Decoding the challenging mimickers of osteomyelitis

Osteomyelitis (OM) is an infection of the bone that can present with a broad spectrum of clinical, laboratory, and radiological findings. Its diagnosis remains a clinical challenge, especially due to a range of non-infectious conditions that can mimic its presentation. These mimickers, both inflammatory and neoplastic, can lead to delayed or inappropriate management if not correctly identified. This review aims to highlight and analyze the key mimickers of OM, elucidate the distinguishing features of each, and provide a framework for clinicians to navigate these diagnostic challenges using an evidence-based, multidisciplinary approach. A comprehensive literature review was performed using different published articles in peer-reviewed journals. Emphasis was placed on recent advances in imaging modalities, including radiograph, computed tomography scan, magnetic resonance imaging, radionuclide scan, and their role in differentiating mimickers. Key mimickers of OM include bone tumors (e.g., Ewing sarcoma, lymphoma, osteoid osteoma), inflammatory arthropathies (e.g., gout, rheumatoid arthritis, chronic recurrent multifocal osteomyelitis [CRMO]), metabolic bone diseases (e.g., Charcot arthropathy), and post-traumatic bone changes. Imaging findings often overlap, such as marrow edema, periosteal reaction, or cortical destruction. However, certain features – like a nidus in osteoid osteoma or diffuse uptake patterns in metabolic bone disease, multifocal manifestation in CRMO can guide the diagnosis. Distinguishing OM from its mimickers is imperative for targeted management and optimal patient outcomes. Accurate diagnosis necessitates a holistic approach combining clinical history, laboratory investigations, advanced imaging, and, where necessary, biopsy. Greater awareness and understanding of these mimicking conditions among radiologists, pathologists, and clinicians can prevent misdiagnosis and facilitate timely intervention.