Diagnostic assessment and interpretation:
Lab investigation showed WBC 8000 lymphocytosis mainly, elevated ESR (118) and normal CRP levels. X-ray of the right ankle showed three cystic lesion at the distal tibia (the most distal one was peri-articular and subchondral), one cyst at the lateral malleolus and another one at the calcaneum no periosteal reaction (figure-1). A CT scan reveals multiple intraosseous cystic lesions with sclerotic, well define margins with narrow zone of transition in tibia, calcaneum, talus and many tarsal bones; largest one at distal tibia (Figure-2 and -3). An MRI reveals edema and bone destruction and new bone formation. Surgical core needle biopsy showed chronic granulomatous inflammation which suggests tuberculous osteomyelitis. Expert gene test was confirmative for this diagnosis.