Two cases of chronic recurrent multifocal osteomyelitis: radiological and scintigraphic findings

The multifaceted presentation of chronic recurrent multifocal osteomyelitis: a series of 486 cases from the Eurofever international registry

OBJECTIVES

Chronic non-bacterial osteomyelitis (CNO) or chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory disorder characterized by sterile bone osteolytic lesions. The aim of this study was to evaluate the demographic data and clinical, instrumental and therapeutic features at baseline in a large series of CNO/CRMO patients enrolled in the Eurofever registry.

METHODS

A web-based registry collected retrospective data on patients affected by CRMO/CNO. Both paediatric and adult centres were involved.

RESULTS

Complete baseline information on 486 patients was available (176 male, 310 female). The mean age of onset was 9.9 years. Adult onset (>18 years of age) was observed in 31 (6.3%) patients. The mean time from disease onset to final diagnosis was 1 year (range 0-15). MRI was performed at baseline in 426 patients (88%), revealing a mean number of 4.1 lesions. More frequent manifestations not directly related to bone involvement were myalgia (12%), mucocutaneous manifestations (5% acne, 5% palmoplantar pustulosis, 4% psoriasis, 3% papulopustular lesions, 2% urticarial rash) and gastrointestinal symptoms (8%). A total of 361 patients have been treated with NSAIDs, 112 with glucocorticoids, 61 with bisphosphonates, 58 with MTX, 47 with SSZ, 26 with anti-TNF and 4 with anakinra, with a variable response.

CONCLUSION

This is the largest reported case series of CNO patients, showing that the range of associated clinical manifestations is rather heterogeneous. The study confirms that the disease usually presents with an early teenage onset, but it may also occur in adults, even in the absence of mucocutaneous manifestations.

Rare presentation of Brodie's abscess in the acromion process and the value of the penumbra sign

A 17-year-old male patient presented with a swelling on his right shoulder 1 week after a fall. MRI revealed a superficial fluid collection of the acromion and trapezius muscle, with slight enhancement of the wall. The swelling burst open spontaneously after failed conservative therapy and was treated with surgical drainage and antibiotics. Tissue cultures showed a Staphylococcus aureus 1 year later, he presented with local red discolouration and a recurrent painful swelling that fluctuated at palpation. Radiographs showed a lytic lesion of the acromion process. MRI showed a sinus in the lytic cavity and a penumbra sign, which helped to identify this extremely rare occurrence of Brodie's abscess in the acromion process that was breaking through to the subcutaneous fat. The abscess was treated successfully with surgical drainage and intravenous antibiotics. In retrospect, the first MRI showed a small cortical indentation, with slight oedema of the acromion process.

Chronic non-bacterial osteomyelitis in children

BACKGROUND

Chronic recurrent multifocal osteomyelitis (CRMO) in children is a chronic non-suppurative inflammation involving multiple sites. Some children affected by chronic non-bacterial osteomyelitis (CNO) do not have multiple lesions or a recurrent course.

OBJECTIVE

To characterise the long term outcome of children with the full spectrum of CNO.

METHODS

30 children diagnosed with CNO were followed up for a mean of 5.6 years and their disease assessed using a clinical score, multiple imaging, and a diagnostic biopsy, including extensive microbial analysis.

RESULTS

9 patients had unifocal non-relapsing disease, 3 unifocal lesions with relapses, 9 multifocal lesions without relapses, and 9 multifocal lesions with relapses (CRMO). Granulocytes were present significantly more often in CRMO than in unifocal and non-recurrent lesions. Pustulosis was more common in multifocal cases regardless of recurrence. Mean duration of treatment in 15 children with a single occurrence was 9.2 months. Naproxen treatment was generally effective. Naproxen treatment in 12 patients with relapses lasted 25 months. However, 7 of these were not effectively treated with naproxen alone. Five were treated with oral glucocorticoids for 27 days in addition to naproxen, which induced remission in four, lasting for at least 1.5 years. Longitudinal growth of affected bones was not altered, except for the development of hyperostosis.

CONCLUSION

CNO is a spectrum of inflammatory conditions, with CRMO being the most severe. Most children with CNO have a favourable outcome of the disease. Oral glucocorticoids may be necessary in severe recurrent cases.

Nuclear medicine topics in pediatric musculoskeletal disease: techniques and applications

Musculoskeletal scintigraphy has excellent sensitivity for the evaluation of benign disease in children. Using illustrative cases, a spectrum of techniques and applications of nuclear medicine studies for benign bone diseases are presented. An approach to the use and evaluation of bone density evaluation in children also is discussed.

Imaging of chronic recurrent multifocal osteomyelitis

The disease of CRMO is a "great clinical and radiologic mimic. There are no specific clinical or laboratory findings and no pathognomonic imaging or pathologic features have been described. Because the disease is not well known by clinician, radiologist, and pathologist alike, it is likely to be more common than the literature implies. It has been suggested that the diagnosis of CRMO requires an interdisciplinary team approach dependent on the cooperation of the pediatrician, orthopedic surgeon, pathologist, and microbiologist. We strongly advocate the addition of the radiologist to this list. We believe that it is the informed radiologist who frequently suggests the correct diagnosis.