Disseminated tuberculosis associated with reactive arthritis of Poncet in an immunocompetent patient,

AnBrasDermatol.2020;95(3):343---346

Anais

Brasileiros

de

Dermatologia

CASE

REPORT

Disseminated

tuberculosis

associated

with

reactive

arthritis

of

Poncet

in

an

immunocompetent

patient

夽,夽夽

Juliana

de

Oliveira

Alves

Calado

,

Anna

Carolina

Miola

,

Maria

Regina

Cavariani

Silvares

,

Silvio

Alencar

Marques

DepartmentofDermatologyandRadiotherapy,FaculdadedeMedicinadeBotucatu,UniversidadeEstadualPaulista,Botucatu,SP, Brazil

Received25May2019;accepted30August2019 Availableonline20March2020

KEYWORDS

Arthritis,reactive;

Dermatology; Tuberculosis, cutaneous

Abstract Cutaneoustuberculosisisarareextrapulmonarymanifestationoftuberculosiswhich, likedisseminatedtuberculosis,commonlyoccursinimmunocompromisedpatients.Poncet reac-tivearthritisisaseronegativearthritisaffecting patientswithextrapulmonarytuberculosis, which isuncommon eveninendemic countries. We reportapreviouslyhealthy23-year-old male patientwith watery diarrheaassociated witherythematous ulcerson thelowerlimbs andoligoarthritisofthehands.Histopathologicalexaminationoftheskinshowedepithelioid granulomatousprocesswithpalisadegranulomasandcentralcaseousnecrosis.AFBscreening by Ziehl---Neelsenstaining showedintactbacilli,theculturewaspositive forMycobacterium tuberculosis,andcolonoscopyrevealedmultipleshallowulcers.Disseminatedtuberculosis asso-ciatedwithreactivePoncetarthritiswasdiagnosed,withanimprovementoftheclinicaland skinconditionafterappropriatetreatment.

©2020SociedadeBrasileira deDermatologia.PublishedbyElsevierEspa˜na,S.L.U.Thisisan openaccessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

夽 _{Howtocitethisarticle:Calado JOA,MiolaAC,SilvaresMRC,}

Marques SA. Disseminated tuberculosis associated with reactive arthritisofPoncetinanimmunocompetentpatient.AnBras Der-matol.2020;95:340---3.

夽夽_{Study conducted at the Department of Dermatology and}

Radiotherapy, Faculdadede Medicina de Botucatu, Universidade EstadualPaulista,Botucatu,SP,Brazil.

∗_{Correspondingauthor.}

E-mail:annafmrp@yahoo.com.br(A.C.Miola).

Introduction

Althoughtuberculosis(TB)isoneofthemostcommon dise-asesin humans,itscutaneous formisrareand represents about 1---2%of cases of extrapulmonaryTB, which corres-pondsto10%ofthetotalcases.1,2_{Clinically,therearethree}

types:endogenouscutaneousTB(byhematogenousspread), exogenous cutaneous TB (by inoculation) or tuberculids (hypersensitivityreactiontoMycobacteriumtuberculosis)3

Thetreatmentusuallyperformedwithrifampicin,isoniazid, pyrazinamideandethambutol(RIPE)providesresolutionof cutaneousTBcases.

https://doi.org/10.1016/j.abd.2019.08.031

0365-0596/©2020SociedadeBrasileiradeDermatologia.PublishedbyElsevierEspa˜na,S.L.U.ThisisanopenaccessarticleundertheCC BYlicense(http://creativecommons.org/licenses/by/4.0/).

344 CaladoJOetal.

Figure1 Well-delimitedulcerwithcleanfloorontheleg.

Figure2 Shallowulcersonthepenis,withfibrin-containing floor.

Tuberculosisisconsideredmultifocalwhenthereis invol-vement of at least two extrapulmonary sites, with or without pulmonary involvement. Itaccounts for one-third ofthe mortalityamong patientsinfected withthe human immunodeficiencyvirus(HIV),butitcanalsoaffect immu-nocompetentpatients.4

Poncet’sreactivearthritiswasdescribedbyAntonin Pon-cetin1897asaTB-associatedpolyarthritisandiscurrently definedbypolyarthritisoroligoarthritisinthepresenceof TB,usuallyvisceral.Despitetheinvolvementofthejoints, nobacilliare found in thejoint fluidof the symptomatic patients,5,6 _{and the patients present an improvement of}

thejointconditionafteradequateTBtreatment.7_Withthis

case,wereporttherareassociation ofcutaneousTB with reactivearthritisofPoncet,aswellasgeneralimprovement oftheclinicalpictureafteradequatetreatment withRIPE scheme.

Case

report

A23-year-oldmalepatient,previouslyhealthy,startedwith waterydiarrhea,abdominalpain andweightloss of 6 kg, associatedwithnocturnalepisodesoffever,9monthsbefore admission. He denied the consumption of alcohol or illi-cit drugs. The patient evolved with multiple ulcers with necroticcrust,somewithgranularfloorandraisedborders, associatedwith softerythematous painful nodules onthe lower limbs and ulcers of the fibrinous floor in the glans (Figs.1and2).Inaddition,hecomplainedofarthralgiain the phalanges, with signs of oligoarthritis of small joints onphysical 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

Figure3 Epithelioidgranulomatousprocessinthedeep der-mis.

Figure 4 Presenceof multiplesolid bacilli (Ziehl---Neelsen, ×40).

Figure5 Completehealing ofleglesionsafter twomonths withRIPEtreatment.

of any kind ofimmunosuppression.At colonoscopy, multi-ple shallowulcers covered by thickfibrin associatedwith enanthem, mainlyinthesigmoid,andaftoidulcersin the proximal rectum were evidenced. The tuberculin sensiti-vity test (PPD) was negative and the chest X-ray had no alterations.Anatomopathologicalexaminationofoneofthe ulcers was performed onthe lower limb, which revealed an epithelioidgranulomatous processwithpalisade granu-lomasandcentralcaseousnecrosis.The studyofacid-fast bacilli(AFB)byZiehl-Neelsenstainingshowedintactbacilli (Figs.3and4),andculturewaspositiveforM. tuberculo-sis,confirming thediagnostic hypothesis ofcutaneousTB. Thehistopathologicalanalysisoftheintestinalbiopsy reve-aledamildinflammatoryinfiltratewithoutthepresenceof bacilli.AfterthebeginningoftheRIPEtreatmentregimen, the patient evolved with complete healing of the ulcers (Figs.5 and6)andgradual resolutionof thediarrheaand oligoarthritis.

Disseminatedtuberculosiswithreactivearthritis 345

Figure6 Completehealingofpenilelesionsaftertwomonths withRIPEtreatment.

Discussion

Tuberculosis is an importantpublic health problem, espe-ciallyin underdevelopedcountries.Inthelastdecades,it hasbeenreclassifiedasare-emergingdiseasedueto incre-asedpoverty,malnutrition,increasedcoinfectionwithHIV, useofimmunosuppressivedrugsandcasesresistanttothe drugsusedintreatment.

Multifocalformsarerareandaccountfor9---10%ofcases of extrapulmonary disease. It accounts for one-third of the mortality among HIV-infected patients, but may also affect immunocompetentindividuals, withmortalityrates ranging from 16% to25%, although the risk of developing extrapulmonary lesions is proportional to the degree of immunodeficiency.8_{UnlikemiliaryTB,itmaynotaffectthe}

lungs,asinthecasehereinreported.9

Therearehypothesestryingtojustifytheoccurrenceof multifocal TB in immunocompetent patients, such as the intensityoftransmissioninthecommunity,Mendelian sus-ceptibilitysyndrometomycobacterialinfectionsduetothe existence of defects of interleukin-12, and malnutrition, amongothers.4,8 _{In thecase reported,there wasno}

per-sonalor familyhistoryofimmunosuppression;however,at thefirstvisit,thepatientwasevidentlymalnourished,which mayjustifythepresenceofmultiplesitesofTB.

The diagnosis ofcutaneousTB shouldbedifferentiated fromleishmaniasis, leprosy, cat scratchdisease and deep fungalinfections.The concomitantpresenceofpulmonary TB orin other organsincreasesthediagnostic probability, whichcanbeconfirmedbyPPD,microbiologicalexamination withcultureand/orPCR.8_{Inthecasereportedhere,through}

the positive culture and the presence of numerous AFB in Ziehl---Neelsen staining examination, the diagnosis was confirmed andthe patient wassubmittedtoRIPE scheme appropriately,withimprovementoftheconditionattheend oftreatment.

IntestinalTBmayhave avariableandnonspecific clini-calpicture,andanatomopathologicalexaminationmaynot indicateAFBinfectioninupto29%ofcases.However, colo-noscopymayrevealshallowulcersintheileocecalregion, with improvement after treatment, asoccurred with the patientreported.10

The description of Poncet’s reactive arthritis consists in polyarthritis or oligoarthritis associated with active TB, without the presence of bacilli in the joints.6 _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 pre-dominate, with improvement after use of non-steroidal anti-inflammatory drugs, usually after 5 months of onset ofsymptoms.Thediagnosisismostlyclinicalandthereare nowelldefineddiagnosticcriteria,giventhelowfrequency ofthecondition. MostpatientsimproveduringorafterTB treatment,andcasesofchronificationarerare.Itsclinical diagnosisisimportant,sinceclinicalmanagementshouldbe performedtogetherwithanexperiencedrheumatologist,in viewoftheconsequencesofinadequateimmunosuppression inapatientinfectedwithM.tuberculosis.Inthiscase,the rheumatologyteamchosehydroxychloroquine,avoiding pro-longedimmunosuppression,withgoodcontrolofthedisease duringRIPE scheme andresolution of oligoarthritisat the end of treatment. This case alerts us to the possibility ofsevere,multifocal,cutaneousexpression,requiring spe-cialcareandmultidisciplinarycare,makingitnecessaryto berecognizedbythe dermatologistincountrieswhere TB remainsendemic.

Financial

support

Nonedeclared.

Authors’

contributions

JulianaAlves Calado: Approval of thefinal version of the manuscript; elaboration and writing of the manuscript; critical review of the literature; critical review of the manuscript.

Anna Carolina Miola: Approval of the final version of themanuscript;elaborationandwritingofthemanuscript; critical review of the literature; critical review of the manuscript.

MariaReginaCavarianiSilvares:Approvalofthefinal ver-sion of the manuscript; critical review of the literature; criticalreviewofthemanuscript.

SilvioAlencarMarques:Approval ofthefinal versionof the manuscript; critical review of the literature; critical reviewofthemanuscript.

Conflicts

of

interest

Nonedeclared.

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