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Bouchalova K, Pytelova Z. Chronic non-bacterial osteomyelitis (CNO) and chronic recurrent multifocal osteomyelitis (CRMO) with a focus on pamidronate therapy. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2024. [PMID: 38682664 DOI: 10.5507/bp.2024.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2024] Open
Abstract
Chronic recurrent multifocal osteomyelitis (CRMO), also called chronic nonbacterial osteomyelitis (CNO) or nonbacterial osteomyelitis (NBO), is a rare autoinflammatory bone disease of unknown etiology. However, the number of patients properly diagnosed would increase with better knowledge of the disease. In this regard, whole-body magnetic resonance imaging (WB MRI) has been found to be a better predictor of active lesions than clinical examination. Importantly, the RINBO index (radiologic index for NBO) quantifies the involvement based on the WB MRI. Further, a chronic nonbacterial osteomyelitis MRI scoring (CROMRIS) has been developed as an online tool for assessing WB MRI. The therapy consists of non-steroidal anti-inflammatory drugs (NSAIDs), bisphosphonates (pamidronate, zoledronate, etc.) and other drugs, including biologics. Pamidronate is an appropriate and safe therapy. The first pilot prospective randomised controlled trial (RCT) on pamidronate vs. placebo was carried out in adults. No RCT has been done in children yet. Besides RCTs, there are a number of issues to be explored in future, i.e. predictors of therapy effect, optimal therapy duration, predictors of therapy discontinuation and evaluation of optimal therapy protocol. Recently, the CNO clinical disease activity score (CDAS) was constructed and validated but the classification criteria are still being developed. As collaboration on this rare disease is essential, a prospective Chronic Nonbacterial Osteomyelitis International Registry (CHOIR) was established to generate future comparative effectiveness research data.
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Affiliation(s)
- Katerina Bouchalova
- Department of Pediatrics, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic
| | - Zuzana Pytelova
- Department of Pediatrics, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic
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Hospach T, Kallinich T, Martin L, V Kalle T, Reichert F, Girschick HJ, Hedrich CM. [Arthritis and osteomyelitis in childhood and adolescence-Bacterial and nonbacterial]. Z Rheumatol 2024:10.1007/s00393-024-01504-z. [PMID: 38653784 DOI: 10.1007/s00393-024-01504-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/29/2024] [Indexed: 04/25/2024]
Abstract
Bacterial arthritis and osteomyelitis are usually acute diseases, which in this way differ from the often insidious course of nonbacterial osteomyelitis; however, there is often an overlap both in less acute courses of bacterial illnesses and also in nonbacterial osteitis. The overlapping clinical phenomena can be explained by similar pathophysiological processes. In bacteria-related illnesses the identification of the pathogen and empirical or targeted anti-infectious treatment are prioritized, whereas no triggering agent is known for nonbacterial diseases. The diagnostics are based on the exclusion of differential diagnoses, clinical scores and magnetic resonance imaging (MRI). An activity-adapted anti-inflammatory treatment is indicated.
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Affiliation(s)
- T Hospach
- Zentrum für Pädiatrische Rheumatologie, Olgahospital, Klinikum Stuttgart (ZEPRAS), Kriegsbergstr 62, 70176, Stuttgart, Deutschland.
| | - T Kallinich
- Klinik für Pädiatrie m.S. Pneumologie, Immunologie und Intensivmedizin, Charité, Universitätsmedizin Berlin, Berlin, Deutschland
| | - L Martin
- Klinik für Pädiatrie m.S. Pneumologie, Immunologie und Intensivmedizin, Charité, Universitätsmedizin Berlin, Berlin, Deutschland
| | - T V Kalle
- Radiologisches Institut, Olgahospital, Klinikum Stuttgart, Stuttgart, Deutschland
| | - F Reichert
- Pädiatrische Infektiologie, Olgahospital, Klinikum Stuttgart, Stuttgart, Deutschland
| | - H J Girschick
- Vivantes Klinikum Friedrichshain, Berlin, Deutschland
| | - C M Hedrich
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, Großbritannien
- Department of Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, Großbritannien
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Tharwat S, Nassar MK. Musculoskeletal symptoms and their impact on health-related quality of life in chronic nonbacterial osteomyelitis patients. Pediatr Rheumatol Online J 2024; 22:34. [PMID: 38448884 PMCID: PMC10916259 DOI: 10.1186/s12969-024-00971-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 02/22/2024] [Indexed: 03/08/2024] Open
Abstract
INTRODUCTION Chronic non-bacterial osteomyelitis (CNO) is a rare, non-infection- related inflammatory disorder that affects children and teens. Clinical manifestations of CNO range widely from moderate, time-limited, monofocal inflammation of the bone to extreme multifocal or chronically active inflammation of the bone. OBJECTIVES The main aim of this study was to explore the correlation between musculoskeletal (MSK) symptoms and health-related quality of life (HRQoL) in patients with CNO. METHODS Children and adults with CNO and their parents were asked to answer a web-based survey. The survey consisted of multiple questions centered around demographic, clinical and therapeutic data, MSK discomfort form based on the Nordic MSK Questionnaire and HRQoL based on Pediatric Quality of Life Inventory-4 (PedsQL-4) and PedsQL rheumatology module. The inclusion criteria included diagnosis of CNO before the age of 18. Patients who had malignancies or any chronic rheumatic, MSK, neurological disease prior to CNO onset were excluded. RESULTS There was a total of 68 participants, mostly females (66.2%), with median age 14 years and median disease duration 4.75 years. The median number of bones affected by CNO was 5 and ranged from 1 to 24 bones. Among the studied patients, 45 patients (66.2%) had MSK manifestations at the last month. The most commonly affected part was ankle and feet (26.5%). Regarding HRQoL, patients with MSK manifestations had lower scores than did patients without in PedsQL-4 (p < 0.001) including domains of physical functioning (p < 0.001), emotional functioning (p = 0.033), social functioning (p < 0.001) and school functioning (p = 0.007) in addition to lower scores in PedsQL rheumatology module (p < 0.001) including domains of pain and hurt (p < 0.001), daily activities (p < 0.001), treatment (p = 0.035), worry (p = 0.001) and communication (p < 0.001). CONCLUSION MSK manifestations have a negative impact on HRQoL in CNO patients. So, early identification and treatment are highly recommended.
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Affiliation(s)
- Samar Tharwat
- Rheumatology & Immunology Unit, Department of Internal Medicine, Faculty of Medicine, Mansoura University, Mansoura, Egypt.
- Department of Internal Medicine, Faculty of Medicine, Horus University, New Damietta, Egypt.
- Mansoura University Hospital, El Gomhouria St, 35511, Mansoura, Dakahlia Governorate, Egypt.
| | - Mohammed Kamal Nassar
- Mansoura Nephrology & Dialysis Unit (MNDU), Department of Internal Medicine, Faculty of Medicine, Mansoura University, Mansoura, Egypt
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Saffarzadeh M, Haydar S, Chan D, Andrews G, Ouellette H, Mallinson P, Munk PL, Sheikh A. A clinico-radiological review of chronic non-bacterial osteomyelitis in paediatrics, adolescents, and adults: demystifying a forgotten differential. Clin Radiol 2024; 79:170-178. [PMID: 38160105 DOI: 10.1016/j.crad.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 12/05/2023] [Indexed: 01/03/2024]
Abstract
Chronic non-bacterial osteomyelitis (CNO), also known as non-bacterial osteitis, is a chronic autoinflammatory disease of unknown aetiology that primarily occurs in the paediatric population, although rare cases of adult-onset disease also exist. CNO has non-specific clinical and radiological presentations, and the affected population often present with bone pain of insidious onset secondary to sterile bony inflammation that can be associated with swelling, focal tenderness, and warmth at the affected sites. The pattern of bony involvement appears to be dependent on the age of onset, with adults frequently having axial skeletal lesions and children and adolescents often being affected in the appendicular skeletal sites. CNO is a diagnosis of exclusion, and imaging is heavily relied on to identify and characterise the bony lesions in addition to exclude diseases that can mimic CNO. Magnetic resonance imaging is often the reference standard with biochemical and histopathological findings being complementary. Although combining imaging methods can be used to facilitate the diagnosis, a single technique could be adequate depending on the clinical picture. Given the relatively rare incidence of CNO, limited awareness of the disease among care providers, and its similarity in clinical and radiological presentation to various bony diseases, there are often long delays in diagnosis, with adults being unfavourably affected compared to paediatrics and adolescents. This review of CNO will describe the condition, overview its clinical presentation, highlight the radiological features, and emphasise clinical pearls that can aid in diagnosis and ruling out the mimics.
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Affiliation(s)
- M Saffarzadeh
- Faculty of Medicine, The University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada.
| | - S Haydar
- Department of Radiology, Vancouver General Hospital, 2775 Laurel St, Vancouver, BC V5Z 1M9, Canada
| | - D Chan
- Department of Radiology, Vancouver General Hospital, 2775 Laurel St, Vancouver, BC V5Z 1M9, Canada
| | - G Andrews
- Faculty of Medicine, The University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada; Department of Radiology, Vancouver General Hospital, 2775 Laurel St, Vancouver, BC V5Z 1M9, Canada
| | - H Ouellette
- Faculty of Medicine, The University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada; Department of Radiology, Vancouver General Hospital, 2775 Laurel St, Vancouver, BC V5Z 1M9, Canada
| | - P Mallinson
- Faculty of Medicine, The University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada; Department of Radiology, Vancouver General Hospital, 2775 Laurel St, Vancouver, BC V5Z 1M9, Canada
| | - P L Munk
- Faculty of Medicine, The University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada; Department of Radiology, Vancouver General Hospital, 2775 Laurel St, Vancouver, BC V5Z 1M9, Canada
| | - A Sheikh
- Faculty of Medicine, The University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada; Department of Radiology, Vancouver General Hospital, 2775 Laurel St, Vancouver, BC V5Z 1M9, Canada
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Zhao Y, Su J, Xu CY, Li YB, Hu T, Li Y, Yang L, Zhao Q, Zhang WY. Establishment of a mandible defect model in rabbits infected with multiple bacteria and bioinformatics analysis. Front Bioeng Biotechnol 2024; 12:1350024. [PMID: 38282893 PMCID: PMC10811100 DOI: 10.3389/fbioe.2024.1350024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 01/04/2024] [Indexed: 01/30/2024] Open
Abstract
Objective: A model of chronic infectious mandibular defect (IMD) caused by mixed infection with Staphylococcus aureus and Pseudomonas aeruginosa was established to explore the occurrence and development of IMD and identify key genes by transcriptome sequencing and bioinformatics analysis. Methods: S. aureus and P. aeruginosa were diluted to 3 × 108 CFU/mL, and 6 × 3 × 3 mm defects lateral to the Mandibular Symphysis were induced in 28 New Zealand rabbits. Sodium Morrhuate (0.5%) and 50 μL bacterial solution were injected in turn. The modeling was completed after the bone wax closed; the effects were evaluated through postoperative observations, imaging and histological analyses. Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway, and protein‒protein interaction (PPI) network analyses were performed to investigate the function of the differentially expressed genes (DEGs). Results: All rabbits showed characteristics of infection. The bacterial cultures were positive, and polymerase chain reaction (PCR) was used to identify S. aureus and P. aeruginosa. Cone beam CT and histological analyses showed inflammatory cell infiltration, pus formation in the medullary cavity, increased osteoclast activity in the defect area, and blurring at the edge of the bone defect. Bioinformatics analysis showed 1,804 DEGs, 743 were upregulated and 1,061 were downregulated. GO and KEGG analyses showed that the DEGs were enriched in immunity and osteogenesis inhibition, and the core genes identified by the PPI network were enriched in the Hedgehog pathway, which plays a role in inflammation and tissue repair; the MEF2 transcription factor family was predicted by IRegulon. Conclusion: By direct injection of bacterial solution into the rabbit mandible defect area, the rabbit chronic IMD model was successfully established. Based on the bioinformatics analysis, we speculate that the Hedgehog pathway and the MEF2 transcription factor family may be potential intervention targets for repairing IMD.
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Affiliation(s)
- Yuan Zhao
- Department of Stomatology, 920th Hospital of Joint Logistics Support Force of People’s Liberation Army of China, Kunming, China
- Postgraduate Research Institute, Kunming Medical University, Kunming, China
| | - Jun Su
- Department of Stomatology, 920th Hospital of Joint Logistics Support Force of People’s Liberation Army of China, Kunming, China
| | - Chong-yan Xu
- Department of Stomatology, 920th Hospital of Joint Logistics Support Force of People’s Liberation Army of China, Kunming, China
- Postgraduate Research Institute, Kunming Medical University, Kunming, China
| | - Yan-bo Li
- Postgraduate Research Institute, Kunming Medical University, Kunming, China
| | - Tong Hu
- Department of Stomatology, 920th Hospital of Joint Logistics Support Force of People’s Liberation Army of China, Kunming, China
- Postgraduate Research Institute, Kunming Medical University, Kunming, China
| | - Yi Li
- Department of Stomatology, 920th Hospital of Joint Logistics Support Force of People’s Liberation Army of China, Kunming, China
- Postgraduate Research Institute, Kunming Medical University, Kunming, China
| | - Li Yang
- Department of Stomatology, 920th Hospital of Joint Logistics Support Force of People’s Liberation Army of China, Kunming, China
| | - Qiang Zhao
- Department of Stomatology, 920th Hospital of Joint Logistics Support Force of People’s Liberation Army of China, Kunming, China
| | - Wen-yun Zhang
- Department of Stomatology, 920th Hospital of Joint Logistics Support Force of People’s Liberation Army of China, Kunming, China
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Kaya Akca U, Sag E, Aydın B, Tasdemir NK, Kasap Cuceoglu M, Basaran O, Batu ED, Bilginer Y, Ozen S. Chronic non-bacterial osteomyelitis and immune checkpoint molecules. Clin Rheumatol 2024; 43:553-560. [PMID: 37676588 DOI: 10.1007/s10067-023-06761-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 08/18/2023] [Accepted: 08/27/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVE We aimed to investigate the plasma levels and cell surface expression of two checkpoint molecules, TIM-3 (T cell immunoglobulin and mucin domain-containing protein 3) and PD-1 (programmed cell death protein 1), in pediatric patients with chronic non-bacterial osteomyelitis (CNO). METHODS Plasma samples of CNO patients were collected at diagnosis or during biologic agent treatment. Plasma levels of TIM-3 and PD-1 were measured using the sandwich enzyme-linked immunosorbent assay method, and the expression of the two immune checkpoint molecules on the cell surface was analyzed by isolating peripheral blood mononuclear cells by density gradient centrifugation technique. RESULTS Twenty-seven patients with CNO (14 boys, 51.9%) and six healthy controls (3 boys, 50%) were enrolled in the study. There were no age differences between CNO patients and healthy controls (median age 14.5 vs. 13.5 years, respectively, p=0.762). Of the CNO patients, 18 were included at the time of diagnosis while 9 were receiving biologic treatment at enrollment. The median plasma PD-1 levels were significantly lower in the CNO group than in the healthy controls (p=0.011). However, no significant difference was found in the cellular expression of PD-1 and TIM-3 on CD3+CD4+ T cells in patients and healthy controls (p=0.083 and p=0.245, respectively). There was also no statistically significant difference in plasma TIM-3 levels of the patient and control groups (p=0.981). CONCLUSION CNO is an autoinflammatory disease, and overall, our results suggest that T cell exhaustion may not be significant in CNO. Further research is needed to find out whether the immune checkpoints are mainly associated with autoimmunity but not autoinflammation. Key Points • The median plasma PD-1 levels were significantly lower in the CNO group than in the healthy controls. • No significant difference was found in the cellular expression of PD-1 and TIM-3 on CD3+CD4+ T cells in patients and healthy controls. • Our results suggest that T cell exhaustion may not be significant in CNO pathogenesis.
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Affiliation(s)
- Ummusen Kaya Akca
- Division of Pediatric Rheumatology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Sihhiye Campus, 06100, Ankara, Turkey
| | - Erdal Sag
- Division of Pediatric Rheumatology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Sihhiye Campus, 06100, Ankara, Turkey
- Translational Medicine Laboratories, Pediatric Rheumatology Unit, Hacettepe University, Ankara, Turkey
| | - Busra Aydın
- Translational Medicine Laboratories, Pediatric Rheumatology Unit, Hacettepe University, Ankara, Turkey
| | - Nur Kubra Tasdemir
- Translational Medicine Laboratories, Pediatric Rheumatology Unit, Hacettepe University, Ankara, Turkey
| | - Muserref Kasap Cuceoglu
- Division of Pediatric Rheumatology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Sihhiye Campus, 06100, Ankara, Turkey
| | - Ozge Basaran
- Division of Pediatric Rheumatology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Sihhiye Campus, 06100, Ankara, Turkey
| | - Ezgi Deniz Batu
- Division of Pediatric Rheumatology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Sihhiye Campus, 06100, Ankara, Turkey
| | - Yelda Bilginer
- Division of Pediatric Rheumatology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Sihhiye Campus, 06100, Ankara, Turkey
| | - Seza Ozen
- Division of Pediatric Rheumatology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Sihhiye Campus, 06100, Ankara, Turkey.
- Translational Medicine Laboratories, Pediatric Rheumatology Unit, Hacettepe University, Ankara, Turkey.
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Abstract
Chronic recurrent multifocal osteomyelitis (CRMO) is an underrecognized autoinflammatory disease affecting the skeletal system. Its vague symptoms are often first attributed to growing pains, infection, or malignancy, which can lead to a delay in diagnosis for days to years. Untreated CRMO has the potential to cause debilitating skeletal deformities, arthritis, and chronic pain; hence early recognition and treatment are paramount. MRI is the gold standard for diagnosis. Treatment consists of various antiinflammatory medications and may also include bisphosphonates if vulnerable skeletal sites are involved. Even when treated, the disease may have a relapsing course lasting years.
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Affiliation(s)
- Bridget A Rafferty
- Medical College of Wisconsin, 8701 W. Watertown Plank Road, Milwaukee, WI 53226, USA
| | - Pooja Thakrar
- Medical College of Wisconsin/Children's Wisconsin, 9000 W. Wisconsin Avenue, MS-721, Milwaukee, WI 53226, USA.
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Li SWS, Roberts E, Hedrich C. Treatment and monitoring of SAPHO syndrome: a systematic review. RMD Open 2023; 9:e003688. [PMID: 38151265 PMCID: PMC10753757 DOI: 10.1136/rmdopen-2023-003688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/24/2023] [Indexed: 12/29/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Synovitis acne pustulosis hyperostosis osteitis (SAPHO) is a rare heterogeneous disease of unknown aetiopathology. Externally validated and internationally agreed diagnostic criteria or outcomes and, as a result, prospective randomised controlled trials in SAPHO are absent. Consequently, there is no agreed treatment standard. This study aimed to systematically collate and discuss treatment options in SAPHO. METHODS Following 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses' guidance, a systematic literature search was conducted using PubMed, Scopus and Web of Science databases. Prospective clinical studies and retrospective case collections discussing management and outcomes in SAPHO involving five or more participants were included. Articles not published in English, studies not reporting defined outcomes, and studies solely relying on patient-reported outcomes were excluded. RESULTS A total of 28 studies (20 observational, 8 open-label clinical studies) reporting 796 patients of predominantly European ethnicity were included. Reported therapies varied greatly, with many centres using multiple treatments in parallel. Most patients (37.1%) received non-steroidal anti-inflammatory drugs alone or in combination. Bisphosphonates (22.1%), conventional (21.7%) and biological (11.3%) disease-modifying antirheumatic drugs were the next most frequently reported treatments. Reported outcomes varied and delivered mixed results, which complicates comparisons. Bisphosphonates demonstrated the most consistent improvement of osteoarticular symptoms and were associated with transient influenza-like symptoms. Paradoxical skin reactions were reported in patients treated with TNF inhibitors, but no serious adverse events were recorded. Most treatments had limited or mixed effects on cutaneous involvement. A recent study investigating the Janus kinase inhibitor tofacitinib delivered promising results in relation to skin and nail involvement. CONCLUSIONS No single currently available treatment option sufficiently addresses all SAPHO-associated symptoms. Variable, sometimes descriptive outcomes and the use of treatment combinations complicate conclusions and treatment recommendations. Randomised clinical trials are necessary to generate reliable evidence.
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Affiliation(s)
- Sophie W S Li
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Eve Roberts
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Christian Hedrich
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
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Sundqvist M, Christenson K, Wekell P, Björnsdottir H, Dahlstrand Rudin A, Sanchez Klose FP, Kallinich T, Welin A, Björkman L, Bylund J, Karlsson-Bengtsson A, Berg S. Severe chronic non-bacterial osteomyelitis in combination with total MPO deficiency and responsiveness to TNFα inhibition. Front Immunol 2023; 14:1233101. [PMID: 37954595 PMCID: PMC10637399 DOI: 10.3389/fimmu.2023.1233101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 10/10/2023] [Indexed: 11/14/2023] Open
Abstract
We describe a female patient suffering from severe chronic non-bacterial osteomyelitis (CNO) with systemic inflammation and advanced malnutrition and complete deficiency of myeloperoxidase (MPO). CNO is a rare autoinflammatory bone disorder associated with dysregulation of the innate immune system. MPO deficiency is a genetic disorder with partial or complete absence of the phagocyte peroxidase MPO. MPO deficiency has no established clinical phenotype but reports indicate increased susceptibility to infection and chronic inflammation. The patient's symptoms began at 10 years of age with pain in the thighs, systemic inflammation and malnutrition. She was diagnosed with CNO at 14 years of age. Treatment with nonsteroidal anti-inflammatory drugs, corticosteroids, bisphosphonates or IL1-receptor antagonists (anakinra) did not relieve the symptoms. However, the patient responded instantly and recovered from her clinical symptoms when treated with TNFα blockade (adalimumab). Three years after treatment initiation adalimumab was withdrawn, resulting in rapid symptom recurrence. When reintroducing adalimumab, the patient promptly responded and went into remission. In addition to clinical and laboratory profiles, neutrophil functions (reactive oxygen species, ROS; neutrophil extracellular traps, NETs; degranulation; apoptosis; elastase activity) were investigated both in a highly inflammatory state (without treatment) and in remission (on treatment). At diagnosis, neither IL1β, IL6, nor TNFα was significantly elevated in serum, but since TNFα blockade terminated the inflammatory symptoms, the disease was likely TNFα-driven. All neutrophil parameters were normal both during treatment and treatment withdrawal, except for MPO-dependent intracellular ROS- and NET formation. The role of total MPO deficiency for disease etiology and severity is discussed.
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Affiliation(s)
- Martina Sundqvist
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg, Sweden
| | - Karin Christenson
- Department of Oral Microbiology and Immunology, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Per Wekell
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Pediatrics, NU Hospital Group, Uddevalla, Sweden
- Department of Pediatric Rheumatology and Immunology, Queen Silvia Children’s Hospital, Gothenburg, Sweden
| | - Halla Björnsdottir
- Department of Oral Microbiology and Immunology, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Agnes Dahlstrand Rudin
- Department of Oral Microbiology and Immunology, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Felix P. Sanchez Klose
- Department of Oral Microbiology and Immunology, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Tilmann Kallinich
- Department of Pediatric Pneumology, Immunology and Critical Care Medicine, Charité Universitätsmedizin Berlin, Deutsches Rheuma-Forschungszentrum (DRFZ), Institute of the Leibniz Association, Berlin, Germany
| | - Amanda Welin
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg, Sweden
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Faculty of Medicine, Linköping University, Linköping, Sweden
| | - Lena Björkman
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg, Sweden
- Unit of Rheumatology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johan Bylund
- Department of Oral Microbiology and Immunology, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anna Karlsson-Bengtsson
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg, Sweden
- Division of Chemical Biology, Department of Life Sciences, Chalmers University of Technology, Gothenburg, Sweden
| | - Stefan Berg
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Pediatric Rheumatology and Immunology, Queen Silvia Children’s Hospital, Gothenburg, Sweden
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Singhal S, Landes C, Shukla R, McCann LJ, Hedrich CM. Classification and management strategies for paediatric chronic nonbacterial osteomyelitis and chronic recurrent multifocal osteomyelitis. Expert Rev Clin Immunol 2023; 19:1101-1116. [PMID: 37224535 DOI: 10.1080/1744666x.2023.2218088] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 05/04/2023] [Accepted: 05/22/2023] [Indexed: 05/26/2023]
Abstract
INTRODUCTION Chronic non-bacterial osteomyelitis (CNO) is an autoinflammatory bone disease that most commonly affects children and adolescents causing significant pain and damage to bones. The absence of diagnostic criteria and biomarkers, an incomplete understanding of the molecular pathophysiology, and lack of evidence from randomized and controlled trials make the diagnosis and care challenging. AREAS COVERED This review provides an overview of the clinical and epidemiological features of CNO and displays diagnostic challenges and how they can be addressed following strategies used internationally and by the authors. It summarizes the molecular pathophysiology, including pathological activation of the NLRP3 inflammasome and IL-1 secretion, and how these observations can inform future treatment strategies. Finally, it provides a summary of ongoing initiatives aiming at classification criteria (ACR/EULAR) and outcome measures (OMERACT) that will enable the generation of evidence through clinical trials. EXPERT OPINION Scientific efforts have linked molecular mechanisms to cytokine dysregulation in CNO, thereby delivering arguments for cytokine blocking strategies. Recent and ongoing collaborative international efforts are providing the basis to move toward clinical trials and target directed treatments for CNO that find approval by regulatory agencies.
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Affiliation(s)
- Shabnam Singhal
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Caren Landes
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
- Department of Paediatric Radiology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Rajeev Shukla
- Department of Paediatric Histopathology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Liza J McCann
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Christian M Hedrich
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
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11
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Mohanna M, Roberts E, Whitty L, Gritzfeld JF, Pain CE, Girschick HJ, Preston J, Hadjittofi M, Anderson C, Ferguson PJ, Theos A, Hedrich CM. Priorities in Chronic nonbacterial osteomyelitis (CNO) - results from an international survey and roundtable discussions. Pediatr Rheumatol Online J 2023; 21:65. [PMID: 37391782 DOI: 10.1186/s12969-023-00851-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 06/16/2023] [Indexed: 07/02/2023] Open
Abstract
OBJECTIVE Chronic nonbacterial osteomyelitis (CNO) is an autoinflammatory bone disorder that predominantly affects children and young people. The pathophysiology and molecular mechanisms of CNO remain poorly understood, and diagnostic criteria and biomarkers are lacking. As a result, treatment is empiric and follows personal experience, case series and expert consensus plans. METHODS A survey was designed to gain insight on clinician and patient experiences of diagnosing and treating CNO and to collate opinions on research priorities. A version containing 24 questions was circulated among international expert clinicians and clinical academics (27 contacted, 21 responses). An equivalent questionnaire containing 20 questions was shared to explore the experience and priorities of CNO patients and family members (93 responses). RESULTS Responses were used to select topics for four moderated roundtable discussions at the "International Conference on CNO and autoinflammatory bone disease" (Liverpool, United Kingdom, May 25-26th, 2022). The group identified deciphering the pathophysiology of CNO to be the highest priority, followed by clinical trials, necessary outcome measures and classification criteria. Surprisingly, mental wellbeing scored behind these items. CONCLUSIONS Agreement exists among clinicians, academics, patients and families that deciphering the pathophysiology of CNO is of highest priority to inform clinical trials that will allow for the approval of medications for the treatment of CNO by regulatory agencies.
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Affiliation(s)
- M Mohanna
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - E Roberts
- Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - L Whitty
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - J F Gritzfeld
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - C E Pain
- Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - H J Girschick
- Klinik Für Kinder- Und Jugendmedizin, Vivantes Netzwerk Für Gesundheit GmbH, Klinikum Im Friedrichshain, Berlin, Germany
| | - J Preston
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - M Hadjittofi
- Clinical Health Psychology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - C Anderson
- Royal Hospital for Children and Young People, Edinburgh, UK
| | - P J Ferguson
- Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - A Theos
- Department of Human Science, CRMO Patient/Parent Partner, Georgetown University, Washington, DC, USA
| | - C M Hedrich
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
- Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK.
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12
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Hetrick R, Oliver M. Pediatric autoinflammatory bone disorders-a mini review with special focus on pathogenesis and inborn errors of immunity. Front Pediatr 2023; 11:1169659. [PMID: 37342528 PMCID: PMC10277822 DOI: 10.3389/fped.2023.1169659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 05/17/2023] [Indexed: 06/23/2023] Open
Abstract
Autoinflammatory bone disorders are a group of diseases characterized by sterile osteomyelitis. This includes chronic nonbacterial osteomyelitis and the monogenic forms, Majeed syndrome and deficiency of the interleukin-1 receptor antagonist. These disorders result from innate immune system dysregulation and cytokine imbalance that triggers inflammasome activation causing downstream osteoclastogenesis and excessive bone remodeling. In this review, we will summarize the immunopathogenesis of pediatric autoinflammatory bone diseases with a special focus on the genetics and inborn errors of immunity, while briefly touching on the clinical manifestations and management of each disease as well as areas for future research.
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13
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Hedrich CM, Beresford MW, Dedeoglu F, Hahn G, Hofmann SR, Jansson AF, Laxer RM, Miettunen P, Morbach H, Pain CE, Ramanan AV, Roberts E, Schnabel A, Theos A, Whitty L, Zhao Y, Ferguson PJ, Girschick HJ. Gathering expert consensus to inform a proposed trial in chronic nonbacterial osteomyelitis (CNO). Clin Immunol 2023; 251:109344. [PMID: 37098355 DOI: 10.1016/j.clim.2023.109344] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/23/2022] [Accepted: 04/07/2023] [Indexed: 04/27/2023]
Abstract
Chronic nonbacterial osteomyelitis (CNO) is an autoinflammatory bone disease that primarily affects children and adolescents. CNO is associated with pain, bone swelling, deformity, and fractures. Its pathophysiology is characterized by increased inflammasome assembly and imbalanced expression of cytokines. Treatment is currently based on personal experience, case series and resulting expert recommendations. Randomized controlled trials (RCTs) have not been initiated because of the rarity of CNO, expired patent protection of some medications, and the absence of agreed outcome measures. An international group of fourteen CNO experts and two patient/parent representatives was assembled to generate consensus to inform and conduct future RCTs. The exercise delivered consensus inclusion and exclusion criteria, patent protected (excludes TNF inhibitors) treatments of immediate interest (biological DMARDs targeting IL-1 and IL-17), primary (improvement of pain; physician global assessment) and secondary endpoints (improved MRI; improved PedCNO score which includes physician and patient global scores) for future RCTs in CNO.
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Affiliation(s)
- C M Hedrich
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK.
| | - M W Beresford
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - F Dedeoglu
- Boston Children's Hospital & Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - G Hahn
- Department of Radiology, University Medical Center Carl Gustav Carus, TU Dresden, Germany
| | - S R Hofmann
- Department of Paediatrics, University Medical Center Carl Gustav Carus, TU Dresden, Germany
| | - A F Jansson
- Department of Pediatrics, Dr von Hauner Children's Hospital, Ludwig Maximilian University, Munich, Germany
| | - R M Laxer
- The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - P Miettunen
- University of Calgary, Calgary, Alberta, Canada
| | - H Morbach
- Pediatric Immunology, University Childrens' Hospital Würzburg, Würzburg, Germany
| | - C E Pain
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - A V Ramanan
- Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol and Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - E Roberts
- CNO/CRMO Patient Partner, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - A Schnabel
- Department of Paediatrics, University Medical Center Carl Gustav Carus, TU Dresden, Germany
| | - A Theos
- CNO/CRMO Patient/parent Partner, Department of Human Science, Georgetown University, Washington, DC, USA
| | - L Whitty
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, UK
| | - Y Zhao
- Seattle Children's Hospital, University of Washington, Seattle, United States of America
| | - P J Ferguson
- University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - H J Girschick
- Vivantes Children's Hospital in Friedrichshain, Berlin, Germany
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14
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Quintana-Ortega C, Prieto-Moreno Pfeifer A, Palomino Lozano L, Lancharro Á, Saavedra Lozano J, Villa-García ÁJ, Seoane-Reula E. Colchicine as rescue treatment in two pediatric patients with chronic recurrent multifocal osteomyelitis (CRMO). Mod Rheumatol Case Rep 2023; 7:215-218. [PMID: 35134976 DOI: 10.1093/mrcr/rxac010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/03/2021] [Accepted: 01/26/2022] [Indexed: 01/07/2023]
Abstract
Chronic recurrent multifocal osteomyelitis (CRMO) is a rare idiopathic autoinflammatory bone disease characterised by noninfective inflammation of bones. Diagnostic approach is challenging and requires exclusion of other causes such as malignancies or infections. Nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids are usually applied as first-line therapy in CRMO patients; however, some cases require more intensive therapy with second-line agents to control disease activity. We hereby describe the use of colchicine as a nonconventional second-line disease-modifying antirheumatic drug in two pediatric patients with CRMO refractory to NSAIDs and corticosteroids. Our data indicate that colchicine might prove an important area for future research as a potential therapeutic option with easy administration, low cost, and a good safety profile in CRMO patients refractory to first-line therapy.
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Affiliation(s)
| | | | | | - Ángel Lancharro
- Department of Pediatric Radiology, Gregorio Marañón University Hospital, Madrid, Spain
| | - Jesús Saavedra Lozano
- Department of Pediatric Infectious Diseases, Gregorio Marañón University Hospital, Madrid, Spain
| | - Ángel José Villa-García
- Department of Pediatric Orthopedic and Trauma Surgery, Gregorio Marañón University Hospital, Madrid, Spain
| | - Elena Seoane-Reula
- Department of Pediatric Allergy and Immunology, Primary Immunodeficiencies Unit Gregorio Marañón University General Hospital, Madrid, Spain
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15
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Salazar LM, Cone R, Morrey BF. Chronic nonbacterial monoarticular osteomyelitis of the elbow. JSES REVIEWS, REPORTS, AND TECHNIQUES 2022; 2:592-596. [PMID: 37588451 PMCID: PMC10426514 DOI: 10.1016/j.xrrt.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
| | - Robert Cone
- Department of Radiology, UT Health San Antonio, San Antonio, TX, USA
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16
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Nico MAC, Araújo FF, Guimarães JB, da Cruz IAN, Silva FD, Carneiro BC, Filho AGO. Chronic nonbacterial osteomyelitis: the role of whole-body MRI. Insights Imaging 2022; 13:149. [PMID: 36114435 PMCID: PMC9481810 DOI: 10.1186/s13244-022-01288-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 08/24/2022] [Indexed: 11/12/2022] Open
Abstract
Background Chronic nonbacterial osteomyelitis (CNO), also known as chronic recurrent multifocal osteomyelitis, is a noninfectious autoinflammatory disorder that occurs primarily in children and adolescents and is characterized by episodic musculoskeletal pain with a protracted course. Main body Traditionally, the diagnosis of CNO is made by exclusion and commonly requires bone biopsy to rule out infection and malignancy. However, bone biopsy may be avoided when imaging and clinical characteristic features are present, such as multifocal bone lesions at typical sites, no constitutional symptoms and no signs of infection in laboratory test results. Whole-body magnetic resonance imaging (WB-MRI) can assess signs of acute and chronic inflammation and enables the detection of CNO typical patterns of lesion location and distribution, thereby helping to exclude differential diagnosis. The goal of the present study paper is to review the main clinical and imaging aspects of the disease with emphasis on the role of WB-MRI in the diagnosis, assessment of disease burden and follow-up monitoring. Conclusion Radiologists need to be familiar with the imaging features to suggest the diagnosis as the early therapy may help to avoid irreversible secondary damage of skeletal system.
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17
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Efthimiou P, Petryna O, Nakasato P, Kontzias A. New insights on multigenic autoinflammatory diseases. Ther Adv Musculoskelet Dis 2022; 14:1759720X221117880. [PMID: 36081748 PMCID: PMC9445512 DOI: 10.1177/1759720x221117880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 07/14/2022] [Indexed: 11/16/2022] Open
Abstract
Autoinflammatory diseases are disorders of the innate immune system, which can be either monogenic due to a specific genetic mutation or complex multigenic due to the involvement of multiple genes. The aim of this review is to explore and summarize the recent advances in pathogenesis, diagnosis, and management of genetically complex autoinflammatory diseases, such as Schnitzler's syndrome; adult-onset Still's disease; synovitis, acne, pustulosis, hyperostosis, osteitis syndrome/chronic recurrent multifocal osteomyelitis/chronic non-bacterial osteomyelitis; Adamantiades-Behçet's disease; Yao syndrome; and periodic fever with aphthous stomatitis, pharyngitis, and adenitis syndrome. The PubMed database was screened for relevant articles using free text words and specific search strings. The search was limited to English-language articles, reporting the results of studies in humans, published through March 2021. Evidence from literature suggest that these rare multigenic autoinflammatory diseases can present with different clinical features and the diagnosis of these diseases can be challenging due to a combination of nonspecific manifestations that can be seen in a variety of other conditions. Diagnostic delays and disease complications may occur due to low disease awareness and the lack of pathognomonic markers. The pathogeneses of these diseases are complex and in some cases precise pathogenesis is not clearly understood. Conventional treatments are commonly used for the management of these conditions, but biologics have shown promising results. Biologics targeting proinflammatory cytokines including IL-1, IL-6, TNF-α, IL-17A and IL-18 have been shown to ameliorate signs and symptoms of different multigenic autoinflammatory diseases.
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Affiliation(s)
- Petros Efthimiou
- New York Rheumatology Care, Ross University School of Medicine, New York, USA
| | - Olga Petryna
- NYU Grossman School of Medicine, New York, NY, USA
| | | | - Apostolos Kontzias
- Department of Rheumatology, Stony Brook University School of Medicine, Stony Brook, NY, USA
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18
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Kaut S, Van den Wyngaert I, Christiaens D, Wouters C, Noppe N, Herregods N, Dehoorne J, De Somer L. Chronic nonbacterial osteomyelitis in children: a multicentre Belgian cohort of 30 children. Pediatr Rheumatol Online J 2022; 20:41. [PMID: 35698069 PMCID: PMC9195463 DOI: 10.1186/s12969-022-00698-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 05/27/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND To evaluate clinical characteristics, imaging findings, therapeutic approach and outcome of paediatric patients with Chronic Non-Bacterial Osteomyelitis (CNO). METHODS Retrospective review of 30 children diagnosed with CNO at two tertiary care centres in Belgium. Imaging data were evaluated by blinded paediatric radiologists. RESULTS Mean age at onset was 10.3 years and mean age at diagnosis was 11.7 years. Bone pain was the leading symptom (29/30 patients). Out of 180 symptomatic lesions, 131 were confirmed on MRI as hyperintense geographic lesions on STIR images at the metaphysis and epiphysis adjacent to growth plates of tubular bones. The most common sites of involvement were the lower limbs, spine, sternoclavicular joint and humerus. For nearly half of the patients (14/30) monotherapy with NSAIDs was sufficient to obtain remission. The remaining 16 patients received second-line therapy: bisphosphonates (n = 15/30), disease-modifying antirheumatic drugs (n = 7/30), etanercept (n = 4/30) and tocilizumab (n = 1/30). Remission was reached after a mean time of 37.6 months in 26/30 patients. The prognosis was worse for patients with spinal involvement, resulting in more long-term sequelae. CONCLUSIONS We present a multicentre paediatric cohort of 30 CNO patients. A typical pattern of bone involvement could be found on MRI. NSAIDs were administered as first-line treatment. Second-line strategies included bisphosphonates, corticosteroids, methotrexate, etanercept and tocilizumab. TRIAL REGISTRATION Retrospectively registered. Registratienummer EC KUL: MP018023.
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Affiliation(s)
- Sara Kaut
- grid.410569.f0000 0004 0626 3338Department of Paediatrics, Leuven University Hospitals, Leuven, Belgium
| | - Ine Van den Wyngaert
- grid.410569.f0000 0004 0626 3338Department of Paediatrics, Leuven University Hospitals, Leuven, Belgium
| | - Davy Christiaens
- grid.410569.f0000 0004 0626 3338Department of Radiology, Leuven University Hospitals, Leuven, Belgium
| | - Carine Wouters
- grid.410569.f0000 0004 0626 3338Department of Paediatrics, Paediatric Rheumatology and Immune-Inflammatory Diseases, Leuven University Hospitals, Herestraat 49, 3000 Leuven, Belgium
| | - Nathalie Noppe
- grid.410569.f0000 0004 0626 3338Department of Radiology, Leuven University Hospitals, Leuven, Belgium
| | - Nele Herregods
- grid.410566.00000 0004 0626 3303Department of Paediatric Radiology, Ghent University Hospital, Ghent, Belgium
| | - Joke Dehoorne
- grid.410566.00000 0004 0626 3303Paediatric Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - Lien De Somer
- Department of Paediatrics, Paediatric Rheumatology and Immune-Inflammatory Diseases, Leuven University Hospitals, Herestraat 49, 3000, Leuven, Belgium.
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19
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Ferjani Hanene L, Makhlouf Y, Maatallah K, Triki W, Ben Nessib D, Kaffel D, Hamdi W. Management of chronic recurrent multifocal osteomyelitis: review and update on the treatment protocol. Expert Opin Biol Ther 2022; 22:781-787. [PMID: 35574685 DOI: 10.1080/14712598.2022.2078161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory disorder primarily affecting children. It is characterized by a peripheral involvement of the metaphysis of long bones rather than axial involvement. Due to the scarcity of the disease, there are no guidelines regarding its management. AREAS COVERED This review aims to provide an overview of the different therapeutic alternatives and recent protocols. For this reason, first-line and second-line treatment, as well as the impact of new therapies, are discussed in depth. We conducted a search through PubMed on the different aspects of CRMO. Outcomes were categorized as first and second-line treatments. EXPERT OPINION Non-steroidal anti-inflammatory drugs remain the keystone of CRMO management and are proposed as the first-line treatment. In the case of vertebral involvement, bisphosphonate should be considered, even as a first-line treatment. Several case series and retrospective studies highlight the efficacy of anti-TNF agents. Their use could be an optimal treatment choice for CRMO with comorbid immune-mediated diseases. The potentially favorable effect of interleukin-1 antagonists remains to be determined.
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Affiliation(s)
- Lassoued Ferjani Hanene
- Department of Rheumatology, Mohammed Kassab National Institute of Orthopedics Mannouba, Tunisia.,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia.,Research Unit UR17SP04, 2010 Ksar Said, Tunis, Tunisia
| | - Yasmine Makhlouf
- Department of Rheumatology, Mohammed Kassab National Institute of Orthopedics Mannouba, Tunisia.,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - Kaouther Maatallah
- Department of Rheumatology, Mohammed Kassab National Institute of Orthopedics Mannouba, Tunisia.,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia.,Research Unit UR17SP04, 2010 Ksar Said, Tunis, Tunisia
| | - Wafa Triki
- Department of Rheumatology, Mohammed Kassab National Institute of Orthopedics Mannouba, Tunisia.,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia.,Research Unit UR17SP04, 2010 Ksar Said, Tunis, Tunisia
| | - Dorra Ben Nessib
- Department of Rheumatology, Mohammed Kassab National Institute of Orthopedics Mannouba, Tunisia.,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia.,Research Unit UR17SP04, 2010 Ksar Said, Tunis, Tunisia
| | - Dhia Kaffel
- Department of Rheumatology, Mohammed Kassab National Institute of Orthopedics Mannouba, Tunisia.,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia.,Research Unit UR17SP04, 2010 Ksar Said, Tunis, Tunisia
| | - Wafa Hamdi
- Department of Rheumatology, Mohammed Kassab National Institute of Orthopedics Mannouba, Tunisia.,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia.,Research Unit UR17SP04, 2010 Ksar Said, Tunis, Tunisia
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20
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Schnabel A, Nashawi M, Anderson C, Felsenstein S, Lamoudi M, Poole-Cowley J, Lindell E, Oates B, Fowlie P, Walsh J, Ellis T, Hahn G, Goldspink A, Martin N, Mahmood K, Hospach T, Lj M, Hedrich CM. TNF-inhibitors or bisphosphonates in chronic nonbacterial osteomyelitis? - Results of an international retrospective multicenter study. Clin Immunol 2022; 238:109018. [PMID: 35460903 DOI: 10.1016/j.clim.2022.109018] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 04/12/2022] [Accepted: 04/14/2022] [Indexed: 12/26/2022]
Abstract
Chronic nonbacterial osteomyelitis (CNO) can cause significant morbidity, including bone pain and damage. In the absence of clinical trials, treatments include non-steroidal anti-inflammatory drugs, corticosteroids, TNF-inhibitors (TNFi) and/or bisphosphonates. In a retrospective chart review in the United Kingdom and Germany, we investigated response to TNFi and/or pamidronate. Ninety-one patients were included, receiving pamidronate (n = 47), TNFi (n = 22) or both sequentially (n = 22). Patients with fatigue [p = 0.003] and/or arthritis [p = 0.002] were more frequently treated with TNFi than pamidronate. Both therapies were associated with clinical remission at 6 months, and reduction of bone lesions on MRI at 12 months. While not reaching statistical significance, pamidronate resulted in faster resolution of MRI lesions. Fewer flares were observed with TNFi. Failure to respond to pamidronate was associated with female sex [p = 0.027], more lesions on MRI [p = 0.01] and higher CRP levels [p = 0.03]. Randomized clinical trials are needed to confirm observations and generate evidence.
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Affiliation(s)
- A Schnabel
- Pädiatrische Rheumatologie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany.
| | - M Nashawi
- Pädiatrische Rheumatologie, Klinikum Stuttgart, Germany; Department of Pediatrics, King Abdulaziz University, Jeddah, Saudi Arabia
| | - C Anderson
- Royal Hospital for Children and Young People, Edinburgh, United Kingdom
| | - S Felsenstein
- Department of Infectious Disease and Immunology, Alder Hey Children's NHS Foundation Trust, United Kingdom
| | - M Lamoudi
- Royal Hospital for Children and Young People, Edinburgh, United Kingdom
| | - J Poole-Cowley
- Royal Hospital for Sick Children, Glasgow, United Kingdom
| | - E Lindell
- University Hospital Crosshouse, Kilmarnock, United Kingdom
| | - B Oates
- University Hospital Crosshouse, Kilmarnock, United Kingdom
| | - P Fowlie
- Ninewells Hospital, Dundee, United Kingdom
| | - J Walsh
- Royal Hospital for Sick Children, Glasgow, United Kingdom
| | - T Ellis
- Pädiatrische Rheumatologie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | - G Hahn
- Department of Radiology, Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | - A Goldspink
- Raigmore Hospital, Inverness, United Kingdom
| | - N Martin
- Royal Hospital for Sick Children, Glasgow, United Kingdom
| | - K Mahmood
- Department of Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | - T Hospach
- Pädiatrische Rheumatologie, Klinikum Stuttgart, Germany
| | - McCann Lj
- Department of Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | - C M Hedrich
- Department of Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom.
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21
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Tsumura M, Miki M, Mizoguchi Y, Hirata O, Nishimura S, Tamaura M, Kagawa R, Hayakawa S, Kobayashi M, Okada S. Enhanced osteoclastogenesis in patients with MSMD due to impaired response to IFN-γ. J Allergy Clin Immunol 2021; 149:252-261.e6. [PMID: 34176646 DOI: 10.1016/j.jaci.2021.05.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/06/2021] [Accepted: 05/11/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Patients with Mendelian susceptibility to mycobacterial disease (MSMD) experience recurrent and/or persistent infectious diseases associated with poorly virulent mycobacteria. Multifocal osteomyelitis is among the representative manifestations of MSMD. The frequency of multifocal osteomyelitis is especially high in patients with MSMD etiologies that impair cellular response to IFN-γ, such as IFN-γR1, IFN-γR2, or STAT1 deficiency. OBJECTIVES This study sought to characterize the mechanism underlying multifocal osteomyelitis in MSMD. METHODS GM colonies prepared from bone marrow mononuclear cells from patients with autosomal dominant (AD) IFN-γR1 deficiency, AD STAT1 deficiency, or STAT1 gain of function (GOF) and from healthy controls were differentiated into osteoclasts in the presence or absence of IFN-γ. The inhibitory effect of IFN-γ on osteoclastogenesis was investigated by quantitative PCR, immunoblotting, tartrate-resistant acid phosphatase staining, and pit formation assays. RESULTS Increased osteoclast numbers were identified by examining the histopathology of osteomyelitis in patients with AD IFN-γR1 deficiency or AD STAT1 deficiency. In the presence of receptor activator of nuclear factor kappa-B ligand and M-CSF, GM colonies from patients with AD IFN-γR1 deficiency, AD STAT1 deficiency, or STAT1 GOF differentiated into osteoclasts, similar to GM colonies from healthy volunteers. IFN-γ concentration-dependent inhibition of osteoclast formation was impaired in GM colonies from patients with AD IFN-γR1 deficiency or AD STAT1 deficiency, whereas it was enhanced in GM colonies from patients with STAT1 GOF. CONCLUSIONS Osteoclast differentiation is increased in AD IFN-γR1 deficiency and AD STAT1 deficiency due to an impaired response to IFN-γ, leading to excessive osteoclast proliferation and, by inference, increased bone resorption in infected foci, which may underlie multifocal osteomyelitis.
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Affiliation(s)
- Miyuki Tsumura
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - Mizuka Miki
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan; Department of Pediatrics, Hiroshima Red Cross Hospital and Atomic-bomb Survivors Hospital, Hiroshima, Japan
| | - Yoko Mizoguchi
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - Osamu Hirata
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan; Hidamari Children Clinic, Hiroshima, Japan
| | - Shiho Nishimura
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan; Department of Pediatrics, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Moe Tamaura
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan; Department of Pediatrics, Hiroshima-Nishi Medical Center, Hiroshima, Japan
| | - Reiko Kagawa
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - Seiichi Hayakawa
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - Masao Kobayashi
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan; Japanese Red Cross, Chugoku-Shikoku Block Blood Center, Hiroshima, Japan
| | - Satoshi Okada
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan.
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22
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Establishing core domain sets for Chronic Nonbacterial Osteomyelitis (CNO) and Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis (SAPHO): A report from the OMERACT 2020 special interest group. Semin Arthritis Rheum 2021; 51:957-961. [PMID: 34176644 DOI: 10.1016/j.semarthrit.2021.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/21/2021] [Accepted: 05/31/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE A working group was established to develop a core domain set (CDS) for Chronic Nonbacterial Osteomyelitis (CNO) and Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis (SAPHO) following the OMERACT filter 2.1. METHODS A scoping review to identify disease-related manifestations was performed, followed by a special interest group (SIG) session at OMERACT2020 to begin the CNO/SAPHO CDS framework. RESULTS Candidate items were identified from the scoping review and most fell under Life Impact and Pathophysiology Manifestation core areas. A SIG agreed on the need to develop a CDS for CNO and SAPHO (100%) and for children and adults (91%). CONCLUSION Based on candidate items identified, qualitative research and Delphi surveys will be performed as next steps.
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23
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Juszczak B, Sułko J. Patient-reported effectiveness and safety of Pamidronate in NSAIDs-refractory chronic recurrent multifocal osteomyelitis in children. Rheumatol Int 2021; 42:699-706. [PMID: 34018012 PMCID: PMC8940851 DOI: 10.1007/s00296-021-04886-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 05/03/2021] [Indexed: 12/03/2022]
Abstract
To evaluate patient-reported effectiveness, safety and social influence of Pamidronate in the therapy of NSAIDs-refractory Chronic Recurrent Multifocal Osteomyelitis in children. Authors reviewed self-created questionnaires, which asked patients for symptoms alleviation, adverse drug reactions frequency and degree of severity and daily activities self-reliance. Only surveys with complete answers, which were returned to authors by an e-mail from juvenile patients treated for NSAIDs-refractory Chronic Recurrent Multifocal Osteomyelitis at the University Children’s Hospital of Cracow were analyzed. Between 2010 and 2019, 61 children were diagnosed with NSAIDs-refractory Chronic Recurrent Multifocal Osteomyelitis at our department. Out of 61 requests sent, 42 complete replies (33 females, 9 males) were gathered and analyzed. All patients included in this research were administered with at least one set of Pamidronate intravenously in the dose of 1 mg/kg/day for 3 consecutive days. Our analysis shows remarkable in terms of patient’s impressions decrease of pain intensity after 2.5 series of Pamidronate on average, and total pain resolution after 5.9 series on average. Overall number of adverse drug reaction events reported by responders was 105. One patient developed drug-dependent renal insufficiency in the course of therapy. Outcome assessment indicates that nearly 50% of the studied population was more eager to participate in social life just after the first infusion of the drug. 95% of the surveyed unanimously agreed to recommend Pamidronate therapy to cure NSAIDs-refractory CRMO. 39 out of 42 (93%) patients considered Pamidronate effective at the end of the treatment. Onset of Pamidronate’s action is gradual and differs in terms of symptoms alleviation between sexes. The therapy can induce considerable number of adverse drug reactions (2.5 per patient). Only 3 out of 42 (7%) patients were free from any ADRs. To demonstrate the impact of the use of Pamidronate on daily activities more precisely, further research with quantification of the quality of life is warranted.
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Affiliation(s)
- Bartłomiej Juszczak
- Department of Orthopaedics, Children's University Hospital of Cracow, ul. Wielicka 265, 30-663, Cracow, Poland.
| | - Jerzy Sułko
- Department of Orthopaedics, Children's University Hospital of Cracow, ul. Wielicka 265, 30-663, Cracow, Poland
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24
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Ramautar AI, Appelman-Dijkstra NM, Lakerveld S, Schroijen MA, Snel M, Winter EM, Hamdy NA. Chronic Nonbacterial Osteomyelitis of the Sternocostoclavicular Region in Adults: A Single-Center Dutch Cohort Study. JBMR Plus 2021; 5:e10490. [PMID: 33977206 PMCID: PMC8101619 DOI: 10.1002/jbm4.10490] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 02/13/2021] [Indexed: 01/15/2023] Open
Abstract
Sternocostoclavicular hyperostosis (SCCH) is a rare autoinflammatory bone disorder caused by chronic nonbacterial osteomyelitis (CNO), which is associated with sclerosis and hyperostosis primarily affecting the sternum, the medial end of the clavicles, and the first ribs. Other areas of the axial skeleton may also be affected. The more severe synovitis–acne–pustulosis–hyperostosis–osteitis (SAPHO) syndrome is additionally associated with dermatoses and joint manifestations. This Dutch retrospective cross‐sectional single‐center cohort study characterizes the spectrum of clinical features in adult CNO/SCCH patients at the time of diagnosis. The only inclusion criteria was the availability of complete sets of clinical and imaging data systematically collected over three decades using in‐house protocols. Data from 213 predominantly female patients (88%) with a median age of 36 years at presentation were studied. The mean diagnostic delay was 5 ± 5 years. The main symptoms were chronic pain (92%), bony swelling (61%), and restricted shoulder girdle function (46%); 32% had palmoplantar pustulosis and 22% had autoimmune disease. The majority (73%) had isolated SCCH; 59 (27%) had additional localizations in vertebrae (19%), the mandible (9%), or both (2%); 4 had SAPHO. The prevalence of current or past smoking was high (58%), particularly for patients with palmoplantar pustulosis (76%). There was a significant relationship between delay in diagnosis and both the extent of affected skeletal sites (p = 0.036) and erythrocyte sedimentation rate levels (p = 0.023). Adult‐onset CNO is characterized by distinctive clinical and radiological features, but diverse aspects of its spectrum are currently not fully captured by a comprehensive classification. Delayed diagnosis is still common and potentially associated with irreversible structural changes and debilitating chronic symptoms, increasing the burden of illness and negatively impacting on quality of life. It is hoped that findings from this study will dispel confusion about nomenclature and classification of adult‐onset CNO and increase awareness of its distinctive clinical and radiological features, and thus facilitate early diagnosis and referral for treatment, which should positively impact prognosis by preventing disease progression, although this remains to be established. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.
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Affiliation(s)
- Ashna Ie Ramautar
- Centre for Bone Quality, Department of Medicine, Division of Endocrinology Leiden University Medical Center Leiden The Netherlands
| | - Natasha M Appelman-Dijkstra
- Centre for Bone Quality, Department of Medicine, Division of Endocrinology Leiden University Medical Center Leiden The Netherlands
| | - Shannon Lakerveld
- Centre for Bone Quality, Department of Medicine, Division of Endocrinology Leiden University Medical Center Leiden The Netherlands
| | - Marielle A Schroijen
- Centre for Bone Quality, Department of Medicine, Division of Endocrinology Leiden University Medical Center Leiden The Netherlands
| | - Marieke Snel
- Centre for Bone Quality, Department of Medicine, Division of Endocrinology Leiden University Medical Center Leiden The Netherlands
| | - Elizabeth M Winter
- Centre for Bone Quality, Department of Medicine, Division of Endocrinology Leiden University Medical Center Leiden The Netherlands
| | - Neveen At Hamdy
- Centre for Bone Quality, Department of Medicine, Division of Endocrinology Leiden University Medical Center Leiden The Netherlands
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25
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Igarashi R, Hoshina T, Oho K, Shimajiri S, Kusuhara K. A Pediatric Case of Gingival Swelling and Chilblains as Previously Unrecognized Manifestations of Chronic Nonbacterial Osteomyelitis. J Clin Rheumatol 2021; 27:e93-e94. [PMID: 31972737 DOI: 10.1097/rhu.0000000000001270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Ryota Igarashi
- From the Department of Pediatrics, School of Medicine, University of Occupational and Environmental Health
| | - Takayuki Hoshina
- From the Department of Pediatrics, School of Medicine, University of Occupational and Environmental Health
| | - Kotaro Oho
- Department of Dentistry and Oral Surgery, University Hospital of Occupational and Environmental Health
| | - Shohei Shimajiri
- Department of Surgical Pathology, School of Medicine, University of Occupational and Environmental Health, Japan
| | - Koichi Kusuhara
- From the Department of Pediatrics, School of Medicine, University of Occupational and Environmental Health
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26
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Chronic nonbacterial osteomyelitis (CNO) and chronic recurrent multifocal osteomyelitis (CRMO). J Transl Autoimmun 2021; 4:100095. [PMID: 33870159 PMCID: PMC8040271 DOI: 10.1016/j.jtauto.2021.100095] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/22/2021] [Accepted: 03/10/2021] [Indexed: 01/01/2023] Open
Abstract
Chronic nonbacterial osteomyelitis (CNO) is an inflammatory bone disorder that most frequently affects children and adolescents. Chronic recurrent multifocal osteomyelitis (CRMO) is a severe form of CNO, usually characterized by symmetrical inflammatory bone lesions and its waxing and waning character. Sometimes severe and chronic pain can significantly affect the quality of life and psychosocial development of individuals affected. In the absence of prospectively tested and widely accepted diagnostic criteria or disease biomarkers, CNO remains a diagnosis of exclusion, and infections, malignancy and other differentials require consideration (1). The pathophysiology of CNO is not fully understood, but imbalanced cytokine expression and increased inflammasome activation in monocytes from CNO patients contribute to a pro-inflammatory phenotype that contributes to bone inflammation (2). Currently, no medications are licensed for the use in CNO. Most patients show at least some response to nonsteroidal anti-inflammatory drugs, others require more aggressive treatment that can include corticosteroids, cytokine-blocking agents and/or bisphosphonates (3). While under the care of an experienced team and sufficient treatment, the prognosis is good, but some patients will develop sequalae which can include vertebral compression fractures (1). CNO is an autoinflammatory bone disorder mostly affecting children and adolescents. Dysregulated cytokine expression and pathological activation of inflammasomes play a central role. Treatment is based on experience from case series and expert consensus treatment plans. Understanding the exact molecular pathophysiology will allow patient stratification and individualized treatment.
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27
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Yamashita J, Sawa N, Sawa Y, Miyazono S. Effect of bisphosphonates on healing of tooth extraction wounds in infectious osteomyelitis of the jaw. Bone 2021; 143:115611. [PMID: 32829042 DOI: 10.1016/j.bone.2020.115611] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Antiresorptive agent-related osteonecrosis of the jaw (ARONJ) and infectious osteomyelitis of the jaw (OMJ) in antiresorptive-naïve patients are different disease entities. Although osteoclast inhibition is at the center of the pathogenesis of ARONJ, the role of osteoclast inhibition in infectious OMJ is unknown. The objective of this study was to determine the effect of bisphosphonate osteoclast inhibition in infectious OMJ. METHODS Osteomyelitis was induced in mice by S. aureus inoculation. The establishment of OMJ was verified by the culture of bone marrow samples obtained from the mandible. Infected animals received either zoledronic acid (ZA) or saline starting at week-2. Treated animals along with non-infected animals underwent tooth extractions at week-4 post-infection. Healing was assessed every week using in vivo micro-computed tomography and intraoral photos. Animals were euthanized at week-8 and cervical lymph nodes were assessed for lymphatic and blood vessels. RESULTS Tooth extraction wounds did not heal in animals with OMJ. These wounds were characterized by incomplete soft tissue coverage, sporadic bone fill in the sockets, and inflammatory cell accumulation in the connective tissue at 4 weeks after tooth extractions. Conversely, the majority of tooth extraction wounds in the infected animals treated with ZA had improved healing with better bone fill than even non-infected control animals. Consistently, atrophic lymphatic vessels were noted in the draining lymph nodes in animals with OMJ. However, infected animals treated with ZA had lymphatic vessels that were unaltered and showed a similar appearance to those in non-infected control animals. CONCLUSION ZA treatment promoted wound healing in the jaw with infectious osteomyelitis. Clearly, antiresorptive therapy is contraindicated in patients with ARONJ. However, our finding suggests that osteoclast inhibition is potentially an effectual remedy for infectious OMJ in antiresorptive-naïve patients.
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Affiliation(s)
- Junro Yamashita
- Center for Regenerative Medicine, Fukuoka Dental College, Fukuoka, Japan; Department of Oral Rehabilitation, Fukuoka Dental College, Fukuoka, Japan.
| | - Naruhiko Sawa
- Center for Regenerative Medicine, Fukuoka Dental College, Fukuoka, Japan; Department of Oral Rehabilitation, Fukuoka Dental College, Fukuoka, Japan
| | - Yoshihiko Sawa
- Department of Oral Function and Anatomy, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shoji Miyazono
- Department of Oral Rehabilitation, Fukuoka Dental College, Fukuoka, Japan
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28
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Chronic nonbacterial osteomyelitis - clinical and magnetic resonance imaging features. Pediatr Radiol 2021; 51:282-288. [PMID: 33033917 PMCID: PMC7846524 DOI: 10.1007/s00247-020-04827-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 06/25/2020] [Accepted: 08/23/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Chronic nonbacterial osteomyelitis (CNO) is a rare autoinflammatory bone disorder. Little information exists on the use of imaging techniques in CNO. MATERIALS AND METHODS We retrospectively reviewed clinical and MRI findings in children diagnosed with CNO between 2012 and 2018. Criteria for CNO included unifocal or multifocal inflammatory bone lesions, symptom duration >6 weeks and exclusion of infections and malignancy. All children had an MRI (1.5 tesla) performed at the time of diagnosis; 68 of these examinations were whole-body MRIs including coronal short tau inversion recovery sequences, with additional sequences in equivocal cases. RESULTS We included 75 children (26 boys, or 34.7%), with mean age 10.5 years (range 0-17 years) at diagnosis. Median time from disease onset to diagnosis was 4 months (range 1.5-72.0 months). Fifty-nine of the 75 (78.7%) children presented with pain, with or without swelling or fever, and 17 (22.7%) presented with back pain alone. Inflammatory markers were raised in 46/75 (61.3%) children. Fifty-four of 75 (72%) had a bone biopsy. Whole-body MRI revealed a median number of 6 involved sites (range 1-27). Five children (6.7%) had unifocal disease. The most commonly affected bones were femur in 46 (61.3%) children, tibia in 48 (64.0%), pelvis in 29 (38.7%) and spine in 20 (26.7%). Except for involvement of the fibula and spine, no statistically significant differences were seen according to gender. CONCLUSION Nearly one-fourth of the children presented with isolated back pain, particularly girls. The most common sites of disease were the femur, tibia and pelvic bones. Increased inflammatory markers seem to predict the number of MRI sites involved.
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29
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Kanda R, Nakano K, Miyagawa I, Iwata S, Nakayamada S, Tanaka Y. A case of bone destruction caused by chronic non-bacterial osteomyelitis (CNO) successfully repaired with a tumour necrosis factor-α (TNF-α) inhibitor, adalimumab. Mod Rheumatol Case Rep 2020; 4:196-201. [PMID: 33087018 DOI: 10.1080/24725625.2020.1749360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Chronic Non-bacterial Osteomyelitis (CNO) is an autoinflammatory bone disorder that causes non-bacterial and non-neoplastic osteomyelitis. CNO appeared to the long bone, clavicle, pelvis, and spine on children commonly. This time, we report a case with osteomyelitis of the mandible for the adult-onset. A 25-year-old woman presented pustulosis palmaris/pustular psoriasis after the extraction of the lower right tooth 1 year before hospitalisation. She felt pain and swelling of the right jaw and an antibiotic, NSAIDs, and glucocorticoids were ineffective. The cortical osteotomy of right mandibular bone was carried out 2 months before hospitalisation, but the symptom was not improved and she was admitted to our hospital. For pustular psoriasis with CNO, we treated her with adalimumab and the pain and swelling in her right jaw disappeared immediately. One and two years after the treatment, osteolytic and sclerotic bone lesion and osteomyelitis were improved in both Computed Tomography (CT) and Magnetic Resonance Imaging (MRI). An anti-TNF-α antibody may be an effective therapy for CNO resistant to conventional treatment.
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Affiliation(s)
- Ryuichiro Kanda
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Kazuhisa Nakano
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Ippei Miyagawa
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Shigeru Iwata
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Shingo Nakayamada
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
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30
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Decker E, Rehm J, Bertram S, Schmalzing M. [Extranodal B-cell lymphoma in the distal femur with pre-existing CRMO]. Z Rheumatol 2020; 80:78-84. [PMID: 33057785 DOI: 10.1007/s00393-020-00911-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2020] [Indexed: 10/23/2022]
Abstract
CRMO is a rare form of nonbacterial osteomyelitis, which is mainly found in children. The diagnosis is complex because bone tumors or lymphoma must also be excluded. The case report describes the development of a solitary femoral lymphoma on the basis of a known CRMO disease as well as the differential diagnostic pitfalls.
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Affiliation(s)
- E Decker
- Innere Medizin/SP Rheumatologie, MVZ am Kreiskrankenhaus Alsfeld, Schwabenröder Str. 81, 36304, Alsfeld, Deutschland.
| | - J Rehm
- RadMedics GmbH, Fritzlar, Deutschland
| | - S Bertram
- Institut für Pathologie, Universitätsklinikum Essen, Essen, Deutschland
| | - M Schmalzing
- Abt. Rheumatologie und klinische Immunologie, Medizinische Klinik II, Universitätsklinikum Würzburg, Würzburg, Deutschland
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31
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Bewegungsstörungen bei chronischen Erkrankungen. Monatsschr Kinderheilkd 2020. [DOI: 10.1007/s00112-020-00931-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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32
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Hedrich CM, Morbach H, Reiser C, Girschick HJ. New Insights into Adult and Paediatric Chronic Non-bacterial Osteomyelitis CNO. Curr Rheumatol Rep 2020; 22:52. [PMID: 32705386 PMCID: PMC7378119 DOI: 10.1007/s11926-020-00928-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Purpose of Review To describe in detail the clinical synopsis and pathophysiology of chronic non-bacterial osteomyelitis and SAPHO syndrome. Recent Findings Chronic non-bacterial osteomyelitis (CNO) has been identified as a disease entity for almost 50 years. This inflammatory bone disorder is characterized by osteolytic as well as hyperostotic/osteosclerotic lesions. It is chronic in nature, but it can present with episodic flairs and phases of remission, which have led to the denomination “chronic recurrent osteomyelitis”, with its severe multifocal form “chronic recurrent multifocal osteomyelitis” (CRMO). For almost three decades, an infectious aetiology had been considered, since especially Propionibacterium acnes had been isolated from bone lesions of individual patients. However, this concept has been challenged since long-term antibiotic therapy did not alter the course of disease and modern microbiological techniques (including PCR) failed to confirm bone infection as an underlying cause. Over recent years, a profound dysregulation of cytokine expression profiles has been demonstrated in innate immune cells of CNO patients. A hallmark of monocytes from CNO patients is the failure to produce immune regulatory cytokines interleukin-10 (IL-10) and IL-19, which have been linked with genetic and epigenetic alterations. Subsequently, a significant upregulation of pro-inflammatory, NLRP3 inflammasome-dependent cytokines (IL-1β and TNF-α), has been demonstrated. Summary The current knowledge on CNO, the underlying molecular pathophysiology, and modern imaging strategies are summarized; differential diagnoses, treatment options, outcome measures, as well as quality of life studies are discussed.
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Affiliation(s)
- Christian M Hedrich
- Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, East Prescot Road, Liverpool, L14 5AB, Great Britain, UK
| | - Henner Morbach
- Pediatric Rheumatology and Immunology, Department of Pediatrics, University of Würzburg, Josef-Schneider-Str.2, 98080, Würzburg, Germany
| | - Christiane Reiser
- Department of Pediatrics, Pediatric Rheumatology and Immunology, Landeskrankenhaus Bregenz, Carl-Pedenz-Straße 12, 6900, Bregenz, Austria
| | - Hermann J Girschick
- Vivantes Klinikum Friedrichshain, Children's Hospital, Landsberger Allee 49, 10249, Berlin, Germany. .,University Childrens Hospital, Julius Maximilians Universität Würzburg, Würzburg, Germany.
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33
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Kraus R, Laxer RM. Characteristics, Treatment Options, and Outcomes of Chronic Non-bacterial Osteomyelitis in Children. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2020. [DOI: 10.1007/s40674-020-00149-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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34
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How nonbacterial osteomyelitis could be discriminated from tuberculosis in the early stages: the simple algorithm. Clin Rheumatol 2020; 39:3825-3832. [DOI: 10.1007/s10067-020-05174-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 05/11/2020] [Accepted: 05/15/2020] [Indexed: 12/19/2022]
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35
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Świdrowska-Jaros J, Smolewska E. A complicated path to the CRMO diagnosis - case of a 9 year old girl whose story comes full circle. BMC Musculoskelet Disord 2019; 20:392. [PMID: 31470834 PMCID: PMC6717389 DOI: 10.1186/s12891-019-2776-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 08/22/2019] [Indexed: 11/18/2022] Open
Abstract
Background Chronic recurrent multifocal osteomyelitis (CRMO) is a rare idiopathic autoinflammatory bone disease that mostly affects children and adolescents. It is a diagnosis of exclusions since no clinical signs and symptoms are pathognomonic. Radiological tests are often essential, but bone biopsy may be needed in unclear cases. Case presentation A 9-year-old Caucasian girl with a history of bone pain. The data from the history and results of laboratory tests suggested osteomyelitis, but no adequate response to the treatment was observed. A number of imaging tests did not confirm the diagnosis, therefore a bone biopsy was necessary. Conclusions Differential diagnosis of CRMO is challenging and it is based on exclusions. Since it might be misdiagnosed or mistreated, bone biopsy should be considered in patients reporting bone pain who are unresponsive to treatment.
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Affiliation(s)
- Joanna Świdrowska-Jaros
- Department of Paediatric Cardiology and Rheumatology, Medical University of Lodz, Łódz, Poland.
| | - Elżbieta Smolewska
- Department of Paediatric Cardiology and Rheumatology, Medical University of Lodz, Łódz, Poland
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36
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Young S, Sharma N, Lee JH, Chitu V, Neumeister V, Sohr E, Stanley ER, Hedrich CM, Craig AWB. Mast cells enhance sterile inflammation in chronic nonbacterial osteomyelitis. Dis Model Mech 2019; 12:dmm.040097. [PMID: 31416928 PMCID: PMC6737947 DOI: 10.1242/dmm.040097] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 07/21/2019] [Indexed: 12/19/2022] Open
Abstract
Chronic nonbacterial osteomyelitis (CNO) is an autoinflammatory bone disease, and patients with active or recurrent bone inflammation at multiple sites are diagnosed with chronic recurrent multifocal osteomyelitis (CRMO). The Chronic multifocal osteomyelitis (CMO) mouse model develops IL-1β-driven sterile bone lesions reminiscent of severe CRMO. The goal of this study was to evaluate the potential involvement of mast cells in CMO/CRMO. Here, we show that mast cells accumulate in inflamed tissues from CMO mice and that mast cell protease Mcpt1 can be detected in the peripheral blood. A transgenic model of connective tissue mast cell depletion (Mcpt5-Cre:Rosa26-Stopfl/fl-DTa) was crossed with CMO mice and the resulting mice (referred to as CMO/MC–) showed a significant delay in disease onset compared with age-matched CMO mice. At 5-6 months of age, CMO/MC– mice had fewer bone lesions and immune infiltration in the popliteal lymph nodes that drain the affected tissues. In bone marrow-derived mast cell cultures from CMO mice, cytokine production in response to the alarmin IL-33 was elevated compared with wild-type cultures. To test the relevance of mast cells to human CRMO, we tested serum samples from a cohort of healthy controls and from CRMO patients at diagnosis. Interestingly, mast cell chymase was elevated in CRMO patients as well as in patients with oligoarticular juvenile arthritis. Tryptase-positive mast cells were also detected in bone lesions from CRMO patients and patients with bacterial osteomyelitis. Together, our results identify mast cells as cellular contributors to bone inflammation in CMO/CRMO and provide rationale for further study of mast cells as therapeutic targets. Summary: This paper reports that mast cells promote bone loss in an autoinflammatory disease model and that mast cell mediators were detected in autoinflammatory disease patient samples.
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Affiliation(s)
- Stephanie Young
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON K7L 3N6, Canada
| | - Namit Sharma
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON K7L 3N6, Canada
| | - Jae Hoon Lee
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON K7L 3N6, Canada
| | - Violeta Chitu
- Department of Developmental and Molecular Biology, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Volker Neumeister
- Departments of Clinical Chemistry and Laboratory Medicine, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden 01307, Germany
| | - Elisabeth Sohr
- Pediatric Rheumatology and Immunology, Children's Hospital Dresden, Technical University Dresden, Dresden 01307, Germany
| | - E Richard Stanley
- Department of Developmental and Molecular Biology, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Christian M Hedrich
- Pediatric Rheumatology and Immunology, Children's Hospital Dresden, Technical University Dresden, Dresden 01307, Germany.,Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool L14 5AB, UK.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool L14 5AB, UK
| | - Andrew W B Craig
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, ON K7L 3N6, Canada
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Skrabl-Baumgartner A, Singer P, Greimel T, Gorkiewicz G, Hermann J. Chronic non-bacterial osteomyelitis: a comparative study between children and adults. Pediatr Rheumatol Online J 2019; 17:49. [PMID: 31337412 PMCID: PMC6651954 DOI: 10.1186/s12969-019-0353-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 07/11/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND To compare clinical presentation, diagnostic and treatment strategies, and outcome between pediatric and adult patients with chronic non-bacterial osteomyelitis (CNO). METHODS Retrospective single-centre comparative study of pediatric and adult patients diagnosed with chronic recurrent multifocal osteomyelitis (CRMO)/CNO or synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome treated at the Medical University of Graz. RESULTS 24 pediatric patients diagnosed with CRMO/CNO and 10 adult patients diagnosed with SAPHO syndrome were compared. Median age at diagnosis was 12.3 years (range 7.9-18.9) in the pediatric group and 32.5 years (range 22-56) in the adult group. Median time to diagnosis was shorter in children than in adults (0.3 vs. 1.0 years). Initial clinical presentation, laboratory and histopathological findings were similar in children and adults. Mean numbers of bone lesions were comparable between pediatric and adult patients (3.1 vs. 3.0), as were rates of skin involvement (33% vs. 30%). Sternal involvement was more frequent in adults whereas involvement of clavicle and long bones was more frequent in children (41.7% vs.10, 33% vs. 10%). Computerized tomography (CT) was used more often in adults, whereas whole-body magnetic resonance imaging (MRI) was used only in children. Bisphosphonates were applied more often in children and outcome was better in children than in adults (62.5% vs.30%). CONCLUSION Results of our study suggest that CNO/CRMO and SAPHO syndrome in children and adults might represent a single clinical syndrome that needs a similar diagnostic and therapeutic approach.
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Affiliation(s)
- Andrea Skrabl-Baumgartner
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz, Austria.
| | - Peter Singer
- 0000 0000 8988 2476grid.11598.34Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz, Austria
| | - Theresa Greimel
- 0000 0000 8988 2476grid.11598.34Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz, Austria
| | - Gregor Gorkiewicz
- 0000 0000 8988 2476grid.11598.34Diagnostic & Research Institute of Pathology, Medical University Graz, Graz, Austria
| | - Josef Hermann
- 0000 0000 8988 2476grid.11598.34Division of Rheumatology and Immunology, Department of Internal Medicine, Medical University Graz, Graz, Austria
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Julia N, Katharina R, Hermann G, Annette HW, Henner M, Helge H, Christine H. Physical activity and health-related quality of life in chronic non-bacterial osteomyelitis. Pediatr Rheumatol Online J 2019; 17:45. [PMID: 31319856 PMCID: PMC6639948 DOI: 10.1186/s12969-019-0351-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 07/08/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Chronic non-bacterial osteomyelitis (CNO) is an autoinflammatory disorder of the skeletal system of yet unknown etiology. Patients present with local bone pain and inflammation and - to our experience - often suffer from functional impairment with significant disabilities of daily life. The objective of this study was to assess physical activity, fitness and health-related quality of life (HRQOL) in adolescents with established diagnosis of CNO versus healthy controls (HC). METHODS 15 patients with CNO and 15 age and gender matched HC aged 13-18 years, completed questionnaires, performed an incremental exercise test with gas exchange measures up to voluntary fatigue and wore an accelerometer over 7 days at home to assess physical activity behavior. RESULTS At the time of assessment, 5 CNO patients were in clinical, one in radiological and 5 in clinical and radiological remission. 7 did not receive any therapy at the time of assessment. The results of the exercise test and of the accelerometry did not show any significant difference between CNO and HC. However, reported sports participation was lower in patients with CNO and PedsQL3.0 and 4.0 showed significant lower values in most of the scores indicating reduced HRQOL. CONCLUSION Although most CNO patients showed a favorable course of disease without any relevant differences in objective measurements of physical activity and fitness versus HC at the time of assessment, questionnaires revealed perceived limitations. Further studies are needed to measure HRQOL and to validate questionnaires in patients with CNO against objective measures including more participants with a higher level of disease activity.
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Affiliation(s)
- Nentwich Julia
- grid.488568.fPediatric Rheumatology and Osteology, University Children’s Hospital Wuerzburg, Josef-Schneider-Str. 2, 97080 Wuerzburg, Germany
| | - Ruf Katharina
- grid.488568.fPediatric Pulmonology and Sports Medicine, University Children’s Hospital Wuerzburg, Wuerzburg, Germany
| | - Girschick Hermann
- Children’s Hospital, Vivantes Hospital im Friedrichshain, Berlin, Germany
| | - Holl-Wieden Annette
- grid.488568.fPediatric Rheumatology and Osteology, University Children’s Hospital Wuerzburg, Josef-Schneider-Str. 2, 97080 Wuerzburg, Germany
| | - Morbach Henner
- grid.488568.fPediatric Rheumatology and Osteology, University Children’s Hospital Wuerzburg, Josef-Schneider-Str. 2, 97080 Wuerzburg, Germany
| | - Hebestreit Helge
- grid.488568.fPediatric Pulmonology and Sports Medicine, University Children’s Hospital Wuerzburg, Wuerzburg, Germany
| | - Hofmann Christine
- Pediatric Rheumatology and Osteology, University Children's Hospital Wuerzburg, Josef-Schneider-Str. 2, 97080, Wuerzburg, Germany.
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Surace AEA, Hedrich CM. The Role of Epigenetics in Autoimmune/Inflammatory Disease. Front Immunol 2019; 10:1525. [PMID: 31333659 PMCID: PMC6620790 DOI: 10.3389/fimmu.2019.01525] [Citation(s) in RCA: 134] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 06/18/2019] [Indexed: 12/21/2022] Open
Abstract
Historically, systemic self-inflammatory conditions were classified as either autoinflammatory and caused by the innate immune system or autoimmune and driven by adaptive immune responses. However, it became clear that reality is much more complex and that autoimmune/inflammatory conditions range along an “inflammatory spectrum” with primarily autoinflammatory vs. autoimmune conditions resembling extremes at either end. Epigenetic modifications influence gene expression and alter cellular functions without modifying the genomic sequence. Methylation of CpG DNA dinucleotides and/or their hydroxymethylation, post-translational modifications to amino termini of histone proteins, and non-coding RNA expression are main epigenetic events. The pathophysiology of autoimmune/inflammatory diseases has been closely linked with disease causing gene mutations (rare) or a combination of genetic susceptibility and epigenetic modifications arising from exposure to the environment (more common). Over recent years, progress has been made in understanding molecular mechanisms involved in systemic inflammation and the contribution of innate and adaptive immune responses. Epigenetic events have been identified as (i) central pathophysiological factors in addition to genetic disease predisposition and (ii) as co-factors determining clinical pictures and outcomes in individuals with monogenic disease. Thus, a complete understanding of epigenetic contributors to autoimmune/inflammatory disease will result in approaches to predict individual disease outcomes and the introduction of effective, target-directed, and tolerable therapies. Here, we summarize recent findings that signify the importance of epigenetic modifications in autoimmune/inflammatory disorders along the inflammatory spectrum choosing three examples: the autoinflammatory bone condition chronic nonbacterial osteomyelitis (CNO), the “mixed pattern” disorder psoriasis, and the autoimmune disease systemic lupus erythematosus (SLE).
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Affiliation(s)
- Anna Elisa Andrea Surace
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Christian M Hedrich
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, United Kingdom.,Pädiatrische Rheumatologie, Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden, Germany
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Ramanan AV, Hampson LV, Lythgoe H, Jones AP, Hardwick B, Hind H, Jacobs B, Vasileiou D, Wadsworth I, Ambrose N, Davidson J, Ferguson PJ, Herlin T, Kavirayani A, Killeen OG, Compeyrot-Lacassagne S, Laxer RM, Roderick M, Swart JF, Hedrich CM, Beresford MW. Defining consensus opinion to develop randomised controlled trials in rare diseases using Bayesian design: An example of a proposed trial of adalimumab versus pamidronate for children with CNO/CRMO. PLoS One 2019; 14:e0215739. [PMID: 31166977 PMCID: PMC6550371 DOI: 10.1371/journal.pone.0215739] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 04/08/2019] [Indexed: 11/25/2022] Open
Abstract
Introduction Chronic nonbacterial osteomyelitis (CNO) is a rare autoinflammatory bone disorder primarily affecting children and adolescents. It can lead to chronic pain, bony deformities and fractures. The pathophysiology of CNO is incompletely understood. Scientific evidence suggests dysregulated expression of pro- and anti-inflammatory cytokines to be centrally involved. Currently, treatment is largely based on retrospective observational studies and expert opinion. Treatment usually includes nonsteroidal anti-inflammatory drugs and/or glucocorticoids, followed by a range of drugs in unresponsive cases. While randomised clinical trials are lacking, retrospective and prospective non-controlled studies suggest effectiveness of TNF inhibitors and bisphosphonates. The objective of the Bayesian consensus meeting was to quantify prior expert opinion. Methods Twelve international CNO experts were randomly chosen to be invited to a Bayesian prior elicitation meeting. Results Results showed that a typical new patient treated with pamidronate would have an 84% chance of improvement in their pain score relative to baseline at 26 weeks and an 83% chance on adalimumab. Experts thought there was a 50% chance that a new typical patient would record a pain score of 28mm (pamidronate) to 30mm (adalimumab) or better at 26 weeks. There was a modest trend in prior opinion to indicate an advantage of pamidronate vs adalimumab, with a 68% prior chance that pamidronate is superior to adalimumab by some margin. However, it is clear that there is considerable uncertainty about the precise relative merits of the two treatments. Conclusions The rarity of CNO leads to challenges in conducting randomised controlled trials with sufficient power to provide a definitive outcome. We address this using a Bayesian design, and here describe the process and outcome of the elicitation exercise to establish expert prior opinion. This opinion will be tested in the planned prospective CNO study. The process for establishing expert consensus opinion in CNO will be helpful for developing studies in other rare paediatric diseases.
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Affiliation(s)
- A. V. Ramanan
- Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol and Bristol Medical School, University of Bristol, Bristol, United Kingdom
- * E-mail:
| | - L. V. Hampson
- Statistical Methodology and Consulting, Novartis Pharma AG, Basel, Switzerland
| | - H Lythgoe
- Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
- Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
| | - A. P. Jones
- Clinical Trials Research Centre, Department of Biostatistics, University of Liverpool, Liverpool, United Kingdom
| | - B Hardwick
- Clinical Trials Research Centre, Department of Biostatistics, University of Liverpool, Liverpool, United Kingdom
| | - H Hind
- Clinical Trials Research Centre, Department of Biostatistics, University of Liverpool, Liverpool, United Kingdom
| | - B Jacobs
- Paediatrics, Royal National Orthopaedic Hospital, London, United Kingdom
| | - D Vasileiou
- Department of Mathematics and Statistics, Fylde College, Lancaster University, Lancaster, United Kingdom
| | - I Wadsworth
- Department of Mathematics and Statistics, Fylde College, Lancaster University, Lancaster, United Kingdom
| | - N Ambrose
- Rheumatology, University College Hospital, London, United Kingdom
| | - J Davidson
- Paediatric Rheumatology, Royal Hospital for Children, Glasgow, United Kingdom
| | - P. J. Ferguson
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, IA, United States of America
| | - T Herlin
- Department of Paediatrics, Aarhus University, Aarhus, Denmark
| | - A Kavirayani
- Paediatric Rheumatology, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - O. G. Killeen
- National Centre for Paediatric Rheumatology, Our Lady’s Children Hospital, Crumlin, Dublin, Ireland
| | - S Compeyrot-Lacassagne
- Rheumatology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - R. M. Laxer
- Department of Paediatrics, University of Toronto, The Hospital for Sick Children, Toronto, Canada
| | - M Roderick
- Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol and Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - J. F. Swart
- Paediatric Rheumatology, University Medical Centre Utrecht, Utrecht, Netherlands
| | - C. M. Hedrich
- Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
| | - M. W. Beresford
- Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom
- Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust, Liverpool, United Kingdom
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Goetti P, Pham C, Gallusser N, Becce F, di Summa PG, Vauclair F, Cherix S. Total clavicle reconstruction with free peroneal graft for the surgical management of chronic nonbacterial osteomyelitis of the clavicle: a case report. BMC Musculoskelet Disord 2019; 20:211. [PMID: 31084601 PMCID: PMC6515610 DOI: 10.1186/s12891-019-2588-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 04/24/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic nonbacterial osteomyelitis (CNO) is a rare chronic autoinflammatory syndrome affecting mainly children and young adults. The natural history of the disease is marked by recurrent pain as the mainstay of inflammatory outbreaks. Typical radiographic findings are osteosclerosis and hyperostosis of the medial clavicle, sternum and first rib. Compression of the brachial plexus is exceedingly rare and one of the few surgical indications. Literature on total clavicle reconstruction is scarce. While claviclectomy alone has been associated with fair functional and cosmetic outcomes, several reconstruction techniques with autograft, allograft or even cement ("Oklahoma prosthesis") have been reported with the aim of achieving better pain control, cosmetic outcome and protecting the brachial plexus and subclavian vessels. We herewith report a unique case of complicated CNO of the clavicle treated with total clavicle reconstruction using a free peroneal graft. CASE PRESENTATION A 21-year-old female patient presented with CNO of her left clavicle, associated with recurrent, progressive and debilitating pain as well as limited range of motion. In recent years, she started complaining of paresthesia, weakness and pain radiating to her left arm during arm abduction. The clavicle diameter reached 6 cm on computed tomography, with direct compression of the brachial plexus and subclavian vessels. Following surgical biopsy for diagnosis confirmation, she further developed a chronic cutaneous fistula. Therefore, a two-stage total clavicle reconstruction using a vascularized peroneal graft stabilized by ligamentous reconstruction was performed. At two-year follow-up, complete pain relief and improvement of her left shoulder Constant-Murley score were observed, along with satisfactory cosmetic outcome. CONCLUSIONS This case illustrates a rarely described complication of CNO with direct compression of the brachial plexus and subclavian vessels, and chronic cutaneous fistula. To our knowledge, there is no consensus regarding the optimal management of this rare condition in this context. Advantages and complications of clavicle reconstruction should be carefully discussed with patients due to limited evidence of superior clinical outcome and potential local and donor-site complications. While in our case the outcomes met the patient's satisfaction, it remains an isolated case and further reports are awaited to help surgeons and patients in their decision process.
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Affiliation(s)
- Patrick Goetti
- Department of Orthopaedics and Traumatology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
| | - Chau Pham
- Department of Orthopaedics and Traumatology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Nicolas Gallusser
- Department of Orthopaedics and Traumatology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Fabio Becce
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Pietro G di Summa
- Department of Plastic, Reconstructive and Hand Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Frédéric Vauclair
- Department of Orthopaedics and Traumatology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Stéphane Cherix
- Department of Orthopaedics and Traumatology, Lausanne University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland
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Buch K, Thuesen ACB, Brøns C, Schwarz P. Chronic Non-bacterial Osteomyelitis: A Review. Calcif Tissue Int 2019; 104:544-553. [PMID: 30456556 DOI: 10.1007/s00223-018-0495-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 11/12/2018] [Indexed: 10/27/2022]
Abstract
Chronic non-bacterial osteomyelitis (CNO) is a rare auto-inflammatory bone disorder, with a prevalence of around one in a million patients. In the more severe form, it is referred to as chronic recurrent multifocal osteomyelitis (CRMO). We present the current knowledge on epidemiology, pathophysiology as well as diagnostic options and treatment regimens. CNO/CRMO most commonly affects children and lesions are often seen in the metaphyseal plates of the long bones, but cases have been described affecting all age groups as well as lesions in almost every bone. It is, therefore, a disease that clinicians can encounter in many different settings. Diagnosis is mainly a matter of exclusion from differential diagnoses such as bacterial osteomyelitis and cancer. Magnetic resonance imaging is the best radiological method for diagnosis coupled with a low-grade inflammation and a history of recurring episodes. Treatment is based on case reports and consists of alleviating symptoms with non-steroidal anti-inflammatory drugs since the disease is often self-limiting. Recently, more active treatments using either bisphosphonates or biological treatment are becoming more common, to prevent long term bone damage. In general, due to its rarity, much remains unclear regarding CNO/CRMO. We review the known literature on CNO/CRMO and propose areas of interest as well as possible ways to make current diagnostic criteria more detailed. We also find unifocal cases of the jaw to be a possible sub-type that may need its own set of criteria.
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Affiliation(s)
- Kristian Buch
- Department of Endocrinology, Diabetes and Bone-metabolic Research Unit, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Anne Cathrine Baun Thuesen
- Department of Endocrinology, Diabetes and Bone-metabolic Research Unit, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Charlotte Brøns
- Department of Endocrinology, Diabetes and Bone-metabolic Research Unit, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Peter Schwarz
- Department of Endocrinology, Diabetes and Bone-metabolic Research Unit, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.
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Kim SM, Lee SK. Chronic non-bacterial osteomyelitis in the jaw. J Korean Assoc Oral Maxillofac Surg 2019; 45:68-75. [PMID: 31106134 PMCID: PMC6502749 DOI: 10.5125/jkaoms.2019.45.2.68] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/13/2018] [Accepted: 08/21/2018] [Indexed: 12/29/2022] Open
Abstract
Chronic recurrent multifocal osteomyelitis (CRMO) is one of the most severe form of chronic non-bacterial osteomyelitis (CNO), which could result in bone and related tissue damage. This autoinflammatory bone disorder (ABD) is very difficult for its clinical diagnosis because of no diagnostic criteria or biomarkers. CRMO in the jaw must be suspected in the differential diagnosis of chronic and recurrent bone pain in the jaw, and a bone biopsy should be considered in chronic and relapsing bone pain with swelling that is unresponsive to treatment. The early diagnosis of CRMO in the jaw will prevent unnecessary and prolonged antibiotic usage or unnecessary surgical intervention. The updated researches for the identification of genetic and molecular alterations in CNO/CRMO should be studied more for its correct pathophysiological causes and proper treatment guidelines. Although our trial consisted of reporting items from Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), there are very few articles of randomized controlled trials. This article was summarized based on the author's diverse clinical experiences. This paper reviews the clinical presentation of CNO/CRMO with its own pathogenesis, epidemiology, recent research studies, and general medications. Treatment and monitoring of the jaw are essential for the clear diagnosis and management of CNO/CRMO patients in the field of dentistry and maxillofacial surgery.
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Affiliation(s)
- Soung Min Kim
- Oral and Maxillofacial Microvascular Reconstruction LAB, Brong Ahafo Regional Hospital, Sunyani, Ghana.,Department of Oral and Maxillofacial Surgery, School of Dentistry and Dental Research Institute, Seoul National University, Seoul, Korea
| | - Suk Keun Lee
- Department of Oral Pathology, College of Dentistry and Institute of Oral Science, Gangneung-Wonju National University, Gangneung, Korea
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Oligbu G, Jacobs B, Khan T. The Dilemma of Chronic Recurrent Multifocal Osteomyelitis. ACTA ACUST UNITED AC 2019; 16:490-492. [PMID: 30616941 DOI: 10.1016/j.reuma.2018.10.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 09/28/2018] [Accepted: 10/18/2018] [Indexed: 12/31/2022]
Abstract
Chronic recurrent multifocal osteomyelitis (CRMO) is a rare idiopathic inflammatory disease that affects mainly children and young adults, resulting in significant morbidity especially if not diagnosed early. The clinical signs and symptoms are nonspecific, with a consequential delay in diagnosis. Radiological and histopathological criteria are important for its definition. Two cases of CRMO are reported, highlighting the diagnostic challenge and demonstrating the importance of timely investigations.
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Affiliation(s)
- Godwin Oligbu
- Children and Adolescence Unit, Royal National Orthopaedic Hospital, Stanmore, UK; Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St. George's, University of London, UK.
| | - Benjamin Jacobs
- Children and Adolescence Unit, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Tahir Khan
- Children and Adolescence Unit, Royal National Orthopaedic Hospital, Stanmore, UK
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Cat-Scratch Disease, a Diagnostic Consideration for Chronic Recurrent Multifocal Osteomyelitis. J Clin Rheumatol 2018; 24:287-290. [DOI: 10.1097/rhu.0000000000000653] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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46
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Zhao Y, Wu EY, Oliver MS, Cooper AM, Basiaga ML, Vora SS, Lee TC, Fox E, Amarilyo G, Stern SM, Dvergsten JA, Haines KA, Rouster-Stevens KA, Onel KB, Cherian J, Hausmann JS, Miettunen P, Cellucci T, Nuruzzaman F, Taneja A, Barron KS, Hollander MC, Lapidus SK, Li SC, Ozen S, Girschick H, Laxer RM, Dedeoglu F, Hedrich CM, Ferguson PJ. Consensus Treatment Plans for Chronic Nonbacterial Osteomyelitis Refractory to Nonsteroidal Antiinflammatory Drugs and/or With Active Spinal Lesions. Arthritis Care Res (Hoboken) 2018; 70:1228-1237. [PMID: 29112802 DOI: 10.1002/acr.23462] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 10/31/2017] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To develop standardized treatment regimens for chronic nonbacterial osteomyelitis (CNO), also known as chronic recurrent multifocal osteomyelitis (CRMO), to enable comparative effectiveness treatment studies. METHODS Virtual and face-to-face discussions and meetings were held within the CNO/CRMO subgroup of the Childhood Arthritis and Rheumatology Research Alliance (CARRA). A literature search was conducted, and CARRA membership was surveyed to evaluate available treatment data and identify current treatment practices. Nominal group technique was used to achieve consensus on treatment plans for CNO refractory to nonsteroidal antiinflammatory drug (NSAID) monotherapy and/or with active spinal lesions. RESULTS Three consensus treatment plans (CTPs) were developed for the first 12 months of therapy for CNO patients refractory to NSAID monotherapy and/or with active spinal lesions. The 3 CTPs are methotrexate or sulfasalazine, tumor necrosis factor inhibitors with optional methotrexate, and bisphosphonates. Short courses of glucocorticoids and continuation of NSAIDs are permitted for all regimens. Consensus was achieved on these CTPs among CARRA members. Consensus was also reached on subject eligibility criteria, initial evaluations that should be conducted prior to the initiation of CTPs, and data items to collect to assess treatment response. CONCLUSION Three consensus treatment plans were developed for pediatric patients with CNO refractory to NSAIDs and/or with active spinal lesions. Use of these CTPs will provide additional information on efficacy and will generate meaningful data for comparative effectiveness research in CNO.
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Affiliation(s)
- Yongdong Zhao
- Seattle Children's Hospital, University of Washington, Seattle
| | | | - Melissa S Oliver
- Stanford Children's Health, Stanford University, Palo Alto, California
| | | | | | | | - Tzielan C Lee
- Stanford Children's Health, Stanford University, Palo Alto, California
| | - Emily Fox
- Children's Mercy, Kansas City, Missouri
| | - Gil Amarilyo
- Schneider Children's Medical Center of Israel, Petach Tikva Israel, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | | | - Kathleen A Haines
- Joseph M. Sanzari Children's Hospital, Hackensack University Medical Center, Hackensack, New Jersey
| | | | - Karen B Onel
- Hospital for Special Surgery, New York, New York
| | - Julie Cherian
- Stony Brook Children's Hospital, Stony Brook, New York
| | - Jonathan S Hausmann
- Boston Children's Hospital and Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | - Angela Taneja
- Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Karyl S Barron
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
| | | | | | - Suzanne C Li
- Joseph M. Sanzari Children's Hospital, Hackensack University Medical Center, Hackensack, New Jersey
| | - Seza Ozen
- Hacettepe University, Ankara, Turkey
| | | | - Ronald M Laxer
- The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | | | - Christian M Hedrich
- Children's Hospital Dresden, University Medical Center Carl Gustav Carus, TU Dresden, Dresden, Germany, and Institute of Translational Medicine, University of Liverpool, and Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
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Brandt D, Sohr E, Pablik J, Schnabel A, Kapplusch F, Mäbert K, Girschick JH, Morbach H, Thielemann F, Hofmann SR, Hedrich CM. CD14 + monocytes contribute to inflammation in chronic nonbacterial osteomyelitis (CNO) through increased NLRP3 inflammasome expression. Clin Immunol 2018; 196:77-84. [PMID: 29723617 DOI: 10.1016/j.clim.2018.04.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Revised: 04/28/2018] [Accepted: 04/29/2018] [Indexed: 12/20/2022]
Abstract
The pathophysiology of chronic nonbacterial osteomyelitis (CNO) remains incompletely understood. Increased NLRP3 inflammasome activation and IL-1β release in monocytes from CNO patients was suggested to contribute to bone inflammation. Here, we dissect immune cell infiltrates and demonstrate the involvement of monocytes across disease stages. Differences in cell density and immune cell composition may help to discriminate between BOM and CNO. However, differences are subtle and infiltrates vary in CNO. In contrast to other cells involved, monocytes are a stable element during all stages of CNO, which makes them a promising candidate in the search for "drivers" of inflammation. Furthermore, we link increased expression of inflammasome components NLRP3 and ASC in monocytes with site-specific DNA hypomethylation around the corresponding genes NLRP3 and PYCARD. Our observations deliver further evidence for the involvement of pro-inflammatory monocytes in the pathophysiology of CNO. Cellular and molecular alterations may serve as disease biomarkers and/or therapeutic targets.
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Affiliation(s)
- D Brandt
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - E Sohr
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - J Pablik
- Institut für Pathologie, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - A Schnabel
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - F Kapplusch
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - K Mäbert
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - J H Girschick
- Children's Hospital, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - H Morbach
- University Children's Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - F Thielemann
- UniversitätsCentrum für Orthopädie und Unfallchirurgie, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - S R Hofmann
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - C M Hedrich
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden, Germany; Institute of Translational Medicine, Department of Women's and Children's Health, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK.
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Hamrick HJ. Chronic Nonbacterial Osteomyelitis of the Mandible: Recognition, Etiology, and Management. Clin Pediatr (Phila) 2018; 57:475-477. [PMID: 28805072 DOI: 10.1177/0009922817721157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Harvey J Hamrick
- 1 University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Girschick H, Finetti M, Orlando F, Schalm S, Insalaco A, Ganser G, Nielsen S, Herlin T, Koné-Paut I, Martino S, Cattalini M, Anton J, Mohammed Al-Mayouf S, Hofer M, Quartier P, Boros C, Kuemmerle-Deschner J, Pires Marafon D, Alessio M, Schwarz T, Ruperto N, Martini A, Jansson A, Gattorno M. The multifaceted presentation of chronic recurrent multifocal osteomyelitis: a series of 486 cases from the Eurofever international registry. Rheumatology (Oxford) 2018; 57:1203-1211. [PMID: 29596638 DOI: 10.1093/rheumatology/key058] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 02/08/2018] [Indexed: 01/28/2023] Open
Abstract
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.
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Affiliation(s)
- Hermann Girschick
- Paediatric and Adolescent Medicine, Perinatal Centre, Clinic for Paediatric and Adolescent Medicine, Vivantes Klinikum Berlin, Germany
- Section of Paediatric Rheumatology, Children's Hospital, Osteology, Immunology and Infectious Diseases, University of Wuerzburg, Germany
| | - Martina Finetti
- Istituto Giannina Gaslini, Pediatria II, Reumatologia, Genoa
| | - Francesca Orlando
- Istituto Giannina Gaslini, Pediatria II, Reumatologia, Genoa
- Dipartimento di Pediatria, Università di Napoli Federico II, Naples
| | - Susanne Schalm
- Klinikum der Universität, von Haunersches Kinderspital, Munich, Germany
| | | | - Gerd Ganser
- Clinic of Paediatric Rheumatology, St. Josef-Stift Hospital, Sendenhorst, Germany
| | - Susan Nielsen
- Paediatric Rheumatology, Rigshospitalet, Copenhagen, Denmark
| | - Troels Herlin
- Skejby Sygehus, Aarhus University Hospital, Aarhus, Denmark
| | - Isabelle Koné-Paut
- Service de rhumatologie pédiatrique, Le Kremlin-Bicêtre University Hospital, Paris-Sud University, Paris, France
| | - Silvana Martino
- Dipartimento di Scienze Pediatriche e dell'Adolescenza, University of Torino, Torino, Italy
| | - Marco Cattalini
- Unita di Immunologia e Reumatologia Pediatrica, Clinica Pediatrica dell'Universita di Brescia, Spedali Civili, Brescia, Italy
| | - Jordi Anton
- Paediatric Rheumatology, Hospital Sant Joan de Déu. Universitat de Barcelona, Spain
| | | | - Michael Hofer
- Centre Multisite Romand de Rhumatologie Pediatrique/Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Pierre Quartier
- IMAGINE Institute, Paris-Descartes University, Necker Children's Hospital, Paris, France
| | - Christina Boros
- Paediatrics and Reproductive Health, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | | | | | - Maria Alessio
- Dipartimento di Pediatria, Università di Napoli Federico II, Naples
| | - Tobias Schwarz
- Section of Paediatric Rheumatology, Children's Hospital, Osteology, Immunology and Infectious Diseases, University of Wuerzburg, Germany
- Clinic of Paediatric Rheumatology, St. Josef-Stift Hospital, Sendenhorst, Germany
| | | | - Alberto Martini
- Direzione Scientifica, Istituto Giannina Gaslini, Genoa, Italy
| | - Annette Jansson
- Klinikum der Universität, von Haunersches Kinderspital, Munich, Germany
| | - Marco Gattorno
- Istituto Giannina Gaslini, Pediatria II, Reumatologia, Genoa
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Brandt D, Hedrich CM. TCRαβ +CD3 +CD4 -CD8 - (double negative) T cells in autoimmunity. Autoimmun Rev 2018; 17:422-430. [PMID: 29428806 DOI: 10.1016/j.autrev.2018.02.001] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 12/07/2017] [Indexed: 12/14/2022]
Abstract
TCRαβ+CD3+CD4-CD8- "double negative" (DN) T cells comprise a small subset of mature peripheral T cells. The origin and function of DN T cells are somewhat unclear and discussed controversially. While DN T cells resemble a rare and heterogeneous T cell subpopulation in healthy individuals, numbers of TCRαβ+ DN T cells are expanded in several inflammatory conditions, where they also exhibit distinct effector phenotypes and infiltrate inflamed tissues. Thus, DN T cells may be involved in systemic inflammation and tissue damage in autoimmune/inflammatory conditions, including SLE, Sjögren's syndrome, and psoriasis. Here, the current understanding of the origin and phenotype of DN T cells, and their role in the instruction of immune responses, autoimmunity and inflammation will be discussed in health and disease.
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Affiliation(s)
- D Brandt
- Division of Pediatric Rheumatology and Immunology, Children's Hospital Dresden, Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - C M Hedrich
- Division of Pediatric Rheumatology and Immunology, Children's Hospital Dresden, Faculty of Medicine Carl Gustav Carus, TU Dresden, Dresden, Germany; Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK.
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