The Physician's Guide to Laboratory Test Selection and Interpretation

Osteomyelitis
Diagnosis
Indications for Testing History and physical suggestive of osteomyelitis Chronic, non-healing ulcer that can be probed to the bone (particularly in a diabetic patient) Laboratory Testing CBC may help in differentiating bacterial etiology versus other cause; frequently shows leukocytosis and left shift to immature forms May be normal in chronic osteomyelitis Blood culture detect bacterial infection; requires 3-5 sets from separate venipuncture sites Positive in 50% of children ESR/CRP frequently elevated, but not diagnostic Bone culture diagnostic if positive PCR not widely available, may be useful if all cultures are negative Most useful for Bartonella henselae and Kingella kingae Imaging Studies Plain x-ray films may not demonstrate presence of osteomyelitis until 10-14 days after infection is established Negative film does not rule out diagnosis Evidence for osteomyelitis on film is periosteal lifting or lytic lesions Bone scan with technetium-99 pyrophosphate most useful if 3-phase scintigraphy is used 90% sensitive in long bone osteomyelitis MRI probably most sensitive imaging tool but may not distinguish infections from other bone disorders Bone marrow edema, abscesses May need to use 18FDG-PET for vertebral osteomyelitis CT not as sensitive as MRI; not useful if metal is near the infection In acute osteomyelitis, CT can depict changes earlier in disease process than plain imaging Differential Diagnosis Arthritis Septic Degenerative Crystalline Reactive Juvenile rheumatoid arthritis Neuropathic disease Metastatic bone disease Paget disease

Monitoring

CRP/ESR may be helpful in gauging success of therapy; values should decrease into the normal range with successful therapy

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The Physician's Guide to Laboratory Test Selection and Interpretation

Clinical Background

Osteomyelitis is an infection of the bone acquired hematogenously or by contiguous site infection. Epidemiology Incidence 2/10,000 Sex M>F (slight risk increases through childhood, peaks in adolescence and falls to a low ratio in adults) Age bimodal age distribution Children acute hematogenous osteomyelitis Adults direct trauma/contiguous focus osteomyelitis; vertebral osteomyelitis Risk Factors Children Blunt trauma Postoperative Adults Peripheral vascular disease Diabetes mellitus Renal or hepatic failure Immunosuppression Malignancy Neuropathy Intravenous drug use Trauma Surgery particularly prosthetic implants Organisms Most common organism Staphylococcus aureus Diabetes mellitus, peripheral vascular disease Streptococcus spp, coagulase-positive and -negative Staphylococcus spp, Enterococcus spp, anaerobic spp, often polymicrobial Intravenous drug use Pseudomonas aeruginosa Infants and children Staphylococcus spp, S. pneumoniae, Group A Streptococcus (especially post-chickenpox), Kingella kingae Neonates Group B Streptococcus, gram-negative species Hemoglobinopathies Salmonella spp Clinical Presentation Constitutional fever, nonspecific pain Soft tissue inflammation overlying area of osteomyelitis Open and non-healing wound over area of bone Vertebral disease may present with severe back pain Treatment Rapid initiation of antibiotics Bone debridement may be necessary Removal of prosthesis and hardware usually required

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The Physician's Guide to Laboratory Test Selection and Interpretation

Lab Tests

Indications for Laboratory Testing Tests generally appear in the order most useful for common clinical situations. For test-specific information, refer to the test number in the ARUP Laboratory Test Directory on the ARUP Web site at www.aruplab.com. Test Name and Number CBC with Platelet Count & Automated Differential 0040003 Recommended Use Initial testing for infection Limitations Follow Up

Method: Automated Cell Count with Flow Cell Differential Blood Culture Evaluate presence of infection 0060102 Method: BACTEC continuous monitoring system. Standard reference procedures for identification of aerobic and anaerobic microorganisms Sedimentation Rate, Westergren (ESR) 0040325 Method: Westergren C-Reactive Protein 0050180 Method: Quantitative Immunoturbidimetry

Testing is limited to the University of Utah Health Sciences Center only

Evaluate presence of infection; frequently elevated but not diagnostic

Evaluate presence of infection; frequently elevated but not diagnostic

ARUP LABORATORIES | 500 Chipeta Way | Salt Lake City, Utah 84108-1221 | (800) 522-2787 | www.arupconsult.com | www.aruplab.com
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The Physician's Guide to Laboratory Test Selection and Interpretation

Bone Culture 0060103 Method: Standard reference procedures for aerobic bacterial culture and identification Additional Tests Available Test Name and Number

Evaluate presence of infection

Comments

Bartonella DNA Detection by PCR 0093057 Method: Qualitative Polymerase Chain Reaction General References Berendt T, Byren I. Bone and joint infection.Clin Med. 2004; 4 (6) :510-518. Calhoun JH, Manring MM. Adult osteomyelitis.Infect Dis Clin North Am. 2005; 19 (4) :765-786. Concia E, Prandini N, Massari L, Ghisellini F, Consoli V, Menichetti F, Lazzeri E. Osteomyelitis: clinical update for practical guidelines.Nucl Med Commun. 2006; 27 (8) :645-660. Coviello V, Stevens MR. Contemporary concepts in the treatment of chronic osteomyelitis.Oral Maxillofac Surg Clin North Am. 2007; 19 (4) :523-34, vi. Geiger S, McCormick F, Chou R, Wandel AG. War wounds: lessons learned from Operation Iraqi Freedom.Plast Reconstr Surg. 2008; 122 (1) :146-153. Goergens ED, McEvoy A, Watson M, Barrett IR. Acute osteomyelitis and septic arthritis in children.J Paediatr Child Health. 2005; 41 (1-2) :59-62. Healy B, Freedman A. Infections.BMJ. 2006; 332 (7545) :838-841. Kaplan SL. Osteomyelitis in children.Infect Dis Clin North Am. 2005; 19 (4) :787-97, vii. Leibovici L. Review: magnetic resonance imaging is an accurate test for diagnosing foot osteomyelitis.ACP J Club. 2007; 147 (1) :20-. Palestro CJ, Love C, Miller TT. Infection and musculoskeletal conditions: Imaging of musculoskeletal infections.Best Pract Res Clin Rheumatol. 2006; 20 (6) :1197-1218. Pineda C, Vargas A, Rodriguez AV. Imaging of osteomyelitis: current concepts.Infect Dis Clin North Am. 2006; 20 (4) :789-825. Prandini N, Lazzeri E, Rossi B, Erba P, Parisella MG, Signore A. Nuclear medicine imaging of bone infections.Nucl Med Commun. 2006; 27 (8) :633-644. Sia IG, Berbari EF. Infection and musculoskeletal conditions: Osteomyelitis.Best Pract Res Clin Rheumatol. 2006; 20 (6) :1065-1081. Ziran BH. Osteomyelitis.J Trauma. 2007; 62 (6 Suppl) :S59-S60. Reviewed by Fisher, Mark A., PhD. Medical Director, Bacteriology and Antimicrobials at ARUP Laboratories; Assistant Professor of Pathology, University of Utah

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The Physician's Guide to Laboratory Test Selection and Interpretation

Lehman, Christopher M., MD. Co-Medical Director, University Hospital Clinical Laboratory; Professor of Pathology (Clinical), University of Utah Roberts, William L., MD, PhD. Medical Director, Automated Core Laboratory at ARUP Laboratories; Professor of Pathology, University of Utah Related Content Diabetes Mellitus Hemoglobinopathies Rheumatoid Arthritis - RA Staphylococcal Disease Streptococcal Disease, Group A - Group A, Strep Streptococcal Disease, Group B - Group B, Strep
Comprehensive Review: May 2011 Last Update: May 2011

ARUP LABORATORIES | 500 Chipeta Way | Salt Lake City, Utah 84108-1221 | (800) 522-2787 | www.arupconsult.com | www.aruplab.com
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