world 's largest number of tuberculosis ( tb ) patients reside in india which makes around 26% of world tb population . of all gastrointestinal tract , peritoneum , lymph - node , liver , spleen and genitourinary tract can be involved in abdominal tb . abdominal tb is a great mimicker and often difficult to diagnose . because of non - specific signs and symptoms and frequent false negative results with standard tests , it is often confused with gastrointestinal inflammatory , malignant a 50-year - old female patient presented with high grade fever and arthralgias since 8 weeks . bilateral metacarpo - phalyngeal , wrist and large joints were swollen , painful and had morning stiffness lasting 30 minutes . two weeks prior she developed a non - pruritic , non - photosensitive macular rash over the trunk which resolved spontaneously . over the preceding 4 weeks , she was having severe anorexia , malaise , multiple painful oral ulcers and had lost 7-kg weight . patient also complained of alopecia [ figure 1 ] developing with the onset of fever . there was no history of cough , diarrhea , vomiting , abdominal pain or any other significant infection . patient took treatment initially at a local health centre with acetaminophen 1.5 g / day for 5 days and amoxicillin 1.5 g / day for 5 days but with no relief , after which she was referred to us . examination revealed oral temperature of 39c , mild pallor , non - scarring alopecia and mild hepatospleenomegaly . wrist , knee and ankle joints were bilaterally swollen and tender without any joint restriction . figure showing non scarring alopecia investigations [ table 1 ] revealed , normocytic normochromic anemia and leucocytosis with marked neutrophilia . erythrocyte sedimentation rate ( esr ) was raised with very high serum ferritin levels ( 3850 ng / ml ) , which was repeated twice showing similar values . except for mildly elevated transaminase levels rest of the liver and renal function tests , sputum smear for acid fast bacilli ( afb ) , tb - pcr ( polymerase chain reaction ) and adenosine deaminase ( ada ) of ultrasound - guided aspirated ascitic fluid were all negative . she was started with injectable pipracillin - tazobactam 4.5 gm quarter in die ( qid ) with metronidazole 200 mg ter in die ( tid ) and doxycycline 200 mg bis in die ( bid ) along with supportive treatment . repeated blood counts during her stay in the hospital after starting antibiotics showed no decline in the levels . keeping in view the very high serum ferritin levels along with fever , arthralgias , macular rash , elevated liver enzymes and erythrocyte sedimentation rate with neutrophilia , a presumptive diagnosis of aosd was made fulfilling yamaguchi criteria [ table 2 ] . seven days later , patient developed severe abdominal pain and vomiting when repeat ct abdomen showed multiple enlarged and matted mesenteric and periportal lymph - nodes with mid ascitis [ figure 3 ] . laparoscopy guided lymph - node biopsy revealed caseating granulomas without afb [ figure 4 ] and the tissue was sent for mycobacterial culture . as ct - chest showed no evidence of any pulmonary parenchymal or thoracic lymph node involvement , a fungal etiology was unlikely . considering the fact that the most common cause of caseating granuloma in india is tuberculosis , and that abdominal tuberculosis is paucibacillary , we kept the provisional diagnosis of abdominal tuberculosis . patient improved significantly with four drugs anti - tubercular therapy for 6 months , and is asymptomatic under our regular follow - up over the last 8 months . patient was advised repeat laparoscopy , but did not consent for the same as she had improved . table showing laboratory investigations x - rays of both wrist joints and hands ( ap view ) showing mild periarticular soft tissue swelling with no evidence of destruction or joint space narrowing table showing yamaguchi 's criteria contrast enhanced computed tomography ( cect ) abdomen showing multiple enlarged and necrotic retroperitoneal lymph nodes histopathology of abdominal lymph node showing granuloma with central caseation aosd is a rare multi - systemic inflammatory disorder of unknown etiology first described in 1971 . it is characterized by fever , arthritis , evanescent skin rash , sore throat and occasional lymphadenopathy , hepatospleenomegaly and serositis . it is associated with marked leucocytosis ( neutrophilia ) , raised serum ferritin levels and abnormal liver function tests . diagnosis of aosd is based on yamaguchi 's criteria [ table 2 ] . before diagnosing aosd , infectious , malignant , ferritin is an intracellular iron binding protein and acute phase reactant whose levels in the body are regulated mainly by levels of iron , cytokine release and chemokine production . it is raised in several acute and chronic inflammatory conditions , however very high serum ferritin levels [ > five times normal ( > 1000 ng / ml ) ] are associated with four uncommon disorders namely , the macrophage activation syndrome , aosd , catastrophic antiphospholipid syndrome and septic shock . serum ferritin levels are marginally increased in isolated tb infection however levels upto 10,000 ng / ml have been reported in hiv and tb coinfection . the diagnosis of abdominal and milliary tb can be challenging due to varied clinical presentations . rai et al . , in their study concluded that laboratory studies , tuberculin skin tests , ziehl - neelsen ( zn ) staining and ct scans can give false negative results in cases of abdominal tuberculosis . iu / l ( sensitivity > 90% ) are considered confirmatory in tb , false negative results increases in patients with decreased ascitic fluid protein concentration . similarly sensitivity of tb - pcr in ascitic fluid is around 93% but with negative afb staining , sensitivity can drop to as low as 33% . acid - fast bacilli can be seen on histological examination by zn staining in only 6 - 8% of patients . abdominal tuberculosis is paucibacillary , histopathological evidence of caseating necrosis can be taken as diagnostic for starting akt till culture reports are awaited in cases of strong clinical suspicion especially in endemic areas . in our patient of abdominal tuberculosis none of the above mentioned investigations were helpful and patient 's clinical findings mimicked aosd . also marked non - scarring alopecia , painful oral ulcers and symmetrical arthralgias associated with elevated esr and quick response to steroids pointed towards an autoimmune etiology . since the incubation period of tb is around 2 - 12 weeks , chances of patient getting secondarily infected during course of steroids are less . poncet 's disease , a rare form of aseptic arthritis can develop in a case of active tuberculosis . clinically it resembles reactive arthritis and can involve any joint but large joints are involved more often . the mechanism behind it is thought to be immunological . as per our literature search , there has been only one case report of tuberculosis with extreme hyperferritinemia mimicking aosd in which the patient had hepatic tuberculosis . such atypical manifestation of not so easily diagnosed abdominal tuberculosis in endemic areas can pose a major diagnostic challenge and delay the necessary treatment . there are no conflicts of interest .
a 50-year - old female presented with fever , symmetrical arthralgias , rash , painful oral ulcerations and alopecia since 8 weeks . 
 examination showed mild hepatospleenomegaly . 
 investigations revealed leucocytosis , neutrophilia , elevated sedimentation rate and raised ferritin levels ( 3850 ng / ml ) . computerized tomography ( ct ) abdomen showed hepatospleenomegaly , mild ascitis and mild bilateral pleural - effusion . after ruling out occult infections , tuberculosis , malignancies and autoimmune diseases by appropriate investigations , and due to raised ferritin levels , adult onset stills disease ( aosd ) was diagnosed . 
 patient responded to oral steroids initially , but after 7 days developed severe abdominal pain . 
 repeat ct showed multiple enlarged , necrotic and matted retroperitoneal lymph nodes with caseating granuloma on histopathology suggesting tuberculosis . 
 patient was given four - drug anti - tubercular treatment and she improved . 
 thus our patient of occult abdominal tuberculosis with reactive arthritis ( poncet 's disease ) presented with hyperferritinemia mimicking aosd . 
 we postulate that extreme hyperferritinemia can be seen in tuberculosis and tuberculosis must be conclusively ruled out before diagnosing aosd in tropics .