CD177, MYBL2, and RRM2 Are Potential Biomarkers for Musculoskeletal Infections
Authors: Agidigbi Taiwo Samuel , Fram Brianna , Molloy Ilda , Riedel Matthew , Wiznia Daniel , Oh Irvin 
Published: February 2025

Background
Biomarkers of infection are measurable indicators that reflect the presence of an infection in the body. They are particularly valuable for detecting infections and tracking treatment responses. Previous transcriptome analysis of peripheral blood mononuclear cells (PBMCs) collected from patients during the active phase of diabetic foot infection identified the upregulation of several genes, including a neutrophil-specific cell surface glycoprotein, CD177, an Myb-related transcription factor 2 (MYBL2), and ribonucleotide reductase regulatory subunit M2 (RRM2). We aimed to investigate whether these observations in diabetic foot infections could be extrapolated to other musculoskeletal infections.

Questions/purposes
(1) Are the protein concentrations of CD177, MYBL2, and RRM2 elevated in serum or PBMCs of patients with musculoskeletal infections? (2) Do serum and PBMC concentrations of CD177, MYBL2, and RRM2 decrease in response to antibiotic therapy? (3) Can these biomarkers give diagnostic accuracy and differentiate patients with musculoskeletal infections from controls?

Methods
From April 2023 to June 2024, we treated 26 patients presenting with clinical symptoms and signs of acute musculoskeletal infections, including elevated inflammatory markers (white blood cell [WBC] and C-reactive protein [CRP]) and local changes such as swelling, erythema, tenderness or pain, warmth, purulent drainage, sinus tract, or wound leading to bone or hardware. Diagnosis included periprosthetic joint infection (PJI), foot and ankle infection (FAI), fracture-related infection (FRI), and septic arthritis of the native joints. Patients with chronic recurrent osteomyelitis, PJI, or FRI were excluded from the study. Among the 26 patients deemed potentially eligible, 19% (5) were excluded for the following reasons: prison inmate (1), unable to provide consent because of severe sepsis (1), mental illness (1), and declined to participate (2). Of the 81% (21) of patients who provided consent, cultures from 9.5% (2) were negative. These two patients were ultimately diagnosed with inflammatory arthritis: gout (1) and rheumatoid arthritis (1); thus, the musculoskeletal infection group for analysis consisted of 73.1% (19 of 26) of patients. A control group of 21 patients undergoing elective foot or ankle deformity correction surgery without infections or systemic inflammation was included. Because foot or ankle deformity is highly unlikely to influence the immunologic profile of the subjects, we believed that these patients would serve as an appropriate control group. Other than the absence of infection and the lower prevalence of diabetes mellitus, the control group was comparable to the study group in terms of demographics and clinical factors, including age and sex distribution. We collected blood samples from both patients and controls and quantified CD177, MYBL2, and RRM2 RNA transcription levels in the PBMC using qRT-PCR. We also assessed protein concentrations in the serum and PBMC using an enzyme-linked immunosorbent assay. A comparative analysis of the three biomarkers was performed on 19 patients with musculoskeletal infections with positive cultures and 21 controls to assess their diagnostic potential using the unpaired nonparametric t-test with the Mann-Whitney test. We obtained 8-week follow-up blood samples from seven patients with musculoskeletal infections who clinically healed. Healing was defined by normalization of inflammatory markers (WBC and CRP) and absence of swelling, erythema, local tenderness or pain, warmth, purulent drainage, sinus tract, or open wound. We performed a comparative analysis of the seven patients during active infection and after treatment to determine a change in the level of CD177, MYBL2, and RRM2 in their serum and PBMCs. These findings were also compared with those of the control group. We evaluated the diagnostic accuracy of CD177, MYBL2, and RRM2 for musculoskeletal infections using receiver operating characteristic (ROC) curve analysis.

Results
The musculoskeletal infections group showed a larger increased serum and PBMC concentrations of CD177, MYBL2, and RRM2 proteins compared with the control group. The mean protein concentrations of CD177, MYBL2, and RRM2 were increased in the serum and PBMC of the musculoskeletal infections group compared with the controls. Serum levels of all biomarkers investigated were higher in musculoskeletal infections group compared with the control group (CD177 227 [155 to 432] versus 54 [10 to 100], difference of medians 173, p < 0.01; MYBL2 255 [231 to 314] versus 180 [148 to 214], difference of medians 75, p < 0.01; RRM2 250 [216 to 305] versus 190 [148 to 255], difference of medians 60, p < 0.01). Similarly, PBMC levels of all biomarkers were higher in the musculoskeletal infections group (CD177 55.3 [39.1 to 80.5] versus 17.5 [10.5 to 27.5], difference of medians 37.8, p < 0.01; MYBL2 144 [114 to 190] versus 91 [70 to 105], difference of medians 53, p < 0.01; RRM2 168 [143 to 202] versus 100 [77.5 to 133], difference of medians 68, p < 0.01). Additionally, serum levels of all biomarkers decreased in seven patients with musculoskeletal infections after infection treatment (CD177 3080 [2690 to 3320] versus 4250 [3100 to 8640], difference of medians 1170, p < 0.01; MYBL2 4340 [4120 to 4750] versus 5010 [4460 to 5880], difference of medians 670, p < 0.01; RRM2 4350 [3980 to 5000] versus 5025 [4430 to 6280], difference of medians 675, p = 0.01). Similarly, PBMC levels of all biomarkers were lower after infection treatment (CD177 805 [680 to 980] versus 1025 [750 to 1610], difference of medians 220, p < 0.01; MYBL2 2300 [2100 to 2550] versus 2680 [2220 to 3400], difference of medians 380, p = 0.02; RRM2 2720 [2500 to 3200] versus 3350 [2825 to 4030], difference of medians 630, p < 0.01). The area under the ROC curve for diagnosing musculoskeletal infections in the serum and PBMC was as follows: CD177 95% confidence interval [CI] > 0.99 and > 0.99, MYBL2 95% CI > 0.99 and > 0.99, and RRM2 95% CI = 0.96 and > 0.99, respectively.

Conclusion
We may utilize blood-based tests for CD177, MYBL2, and RRM2 to aid in the diagnosis of musculoskeletal infections, particularly when arthrocentesis or obtaining tissue culture is challenging. They may also assist in monitoring treatment response. As some of these biomarkers may also be elevated in other inflammatory conditions, a large-scale clinical study is needed to confirm their reliability in differentiating musculoskeletal infections from other inflammatory conditions.

Clinical Relevance
CD177, MYBL2, and RRM2 proteins in blood samples may serve as novel biomarkers for diagnosing and monitoring treatment response in musculoskeletal infections.