mahatma Gandhi medical college, Jaipur
E-mail: vipul.msrmc@gmail.com
Clinical scenario:
A 28 year old male presented with bilateral joint pains for one month involving bilateral knee, ankle, metatarsophalangeal joints, elbow, wrist, metacarpophalangeal and interphalangeal joints.
The Joint pains were associated with stiffness which improved following activity.
No history of fever, weight loss or loss of appetite.
On examination, He was conscious, oriented hemodynamically stable.There was no pallor, icterus, cyanosis, pedal edema.
Joint examination, no redness or local rise of temperature in any joint.
Tenderness was present on palpation of bilateral ankle joints.
Respiratory, cardiovascular and neurological examination was normal.
Hospital course :
We started investigating him on the lines of arthritis like rheumatoid arthritis etc but all preliminary workup was inconclusive apart from ESR which was mildly elevated.
Rheumatoid factor and anti- CCP were normal.
No joint abnormality of x rays.
As we hit the road block,
The patient was carefully examined once again .
A lymph node was found in his Right supraclavicular area .
It was non- tender, hard around 2cm* 3cm
This had been missed unfortunately in the first clinical examination.
Fine Needle Aspiration Cytology of the lymph node , revealed granulomatous necrosis with CBNAAT positive for Mycobacterium tuberculosis.
The patient was started on antitubercular therapy following which the patient showed improvement in joint pain by 1st week .His pain gradually disappeared by the 4th week. Surprisingly apart from joint pains the patient had no constitutional symptoms of tuberculosis like fever, weight loss, loss of appetite etc.
On reviewing the literature, we found this rare presentation of tuberculosis called Poncet disease, in which the patient presents with polyarthritis & no constitutional features of tuberculosis.
To conclude a good clinical examination and not the battery of tests clinched the diagnosis.
Further reading: Poncet’s disease
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