Xanthogranulomatous Osteomyelitis: A Systematic Review of Reported Cases, Diagnostic Challenges, and Treatment Outcomes

Xanthogranulomatous osteomyelitis (XO) is a rare form of chronic osteomyelitis characterized by mass-forming inflammatory lesions rich in lipid-laden macrophages. It commonly presents as an osteolytic, tumor-like bone lesion that may expand rapidly and mimic malignancy on imaging, leading to diagnostic uncertainty. This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to characterize the clinical presentation, diagnostic strategies, treatment approaches, and outcomes of reported XO cases. Case reports and case series with histopathologic confirmation of XO were included. Extracted data encompassed patient demographics, immune status, anatomic involvement, clinical features, diagnostic modalities, management strategies, and outcomes. A total of 21 patients across 19 studies published between 1984 and 2025 were identified. The tibia (24%), rib (16%), and femur (12%) were the most commonly involved bones. Pain (81%) and swelling or mass formation (52.4%) were the predominant presenting features, while systemic symptoms were less frequent. Histopathologic evaluation established the diagnosis in all cases and was supported by radiographic and magnetic resonance imaging findings. Surgical intervention was performed in 76.2% of cases, whereas antimicrobial therapy was inconsistently administered. Complete clinical resolution was reported in all patients with available follow-up, and no XO-related mortality occurred. XO demonstrates non-specific clinical and radiographic features that often mimic bone malignancy. Surgical management appears to be both diagnostically and therapeutically effective in most reported cases, although standardized antimicrobial treatment strategies remain undefined.