A case series and review of Poncet's disease, and the utility of current diagnostic criteria.

AIM: Poncet's disease is a well recognized form of reactive arthritis in the presence of extra-articular tuberculosis. There are very limited case reports even from countries where tuberculosis is common and there are no accepted diagnostic criteria for Poncet's disease. In the present study we are describing clinical features of Poncet's disease from a tuberculosis-endemic region along with a proposal of a new diagnostic criteria. METHODS: All patients diagnosed as having Poncet's disease were included. The clinical details, demographic features, pattern of joint involvement, investigation findings, treatment details and clinical outcomes were recorded on a structured pro forma. RESULTS: Twenty-three patients with Poncet's disease were identified during the study period. Thirteen patients had oligoarthritis and the rest had polyarthritis with ankle joint involvement being most common. The duration of joint symptoms varied from 3 days to 6 years. All patients had non-erosive and non-deforming arthritis. Systemic symptoms were absent in 48% of patients. Mantoux was positive in most cases (81%). Tuberculosis was extrapulmonary in most cases, lymph node tuberculosis being most common. All patients had complete resolution of joint symptoms with anti-tubercular treatment. All the factors contributing to eventual diagnosis of Poncet's disease were carefully analyzed and diagnostic criteria are proposed. In the proposed criteria, there are two essential, two major and three minor criteria. According to these criteria 19 patients had definite and three had probable Poncet's disease. CONCLUSION: The most common presentation of Poncet's is in the form of oligoarthritis. The proposed criteria can be used for diagnosing Poncet's disease.

Randomized controlled trial comparing 2 different starting doses of methotrexate in rheumatoid arthritis.

PURPOSE: Methotrexate (MTX) remains the gold standard disease-modifying antirheumatic drug for the treatment of rheumatoid arthritis (RA). Few studies have compared different starting doses of MTX in RA. We hypothesized that starting with a higher MTX dose may be more effective but associated with more adverse effects. We compared a starting dose of 7.5 versus 15 mg per week of MTX followed by similar fast escalation. METHODS: This was an open-label (blinded assessor), parallel-group, randomized controlled trial that included RA patients aged 18 to 65 years, not on MTX, and having active disease (Disease Activity Score for 28 joints using 3 variables [DAS28(3)] ≥5.1). Patients were randomized to receive MTX at a starting dose of 7.5 mg (group 1) or 15 mg (group 2) per week. The dose of MTX was escalated by 2.5 mg every 2 weeks to a maximum of 25 mg. Patients were seen every 4 weeks, and dose escalation was continued if DAS28(3) was >2.6 and there were no laboratory abnormalities (transaminitis [>2 × upper limit of normal] or cytopenia). The primary endpoint was change in disease activity at 12 weeks (assessed by using the DAS28[3]). Secondary endpoints were patient withdrawals and episodes ofcytopenia or transaminitis. Adverse effects were ascertained by using a questionnaire. Both intention-to-treat and per-protocol analyses were performed. FINDINGS: We enrolled 100 patients (female:male ratio, 78:22) with a mean (SD) age of 43.6 (10.8) years and a disease duration of 4.7 (4.8) years. At baseline, patients had a mean DAS28(3) of 6.2 (0.7) and a Health Assessment Questionnaire score of 1.3 (0.6). Group 1 (7.5 mg) and group 2 (15 mg) included 47 and 53 patients, respectively, with no significant differences in baseline characteristics. At 12 weeks, the mean dose of MTX reached was 17.3 (4.6) mg in group 1 and 23.6 (3.0) mg in group 2 (P < 0.001). The 2 groups had a similar number of patient withdrawals. The mean change in DAS28(3) at 12 weeks in group 1 (-0.47 [0.86]) and group 2 (-0.55 [0.79]) was not significantly different (P = 0.60). The change in the Health Assessment Questionnaire score was also similar in the groups. The frequency of episodes of transaminitis (6 and 7; P = 0.8) and cytopenia (1 and 2; P = 0.9) did not differ significantly between groups 1 and 2, respectively. Results remained the same according to the per-protocol analysis. Among adverse effects, nausea was more common in group 2 compared with group 1 (relative risk, 1.6 [95% CI, 1.1-2.2]). IMPLICATIONS: There were no significant differences in efficacy between the 2 starting doses of MTX. The fast escalation of dose in both groups may have blunted any advantage of starting at a higher dose. Nausea occurred more commonly in patients started on 15 mg of MTX. We suggest longer trials to confirm our findings. ClinicalTrials.gov identifier: NCT01404429.

Chronic arsenic poisoning following ayurvedic medication.

BACKGROUND: Ayurveda, Indian traditional system of medicine, is practiced commonly in South East Asia and in many parts of the world. Many ayurvedic drugs contain heavy metals and may lead to metal toxicity. Of these, chronic lead poisoning is the most common. Chronic arsenic poisoning following the use of ayurvedic medication, though reported, is rare. CASE REPORTS: We describe three patients who presented with features of chronic arsenic poisoning following prolonged ayurvedic medication use. The diagnosis of chronic arsenic poisoning was confirmed by high arsenic levels in the blood, urine, hair, and nails in all the three patients and in ayurvedic drug in two patients. The ayurvedic medication was discontinued and treatment with D-penicillamine started. At 6 months after treatment, blood arsenic levels returned to normal with clinical recovery in all of them. CONCLUSION: Arsenic poisoning following ayurvedic medication is much less common than lead poisoning, though mineral ayurvedic medicines may lead to it. We used D-penicillamine as chelator and all of them recovered. Whether withdrawal of medication alone or D-penicillamine also played a role in recovery is unclear and needs to be assessed.