Chronic recurrent multifocal osteomyelitis presenting as acute scoliosis: a case report and review of literature

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

Background

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

Case Presentation

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

Conclusion

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

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Chronic Recurrent Multifocal Osteomyelitis: A Review of the Noninfectious Inflammatory Bone Disease and Lessons for More Timely Diagnosis

Chronic recurrent multifocal osteomyelitis (CRMO) is an idiopathic autoinflammatory disease of the bone that typically occurs in children and adolescents. CRMO is characterized by recurrent periods of exacerbation and remission of symptomatic, osteolytic/sclerotic sterile bone lesions and is often a diagnosis of exclusion. Treatment consists of multimodal anti-inflammatory medication management by rheumatology and rarely involves surgery. This review summarizes the clinical presentation, pathophysiology, diagnosis, and management of this disease and highlights the role of the orthopedic surgeon. With increased familiarity with CRMO, clinicians will be able to diagnose and treat the condition in a more timely manner. [Orthopedics. 202x;4x(x):xx-xx.].

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Chronic Non-bacterial Osteomyelitis: A Review

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.

Acute scoliosis as an unusual presentation of pneumonia: A case report

We describe the unique case of a child with pneumonia presenting with acute scoliosis and abdominal pain, without any typical features of the disease.A 10-year-old girl presented to the emergency department on 3 consecutive days with right-sided abdominal pain. There were no associated features, in particular, no fevers or respiratory symptoms. On the first 2 presentations, observation,examination, and blood test findings were unremarkable. Chest x-ray and abdominal ultrasound were also normal. On the third presentation a marked scoliosis was noted and abdominal examination revealed right-sided tenderness with rebound. The patient was admitted and a computed tomographic scan of the abdomen arranged. Unexpectedly, this revealed a right lower lobe pneumonia and associated pleural effusion. Despite treatment, the parapneumonic effusion enlarged rapidly and she developed respiratory distress, necessitating transfer to a tertiary centre.The diagnosis of pneumonia can be challenging because of a lack of respiratory signs, the masking of systemic features by antipyretic effects of first-line analgesics, and a high rate of false-negative chest radiographs. The development of acute scoliosis should lead the clinician to strongly consider pneumonia in such circumstances.

[Chronic recurrent multifocal osteomyelitis of the spine : Children and adolescent]

Chronic non-bacterial osteomyelitis (CNO) in childhood and adolescence is a non-infectious autoinflammatory disease of the bone with partial involvement of adjacent joints and soft tissue. The etiology is unknown. The disease can occur singular or recurrent. Individual bones can be affected and multiple lesions can occur. Chronic recurrent multifocal osteomyelitis (CRMO) shows the whole picture of CNO. Accompanying but temporally independent of the bouts of osteomyelitis, some patients show manifestations in the skin, eyes, lungs and the gastrointestinal tract. The article gives an overview of the clinical manifestations, diagnostic procedures, and treatment options for CRMO involvement of the spine based on the current literature and our own cases.

Chronic recurrent multifocal osteomyelitis in association with pyoderma gangraenosum

Background

Chronic recurrent multifocal osteomyelitis (CRMO) is a rare acquired inflammatory skeletal disorder of unknown origin. CRMO was first described by Gideon in 1972 and mainly affects children and young adults of female gender. The CRMO is part of the clinical picture of non-bacterial Osteomyelitis (NBO) and typically presents a relapsing recurring course with both remission and spontaneous exacerbation. CRMO is typically encountered in the limbs and the metaphysis of long bones in particular. Usually the clinical symptoms include painful swellings of the affected regions. This case report describes the rare case of a CRMO of the mandible in association with pyoderma gangraenosum.

Case presentation

A 14-year old female caucasian patient, residing in the south of Germany, presented in the oncological outpatient clinic of our Department of Paediatrics and Adolescent Medicine in June 2014 complaining of increasing neck pain and progressive swelling at her left cheek ongoing for about 6 weeks. These symptoms had been occurring quarterly for 4 years, but had never been as pronounced. Blood biochemistry showed a moderately elevated CRP (35 mg/l) and a significantly increased blood sedimentation rate (BSR 48/120 mm). The panoramic radiograph, however, revealed a bone alteration in the left mandibular region. Further investigations confirmed the diagnosis of CRMO.

Conclusion

The present case underlines the fact that rare diseases might occasionally present with even more rare symptoms. These occasions can obviously be considered to present a considerable diagnostic challenge.

Syndromes with chronic non-bacterial osteomyelitis in the spine

Chronic non-bacterial osteomyelitis (CNO) has been known for over of 40 years. It is an underrecognized entity due to the low number of described cases and poor propagation awareness of the problem. Chronic non-bacterial osteomyelitis is usually confused with infectious spondylodiscitis or malignant lesions, both primary and metastatic. Failing to consider CNO as one of possible lesions of the spine among an array of differential diagnoses may lead to a prolonged ineffective treatment increasing treatment-related morbidity. In this paper the authors describe these two syndromes, with a possible autoimmune background – chronic recurrent multifocal osteomyelitis (CRMO) and SAPHO syndrome – that include CNO being among the manifestations. The authors present the spinal symptomatology of CNO for both syndromes published so far to help spine clinicians organize the information for better usage in everyday clinical practice.

Non-bacterial chronic recurrent osteomyelitis of the clavicle

ABSTRACT

This report details the case of a 12-year-old girl with a painful, progressive swelling of the medial portion of the clavicle with no history of trauma or other constitutional symptoms. All laboratory investigations were normal except for an elevated erythrocyte sedimentation rate (ESR). Initial plain radiographs showed a destructive lesion with magnetic resonance imaging showing features of malignancy. Biopsies revealed osteomyelitis, but with negative bacterial cultures and no evidence of malignancy. Treatment with antibiotics did not result in a favourable response. Over time, the swelling increased in size with episodic exacerbations of pain. Follow-up radiographs showed sclerosis and hyperostosis. After five years, this was recognized as non-bacterial chronic recurrent osteomyelitis of the clavicle.

KEY WORDS

Nonbacterial, chronic recurrent, osteomyelitis, clavicle.

Acute scoliosis in a 3-year-old boy

The case describes the presentation of a fit and well 3-year-old boy to the emergency department of a district general hospital after he developed an acute scoliosis overnight. There was no history of trauma, his observations were normal and he had non-specific symptoms of lethargy and reduced appetite, but no fevers or respiratory distress. Bloods showed raised inflammatory markers and he was referred to orthopaedics as a septic disc as there was some spinal tenderness. An urgent MRI was considered initially but on further examination there was some reduced air entry on the left lung base which a chest radiograph confirmed as a left-sided pneumonia. A diagnosis of pneumonia and secondary functional scoliosis was made. The child was admitted under paediatrics and made a full recovery on antibiotics. At 8 weeks follow-up there was resolution of scoliosis clinically and radiologically.

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

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

Chronic recurrent multifocal osteomyelitis primarily affecting the spine treated with anti-TNF therapy

STUDY DESIGN

A case report describing chronic recurrent multifocal osteomyelitis (CRMO) with initial presentation limited to spine, successfully treated by anti-TNF-alpha therapy after failure of conventional treatment methods.

OBJECTIVE

To describe an unusual manifestation and treatment of a rare disease.

SUMMARY OF BACKGROUND DATA

CRMO is a rare inflammatory bone disease that should be differentiated from bacterial osteomyelitis. Rarely, it can affect the spine and in this case the most important differential diagnosis is infectious spondylodiscitis. The disease has an unpredictable course with exacerbations and spontaneous remissions. Although the majority of cases remit spontaneously (or after the use of nonsteroidal anti-inflammatory drugs [NSAIDs]), some progressive and resistant cases have been reported.

METHODS

We describe a case of CRMO with an unusual clinical presentation emphasizing the importance of this finding as a differential diagnosis of spondylodiscitis and comment on the available treatment alternatives.

RESULTS

A 17-year-old man presented with debilitating dorsal spine pain. Magnetic resonance imaging of the spine revealed bone lesions at multiple vertebral levels. After failure of antibiotic treatment, the diagnosis of CRMO was suggested. An initial good response to NSAIDs was followed by a recurrent course and involvement of peripheral joints besides the use of corticosteroids and other drugs. The introduction of infliximab was followed by complete remission of the disease.

CONCLUSION

Our observation highlights the need of awareness for the differential diagnosis in suspected cases of osteomyelitis not responding to antibiotics. Anti-TNF-alpha agents should be considered in CRMO refractory cases.