Case Report
Disseminated tuberculosis associated with reactive arthritis of Poncet in an immunocompetent patient
Juliana de Oliveira Alves Calado, Anna Carolina Miola
, Maria Regina Cavariani Silvares, Silvio Alencar Marques
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Department of Dermatology and Radiotherapy, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista, Botucatu, SP, Brazil
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It accounts for one-third of the mortality among patients infected with the human immunodeficiency virus (HIV), but it can also affect immunocompetent patients.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Poncet's reactive arthritis was described by Antonin Poncet in 1897 as a TB-associated polyarthritis and is currently defined by polyarthritis or oligoarthritis in the presence of TB, usually visceral. Despite the involvement of the joints, no bacilli are found in the joint fluid of the symptomatic patients,<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5,6</span></a> and the patients present an improvement of the joint condition after adequate TB treatment.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> With this case, we report the rare association of cutaneous TB with reactive arthritis of Poncet, as well as general improvement of the clinical picture after adequate treatment with RIPE scheme.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">A 23-year-old male patient, previously healthy, started with watery diarrhea, abdominal pain and weight loss of 6 kg, associated with nocturnal episodes of fever, 9 months before admission. He denied the consumption of alcohol or illicit drugs. The patient evolved with multiple ulcers with necrotic crust, some with granular floor and raised borders, associated with soft erythematous painful nodules on the lower limbs and ulcers of the fibrinous floor in the glans (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). In addition, he complained of arthralgia in the phalanges, with signs of oligoarthritis of small joints on physical examination. He showed normal exam of the joint fluid and laboratory tests, except for the presence of leukocytes in the feces, and had no previous history of any kind of immunosuppression. At colonoscopy, multiple shallow ulcers covered by thick fibrin associated with enanthem, mainly in the sigmoid, and aftoid ulcers in the proximal rectum were evidenced. The tuberculin sensitivity test (PPD) was negative and the chest X-ray had no alterations. Anatomopathological examination of one of the ulcers was performed on the lower limb, which revealed an epithelioid granulomatous process with palisade granulomas and central caseous necrosis. The study of acid-fast bacilli (AFB) by Ziehl-Neelsen staining showed intact bacilli (<a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 3 and 4</a>), and culture was positive for <span class="elsevierStyleItalic">M. tuberculosis</span>, confirming the diagnostic hypothesis of cutaneous TB. The histopathological analysis of the intestinal biopsy revealed a mild inflammatory infiltrate without the presence of bacilli. After the beginning of the RIPE treatment regimen, the patient evolved with complete healing of the ulcers (<a class="elsevierStyleCrossRefs" href="#fig0025">Figs. 5 and 6</a>) and gradual resolution of the diarrhea and oligoarthritis.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="par0025" class="elsevierStylePara elsevierViewall">Tuberculosis is an important public health problem, especially in underdeveloped countries. In the last decades, it has been reclassified as a re-emerging disease due to increased poverty, malnutrition, increased coinfection with HIV, use of immunosuppressive drugs and cases resistant to the drugs used in treatment.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Multifocal forms are rare and account for 9–10% of cases of extrapulmonary disease. It accounts for one-third of the mortality among HIV-infected patients, but may also affect immunocompetent individuals, with mortality rates ranging from 16% to 25%, although the risk of developing extrapulmonary lesions is proportional to the degree of immunodeficiency.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> Unlike miliary TB, it may not affect the lungs, as in the case herein reported.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">There are hypotheses trying to justify the occurrence of multifocal TB in immunocompetent patients, such as the intensity of transmission in the community, Mendelian susceptibility syndrome to mycobacterial infections due to the existence of defects of interleukin-12, and malnutrition, among others.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">4,8</span></a> In the case reported, there was no personal or family history of immunosuppression; however, at the first visit, the patient was evidently malnourished, which may justify the presence of multiple sites of TB.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The diagnosis of cutaneous TB should be differentiated from leishmaniasis, leprosy, cat scratch disease and deep fungal infections. The concomitant presence of pulmonary TB or in other organs increases the diagnostic probability, which can be confirmed by PPD, microbiological examination with culture and/or PCR.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> In the case reported here, through the positive culture and the presence of numerous AFB in Ziehl–Neelsen staining examination, the diagnosis was confirmed and the patient was submitted to RIPE scheme appropriately, with improvement of the condition at the end of treatment.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Intestinal TB may have a variable and nonspecific clinical picture, and anatomopathological examination may not indicate AFB infection in up to 29% of cases. However, colonoscopy may reveal shallow ulcers in the ileocecal region, with improvement after treatment, as occurred with the patient reported.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The description of Poncet's reactive arthritis consists in polyarthritis or oligoarthritis associated with active TB, without the presence of bacilli in the joints.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Its pathogenesis is poorly understood, but appears to be immune-mediated. The duration of symptoms may vary from months to years, and cases of oligoarthritis predominate, with improvement after use of non-steroidal anti-inflammatory drugs, usually after 5 months of onset of symptoms. The diagnosis is mostly clinical and there are no well defined diagnostic criteria, given the low frequency of the condition. Most patients improve during or after TB treatment, and cases of chronification are rare. Its clinical diagnosis is important, since clinical management should be performed together with an experienced rheumatologist, in view of the consequences of inadequate immunosuppression in a patient infected with <span class="elsevierStyleItalic">M. tuberculosis</span>. In this case, the rheumatology team chose hydroxychloroquine, avoiding prolonged immunosuppression, with good control of the disease during RIPE scheme and resolution of oligoarthritis at the end of treatment. This case alerts us to the possibility of severe, multifocal, cutaneous expression, requiring special care and multidisciplinary care, making it necessary to be recognized by the dermatologist in countries where TB remains endemic.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Financial support</span><p id="par0075" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Authors’ contributions</span><p id="par0055" class="elsevierStylePara elsevierViewall">Juliana Alves Calado: Approval of the final version of the manuscript; elaboration and writing of the manuscript; critical review of the literature; critical review of the manuscript.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Anna Carolina Miola: Approval of the final version of the manuscript; elaboration and writing of the manuscript; critical review of the literature; critical review of the manuscript.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Maria Regina Cavariani Silvares: Approval of the final version of the manuscript; critical review of the literature; critical review of the manuscript.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Silvio Alencar Marques: Approval of the final version of the manuscript; critical review of the literature; critical review of the manuscript.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres1365100" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1254932" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 5 => array:2 [ "identificador" => "sec0025" "titulo" => "Financial support" ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Authors’ contributions" ] 7 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-05-25" "fechaAceptado" => "2019-08-30" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1254932" "palabras" => array:3 [ 0 => "Arthritis, reactive" 1 => "Dermatology" 2 => "Tuberculosis, cutaneous" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cutaneous tuberculosis is a rare extrapulmonary manifestation of tuberculosis which, like disseminated tuberculosis, commonly occurs in immunocompromised patients. Poncet reactive arthritis is a seronegative arthritis affecting patients with extrapulmonary tuberculosis, which is uncommon even in endemic countries. We report a previously healthy 23-year-old male patient with watery diarrhea associated with erythematous ulcers on the lower limbs and oligoarthritis of the hands. Histopathological examination of the skin showed epithelioid granulomatous process with palisade granulomas and central caseous necrosis. AFB screening by Ziehl–Neelsen staining showed intact bacilli, the culture was positive for <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span>, and colonoscopy revealed multiple shallow ulcers. Disseminated tuberculosis associated with reactive Poncet arthritis was diagnosed, with an improvement of the clinical and skin condition after appropriate treatment.</p></span>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Calado JOA, Miola AC, Silvares MRC, Marques SA. Disseminated tuberculosis associated with reactive arthritis of Poncet in an immunocompetent patient. An Bras Dermatol. 2020;95:340–3.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at the Department of Dermatology and Radiotherapy, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista, Botucatu, SP, Brazil.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 498 "Ancho" => 750 "Tamanyo" => 79729 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Well-delimited ulcer with clean floor on the leg.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 495 "Ancho" => 750 "Tamanyo" => 44338 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Shallow ulcers on the penis, with fibrin-containing floor.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 470 "Ancho" => 750 "Tamanyo" => 112182 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Epithelioid granulomatous process in the deep dermis.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 440 "Ancho" => 750 "Tamanyo" => 94734 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Presence of multiple solid bacilli (Ziehl–Neelsen, ×40).</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 498 "Ancho" => 750 "Tamanyo" => 55947 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Complete healing of leg lesions after two months with RIPE treatment.</p>" ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 500 "Ancho" => 750 "Tamanyo" => 47909 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Complete healing of penile lesions after two months with RIPE treatment.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cutaneous tuberculosis overview and current treatment regimens" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L. 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