Imaging of chronic recurrent multifocal osteomyelitis of childhood first presenting with isolated primary spinal involvement

Chronic non-bacterial osteomyelitis (CNO) in childhood and adolescence - a disease with many faces

BACKGROUND

 Chronic non-bacterial osteomyelitis (CNO) is a chronic inflammatory skeletal disease that affects particularly children and adolescents and is often diagnosed with a delay. With whole-body MRI, early diagnosis of this disease is possible in many cases. Since children and adolescents frequently present with non-specific complaints for outpatient radiological diagnosis, every radiologist should have basic knowledge of this complex clinical picture.

MATERIALS

 In this review the basics and current findings regarding the disease are discussed. Unusual courses are also presented.

RESULTS AND CONCLUSION

 With knowledge of the radiographic and MR tomographic characteristics of the mostly multifocal bone lesions, the diagnosis of CNO can be reliably made in many cases. In particular, the early use of whole-body MRI plays an important role. Thus, therapeutic delays and resulting complications and the number of unnecessary biopsies for diagnosis can be reduced.

Vertebra Plana: A Narrative Clinical and Imaging Overview among Possible Differential Diagnoses

Vertebra plana is a rare radiologic condition characterized by a uniform loss of height of a vertebral body that represents a diagnostic challenge for surgeons. The purpose of this study was to review all possible differential diagnoses that may present with a vertebra plana (VP) described in the current literature. For that purpose, we performed a narrative literature review in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, analyzing 602 articles. Patient demographics, clinical presentation, imaging characteristics and diagnoses were investigated. VP is not a pathognomonic feature of Langerhans cell histiocytosis, but other oncologic and non-oncologic conditions should be considered. The list of differential diagnoses, based on our literature review, can be recalled with the mnemonic HEIGHT OF HOMO: H-Histiocytosis; E-Ewing's sarcoma; I-Infection; G-Giant cell tumor; H-Hematologic neoplasms; T-Tuberculosis; O-Osteogenesis imperfecta; F-Fracture; H-Hemangioma; O-Osteoblastoma; M-Metastasis; O-Osteomyelitis, chronic.

Case report: Child chronic nonbacterial osteomyelitis with rapid progressive scoliosis-an association with disease?

Background

Chronic nonbacterial osteomyelitis (CNO) is an auto-inflammatory bone disease that usually develops in childhood. Spinal involvement is a common manifestation of CNO, but it is rare for CNO to lead to rapid progression of scoliosis deformity. Here we present a 9-year-old girl with acute scoliosis with CNO and scoliosis progressed rapidly in 2 months.

Case Presentation

A 9-year-old girl presented bilateral shoulder inequality with pain in the left hypochondrium for 2 months. Standing spinal x-rays showed right convex scoliosis with a 25° Cobb angle. Chest magnetic resonance imaging (MRI) showed that the T8 vertebra was flattened and local bone was destroyed with bone marrow edema. The bone biopsy showed evidence of fibrosis and chronic inflammatory changes with no specific diagnosis. One month later, her scoliosis and bone destruction deteriorated obviously. Thoracic vertebra MRI showed that the T8 vertebra had a compression fracture. ^99mTc-MDP whole-body bone scintigraphy showed intense uptake at T8/9 and the right sacroiliac joint. She was diagnosed with CNO accompanied by rapidly progressive scoliosis. The scoliosis was successfully treated with adalimumab and zoledronic acid, which showed significant improvement after 6 months of follow-up.

Conclusion

Zoledronic acid and adalimumab successfully treated CNO with rapidly progressive scoliosis, but could not prevent vertebral compression.

Not all benign: disease course, complications, and sequalae of chronic recurrent multifocal osteomyelitis in children

PURPOSE OF REVIEW

Advances in pathogenesis of chronic recurrent multifocal osteomyelitis in children (CRMO) have shaped therapeutic strategies. The use of whole-body MRI (WBMRI) and improved awareness of CRMO has increased rates and timeliness of CRMO diagnoses. In this review, we highlight the findings from recently published CRMO cohorts and describe the course, complications, and long-term sequalae of CRMO. It is important for clinicians to be aware of the potential for long-term sequelae in order to optimize therapy and avoid complications.

RECENT FINDINGS

Despite recent advances in defining disease pathogenesis, children with CRMO continue to suffer from complications and deformities. Involvement of the spine can be asymptomatic and is not as rare as previously suggested. This can result in damaging outcomes, such as vertebral fractures and permanent deformities. A subset of patients has polycyclic disease course and some continue to have active disease for years and well into adulthood, with significant impacts on quality of life.

SUMMARY

These recent findings have considerable implication on clinical practice regarding diagnosis, treatment, and monitoring of the disease. Collectively, they support the need for continued monitoring of the disease and screening using comprehensive imaging, such as WBMRI.

Review of spinal involvement in Chronic recurrent multifocal osteomyelitis (CRMO): What radiologists need to know about CRMO and its imitators

Chronic recurrent multifocal osteomyelitis (CRMO) is a distinct disease entity of unknown etiology primarily affecting children and adolescents. It is an autoinflammatory process that typically affects multiple bones with a waxing and waning course. About one third of the patients diagnosed with CRMO have spinal involvement which can lead to long term morbidity. The clinical presentation and imaging features of CRMO involving the spine are nonspecific and can mimic other disease processes like infection or malignancy. Since imaging plays a very important role in the diagnosis and management of CRMO, we intend to highlight various imaging patterns of spinal CRMO alongside its clinical features and briefly discuss its imitators, management and outcomes.

Chronic Nonbacterial Osteomyelitis: Insights into Pathogenesis, Assessment, and Treatment

Chronic nonbacterial osteomyelitis, or its most severe form, chronic recurrent multifocal osteomyelitis, is an autoinflammatory bone disease that causes skeletal inflammation characterized by bone pain and swelling that primarily affects children. It is a diagnosis of exclusion and its clinical presentation may mimic underlying infectious processes and malignancy. Clinical suspicion for this diagnosis and timely referral to pediatric rheumatology is crucial to achieve earlier diagnosis, appropriate treatment, and improved quality of life of affected patients and families. This article focuses on recent insights into the pathogenesis of chronic nonbacterial osteomyelitis and outlines recent advances and ongoing research.

Assessment of disease activity using a whole-body MRI derived radiological activity index in chronic nonbacterial osteomyelitis

BACKGROUND

Based on the recently developed ChRonic nonbacterial Osteomyelitis MRI Scoring tool (CROMRIS), we developed a radiological activity index (RAI-CROMRIS) to obtain a quantification of the overall bone involvement in individual patients.

METHODS

Whole Body Magnetic Resonance Imaging (WB-MRI) images were scored according to parameters included in the RAI-CROMRIS: bone marrow hyperintensity, signal extension, soft tissue/periosteal hyperintensity, bony expansion, vertebral collapse. These parameters were evaluated for each bone unit yielding a score from 0 to 7 and summed up as RAI-CROMRIS including all bone units. We assessed clinical disease activity using a physician global assessment (PGA) and radiological findings in 76 treatment-naïve patients; 46 of 76 were evaluated at 6 and 12 months after initial WB-MRI. Quantitative variables were compared using the Mann-Whitney U test for unmatched groups and the Wilcoxon signed-rank test for paired groups. Correlation was evaluated using Spearman's rank coefficient (r_s).

RESULTS

There was a significant correlation between RAI-CROMRIS and PGA (r_s = 0.32; p = 0.0055), between RAI-CROMRIS and presence of elevated erythrocyte sedimentation rate (p = 0.013) and C-reactive protein (p = 0.0001) at baseline. The RAI-CROMRIS decreased from a median of 17 at baseline to 12 at 6 months (p = 0.004) and remained stable (median 11) at 12 months. A correlation between the RAI-CROMRIS and the PGA was observed at baseline (r_s = 0.41; p = 0.004) and during follow up at 6 months (r_s = 0.33; p = 0.025) and 12 months (r_s = 0.38; p = 0.010). The baseline RAI-CROMRIS (median 20) was significantly higher in patients who subsequently received bisphosphonates than in patients who received other treatments (median 12) and decreased significantly after bisphosphonates (p = 0.008).

CONCLUSIONS

The RAI-CROMRIS was correlated with clinical and laboratory measures of disease activity showing significant short-term changes following treatment with bisphosphonates. This tool could be used in clinical practice and clinical trials after validation.

A Rare Case of Nontraumatic Thoracic Compression Fracture in a 28-Year-Old Man

ABSTRACT

A 28-yr-old African American man with a history of synovitis, acne, pustulosis, hyperostosis, and osteitis syndrome, tobacco use, and sickle cell trait was referred to a physiatrist at a multidisciplinary spine center with a 1-yr history of nontraumatic thoracic back pain that had significantly worsened over the previous 4 wks. In the context of recurrent infections requiring hospital admissions and the patient's immunosuppressed status, magnetic resonance imaging of his thoracic spine was obtained, showing an acute or subacute anterior compression deformity of the T7 vertebral body. He was subsequently provided with a hyperextension brace, physical therapy referral, and a trial of intranasal calcitonin. The patient reported significant improvement in pain at his 3-mo follow-up appointment and continued to show pain and functional improvement in physical therapy sessions up to 6 mos later.

Vertebra Plana in Children May Result from Etiologies Other Than Eosinophilic Granuloma

BACKGROUND

Vertebra plana in children is a diagnostic dilemma for orthopaedic surgeons. This radiographic finding sometimes has been said to be pathognomonic for eosinophilic granuloma (Langerhans cell histiocytosis); however, vertebra plana may also be caused by a range of other conditions. We sought to determine whether vertebra plana can be associated with malignancies other than eosinophilic granuloma.

QUESTIONS/PURPOSES

(1) To report the underlying diagnoses for children with vertebra plana and determine how frequently these patients were found to have eosinophilic granuloma as opposed to an underlying malignant process, (2) to evaluate the occurrence of nondiagnostic results on biopsy, and (3) to determine whether the presenting characteristics of spinal lesions were associated with the ultimate clinical diagnosis.

METHODS

As part of a retrospective review, our institutional electronic medical record was searched for all patients younger than 18 years between 1976 and 2017 whose clinical record included the term vertebra plana. Patients with trauma were excluded. Twenty-seven patients met the inclusion criteria (mean [range] age 9 years [0 to 18]; 12 girls). To address our first research purpose about the underlying diagnoses of patients with vertebra plana, we reviewed the final clinical diagnosis. To address our second research purpose about the utility of biopsy, we reviewed which patients underwent a biopsy and whether it had been diagnostic. To address our third research purpose about the radiographic criteria, we classified the radiographs and compared this to the clinical diagnosis. Vertebral collapse was described as less than 50% collapse, 50% to 100% collapse, symmetrical, and asymmetrical. The location of each lesion was noted.

RESULTS

Twelve of 27 patients had a diagnosis of eosinophilic granuloma. Six of 27 had other neoplastic etiologies, including acute lymphoblastic leukemia, primary germ cell tumor, giant cell tumor, rhabdomyosarcoma and teratoma. Seventeen of 27 patients underwent biopsy to confirm the diagnosis; six biopsies were consistent with eosinophilic granuloma, six for other etiologies, and five were nondiagnostic. With the limited patient numbers available, there was no difference in the frequency of less than 50% loss of height or 50% to 100%, or symmetric and asymmetric loss of height, and location of the lesion among patients with eosinophilic granuloma and those with other diagnoses.

CONCLUSIONS

Eosinophilic granuloma or Langerhans cell histiocytosis is a common cause of vertebra plana, but other causes must be considered in children presenting with this radiographic finding. Six of 27 of patients presenting to our center with vertebra plana had an underlying neoplasm other than eosinophilic granuloma. With the limited patient numbers available, pain, spinal location, and the degree and symmetry of collapse were not associated with a diagnosis of eosinophilic granuloma in this series. Thus, patients presenting with vertebral plana and back pain need a comprehensive work-up and potentially tissue biopsy to determine diagnosis and appropriate treatment.

LEVEL OF EVIDENCE

Level IV, diagnostic study.

Clinical characteristics of pediatric synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome: the first Chinese case series from a single center

INTRODUCTION

Pediatric SAPHO syndrome is regarded as the equivalent of chronic recurrent multifocal osteomyelitis or chronic non-bacterial osteomyelitis. This study aimed to evaluate the clinical features and treatment options for Chinese pediatric patients with SAPHO syndrome.

METHOD

We conducted a single-center, retrospective study on a sample of 24 pediatric patients with SAPHO syndrome who were diagnosed at Peking Union Medical College Hospital from April 2014 to August 2018. The demographic, clinical, laboratory, imaging, histological, and therapeutic data were collected and analyzed.

RESULTS

A total of 15 boys and 9 girls were included. The mean age of onset of bone and skin symptoms was 11.7 ± 3.8 and 14.4 ± 2.7 years, respectively. The mean follow-up period was 39.2 months. Seventeen patients had skin manifestations (46% had severe acne, 100% were boys; 21% had palmoplantar pustulosis, 100% were girls). Bone lesions were localized in four of the following major regions: anterior chest wall (42%), mandible (29%), peripheral bones (50%), and spine and sacroiliac joints (21%). Six patients had been treated with non-steroidal anti-inflammatory drugs, 10 with bisphosphonate, 10 with a tumor necrosis factor-α antagonist, and 1 with glucocorticoids, with variable responses. A total of 70% of the patients had complete remission after bisphosphonate or TNF-α antagonist therapy.

CONCLUSION

Pediatric patients with SAPHO syndrome have different characteristics from other cohorts in the sex ratio, frequency of mandibular involvement, and sex distribution of skin lesions. Bisphosphonate and TNF-α antagonists show a favorable response in pediatric SAPHO syndrome treatment. Key points •Being the first study that describes an Asian pediatric SAPHO case series. •Chinese pediatric patients with SAPHO syndrome have different characteristics from Chinese adult patients and Caucasian pediatric patients.

Chronic non-bacterial osteitis from the patient perspective: a health services research through data collected from patient conferences

OBJECTIVE

Although chronic non-bacterial osteitis (CNO) is an ever-increasingly recognised illness in the paediatric community and the adult healthcare community, a study to assess diagnosing, treatment and the psychosocial aspect of CNO from a large population pool was not available. We aimed to investigate CNO from the patient perspective.

DESIGN

Health services research, patient survey.

SETTING

Ludwig-Maximilians-University (LMU) Pediatric Rheumatology Department CNO Conferences held in June 2013 and June 2015.

PARTICIPANTS

Using a patient survey developed by the LMU Pediatric Rheumatology Department, 105 patients from ages 5 to 63 years were assessed regarding CNO to include epidemiological data, medical history and treatment, initial symptoms, diagnostic procedures, current symptoms, associated diseases, current treating physicians, absences in school and work due to illness and the impact of illness on patient, family and friends.

RESULTS

Active CNO was reported in 90% of patients present, with 73% being women and 27% being men. An overwhelming majority (70%) reported being diagnosed within 18 months of onset of symptoms; however, the initial diagnoses were wide-ranged to include malignancies in 36% to bacterial osteomyelitis in 30%, where the majority were treated with an antibiotic and/or were biopsied. When asked about the psychosocial aspect of this illness, 83% reported that non-bacterial osteitis (NBO) negatively impacted the family, 79% reported that NBO has negatively affected either school or work and 56% reported a negative impact on friendships.

CONCLUSION

Delay of diagnosis, living with differential diagnoses like malignancies and finding specialists for medical care are a few examples of what leads patients into searching for more information. The negative impact on daily life including family relationships, friendships and work/school highlights a need for better psychosocial support such as guidance counselling or psychological support due to three-quarters of patients receiving no such said support.

Clinical heterogeneity of SAPHO syndrome: challenging diagnose and treatment

Synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) syndrome is a rare disease which is often misdiagnosed and under-recognized, because of its peculiar and heterogeneous clinical presentation. Its main features consist of cutaneous and osteoarticular manifestations, the latter affecting more often the anterior chest wall and having typical radiologic findings. There are no validated diagnostic criteria for SAPHO and no guidelines for treatment, due mainly to its rarity; as a consequence, therapy is empirical and aimed to control pain and modifying inflammatory process. To date, the use of anti-TNF agents has been proved to be a valid alternative for patients unresponsive to conventional treatments, such as NSAIDs, corticosteroids, DMARDs and biphosphonates. The clinical heterogeneity of the disease, possibly due to differences in pathogenic mechanism of different manifestations, is challenging for both diagnosis and treatment, which should aim to control both skin and bone involvement in different clinical subsets. Here, we summarize the current status of knowledge about the SAPHO syndrome and present two cases of patients with very different disease manifestations, suggesting the need for personalized treatment.

Chronic recurrent multifocal osteomyelitis beginning with a solitary lesion of the ilium

BACKGROUND

Chronic recurrent multifocal osteomyelitis (CRMO) is an idiopathic inflammatory disease. The initial lesions are typically found in the metaphyses, generally without periosteal reaction.

CASE PRESENTATION

We present a case of a 14-year-old female teenager with relapsing and remitting right iliac pain. There was no evidence of infectious organisms, neoplastic processes, or hematologic malignancy based on laboratory tests. Initial computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated atypical periosteal proliferation in the right ilium. Histopathology demonstrated only non-specific chronic inflammation compatible with CRMO. Two years later, this patient developed left humeral pain. MRI and CT images revealed thickening and marrow edema involving the humeral cortex.

CONCLUSIONS

This case highlights that CRMO can begin as a unifocal lesion and also possibly within the ilium, despite usually being multifocal and involving the long bone metaphysis.

Bacterial Osteomyelitis or Nonbacterial Osteitis in Children: A Study Involving the German Surveillance Unit for Rare Diseases in Childhood

BACKGROUND

Although bacterial osteomyelitis (BO) is a commonly recognized diagnosis in pediatrics, it is often difficult to distinguish from nonbacterial osteitis (NBO). The goal of our study was to distinguish between the 2 disease entities and better define NBO.

METHODS

Using the German Surveillance Unit for Rare Diseases in Childhood (Erhebungseinheit für Seltene Paediatrische Erkrankungen in Deutschland), this prospective study during a 5-year period captured 657 patients at first diagnosis of either BO (n = 378) or NBO (n = 279) while analyzing epidemiologic, clinical and radiologic data.

RESULTS

BO was reported in 1.2 per 100,000 children with a higher prevalence in younger male patients (58%), and NBO was reported in 0.45 per 100,000 children. BO patients tended to present with fevers (68%), elevated inflammation markers (82%) and local swelling (62%) but a shorter course of symptoms than NBO patients. NBO patients presented in good general health (86%) and were more likely to have multifocal lesions (66%). Staphylococcus aureus was the most prominent pathogen (83%), with only one methicillin-resistant S. aureus reported. Complications ranged from arthritis adjacent to the lesion to hyperostosis and vertebral fractures.

CONCLUSIONS

BO and NBO can be distinguished based on symptoms, associated diseases and inflammation markers. NBO should always be considered in pediatric patients presenting with bone lesions and pain, especially in young female patients presenting with good general health, minimal inflammation markers and multifocal lesions in the vertebrae, clavicle and sternum.

Physicians' Perspectives on the Diagnosis and Treatment of Chronic Nonbacterial Osteomyelitis

Background/Purpose. Understanding the practices of pediatric rheumatologists in diagnosing and treating chronic nonbacterial osteomyelitis (CNO) can provide important information to guide the development of consensus treatment plans. The objectives of this study were to determine physicians' approaches to (1) diagnosing and monitoring CNO, (2) ordering a bone biopsy, and (3) making treatment decisions. Methods. A survey was distributed among members of the Childhood Arthritis and Rheumatology Research Alliance using a web-based questionnaire. Results. 121 of 277 (41%) attending physician members completed the survey. Plain radiographs (89%) were most commonly used followed by regional MRI (78%), bone scintigraphy (43%), and whole-body MRI (36%). The top three reasons for performing a biopsy were constitutional findings (66%), unifocal bone lesions (64%), and nocturnal bone pain (45%). Nearly all responders (95%) prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) as initial therapy. For patients who failed NSAID treatment, methotrexate (67%), tumor necrosis factor inhibitors (65%), and bisphosphonates (46%) were the next most commonly used treatments. The presence of a spinal lesion increased the use of bisphosphonate treatment. Conclusion. The diagnostic approach and disease activity monitoring for CNO varied among surveyed physicians. Our survey findings provided important background for the development of consensus treatment plans for CNO.

Chronic recurrent multifocal osteomyelitis with an atypical presentation in an adult man

We present the case of a 33-year-old man with no significant medical history who developed right scapular pain, left-sided sacroiliac joint pain, and lower back pain, and was eventually diagnosed with chronic recurrent multifocal osteomyelitis (CRMO). Imaging demonstrated multiple scattered T2-hyperintense lesions on MRI at the spine and the left SI joint, some of which progressed and one regressed in size on follow-up. Histopathology demonstrated only non-specific chronic inflammation compatible with CRMO. No evidence of infectious organisms or neoplastic processes was found. The pain was relapsing and remitting in nature. Laboratory investigations were notable for no evidence of hematologic malignancy or infection, but only a mild increase in alkaline phosphatase. This case highlights that CRMO, despite being thought of as a childhood-onset disease, can present in adults as well, and also provides illustrative examples of imaging and histological findings.

[Value of whole-body MRI in vertebral fractures]

Chronic recurrent multifocal osteomyelitis (CRMO) is a rare autoinflammatory disease in children. Pathological vertebral fracture may be the first symptom revealing this disease. We describe the case of a 14-year-old boy, with no significant past medical history, who had a sudden dorsal pain after carrying a friend on his back. Plain radiographs and MRI showed fractures of the superior endplate of T5 and T6 associated with a mild degree of kyphosis. MRI allowed ruling out discitis. The diagnostic hypotheses raised were cancer (lymphoma, leukemia), Langerhans cell histiocytosis, osteogenesis imperfecta, and CRMO. A whole-body MRI (wbMRI) was performed and disclosed several clinically silent signal abnormalities in key sites of CRMO (pelvic bone and tibial metaphyses). We point out that CRMO should be systematically added to the list of possible diseases in case of vertebral fracture. In this perspective, wbMRI is a major noninvasive tool to assess the diagnosis of CRMO, and allows avoiding a bone biopsy in most cases.

The SAPHO syndrome revisited with an emphasis on spinal manifestations

The synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome includes a group of chronic, relapsing, inflammatory musculoskeletal disorders with similar manifestations, in particular synovitis, hyperostosis, and osteitis, which may or may not be associated with neutrophilic skin eruptions such as palmoplantar pustulosis and acne conglobata. The syndrome occurs at any age, can involve any skeletal site, and its imaging appearances are variable, depending on the stage/age of the lesion and imaging method. The diagnosis is difficult if there is no skin disease. Awareness of the imaging appearances, especially in the spine, may help the radiologist in avoiding misdiagnosis (e.g., infection, tumor) and unnecessary invasive procedures, while facilitating early diagnosis and selection of an effective treatment. In this article, we provide an overview of the radiological appearances of SAPHO syndrome, focusing on the magnetic resonance imaging findings of vertebral involvement, and present relevant clinical and pathological features that assist early diagnosis.

Chronic recurrent multifocal osteomyelitis (CRMO): a longitudinal case series review

BACKGROUND

Chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory disorder that is currently diagnosed based on clinical, radiologic, pathological and longitudinal findings.

OBJECTIVE

To provide detailed descriptions of CRMO lesion patterns seen on radiographs and MRI and to suggest clinical use of whole-body MRI and propose noninvasive diagnostic strategy.

MATERIALS AND METHODS

Retrospective longitudinal study (1989-2010) of 31 children (22 girls, 9 boys) diagnosed with CRMO. Imaging data were evaluated by two pediatric radiologists.

RESULTS

Mean age at diagnosis was 11 years (3-17). A total of 108 lesions were investigated. The most common sites were the long bone metaphyses (56 lesions in 24 children) especially femoral and tibial (20/24); pelvis (10/31); spine (9/31); clavicle (6/31) and mandible (3/31). In long bones, the radiologic appearance was normal (22/56), mixed lytic and sclerotic (20/56), sclerotic (8/56) or lytic (6/56) often juxtaphyseal (36/56), with hyperostosis or periosteal thickening (10/56). Vertebral involvement was often multifocal (6/9). Medullary edema was seen on MRI (42) with epiphyseal (23/42) or soft-tissue (22/42) inflammation and juxtaphyseal nodule-like appearance (7/42). Whole-body MRI (15/31) was key in detecting subclinical lesions.

CONCLUSION

CRMO is a polymorphous disorder in which whole-body MRI is extremely useful for showing subclinical edema. Vertebral collapse requires long-term monitoring.

Chronic multifocal osteomyelitis: is infectious causation a moot point?

Chronic multifocal osteomyelitis (CMO) is an uncommon disease entity with descriptions possibly emanating from the medical literature over one century ago, and there are numerous disease entities which have been historically detailed and which are probably synonymous. The illness is one of chronicity with exacerbating and remitting focal bony lesions. The differential diagnosis for a bony lesion which ultimately proves to be CMO is initially quite broad. There is no absolute pathognomonic clinical finding, and the diagnosis is highly dependent on clinical course, histopathology, and an absence of microbial infection. Recent studies have focused on immune dysfunction or dysregulation, and there are now many other diseases which are inflammatory in nature and which have been diagnosed among patients with CMO. Despite the aforementioned, the potential for direct infectious causation or indirect causation by infectious stimulation of immunity cannot be entirely excluded. Infection as a mechanism for pathogenesis must continue to be entertained. Multi-centre studies are key to future research.

SAPHO: What radiologists should know

SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) is an umbrella acronym for inflammatory clinical conditions whose common denominator is aseptic osteoarticular involvement with characteristic skin lesions. It involves all ages, can involve any skeletal site, and has variable imaging appearances depending on the stage/age of the lesion and imaging method. It mimics important differentials including infection and neoplasia. Awareness of the imaging features, especially in the spine, facilitates early diagnosis, prevents repeated biopsies, and avoids unnecessary surgery, while initiating appropriate treatment.

Treatment of infections of the spine

Spinal infection may involve the vertebrae, the intervertebral discs, and the adjacent intraspinal and paraspinal soft tissues. It often starts with subtle and insidious clinical signs and symptoms and may development to a debilitating and even life threatening disease. Spinal infections occur with increasing incidence and are nowadays a disease of everyday's practice for physicians treating spinal disorders. Traditionally, conservative treatment consisting of antibiosis and immobilisation is considered the first tier therapy. However, due to a considerably high rate of vertebral column instability or neurological impairment caused by the infected tissue, comprehensive experience with surgical measures have been acquired over the last decades. Thanks to tremendous improvements of surgical implants and techniques, surgical treatment has already begun to challenge conservative treatment to eventually become the first tier therapy for spinal infections in the future. This review seeks to give an overview of epidemiology, pathogenesis, diagnostic evaluation, and current nonsurgical and surgical therapy of spinal infections on the basis of the existing literature, which consists largely of retrospectively acquired data of single-centre experience with sample sizes of less than 100 patients treated with individually defined indications and treatment algorithms, and followed with various outcome parameters.

Spinal involvement in chronic recurrent multifocal osteomyelitis (CRMO) in childhood and effect of pamidronate

There are only a few studies that address the frequency and type of spinal involvement in patients with chronic recurrent multifocal osteomyelitis (CRMO) as well as the outcome of these patients treated with pamidronate (PAM). We performed a retrospective study on patients with CRMO and analyzed clinical and pain assessments as well as regional and whole body MRI findings and compared with posttreatment findings. Of 102 children and adolescents with CRMO, 27 (26%) had involvement of the spine. Vertebral deformities were seen in 14 of these 27 patients, scoliosis or kyphosis in 6. After routine whole body MRI, 19 complained of back pain, whereas eight were asymptomatic with spinal lesions detected incidentally. A total of 72 spinal lesions were detected, thoracic vertebrae being the most commonly affected. Seven patients were treated with PAM; all of whom had vertebral deformities and ongoing back pain. Pain resolution was achieved within 3 months of PAM treatment in every case. One patient subsequently developed a pain amplification syndrome. Repeat MRI performed at a mean interval of 13 months revealed partial or complete resolution of vertebral hyperintensities in every patient. Improvement of vertebral height was seen in a total of three vertebrae in two patients. Severe side effects were not observed. In conclusion, we demonstrated that spinal involvement and associated vertebral deformities with or without kyphoscoliosis are not rare in CRMO, and PAM appears to be an effective and safe treatment for this condition. Although controlled studies are urgently needed, the use of PAM for refractory CRMO with extended spinal involvement (vertebral deformities, kyphosis, and scoliosis) should be considered, especially after failing of conventional therapy.

Chronic recurrent multifocal and aspecific osteomyelitis: a case report

Chronic recurrent multifocal and unspecific osteomyelitis (CRMUO) is a severe form of chronic nonbacterial osteomyelitis. Lesions can be found anywhere in the skeleton, in young patients, such as children or adolescents, chronic nonbacterial osteomyelitis often affects the metaphyses of the long bones. Furthermore, other organs like skin, eyes and gastrointestinal tract can also be affected. Because of symptoms and course of disease vary in significant way, a clinical diagnosis is often difficult. The radiographic appearance suggests subacute or chronic osteomyelitis. CRMUO may mimic acute hematogenous osteomyelitis, but bacterial culture are usually negative and nonspecific histopathological and laboratory findings are present. This kind of osteomyelitis is often diagnosed by exclusion of the two main differential diagnoses-bacterial infections and tumor-by assessing for a characteristic course and the findings by conventional radiography, if necessary supplemented by scintigraphy and magnetic resonance imaging (MRI). The MRI appearance of CRMUO lesions in tubular bones and the spine is often rather characteristic and can support the diagnosis. It is important to diagnose CRMUO to avoid unnecessary diagnostic procedures or therapy, and initiate an appropriate one. We present a case report of a 44-year-old woman diagnosed with CRMUO involving both femurs.

Imaging of chronic recurrent multifocal osteomyelitis

Chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory disorder of children and young adults that is characterized by nonbacterial osteomyelitis. Patients typically present with multifocal bone pain secondary to sterile osseous inflammation, and the disease has a relapsing and remitting course. The cause of CRMO remains unclear, although the results of several studies have suggested a genetic component. The typical imaging findings of CRMO include lytic and sclerotic lesions in the metaphyses of long bones and the medial clavicles. Other common sites of disease are the vertebral bodies, pelvis, ribs, and mandible. CRMO is often bilateral and multifocal at presentation. Owing to the lack of a diagnostic test, CRMO remains a diagnosis of exclusion. Although generally a self-limiting disease, CRMO can have a prolonged course and result in significant morbidity. Radiologists can be the first to suggest this diagnosis given its characteristic radiographic appearance and distribution of disease. Radiologists should be familiar with the typical imaging findings of CRMO to prevent unnecessary multiple biopsies and long-term antibiotic treatment in children with CRMO.

Chronic recurrent multifocal osteomyelitis: comparison of whole-body MR imaging with radiography and correlation with clinical and laboratory data

PURPOSE

To describe whole-body magnetic resonance (MR) imaging appearance of chronic recurrent multifocal osteomyelitis (CRMO) and assess the role of MR imaging versus radiography in diagnosis of disease and correlation with clinical findings and laboratory data.

MATERIALS AND METHODS

Institutional review board approved this retrospective HIPAA-compliant study; informed consent was waived. T1-weighted, short inversion time inversion-recovery, and contrast material-enhanced T1-weighted whole-body MR imaging was performed and two-plane radiographs, clinical findings, and laboratory data were reviewed in 13 children (median age, 13 years) with CRMO. Lesion depiction, location, and characterization and extraskeletal abnormalities were evaluated. MR imaging findings were compared with clinical and laboratory data and radiographic results. Data analysis was performed, and diagnostic performance statistics of radiography, physical examination results, and serum inflammatory markers were calculated. General multilevel linear modeling framework was used. Odds ratios were calculated to estimate effect of age, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) level on reliabilities. Associations of ESR and CRP level with total number of lesions were assessed (chi(2) test).

RESULTS

MR imaging depicted 101 ill-defined edemalike osseous lesions. Most frequent anatomic sites were distal femur (21%, 21 of 101), proximal tibia (17%, 17 of 101), and distal tibia and fibula (14% each, 14 of 101). In tubular bones (70 anatomic sites), metaphysis (86%, 60 of 70) and epiphysis (67%, 47 of 70) were involved. Contiguous physeal relationship (89%, 66 of 74), periosteal reaction (48%, 48 of 101), and symmetric involvement (85%, 11 of 13) were present. MR imaging demonstrated multifocality in all patients. There were no extraskeletal abnormalities and no relationship between serum inflammatory markers and number of symptomatic anatomic sites (P = .472). Sensitivity for radiography was 0.13 (70 of 119); physical examination, 0.31 (52 of 299); and serum inflammatory markers, 0.15 (two of 13).

CONCLUSION

Whole-body MR imaging is useful for detection of CRMO, particularly in indeterminate cases, because it is more likely to show abnormalities.

Chronic recurrent multifocal osteomyelitis: a concise review and genetic update

Chronic recurrent multifocal osteomyelitis is an autoinflammatory disorder characterized by bone pain and fever, a course of exacerbations and remissions, and a frequent association with other inflammatory conditions. Because its etiology is largely unknown, the diagnosis is still based on clinical criteria; treatment is empiric and not always successful. The diagnosis is supported by the presence of osteolytic lesions with surrounding sclerosis apparent on radiographs, and silent asymptomatic lesions frequently appear on nuclear scans. The histologic findings in bone biopsies are nonspecific, showing inflammatory changes with granulocytic infiltration. Several observations suggest the contribution of genetic factors to the etiology of chronic recurrent multifocal osteomyelitis. Indeed, mutations in LPIN2 cause a syndromic form of chronic recurrent multifocal osteomyelitis known as Majeed syndrome, while mutations in pstpip2 cause a murine form of the disorder. The roles played by LPIN2 and the human homolog of pstpip2, PSTPIP2, in the etiology of chronic recurrent multifocal osteomyelitis are uncertain but are currently being investigated. We emphasize the need to validate diagnostic clinical criteria and develop new pathogenesis-based targeted therapy.

Magnetic resonance imaging of spinal infection

This article reviews the pathophysiology of spinal infection and its relevance for imaging. Magnetic resonance imaging (MRI) is the modality with by far the best sensitivity and specificity for spinal infection. The imaging appearances of spinal infection in MRI are outlined, and imaging techniques are discussed. The problems of clinical diagnosis are outlined. There is some emphasis on the MRI differentiation of pyogenic and nonpyogenic infection and on the differential diagnosis of spinal infection centered on the imaging presentation.

Vertebral collapse in an 8-year-old girl

We present a case of an 8-year-old girl with collapse of her T6 and T7 vertebrae secondary to chronic recurrent multifocal osteomyelitis. She presented with chronic abdominal pain and was found to have multiple bony lesions involving her spine, clavicle and mandible. Extensive investigations, including tissue biopsy, were unable to identify an infective cause and there was no response to a prolonged course of intravenous antibiotics. She made a good response to regular non-steroidal anti-inflammatory medication.

Imaging of infectious spinal disorders in children and adults

The aim of this review article is to outline the imaging of infectious disorders of the spine in adults and children. The clinical presentation, potential routes of infection and the pathogens commonly identified are discussed. The value of different imaging modalities in the diagnosis of spinal infection is presented including radiographic, CT, MR imaging and Nuclear Medicine including PET. The use of image guided techniques for diagnosis and subsequent treatment is briefly covered. The major differential diagnoses of infectious disorders of the spine are identified and contrasted with the typical findings in infection. The use of follow up imaging is evaluated.

Chronic Recurrent Multifocal Osteomyelitis Mimicking Osteosarcoma

We report a case of an adolescent female who had an initial outside clinical and imaging presentation that was considered highly suspicious for metastatic osteosarcoma. Extensive evaluation led to the diagnosis of chronic recurrent multifocal osteomyelitis. If this etiology had been considered earlier in the patient's clinical course, her diagnostic evaluation may have been less involved and treatment could have commenced sooner. When this entity is a diagnostic possibility along with neoplasm, strong consideration should be given to proceeding directly to open surgical biopsy due to the difficulty in diagnosing this lesion from small percutaneously-obtained biopsy samples.

Vertebral osteomyelitis without disc involvement

Vertebral osteomyelitis is most commonly due to pyogenic or granulomatous infection and typically results in the combined involvement of the intervertebral disc and adjacent vertebral bodies. Non-infective causes include the related conditions of chronic recurrent multifocal osteomyelitis (CRMO) and SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) syndrome. Occasionally, these conditions may present purely within the vertebral body, resulting in various combinations of vertebral marrow oedema and sclerosis, destructive lesions of the vertebral body and pathological vertebral collapse, thus mimicking neoplastic disease. This review illustrates the imaging features of vertebral osteomyelitis without disc involvement, with emphasis on magnetic resonance imaging (MRI) findings.

SAPHO: syndrome or concept? Imaging findings

The SAPHO syndrome was a term coined to include a variety of musculoskeletal disorders associated with skin conditions, mainly palmoplantar pustulosis and acne conglobata. It is more correctly a spectrum which includes the following: skin lesions, osteoarticular manifestations of synovitis hyperostosis and osteitis affecting particular target sites, and.a clinical course marked by relapses and remissions. The major sites of involvement are the anterior chest wall, the spine, long bones, flat bones, and large and small joints. The distribution and severity of involvement varies from the adult to the pediatric form of chronic recurrent multifocal osteomyelitis (CRMO). The diagnosis of SAPHO syndrome is not difficult when the typical osteoarticular lesions are located in characteristic target sites. The diagnosis is more difficult if atypical sites are involved and there is no skin disease.