Tuberculosis-induced arthritis (Poncet's disease): diagnostic challenges and a workflow for clinical decision-making

Introduction Poncet's disease (PD) is a rare form of TB-associated reactive arthritis, presents a major diagnostic challenge due to its close resemblance to rheumatoid arthritis and tuberculous septic arthritis. A clear diagnostic workflow is essential to support clinical decision-making to prevent misdiagnosis and inappropriate immunosuppressive treatment. This review synthesizes current evidence on the diagnostic characteristics of PD and propose a structured diagnostic workflow to improve clinical decision-making and reduce misdiagnosis. Content A narrative review was conducted using major databases, focusing on publications between 2010 and 2025. Eligible studies included clinical descriptions, diagnostic criteria, differential diagnosis, and outcomes related to PD and TB-associated arthritis. PD is characterized by acute or subacute, non-erosive polyarthritis occurring concurrently with active TB at an extra-articular site. Laboratory tests typically reveal elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) but negative autoantibodies, although low-titer RF or anti-CCP may occur. Synovial fluid is inflammatory but sterile, and imaging reveals no erosive changes - features that help differentiate PD from tuberculous arthritis and rheumatoid arthritis. The most reliable diagnostic indicator is rapid and complete resolution of arthritis following anti-tuberculosis therapy (ATT). A diagnostic workflow integrating clinical screening, TB confirmation, exclusion of mimicking conditions, and therapeutic response assessment is proposed. Summary Poncet's disease remains a diagnosis of exclusion that requires a high index of clinical suspicion. Distinct clinical, laboratory, and imaging features, combined with a favorable response to ATT, are central to establishing the diagnosis. Outlook Implementation of a standardized diagnostic workflow may minimize misdiagnosis, avoid unnecessary immunosuppression, and support timely initiation of ATT. Greater recognition of PD within diagnostic pathways is essential for improving outcomes.