Feb-march-2016

A CASE OF ANKLE ARTHRITIS WITH ERYTHEMA NODOSUM

Authors: Dr. Divya Puri

Here we present the case of a 25 year old female patient, who presented to us with complaints of joint pains.

The patient presented with a history of joint pains and joint swelling since the past one month. The pains were present in both ankles, feet and wrists. Pain was associated with swelling, significant early morning stiffness lasting about half an hour and tenderness. She also noticed the appearance of red tender nodules over the ankles and feet.



The patient denies any history of fever, weight loss, or night sweats. No history of redness eyes or breathlessness, however she did complain of dry cough ever since she had developed these symptoms.

No history of back pain, altered bowel habits or blood in stool.

No history of intake of any drugs recently or of a prolonged course.

here was no significant past or family history.

Treatment history patient had presented to a local doctor with the above complaints, who had investigated her and found her to have a positive rheumatoid factor. She had subsequently been started on 10 mg of methotrexate with 8 mg of methylprednisone once a week, and a daily dose of etoricoxib.

On examination she had tenderness in right wrist, tenderness and swelling in both ankles, right side more than left with tender erythematous nodules present over the right ankle.

Rest of the systemic examination was normal.

Rest of the systemic examination was normal.Lab investigations revealed haemoglobin of 11.6g/dl, TLC of 5.46×1000/µL, platelet count was 283×1000/µL.

ESR was 70 mm/hr, CRP was negative, RF was 23.8 IU, anti CCP was negative, urine routine examination was normal, TSH was 0.7, Mantoux test was positive at 14 mm.

Chest x-ray was normal, CECT chest revealed multiple necrotic mediastinal lymph nodes.

Bronchoscopy was performed and FNAC from the lymph nodes showed numerous lymphohistiocytic clusters and lymphoid cells in varying stages of maturation. Numerous epithelioid cell granulomas were seen. The background showed numerous benign epithelial cells and necrotic material. Gene xpert test showed positivity for mycobacterium tuberculosis.


The patient was started on anti tubercular treatment.

Discussion

This case demonstrates that active tuberculosis infection may be complicated with reactive arthritis.

This is known as Poncet’s disease. It is well known that tuberculosis may affect large joints like the knee and hip. Here the presentation is generally as a septic monoarthritis, and infection is demonstrable in the synovial fluid or on synovial biopsy. Active tuberculosis can cause a sterile reactive arthritis is lesser known.

The diagnosis of Poncet’s is used to indicate active tuberculosis elsewhere in the body manifesting as sterile reactive arthritis commonly affecting the ankles. It has been suggested that Poncet’s is most commonly a manifestation of extra pulmonary tuberculosis and the presence of erythema nodosum is an important hallmark(1).

The differential diagnosis of patients presenting with erythema nodosum and ankle arthritis is most commonly Lofgren’s syndrome, inflammatory bowel disease, tuberculosis and use of certain drugs like oral contraceptive pills.

In our patient a diagnosis of Lofgren’s syndrome was considered. However it was abandoned as the lymph nodes showed necrosis on CT scan, and on histology and subsequently revealed infection. Lofgren’s syndrome is a triad of acute arthritis, erythema nodosum and bilateral hilar lymphadenopathy (2). It is generally a self-limited condition.

In conclusion the differential diagnosis of patients at risk for tuberculosis, presenting with arthritis and erythema nodosum should definitely include Poncet’s disease. Correct identification of this complication of tuberculosis may avoid delay in diagnosis and treatment.

Reference
  1. Wollheim FA. Enteropathic arthritis. In: Kelley WN, Harris ED Jr, Ruddy S, Sledge CB, editors. Textbook of Rheumatology. 5th. Phildelphia: WB Saunders; 1997. p. 1006-14
  2. Glennas A, Kvien TK, Melby K, et al. Acute sarcoid arthritis: occurrence, seasonal onset, clinical features and outcome. Br J Rheumatol 1995;34:45-50