AJR 2004; 183:341-342
© American Roentgen Ray Society
Osteoid Osteoma of the Tarsal Cuboid Mimicking Osteomyelitis
Gyung Kyu Lee1,
Ik Won Kang,
Eil Seong Lee,
Seon Jung Min,
Seong Whi Cho and
Dae Hyun Hwang
1 All authors: Department of Radiology, Hallym University College of Medicine,
Hangang Sacred Heart Hospital, 94-200 Yeongdeungpo-dong, Yeongdeungpo-gu,
Seoul 150-719, Korea.
Received November 5, 2003;
accepted after revision November 18, 2003.
Address correspondence to G. K. Lee
(lgk{at}dreamwiz.com).
Introduction
Osteoid osteoma is a common bone tumor, comprising approximately
10–12% of all benign bone tumors
[1]. This tumor consists of a
centrally located vascularized nidus, typically surrounded by a variable
amount of sclerotic reaction. The nidus is usually 1–10 mm
[2]. This tumor predominantly
occurs in children and young adults and is more common in males with a
male-to-female ratio of 1.6:1 to 4:1
[2]. Clinically, osteoid
osteoma is usually accompanied by nocturnal pain promptly relieved by
salicylates. Although any bone of the skeleton can be involved, approximately
50% of all osteoid osteomas occur in the femur and tibia
[1]. However, osteoid osteoma
occurring in the foot is unusual and accounts for approximately 4% of cases
[3]. The common site in the
bone of the foot is the talus
[4]. Despite these general
clinical characteristics, the preoperative diagnosis of osteoid osteoma
occurring in the foot may be delayed because of unusual location and atypical
symptoms [5,
6].
In this article, we report an unusual case of osteoid osteoma of the cuboid
in a 22-year-old man who presented with foot pain and soft-tissue swelling
mimicking osteomyelitis.
Case Report
A 22-year-old man presented with a 6-month history of pain and swelling in
the lateral aspect of the right foot with no history of previous trauma. He
had been treated as having a case of osteomyelitis of the right foot for about
3 months before presentation at our institution. He was referred to orthopedic
surgery complaining of increased pain in his foot. Pain was not relieved by
nonsteroidal antiinflammatory drugs. Physical examination revealed soft-tissue
swelling and tenderness over the lateral aspect of the right foot. The right
foot was also warmer than the left, but overlying skin was normal in color and
texture. The laboratory data (including WBC and erythrocyte sedimentation
rate) showed unremarkable findings at the time of presentation.
Imaging evaluation included radiography and MRI at our institution.
Radiography showed a sclerotic area on the lateral aspect of the right cuboid
(Fig. 1A). MRI showed a round
focus of low-signal nidus in the dorsolateral aspect of the right cuboid with
extensive surrounding marrow and soft-tissue edema on both spin-echo T1- and
T2-weighted images (Figs. 1B
and 1C). Gadolinium-enhanced
axial T1-weighted images obtained with fat saturation showed pronounced
enhancement of adjacent marrow and soft tissue, indicating edema
(Fig. 1D). Imaging findings
were consistent with an osteoid osteoma.
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Fig. 1B. —22-year-old man presenting with pain and swelling in lateral
aspect of right foot. Sagittal spin-echo T1-weighted (TR/TE, 600/15)
(B) and coronal spin-echo T2-weighted (2,300/90) (C) MR images
show well-defined low signal nidus (open arrow) in dorsolateral
aspect of right cuboid with surrounding marrow and soft-tissue edema
(solid arrow).
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Fig. 1C. —22-year-old man presenting with pain and swelling in lateral
aspect of right foot. Sagittal spin-echo T1-weighted (TR/TE, 600/15)
(B) and coronal spin-echo T2-weighted (2,300/90) (C) MR images
show well-defined low signal nidus (open arrow) in dorsolateral
aspect of right cuboid with surrounding marrow and soft-tissue edema
(solid arrow).
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Fig. 1D. —22-year-old man presenting with pain and swelling in lateral
aspect of right foot. Axial gadolinium-enhanced spin-echo T1-weighted MR image
(812/15) obtained with fat saturation shows pronounced enhancement of adjacent
marrow and soft tissue (arrows) indicating edema.
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Excision was performed, and the diagnosis was confirmed by histology
(Fig. 1E). The patient showed
no evidence of recurrence after 1 year.
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Fig. 1E. —22-year-old man presenting with pain and swelling in lateral
aspect of right foot. Photomicrograph shows abundant new bone formation with
trabeculae lined by enlarged osteoblasts. (H and E, x)
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Discussion
Osteoid osteoma is a common bone tumor, comprising approximately
10–12% of all benign bone tumors
[1]. Osteoid osteoma occurring
in the foot is unusual and accounts for approximately 4% of cases
[3]. The common site in the
bone of the foot is the talus and in 75% subperiosteally at its juxtaarticular
region [4]. Preoperative
diagnosis of osteoid osteoma occurring in the foot may be delayed because of
unusual location and atypical symptoms such as sprained ankle
[5], monoarticular arthritis,
anterior impingement syndrome, and traction spur of the talar neck
[6]. Clinically, osteoid
osteoma is usually accompanied by nocturnal pain promptly relieved by
nonsteroidal antiinflammatory drugs, but, in our patient, pain was not
relieved by their use.
Cross-sectional CT and MRI findings of osteoid osteoma in the radiology
literature are well known [1,
2,
7–11].
The previously described CT findings of osteoid osteoma were reported as a
low-attenuation nidus with possible internal calcification and variable
surrounding sclerosis. On MRI, the nidus of osteoid osteoma shows low or
intermediate signal intensity on spin-echo T1-weighted images, variable signal
intensity on T2-weighted images, and variable enhancement. MRI may be
misleading because of bone-marrow and soft-tissue changes associated with
osteoid osteoma, which may sometimes be extensive
[7–11].
The misleading appearance of osteoid osteoma on MRI often leads to the
diagnosis of osteomyelitis, stress fracture, inflammatory arthritis, or a more
aggressive bone tumor.
The mechanism that results in bone-marrow and soft-tissue edema is
uncertain; however, prostaglandin, which is reported to be a cause of
peritumoral edema on MRI [12],
has been implicated because levels of this inflammatory mediator are elevated
in osteoid osteoma [13]. In
our patient, the nidus showed a round focus of low signal on both spin-echo
T1- and T2-weighted images and no enhancement. Reactive bone-marrow and
soft-tissue edema was present around the nidus. Some authors have indicated
that the presence of marrow edema associated with osteoid osteoma can lead to
incorrect diagnosis [8,
9], but, in our case, we found
that marrow edema around the nidus served to demarcate the region, facilitated
the detection of the nidus, and improved diagnostic confidence. This result
may show that MRI is advantageous in the evaluation of a noncortical lesion,
especially in the case of a large nidus.
In summary, we report an unusual case of osteoid osteoma of the cuboid in a
22-year-old man who presented with foot pain and soft-tissue swelling
mimicking osteomyelitis. Although osteoid osteoma occurring in the foot is
unusual, we believe that it should be considered in the differential diagnosis
of chronic foot or ankle pain, especially if such a symptom occurs in children
and young adults with normal laboratory findings and no history of previous
trauma.
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Introduction
Case Report
