Chronic recurrent multifocal osteomyelitis associated with chronic inflammatory bowel disease in children

Chronic multifocal osteomyelitis: is infectious causation a moot point?

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

Granulomatous pyoderma preceding chronic recurrent multifocal osteomyelitis triggered by vaccinations in a two-year-old boy: a case report

Introduction

Chronic recurrent multifocal osteomyelitis is a rare, systemic, aseptic, inflammatory disorder that involves different sites. Pathogenesis of chronic recurrent multifocal osteomyelitis is currently unknown.

Case presentation

A two-year-old Caucasian boy, diagnosed with chronic recurrent multifocal osteomyelitis with granulomatous pyoderma following routine vaccinations is presented for the first time in the literature.

Conclusion

We conclude that antigen exposures might have provoked this inflammatory condition for our case. Skin and/or bone lesions following vaccinations should raise suspicion of an inflammatory response such as chronic recurrent multifocal osteomyelitis only after thorough evaluation for chronic infection, autoimmune, immunodeficiency or vasculitic diseases.

Chronic nonbacterial osteomyelitis in childhood: prospective follow-up during the first year of anti-inflammatory treatment

Introduction

Chronic nonbacterial osteomyelitis (CNO) is an inflammatory disorder of unknown etiology. In children and adolescents CNO predominantly affects the metaphyses of the long bones, but lesions can occur at any site of the skeleton. Prospectively followed cohorts using a standardized protocol in diagnosis and treatment have rarely been reported.

Methods

Thirty-seven children diagnosed with CNO were treated with naproxen continuously for the first 6 months. If assessment at that time revealed progressive disease or no further improvement, sulfasalazine and short-term corticosteroids were added. The aims of our short-term follow-up study were to describe treatment response in detail and to identify potential risk factors for an unfavorable outcome.

Results

Naproxen treatment was highly effective in general, inducing a symptom-free status in 43% of our patients after 6 months. However, four nonsteroidal anti-inflammatory drug (NSAID) partial-responders were additionally treated with sulfasalazine and short-term corticosteroids. The total number of clinical detectable lesions was significantly reduced. Mean disease activity estimated by the patient/physician and the physical aspect of health-related quality of life including functional ability (global assessment/childhood health assessment questionnaire and childhood health assessment questionnaire) and pain improved significantly. Forty-one percent of our patients showed radiological relapses, but 67% of them were clinically silent.

Conclusions

Most children show a favorable clinical course in the first year of anti-inflammatory treatment with NSAIDs. Relapses and new radiological lesions can occur at any time and at any site in the skeleton but may not be clinically symptomatic. Whole-body magnetic resonance imaging proved to be very sensitive for initial and follow-up diagnostics.

Imaging of chronic recurrent multifocal osteomyelitis

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

Nonbacterial osteitis: a clinical, histopathological, and imaging study with a proposal for protocol-based management of patients with this diagnosis

BACKGROUND

Nonbacterial osteitis (NBO), a term referring to sterile bone lesions with nonspecific histopathological features of inflammation, may be either unifocal or multifocal, acute (< or =6 months) or chronic, and recurrent. Only when the condition is chronic, recurrent, and multifocal is it appropriate to use the term chronic recurrent multifocal osteomyelitis (CRMO). We present our clinical experience as the largest reported series of children with NBO to date.

METHODS

We report a retrospective clinical, histopathological, and radiological study of 41 children with nonbacterial osteitis.

RESULTS

Of 41 children (2-16 years of age) diagnosed with NBO in our institution over the last 6 years, 21 (51%) had recurrent disease and 18 (44%) had multifocal disease. The most common bones affected were the clavicle, femur, and tibia (in order of decreasing prevalence) accounting for 44 (63%) of a total of 70 lesions. Only one individual had SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, osteitis) and no other patients had evidence of bowel or skin disease. In the absence of evidence for an infective etiology, we recommend nonsteroidal anti-inflammatory agents as the firstline therapy and bisphosphonates only in cases of resistant disease.

CONCLUSIONS

On the basis of our findings, we propose using a patient questionnaire and protocol for investigating and managing patients who present with NBO to orthopedic surgeons. We predict that this will benefit patients with this disorder by improving our knowledge of the presenting signs and symptoms and related disorders, rationalizing the therapeutic approach, and allowing us to learn about the natural history of the disease.

SAPHO syndrome in an adult with ulcerative colitis responsive to intravenous pamidronate: a case report and review of the literature

Synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome is a rare group of sterile, inflammatory osteoarticular disorders classically associated with skin lesions. It is occasionally associated with enteropathic disease such as ulcerative colitis. We present a 39-year-old patient with chronic ulcerative colitis who developed enteropathic SAPHO and responded well to pamidronate. We discuss the clinicopathological features with particular attention to bone pathology, and perform a literature review of this fascinating syndrome.

Imaging chronic sclerosing osteitis of the diaphysis of tubular bones

OBJECTIVE

The purpose of this study is to report the radiographic changes seen in chronic sclerosing osteitis of the diaphysis of tubular bones during progression or healing, with CT and MRI correlation. Chronic sclerosing osteitis is an inflammatory condition of bone that can be considered a pediatric subset of the synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) spectrum of disease. Previous descriptions of long-bone involvement focus predominately on metaphyseal lesions. Eleven diaphyseal lesions in seven patients (age range, 13 months-14.5 years) were followed.

CONCLUSION

The marked degree of cortical hyperostosis, medullary narrowing, and cortical lucencies seen in eight of 11 lesions is helpful for recognition of diaphyseal chronic sclerosing osteitis. Early identification of the disorder can prevent unnecessary repeat invasive procedures.

Can chronic recurrent multifocal osteomyelitis predispose to lymphoma of bone? A case report

Chronic recurrent multifocal osteomyelitis (CRMO) and B-cell lymphoma are fairly uncommon conditions that are seen in children. Although CRMO can leave patients with residual deformities and disabilities, it is a benign condition. We describe an unusual situation in which a site adjacent to a biopsy-documented site of CRMO presented 3.5 years later with B-cell lymphoma. B-cell lymphoma can behave in an indolent manner and reports suggest that this condition can initially be mistaken for CRMO. This case presented here underscores the importance of vigilance in the short and long-term management of patients initially diagnosed with CRMO, and raises the possibility that the pathogenesis of the two conditions is related.

Chronic recurrent multifocal osteomyelitis: what is it and how should it be treated?

BACKGROUND

Chronic recurrent multifocal osteomyelitis (CRMO) is the most severe form of chronic nonbacterial osteomyelitis. In children and adolescents, chronic nonbacterial osteomyelitis predominantly affects the metaphyses of the long bones, but lesions can occur at any site in the skeleton. Other organs (the skin, eyes, gastrointestinal tract and lungs) can also be affected. Clinical diagnosis is often difficult because the symptoms and course of disease vary significantly. We present a 10-year-old girl diagnosed with CRMO involving several vertebrae, the femur and the metatarsus.

INVESTIGATIONS

Physical examination, abdominal ultra sonography, conventional X-ray, MRI, technetium bone scan, esophagogastroduodenoscopy, colonoscopy, tests for HLA-B27 and thiopurine methyltransferase, polymerase chain reaction and thoracic vertebral bone biopsies.

DIAGNOSIS

CRMO and Crohn's disease.

MANAGEMENT

The patient's condition improved whilst being treated with NSAIDs for 3 months; however, the patient had an allergic skin reaction to this therapy. Treatment was switched to sulfasalazine, accompanied by 3 weeks of therapy using oral prednisone, but sulfasalazine was discontinued 2 months later because the patient exhibited a minor elevation in the levels of liver enzymes. The patient was free of musculoskeletal symptoms for 6 months, at which time she started to complain again about pain in her back and bowel. Multimodal therapy, consisting of mesasalazine, corticosteroids (budesonide) and azathioprine, induced clinical remission of Crohn's disease.

Autoinflammatory bone disorders

PURPOSE OF REVIEW

This review provides an update on clinical, genetic, and immunologic aspects of the autoinflammatory bone disorders.

RECENT FINDINGS

Chronic noninfectious inflammation of the bone is a clinical feature of both chronic recurrent multifocal osteomyelitis and (to a lesser degree) cherubism. The genes responsible for Majeed syndrome (LPIN2), murine chronic multifocal osteomyelitis (pstpip2), and cherubism (SH3BP2 and possibly PTPN11) have been identified. Murine models of both chronic recurrent multifocal osteomyelitis and cherubism have demonstrated that the bone inflammation is mediated by hematopoietically derived cells and can occur in the absence of a functioning adaptive immune system. As the immunologic defects become better defined, the cells of the myeloid lineage are emerging as the primary players.

SUMMARY

Chronic multifocal osteomyelitis and cherubism are hereditary chronic inflammatory disorders in which bone is the primary inflammatory target. Recent genetic and immunologic discoveries demonstrate involvement of the innate immune system, which places these entities in the category of autoinflammatory disorders.

A missense mutation in pstpip2 is associated with the murine autoinflammatory disorder chronic multifocal osteomyelitis

Chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory disorder that primarily affects bone but is often accompanied by inflammation of the skin and/or gastrointestinal tract. The etiology is unknown but evidence suggests a genetic component to disease susceptibility. Although most cases of CRMO are sporadic, there is an autosomal recessive syndromic form of the disease, called Majeed syndrome, which is due to homozygous mutations in LPIN2. In addition, there is a phenotypically similar mouse, called cmo (chronic multifocal osteomyelitis) in which the disease is inherited as an autosomal recessive disorder. The cmo locus has been mapped to murine chromosome 18. In this report, we describe phenotypic abnormalities in the cmo mouse that include bone, cartilage and skin inflammation. Utilizing a backcross breeding strategy, we refined the cmo locus to a 1.3 Mb region on murine chromosome 18. Within the refined region was the gene pstpip2, which shares significant sequence homology to the PSTPIP1. Mutations in PSTPIP1 have been shown to cause the autoinflammatory disorder PAPA syndrome (pyogenic arthritis, pyoderma gangrenosum and acne). Mutation analysis, utilizing direct sequencing, revealed a single base pair change c.293T --> C in the pstpip2 gene resulting in a highly conserved leucine at amino acid 98 being replaced by a proline (L98P). No other mutations were found in the coding sequence of the remaining genes in the refined interval, although a 50 kb gap remains unexplored. These data suggest that mutations in pstpip2 may be the genetic explanation for the autoinflammatory phenotype seen in the cmo mouse.

Crohn's-associated chronic recurrent multifocal osteomyelitis responsive to infliximab

We report a case of chronic recurrent clavicular osteomyelitis in association with Crohn disease. Steroid therapy resulted in partial remission; however, intractable shoulder pain and an enlarging clavicular mass subsequently recurred. Infliximab therapy resulted in significant improvement in the degree of bone pain and resolution of the large sclerotic clavicular lesion.

[Chronic infections multifocal osteomyelitis vs chronic recurrent multifocal osteomyelitis: with reference to one case]

We present a rare case of chronic infectious multifocal osteomyelitis with affectation symmetric in the both femures in a patient with spondyarthropathic secondary Inflammatory Bowel Disease. The diagnosis was confirmed with culture of the bone biopsy. The aim of this work is the revision of the Chronic Infectious Multifocal Osteomyelitis and the Chronic Recurrent Multifocal Osteomyelitis into SAPHO syndrome that both were the possibilities diagnoses.

Chronic recurrent multifocal osteomyelitis: clinical outcomes after more than five years of follow-up

OBJECTIVE

To determine the clinical outcomes of children with chronic recurrent multifocal osteomyelitis (CRMO).

STUDY DESIGN

Inception cohorts of children with CRMO were established at two tertiary pediatric centers. Outcome data were obtained through review of hospital charts, interview and examination of patients, and completion of questionnaires by patients.

RESULTS

Of 45 eligible subjects, 23 (51%) were assessed. Median time since diagnosis was 13 years (range, 6-25). At evaluation, 6 (26%) had active disease; 18 (78%) had Health Assessment Questionnaire scores of 0 (no/minimal physical disability), and 5 had scores >0. Some impairment was seen in all domains of measurement of quality-of-life test, especially those concerning nonphysical aspects of health. Six (26%) subjects continued to have pain as a result of CRMO. Associated medical problems included arthritis in 6, sacroiliitis in 3, psoriasis in 5, recurrent pustular rashes in 2, and inflammatory bowel disease in 3.

CONCLUSIONS

Long-term clinical outcomes for children with CRMO appear to be generally good, with most subjects having no evidence of disease activity or sequelae. However, a number of subjects had persistent disease and, therefore, remain at risk of physical and psychologic complications. Further research is required to identify patients at risk for persistent disease, and to determine therapies that may prevent morbidity.

Imaging of chronic recurrent multifocal osteomyelitis

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

Multifocal pyogranulomatous osteomyelitis resembling chronic recurrent multifocal osteomyelitis in a lemur

Chronic recurrent multifocal osteomyelitis is a rare inflammatory bone disease of children and adolescents that is characterized by localized swelling and pain in the clavicles and long bones of the limbs. Diagnosis of chronic recurrent multifocal osteomyelitis is made from clinical signs, characteristic radiographic and histopathologic findings, and negative results of microbial cultures. Treatment of chronic recurrent multifocal osteomyelitis in humans includes administration of nonsteroidal anti-inflammatory drugs or immune modulators, which may be effective in lemurs.