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. 2025 Mar 11;64:102973. doi: 10.1016/j.jcot.2025.102973

Tuberculous osteomyelitis masquerading as tumors and tumor-like lesions: A clinico-radiological study of 20 patients

Zile Singh Kundu a, Kunika Kundu b, Parveen Rana c, Pankaj Kumar Sharma d,⁎, Lakshmana Das d, Jyoti Sharma e
PMCID: PMC11952845  PMID: 40160376

Abstract

Background

Tuberculous osteomyelitis is uncommon and may present with varied clinical and radiological presentations. This study aimed to elaborate on how these lesions mimicked different tumors or tumor-like lesions and their successful outcome with antitubercular therapy (ATT).

Methods

A retrospective review of 20 patients with tuberculous osteomyelitis who presented as tumors or tumor-like lesions of bone in the last 10 years. All these were histopathologically proven lesions. Eleven cases with sequestrations required curettage for the extensive lesions. All twenty received ATT for 12 months.

Results

There were 12 males and eight females, with ages ranging from 3 to 61 years (an average of 22.15). Eight cases presented like bone cysts in the metaphyseal area of the long bones, with one cystic lesion in the body of the talus. 2 mimicked chondroblastoma and one patient each, like giant cell tumors and osteoid osteomas, respectively. One patient had multifocal lytic lesions resembling metastasis or multiple myeloma. One patient had two lesions involving the clavicle and the proximal phalanx of the little finger). One lesion in the metatarsal and five in the phalanges of the hand mimicked chondromas. All resolved well, with no residual disability after receiving ATT.

Conclusions

In endemic countries, tuberculosis should always be considered one of the differential diagnoses for lytic bone lesions. Histopathological confirmation is the gold standard for the diagnosis. These can be effectively treated with anti-tubercular medication.

Keywords: Tuberculosis, Long bone, Biopsy, Curettage, Histopathology, Tuberculous osteomyelitis, Tumors

1. Introduction

Tuberculosis (TB) is a significant health issue in developing countries.1, 2, 3 Compared with pulmonary TB, skeletal TB is an uncommon disease involving 10–15 % of all TB patients.3,4 It can affect any bone of the body and may present with varied presentations. Osteoarticular TB has remained a diagnostic mystery particularly when it involves uncommon sites. In view of varied and unusual presentations, the diagnosis may be delayed.5, 6, 7, 8, 9 We are reporting 20 cases of TB osteomyelitis which radiologically mimicked different cystic/lytic bone tumors and tumor-like lesions, including two patients with multifocal lesions. After biopsies or curettage, the diagnosis of tuberculous osteomyelitis was confirmed. All the patients received anti-tubercular treatment (ATT) and had ossification/resolution of the lytic lesions and complete relief from the clinical symptoms

This study aimed to elaborate: 1) How these tuberculous osteomyelitis lesions mimicked different tumors or tumor-like lesions of the bone requiring a high index of suspicion for the diagnosis and 2.) The successful outcome depends on antitubercular therapy, which is the mainstay of the treatment.

2. Methods

A retrospective analysis of prospectively collected data of 787 patients who were presented as tumor or tumor-like lesions of the bone to a tertiary care hospital between 2008 and 2020. Patients with a definitive diagnosis of tuberculous lesions were identified. The clinic-radiological and histopathological data were retrieved from the hospital records. A total of 27 cases were identified. 3 cases were excluded due to incomplete clinical-radiological records or inadequate follow-up, and 4 cases were excluded due to discrepancies in following the institute protocol. The final study population included 20 patients diagnosed and managed according to the standard diagnostic protocol made by the oncology board of the institute (Fig. 1). All patients underwent core needle biopsy using a 12 Gauge Jamshidi needle under image guidance. The diagnosis was confirmed in all the cases with histopathology of tissues after biopsies or curettage of the lesions.

Fig. 1.

Fig. 1

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Standard diagnostic protocol of the author's institute for tumor and tumors like lesions.

The demographic profile of the patients, clinical presentation, radiological features (including plain radiographs and MRI), blood parameters including Complete Blood Count (CBC) for Total Leucocyte count (TLC), Quantitative C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels Liver Function Test (LFT), Renal Function Test (RFT), histopathological findings and culture reports were extracted and compiled. All the included patients had monthly follow-ups for the initial three months and three monthly follow-ups thereafter for a minimum of two years.

2.1. Follow-up investigations

  • 1.

    CBC, ESR, CRP (Quantitative), LFT, RFT & local plain radiographs at 1, 3, 6, 9, 12 & 15 months

  • 2.

    CBC, ESR, CRP (Quantitative) & local plain radiographs at 6 and 12 months after completion of ATT

  • 3.

    MRI at 12-month follow-up and 1 year after completion of ATT

IBM SPSS (26.0) software was used for statistical analysis. Descriptive statistics were presented as mean and standard deviation for continuous variables and frequencies and percentages for categorical variables.

3. Results

The demographic details and outcomes of included patients are summarized in Table 1. There were 20 cases (twelve males and eight females) with a mean age of 22.15 + 17.99 years (range, 3–61 years). All the patients presented with pain and tenderness in deep-seated lesions and with swelling at superficial sites, with the duration of symptoms ranging from 3 to 4 months. Constitutional symptoms like loss of appetite and weight with an increase in evening temperature were observed in only four cases. The Mantoux test was positive, and the erythrocyte sedimentation rate (ESR) (range: 40–100 mm in the first hour) was raised in all the cases. Blood samples for viral markers, including Human Immunodeficiency Virus (HIV) and hepatitis, were negative in all patients. In all cases, chest radiograph findings were unremarkable, without any detectable concomitant healed or active tubercular lesions and sputum for acid-fast bacillus (AFB) was negative. Plain radiographs of the affected part showed lytic/cystic lesions in 19 cases, and extensive sclerosis surrounding the lytic lesion in one case mimicked osteoid osteoma. Magnetic resonance imaging (MRI) has picked up peri-lesional oedema and thus suspected infective pathology. On examination of the biopsy sample, AFB stain and culture were positive only in 5 and 14 patients, respectively. On histopathological examination, Caseous necrosis, epithelioid cells, Langhans giant cells, granulomatous inflammation and other necrosis were seen in 75 %, 95 %, 95 %, 50 % and 70 % of specimens, respectively. Detailed Inflammatory markers and microbiological and histopathological findings of the patients are shown in Table 2. Histopathological image showing necrotizing granulomatous inflammation with epithelioid granulomas with typical Langhans type of giant cells and lymphocytes, confirming the diagnosis of TB, is shown in Fig. 2.

Table 1.

Demographic details, treatment methods and final outcomes of the included patients having Tuberculous osteomyelitis lesions mimicking tumor like lesions.

S.N. Age (yrs.) and sex Location of lesion Presentation of lesion Duration of symptom (weeks) Radiological resemblances Treatment Follow-up (months)
1 9/M Femoral neck Cystic lesion 18 Fibrous dysplasia/bone cyst Curettage/ATT 36
2 19/F Tibial cortex Lytic lesion with surrounding sclerosis 20 Osteoid osteoma Curettage/ATT 29
3 3/M Femoral Neck Cystic lesion 20 Bone cyst Curettage/ATT 27
4 6/M Talus Cystic lesion 28 Bone cyst Curettage/ATT 32
5 5/M Olecranon Lytic lesion 12 Bone cyst Curettage/ATT 24
6 54/M Ulnar diaphysis Cystic lesion 12 Bone cyst Curettage/ATT 30
7 43/M Clavicle Lytic lesion 12 Bone cyst Curettage/ATT 24
8 28/M Distal radius Lytic lesion 12 Giant cell tumor Curettage/ATT 28
9 34/M Distal femur Lytic lesion 20 Bone cyst Curettage/ATT 27
10 16/M Proximal tibial epiphysis Lytic lesion 12 Chondroblastoma Curettage/ATT 32
11 61/M Multifocal Multiple lytic lesions 12 Metastasis/Myeloma Biopsy/ATT 24
12 20/F Distal fibula Lytic lesion 8 Bone cyst Biopsy/ATT 26
13 08/F Proximal phalanx ring finger Lytic lesion 4 Enchondroma Biopsy/ATT 32
14 14/F Distal fibula Lytic lesion 6 Bone cyst Biopsy/ATT 34
15 10/F Proximal phalanx middle finger Lytic lesion 6 Enchondroma Biopsy/ATT 29
16 09/F 5th Metacarpal and clavicle Lytic lesion + periosteal reactions 4 Enchondroma in metacarpal; lytic lesion in clavicle Biopsy/ATT 27
17 16/M Femoral condyle Lytic lesion 12 Bone cyst Curettage/ATT 26
18 15/F 4th Metatarsal Lytic lesion 8 Bone cyst Biopsy/ATT 30
19 60/F Lower end of femur Lytic lesion 8 Bone cyst Biopsy/ATT 25
20 13/M Distal femoral epiphysis Lytic lesion 16 Chondroblastoma Biopsy/ATT 26
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Table 2.

Detailed depiction of inflammatory markers and microbiological and histopathological findings of the patients.

S.N Montoux test (Induration at 72 h)
 CRP
 ESR
 TLC
 AFB STAIN for M.tuberculosis
 BACTEC MGIT culture for M.tuberculosis
 Histopathological findings
mm mg/dL mm/hr Cells/mm3 Caseous Necrosis Epithelioid cells Langhans giant cells Granulomatous inflammation Other Necrosis
1 12 35 114 6730 Negative Positive Yes Yes Yes No Yes
2 12 36 94 8620 Positive Positive Yes Yes Yes Yes Yes
3 12 22 72 4330 Negative Positive Yes Yes Yes Yes No
4 10 24 68 4200 Negative Negative No Yes Yes Yes Yes
5 14 26 86 5450 Positive Positive Yes Yes Yes No Yes
6 10 18 98 8500 Negative Positive Yes Yes Yes Yes No
7 12 15 84 4540 Negative Negative Yes Yes Yes No No
8 13 14 107 7500 Negative Positive Yes Yes Yes Yes Yes
9 12 18.2 92 9000 Negative Negative Yes Yes Yes No No
10 13 14.7 77 3550 Negative Positive No Yes Yes Yes Yes
11 10 72.8 131 7300 Positive Positive Yes Yes Yes No Yes
12 11 20 78 4500 Negative Negative Yes Yes Yes No No
13 12 12 62 6700 Negative Positive Yes Yes Yes No Yes
14 14 18.6 72 8400 Positive Positive No Yes Yes Yes Yes
15 10 11.4 68 6800 Negative Positive No Yes Yes No No
16 14 13 66 9500 Negative Negative Yes Yes Yes Yes Yes
17 11 17 59 6300 Negative Negative Yes Yes Yes No Yes
18 13 13.6 94 7700 Positive Positive Yes Yes Yes Yes Yes
19 13 26 87 9100 Negative Positive Yes Yes Yes Yes Yes
20 10 19.2 108 6700 Negative Positive No Yes Yes No Yes
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Fig. 2.

Fig. 2

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Hematoxylin and Eosin (H&E) stained slide (40X magnification) shows epithelioid granulomas marked by arrow (Image 1).

Clinical examination and conventional radiographs had not suggested the identical feature of infection and mimicked more like tumor or tumor-like lesions. The most common location was the metaphyseal regions of the long bones. Rare cases having multifocal metaphyseal lesions may presented as metastasis, radiologically (Fig. 3). Eight cases presented like bone cysts, i.e., mimicking simple or aneurysmal bone cysts in the metaphyseal area of the long bones (Fig. 4a and 4b) and one patient had a cystic lesion in the body of the talus. One patient had a lytic lesion mimicking giant cell tumor (GCT) in the epiphyseal-metaphyseal area of the distal radius (Fig. 5a), and two lesions mimicked chondroblastoma occurring in proximal tibial (Fig. 5b) and distal femoral epiphyses, respectively. One lesion resembled metastasis/multiple myeloma as multifocal lytic lesions (Fig. 3), and one mimicked osteoid osteoma in the tibial diaphysis. One patient had two lesions involving the clavicle and hand (proximal phalanx in the little finger). There was one case with a cystic lesion in the fourth metatarsal of the left foot and three cases having lesions in the hand (spina Ventosa, Fig. 6) mimicking chondromas and bone cysts, respectively. However, an MRI showed oedema around these lesions, and the possibility of infection or reactive inflammation was suspected.

Fig. 3.

Fig. 3

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Radiographs showing multifocal tuberculosis (TB) shown by arrows in fig a, b and c mimicking metastasis or myeloma in a 61year old patient, while fig d and e showing increased metabolic activities in multiple locations on PET-scan of same patient.

Fig. 4.

Fig. 4

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Plane radiograph showing tubercular lesions mimicking bone cyst (a) and fibrous dysplasia (b) in femoral neck in two different pediatric patients respectively.

Fig. 5.

Fig. 5

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Plane radiograph showing tubercular lesions mimicking giant cell tumor in distal radius (a) and chondroblastoma in proximal tibial epiphysis (b) in two different patients respectively.

Fig. 6.

Fig. 6

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Spina Ventosa (TB dactylitis) of ring finger, clinical (a) and radiographic (b) appearance mimicking enchondroma.

The indication for curettage in our study was inconclusive core needle biopsy and extensive involvement of long bones and periarticular lesions. Of the 11 cases that underwent curettage, 4 were done due to inconclusive core needle biopsy findings, and 7 were due to the location and extension of the lesions. Curettage was performed definitive surgical measure to reduce bacterial load. No bone grafts or substitutes were used to fill the cavities after curettage. Intralesional streptomycin was instilled in the cavities after curettage before surgical closure in all cases.

After definitive histopathological or microbiological confirmation of osseous tuberculous lesions, all patients received ATT according to the following ATT regimen: Isoniazid, Rifampicin, Ethambutol and Pyrazinamide (HRZE) for the first two months, followed by Isoniazid, Rifampicin and Ethambutol (HRE) along with pyridoxine for the next ten months (extendable to 18–24 months on a case-by-case basis). The endpoint of ATT is decided by normalization of inflammatory markers and rradiological signs of bone healing at 12 months follow-up MRI, including remineralisation of the affected bone, resolution of marrow oedema, fatty replacement in the marrow and no contrast enhancement. At the end of ATT treatment, all patients were followed up at 6 monthly intervals.

Protected weight bearing with axillary crutches and support with plaster slab was required in nine cases of lower extremity for the first three months during the post-op follow-up. None of the cases had discharging sinus or pathological fractures at the final follow-up. All the patients had excellent joint movement without any deformity except the limitation of terminal movements in four patients and one cm shortening in three patients, each having lesions in the lower limbs. The follow up period ranged from 24 to 36 months (mean, 28.4 + 3.37 months). All the lesions were resolved or ossified within 18–24 months of the treatment with ATT and surgical intervention in 11 patients.

4. Discussion

Although TB is an uncommon disease in Western countries, it is still endemic in developing countries and a major health issue.1, 2, 3, 4 However, there has recently been a rise in cases, even in affluent countries. Mycobacterium TB may involve any part of the human body in varying severity and presentations depending upon the host immunity and delay in adequate treatment.10,11 About 15 % of the patients present with extrapulmonary involvement, out of which 10 % involve the skeletal system.1,4 TB of the musculoskeletal system most commonly manifests as tubercular spondylitis (50 %), followed by joint diseases affecting the hip, knee, wrist and elbow in descending order.10,11 Joint involvement is usually monoarticular, with more involvement in the knee and hip.4,8

Factors that facilitate TB involvement in particular organs are not yet known.10 However, it may spread secondary to lympho-hematogenous dissemination to the skeleton system during initial pulmonary infection.12 There may not be any evidence of pulmonary lesions in many patients with osteoarticular TB. Various authors have observed that active pulmonary TB is detected simultaneously in only one-third of patients suffering from skeletal TB.1,4,13 None of our cases had evidence of active or healed pulmonary TB.

Skeletal tuberculosis may have varied radiographic and clinical manifestations at presentation.14,15 Early diagnosis, at times, may be difficult due to its indolent nature and lack of specific clinical features and radiographic findings.4,8 Radiological features include surrounding soft tissue inflammation, joint space reduction with subchondral cysts and erosions and cystic lesions.16 Though tuberculous cystic lesions of bone are uncommon, they can occur at any age in endemic areas. In most cases, the disease is detected at late stages since TB lesions are paucibacillary and smears are negative in most cases.2,3 MRI is helpful in the localization of skeletal lesions resulting from TB. The definite diagnosis of osteoarticular TB is by isolating Mycobacterium TB from the affected location. Therefore, a biopsy of bone tissue is the gold standard for detecting osseous TB.14 All the cases in this study were histopathologically or microbiologically proven. Although all patients had a positive Mantoux test, it does not hold any diagnostic value as it has a poor positive predictive value for active disease and also the size of induration is influenced by various medical risk factors.17

Patients from endemic areas may also have a higher incidence of multifocal skeletal involvement. Radiographic features may present as a periosteal reaction, bone sclerosis, and severe bone destruction. While the profile from non-endemic areas is immunocompromised, either of the patients of extreme ages or usually with a debilitating underlying disease, lesions are usually solitary, osteolytic, and involving the axial skeleton, thoracolumbar vertebral bodies, and hips.18

Tuberculous osteomyelitis involves about 3–5 % of cases, where the femur, tibia and fibula are the most commonly affected bones, followed by others.9, 10, 11 However, it can affect any bone in the body.12 Sometimes, it may have varied presentations and remains a diagnostic mystery, particularly when it affects unusual sites.5, 6, 7, 8, 9

‘Jung Ling's disease’ or ‘osteitis tuberculosa multiplex cystoid's’ present as multiple cystic forms where the lesions are radiolucent, round to oval and are situated in the peripheral skeleton near the metaphysis. The cyst-like appearance is due to the variable marginal sclerosis. These ‘cysts’, however, can occur anywhere in the skeleton. Solitary lesions may mimic bacterial and fungal infections, simple or aneurysmal bone cysts, cartilaginous tumors and osteoid osteoma.14,19 Rasool et al. also observed tuberculous osteomyelitis mimicking lesions like chondroblastoma, eosinophilic granuloma, bone cysts, fibrous dysplasia, aneurysmal bone cysts, cartilaginous tumors, osteoid osteoma, granulomatous lesions and certain malignant tumors. All were confirmed by the tissue diagnosis and treated with ATT successfully.6 Literature also revealed unusual presentations and locations of TB-mimicking cysts and lytic tumor-like lesions.20, 21, 22, 23, 24, 25, 26 The lesions in the present series also had different faces masquerading as various tumors and tumors-like lesions.

Tubercular involvement of small bones of hands and feet is known as tubercular dactylitis and is a rare form of extrapulmonary TB, causing spindle-shaped expansion of short tubular bones due to granuloma formation and termed as spina ventosa (Latin-spina: “a short bone” and ventosa: “full of wind, distended”).10,24 We had four cases of spina ventosa: three occurring in hands with dactylitis and one in the metatarsal of the left foot.

The use of Intralesional antibiotics after surgery is extensively studied in cases of spinal tuberculosis and has proven to be helpful in preventing deep incisional infections and surgical site infections. The use of intralesional antibiotics provides a higher local antibiotic concentration and minimizes systemic side effects.27, 28, 29, 30, 31 In the current study intralesional streptomycin was used after curettage before surgical closure in all patients to prevent deep surgical site infections.

If tuberculosis is limited to the bone, the prognosis is better than in the joint disease as there is less deformity and, hence, less residual pain and disability.7 In the present series, all cases had joint sparing lesions with no residual arthritis, deformity or contracture. The mainstay of the treatment is the ATT whereas surgery is indicated in extensive disease of weight-bearing bones, fracture, collapse, sequestration and lesions near the joints.6 We performed curettages along with ATT in 11 out of 20 lesions, and the rest were successfully treated with ATT after biopsies.

5. Conclusion

The study emphasizes the importance of a high degree of suspicion of TB osteomyelitis in cases presenting with bony cysts or lytic lesions, so TB should be one of the differential diagnoses in the endemic regions in these presentations. The histopathological confirmation is the gold standard for the diagnosis. These can be effectively treated with anti-tubercular medication, and there is no need to fill the cavity with bone grafts or bone substitutes.

CRediT authorship contribution statement

Zile Singh Kundu: Conceptualization, Methodology, Formal analysis, Investigation, Writing – review & editing, Resources, Supervision. Kunika Kundu: Formal analysis, Investigation. Parveen Rana: Methodology, Writing – original draft, Writing – review & editing, Supervision. Pankaj Kumar Sharma: Conceptualization, Methodology, Formal analysis, Investigation. Lakshmana Das: Writing – original draft, Writing – review & editing. Jyoti Sharma: Writing – original draft, Writing – review & editing, Resources, Supervision.

Guardian/patient's consent

This is certified that Informed as well as written consent was obtained from all individual participants and their parents/guardian (if minor <18 years) included in the study.

Consent for publication

Informed consent was obtained from all individual participants included in the study.

Ethical statement

Compliance with ethical standards: This study was approved by the Institutional ethical committee.

Funding statement

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. There is no funding granted from any government or non-government organization for study and publication.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgement

we are thankful to all hospital staff members, who helped and assisted for all the procedures.

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