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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 14  |  Issue : 1  |  Page : 66-69

Evaluation of serum procalcitonin levels in patients of acute osteomyelitis and septic arthritis


1 Central Institute of Orthopaedics, VMMC and Safdarjung Hospital, Delhi, India
2 Sports Injury Center, VMMC and Safdarjung Hospital, Delhi, India

Date of Submission16-Mar-2021
Date of Acceptance26-Feb-2022
Date of Web Publication15-Jun-2022

Correspondence Address:
Dr. Deepak Kumar Sharma
A-31, Sai Apartment Sector.13, Rohini, Delhi - 110 085
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jotr.jotr_16_21

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  Abstract 


Aims: The aim is to study the role of serum procalcitonin (PCT) levels in early diagnosis of acute osteomyelitis (OM) and septic arthritis (SA). Settings and Design: This is a prospective study in a tertiary hospital. Subjects and Methods: This study was done at a tertiary care hospital. Thirty-nine patients with SA or acute OM who attended the outpatient department or emergency were included in the study. 39 patients were taken as control group out of which one patient lost to follow-up, so 38 patients were left with control group. PCT level was evaluated by using immunoluminetric assay and a cutoff value of 0.5 ng/ml was taken as positive. After collection of data, sensitivity, specificity, positive predictive value, and negative predictive value are calculated for PCT. Statistical Analysis Used: Mann–Whitney U-test and Kruskal–Wallis test were used. Results: The sensitivity for PCT was 94.87 (95% confidence interval [CI] 82.68–99.37), specificity was 86.84 (95% CI 71.91–95.59), positive predictive value was 88.10%, and negative predictive value was 94.29%, when taking cutoff of 0.5 ng/ml. We have taken 0.5 ng/ml as a cutoff point for PCT; however, as per receiver operator characteristic of this study, the cutoff point was 1.1 ng/ml. Conclusions: This study clearly showed that PCT can be helpful in the early diagnosis of OM and SA, along with other indicators such as total leukocyte count, erythrocyte sedimentation rate, and C-reactive protein.

Keywords: Osteomyelitis, procalcitonin, septic arthritis


How to cite this article:
Kumar N, Pandey VK, Sharma DK, Patralekh MK, Lal H. Evaluation of serum procalcitonin levels in patients of acute osteomyelitis and septic arthritis. J Orthop Traumatol Rehabil 2022;14:66-9

How to cite this URL:
Kumar N, Pandey VK, Sharma DK, Patralekh MK, Lal H. Evaluation of serum procalcitonin levels in patients of acute osteomyelitis and septic arthritis. J Orthop Traumatol Rehabil [serial online] 2022 [cited 2022 Jun 27];14:66-9. Available from: https://www.jotr.in/text.asp?2022/14/1/66/347358




  Introduction Top


Acute OM and SA are common diseases and their diagnosis is clinically supported by investigations such as total leukocyte count (TLC), differential leukocyte count (DLC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), blood culture, ultrasound, skiagram, and magnetic resonance imaging (MRI) of the local part. Pus culture is confirmatory for diagnosis of OM and SA but is positive only in 40%–60% of patients.[1],[2] Early diagnosis is important to prevent complications. These diseases mimic with other conditions such as rheumatoid arthritis, acute poliomyelitis, and scurvy. TLC, ESR, and CRP are helping in diagnosis but are not confirmatory for diagnosis of OM and SA. Procalcitonin (PCT) is an accurate marker for bacterial infection when differentiating bacterial infection from noninfective causes of inflammation or viral infection.[3],[4],[5],[6] In this study, we evaluate the role of PCT in diagnosis of skeletal infections such as OM and SA.


  Subjects and Methods Top


This study was done at a tertiary care hospital. Any patient with SA or acute OM who attended the outpatient department or emergency was included in the study. Aspiration of pus was taken as gold standard for diagnosis and was the criterion for cases to be included in the study. We took 39 individuals as cases. Controls were selected from healthy population. 39 healthy individuals were taken as control, out of which one control was lost to follow-up, so we are left with 38 individuals as control. The patients in whom antibiotics were given before reaching to us, cases with focus of infection elsewhere in body, or immunocompromised cases were excluded from the study. When patients presented to us, thorough history and examination were done. Symptoms for acute OM or SA such as fever, pain, local or joint swelling, painful range of motion, and deformity were seen; pus was aspirated from local part and was sent for Gram staining, culture, and sensitivity. After that, patients were subjected to laboratory investigation as TLC, DLC, ESR, CRP, and PCT. X-ray of the local part anteroposterior and lateral view was taken to see any bony involvement. Ultrasound of local part was done to see any collection in local area. Cutoff value PCT level was evaluated by using immunoluminetric assay and a cutoff value of 0.5 ng/ml was taken as positive. Once diagnosis was confirmed, in the cases of SA, arthrotomy was done, whereas in cases of acute OM, incision and drainage with drilling of bone was done to drain out collected pus under periosteum and bone. After operative intervention, 6 weeks of antibiotics was given to the patients depending on the culture and sensitivity. After collection of data, sensitivity, specificity, positive predictive value, and negative predictive value are calculated for PCT. For interpretation of data, Mann–Whitney U-test and Kruskal–Wallis test were used.


  Results Top


A total of 39 cases and 38 controls were included in the study. The mean age of cases was 23.2 years (OM 28.6, SA 16.2) whereas in the control group, it was 23.7 years. In cases, 26 patients were male and 13 were female, whereas in control group, 21 were male and 17 were female. Pain was the most common symptom and was present in all cases of SA, whereas pain was present in 63.3% of patients and absent in 36.6% of OM. Fever was present in all cases of SA; in OM, fever was present only in 36% of cases. Swelling was present in 82% and 63% of patients of SA and OM, respectively. The sensitivity and specificity for TLC were 64.1 (95% confidence interval [CI] 47.18–78.80) and 97.3 (95% CI 86.19–99.93), for ESR was 84.6 (95% CI 69.47–94.14) and 68.4 (95% CI 51.35–82.50), and for CRP was 74.3 (95% CI 57.87–86.96) and 94.7 (95% CI 82.25–99.36), respectively. The sensitivity for PCT was 94.87 (95% CI 82.68–99.37), specificity was 86.84 (95% CI 71.91–95.59), positive predictive value was 88.10%, and negative predictive value was 94.29%, when taking cutoff of 0.5 ng/ml. We have taken 0.5 ng/ml as cutoff point for PCT; however, as per receiver operator characteristic (ROC) curve of this study, the cutoff point was 1.1 ng/ml [Table 1] and [Table 2], [Graph 1]. Serum PCT value was significantly higher in the test group (OM/SA) as compared to the control group (P < 0.001, Mann–Whitney U-test) [Table 3]. Serum PCT was significantly different in the three groups (Kruskal–Wallis test, P < 0.01). It was significantly higher in both OM and SA groups as compared to control group. Further, it was significantly higher in the SA group compared to the OM group [Graph 2], [Table 4] and [Table 5].
Table 1: ROC curve characteristics for serum procalcitonin

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Table 2: Cutoff results

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Table 3: Serum procalcitonin value was significantly higher in the test group (OM/SA) as compared to the control group (P<0.001, Mann–Whitney U-test)

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Table 4: Considering OM, SA, and control as separate groups, we have descriptive statistics

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Table 5: Comparison of PCT values in OM, SA and Control groups

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  Discussion Top


The diagnosis of OM and SA is mainly clinical and is supported by physical examination and investigations such as elevated leukocytes, raised ESR, and raised CRP levels. High index of suspicion is required for early diagnosis and treatment to prevent complications. Although pus culture is confirmatory for diagnosis of OM and SA, it is positive only in 40%–60% of patients.[1],[2] PCT was found to be a good marker in diagnosing bacterial infections, with its high specificity in previous studies. Its usefulness over markers such as total counts, ESR, and CRP has been described in several conditions such as sepsis, upper respiratory tract infections, pneumonias, pancreatitis, pyelonephritis, and burns and in various other conditions.[3],[7],[8] In this study, we try to extend this benefit for early diagnosis of acute OM and SA. The normal value of PCT is considered as 0.5 ng/ml.[9],[10] Hence, in this study, PCT level above 0.5 ng/ml was considered to be positive. By considering this value, the sensitivity for PCT was 94.87%, specificity 86.84%, positive predictive value 88.10%, and negative predictive value 94.29%. As per ROC curve of this study, the cutoff point was 1.1 ng/ml for PCT. Serum PCT was significantly different in the three groups (Kruskal–Wallis test, P < 0.01). It was significantly higher in both OM and SA groups as compared to control group. In addition, it was significantly higher in the SA group compared to the OM group.


  Conclusion Top


This study clearly showed that PCT can be helpful in the early diagnosis of OM and SA, along with other indicators such as total leukocyte count, erythrocyte sedimentation rate, and C-reactive protein.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Morrey BF, Bianco AJ Jr., Rhodes KH. Septic arthritis in children. Orthop Clin North Am 1975;6:923-34.  Back to cited text no. 1
    
2.
Mathews CJ, Weston VC, Jones A, Field M, Coakley G. Bacterial septic arthritis in adults. Lancet 2010;375:846-55.  Back to cited text no. 2
    
3.
Delèvaux I, André M, Colombier M, Albuisson E, Meylheuc F, Bègue RJ, et al. Can procalcitonin measurement help in differentiating between bacterial infection and other kinds of inflammatory processes? Ann Rheum Dis 2003;62:337-40.  Back to cited text no. 3
    
4.
Martinot M, Sordet C, Soubrier M, Puéchal X, Saraux A, Lioté F, et al. Diagnostic value of serum and synovial procalcitonin in acute arthritis: A prospective study of 42 patients. Clin Exp Rheumatol 2005;23:303-10.  Back to cited text no. 4
    
5.
Söderquist B, Jones I, Fredlund H, Vikerfors T. Bacterial or crystal-associated arthritis? Discriminating ability of serum inflammatory markers. Scand J Infect Dis 1998;30:591-6.  Back to cited text no. 5
    
6.
Butbul-Aviel Y, Koren A, Halevy R, Sakran W. Procalcitonin as a diagnostic aid in osteomyelitis and septic arthritis. Pediatr Emerg Care 2005;21:828-32.  Back to cited text no. 6
    
7.
Eberhard K, Haubitz M, Brunkhorst M, Kliem V, Koch M. Usefulness of procalcitonin for differentiation between activity of systemic autoimmune disease and invasive bacterial infection. Arthritis Rheum 1997;40:7.  Back to cited text no. 7
    
8.
Becker KL, Snider R, Nylen ES. Procalcitonin assay in systemic inflammation, infection, and sepsis: Clinical utility and limitations. Crit Care Med 2008;36:941-52.  Back to cited text no. 8
    
9.
Barassi A, Pallotti F, Melzi d'Eril G. Biological variation of procalcitonin in healthy individuals. Clin Chem 2004;50:1878.  Back to cited text no. 9
    
10.
Shimetani N, Ohba Y, Shimetani K, Mashiko T, Matsuyama N, Ohtani H, et al. Assay for determination of the serum procalcitonin level: Biochemical and clinical evaluation. Rinsho Byori 2001;49:56-60.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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Introduction
Subjects and Methods
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