Chronic Recurrent Multifocal Osteomyelitis: A Case Report with Atypical Presentation

A Case of Sterile Osteomyelitis: Chronic Recurrent Multifocal Osteomyelitis (CRMO)

Chronic recurrent multifocal osteomyelitis (CRMO) is a rarely reported autoimmune inflammatory condition affecting children and young adults. The typical complaint is recurrent severe bone pain at multiple sites; often imaging suggests features of osteomyelitis or malignancy. However, the biopsy is always negative for any growth in culture and histopathology detects only inflammatory cells. This is a diagnosis of exclusion with various diagnostic criteria. We had a 20-year-old male presenting with recurring pain and swelling in the right hand and left foot for more than seven months. Imaging revealed bone marrow edema with the expansion of bone and sclerosis involving the third metacarpal of the right hand and first metatarsal of the left foot. Acute phase reactants were mildly raised with biopsy showing inflammatory cells. However, the cultures grown from the lesion were sterile. After comparing it with the various diagnostic criteria, a diagnosis of CRMO was made.

Idiopathic CRMO and MEFV Gene Variant Alleles: Is There Any Relationship?

Background and Objective

CRMO is an inflammatory disease of bone that occurs more often in children. The clinical manifestations are intermittent fever, pain, and bone lesions, especially in long bones. Although there is an idiopathic type of disease, it is usually associated with some autoimmune disorders. This study evaluates MEFV gene mutations as background pathology of idiopathic CRMO.

Methods

Blood samples of patients, who diagnosed as childhood idiopathic CRMO by imaging and pathologic study from June 2011 until September 2018, have been screened for the 12 common pathogenic variants of MEFV gene mutations.

Result

Nine patients enrolled in this study, and eight of them were male. The most common involvement locations were tibia and femur, and the least ones were zygoma, calcaneus, and radius. The mean duration of the involvement was 1.3 years. Six patients had only 1 involved location, 2 patients showed two sites of involvement, and one patient had three affected areas. There were two positive MEFV gene mutations (22%), as E148Q/wt and K695R/wt both in the heterozygote form. There was no meaningful relationship between MEFV gene mutations and the age of onset, gender, and location of involvement. Patients with positive mutation had more involved sites and long duration of involvement significantly.

Conclusion

There is no significant immunopathogenic relationship between the common MEFV gene variant alleles and CRMO disease.

Chronic recurrent multifocal osteomyelitis-case report of two patients and review of literature

Background

Chronic Recurrent Multifocal Osteomyelitis (CRMO) is an autoinflammatory skeletal disease characterized by unifocal or multifocal nonbacterial inflammatory bone lesions in the metaphysis of long bones. Common sites of CRMO are tibia, pelvis, proximal femur, clavicle, calcaneum and vertebrae. However, unifocal presentation or presentation in adults, atypical locations, and absence of recurrence have also been reported.

Methods and Findings

We describe two cases of female patients with unifocal presentation of nonbacterial inflammatory bone lesions in the upper and lower extremity. Furthermore, a review of literature is presented.

Conclusion

Although CRMO is seen primarily in children and adolescents, and usually occurs in a multifocal pattern, our cases illustrate that this disease can arise in adult patients and in a single location. The diagnosis of CRMO should be made in a multi-disciplinary approach amongst orthopedic surgeons, radiologists and pathologists.

Evolution of chronic recurrent multifocal osteomyelitis in a child shown by MRI

Chronic recurrent multifocal osteomyelitis (CRMO) is a rare idiopathic inflammatory disease that mainly affects children and young adults. The clinical signs and symptoms are nonspecific, hindering and delaying the proper diagnosis.

We report a case of CRMO in a child with chronic pain in the cervical and thoracic spine. Investigations of the pain revealed a diagnosis of osteomyelitis in the biopsy, indicating a course of antibiotic treatment. After a year, there was progressive worsening of the pain, and it soon spread to the left wrist and right ankle. Magnetic resonance imaging of the left wrist and right ankle revealed morphostructural changes. A new biopsy was performed on the wrist and ankle, and osteomyelitis was pinpointed again.

In view of the clinical, radiological, and histopathological findings, the patient was diagnosed with CRMO. The following treatment consisted of nonsteroidal anti-inflammatory drugs, methotrexate, and pamidronate.

The strength of this case is the fact that there was extensive imaging and more than one biopsy, and the patient was followed. Magnetic resonance imaging was valuable in assessing the extent and activity of a lesion.