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How nonbacterial osteomyelitis could be discriminated from tuberculosis in the early stages: the simple algorithm

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Abstract

Chronic nonbacterial osteomyelitis (CNО) and tuberculous osteomyelitis (TBO) are both primarily chronic inflammatory bone diseases with similar clinical and radiological findings, but entirely different in aetiology, pathogenesis, treatment, and outcomes. Our study aimed to evaluate the clinical and laboratory features which could discriminate the CNO and TBO. The study included 124 patients—91 with CNO and 33 with TBO. All patients underwent routine blood tests: WBC, platelets, ESR, C-reactive protein, haemoglobin, and imaging. The ability of each variable to discriminate CNO from TBO was evaluated with sensitivity and specificity analysis, AUC-ROC analysis, and calculating the odds ratio. Patients with TBO had less number of bone foci (p = 0.0000001), onset age (p = 0.00001), rarely articular involvement (p = 0.01), lower haemoglobin level (p = 0.02), higher incidence of TBO in the male subjects (p = 0.002), and higher leukocyte bands (p = 0.0000001). TBO is rarely characterized by spine (p = 0.0009), foot (p = 0.01), and clavicula (p = 0.047) involvement. The diagnostic rule: criteria allowing to differentiate NBO from TBO are negative bone microbiota tests (sensitivity—100.0%, specificity—100.0%) or major discriminative criteria or clavicula involvement alone (sensitivity—11.0%, specificity—100.0%) and at least four from the five additional criteria: number of foci > 1.0 (p = 0.00002), WBC ≤ 11.0 (p = 0.004), neutrophil bands ≤ 120.0 × 106/l (p = 0.002), lymphocytes ≤ 52% (p = 0.0005), and CRP > 0.2 mg/l (p = 0.003). All patients with monofocal CNO required bone biopsy with microbiology assessment. The created provisional criteria may help to discriminate TBO and CNO and should be used only with other known diagnostic tools.

Key Points

• Nonbacterial osteomyelitis and tuberculous osteomyelitis are both primarily chronic inflammatory bone diseases with similar presentations.

• Nonbacterial osteomyelitis and tuberculous osteomyelitis may be associated with other immune-mediated diseases.

• Only bone biopsy can confirm and discriminate both conditions. All patients with monofocal CNO required bone biopsy with microbiology assessment.

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Abbreviations

AUC-ROC:

Area under receiver operating curve

BCG:

bacille Calmette-Guerin

CI:

Confidence interval

CRP:

C-reactive protein

DOR:

Diagnostic odds ratio

ESR:

Erythrocyte sedimentation rate

Mbt:

Mycobacterium tuberculosis

NBO:

Nonbacterial osteomyelitis

NPV:

Negative predictive value

OR:

Odds ratios

PPV:

Positive predictive value

RR:

Relative ratio

Se:

Sensitivity

Sp:

Specificity

TB:

Tuberculosis

TBO:

Tuberculosis osteomyelitis

WBC:

White blood cells

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Funding

This work was supported by the Russian Foundation for Basic Research (grant no. 18-515-57001).

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Authors and Affiliations

  1. Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russian Federation

    Mikhail M. Kostik

  2. Kirov’s Regional Children’s Hospital, Kirov, Russian Federation

    Olga L. Kopchak

  3. Saint-Petersburg Research Institute of Phthisiopulmonology, Saint-Petersburg, Russian Federation

    Alexey S. Maletin, Vyacheslav I. Zorin & Alexander Yu. Mushkin

Authors
  1. Mikhail M. Kostik
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  2. Olga L. Kopchak
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  3. Alexey S. Maletin
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  4. Vyacheslav I. Zorin
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  5. Alexander Yu. Mushkin
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Contributions

Study conception and design: Kostik, Kopchak, Mushkin. Acquisition of data: Kostik, Kopchak, Maletin, Zorin. Analysis and interpretation of data: Kostik, Kopchak, Mushkin. All authors were involved in drafting the article or revising it critically. All authors approved the final version to be submitted for publication. Dr. Kostik, Dr. Kopchak, and Dr. Mushkin had full access to all of the data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis.

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Correspondence to Mikhail M. Kostik.

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Kostik, M.M., Kopchak, O.L., Maletin, A.S. et al. How nonbacterial osteomyelitis could be discriminated from tuberculosis in the early stages: the simple algorithm. Clin Rheumatol 39, 3825–3832 (2020). https://doi.org/10.1007/s10067-020-05174-5

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