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Xu Y, Wang G, Wang Y, Wang W, Kan Y, Yang J. Diagnostic Role of FDG PET/CT in Pediatric Patients With Chronic Recurrent Multifocal Osteomyelitis. Clin Nucl Med 2024; 49:536-539. [PMID: 38598512 DOI: 10.1097/rlu.0000000000005216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
PURPOSE Chronic recurrent multifocal osteomyelitis (CRMO), or chronic nonbacterial osteomyelitis, is difficult to diagnose. The accurate diagnosis of CRMO relies on comprehensive imaging examinations because of its multifocal nature. In this regard, 18 F-FDG PET/CT has demonstrated significant utility in inflammatory diseases. This study tries to determine the value of FDG PET/CT in the evaluation of CRMO. PATIENTS AND METHODS We retrospectively collected imaging data from pediatric CRMO patients who underwent FDG PET/CT scans. Lesions exhibiting abnormal metabolism with/without structural abnormalities on FDG PET/CT were identified as CRMO lesions, and their location and SUV max were recorded. RESULTS A total of 21 pediatric patients with CRMO were included in this study. The median age at diagnosis was 9.4 years. Total 131 foci of abnormal activity were identified using FDG PET/CT imaging. The distribution pattern showed a higher prevalence of lower limbs and pelvis involvement. Among all identified lesions, abnormalities were detected on both PET and CT images of 93 lesions, whereas exclusively positive findings on 18 F-FDG PET alone were observed for 38 of them. CONCLUSIONS Our study findings suggest a higher prevalence of lesions in the bones of the lower limbs and pelvis among children with CRMO. Compared with CT scans, FDG PET exhibits superior sensitivity in detecting these lesions.
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Affiliation(s)
- Yanfeng Xu
- From the Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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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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Jansen RB, Nilsson J, Buch-Larsen K, Kofod T, Schwarz P. Treatment Effect of Zoledronic Acid in Chronic Non-bacterial Osteomyelitis of the Jaw: A Case Series. Calcif Tissue Int 2024; 114:129-136. [PMID: 37991563 PMCID: PMC10803718 DOI: 10.1007/s00223-023-01154-4] [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: 06/25/2023] [Accepted: 10/26/2023] [Indexed: 11/23/2023]
Abstract
Chronic non-bacterial osteomyelitis (CNO) is an autoinflammatory, osteolytic bone disorder sometimes localized to a unifocal site in the jaw, causing long-term pain and reduced function. The aim of this study was to describe the patients with CNO of the jaw, focusing on treatment with zoledronic acid for pain relief. An analysis of medical records of 24 patients with CNO of the jaw, including treatment with zoledronic acid and effects on pain relief. Descriptive statistics and nonparametric tests were used to describe the population and compare treatment effects, respectively. The average treatment period was 33.4 months (median 23; Q1 11.5; Q3 42.0) with an average of 4.1 infusions (median 3; Q1 2; Q3 5) of zoledronic acid. The average pain VAS score (visual analogue scale) was significantly reduced from 7.7 (median 8; Q1 6.5; Q3 8.5) to 2.5 points (median 2; Q1 0.5; Q3 4.5) (p < 0.001). At final visit, 46% of patients reported no pain and 38% reported a reduction of pain. At least 67% of patients had at least one episode of pain recurrence, and most patients experienced the first recurrence within a year of initial treatment. Four patients (16%) had no pain relief from the treatment. In this group of patients with CNO of the jaw, there was a positive response to treatment with zoledronic acid on pain relief, averaging 5.2 points on a pain VAS score, with 84% of patients treated experiencing either a partial or a total reduction in pain after about 2.5 years.
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Affiliation(s)
- Rasmus Bo Jansen
- Department of Endocrinology, Bone-Metabolic Research Unit, Rigshospitalet, Copenhagen, Denmark.
| | - Johanna Nilsson
- Department of Oral and Maxillofacial Surgery, Rigshospitalet Copenhagen, Denmark
| | - Kristian Buch-Larsen
- Department of Endocrinology, Bone-Metabolic Research Unit, Rigshospitalet, Copenhagen, Denmark
| | - Thomas Kofod
- Department of Oral and Maxillofacial Surgery, Rigshospitalet Copenhagen, Denmark
| | - Peter Schwarz
- Department of Endocrinology, Bone-Metabolic Research Unit, Rigshospitalet, Copenhagen, Denmark
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Fu Z, Wang X, Zou L, Zhang Z, Lu M, Zong J, Wang S. Transcriptome analysis based on machine learning reveals a role for autoinflammatory genes of chronic nonbacterial osteomyelitis (CNO). Sci Rep 2023; 13:6514. [PMID: 37085667 PMCID: PMC10121556 DOI: 10.1038/s41598-023-33759-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 04/18/2023] [Indexed: 04/23/2023] Open
Abstract
Chronic nonbacterial osteomyelitis (CNO) is an autoinflammatory bone disorder. The origin and development of CNO involve many complex immune processes, resulting in delayed diagnosis and a lack of effective treatment. Although bioinformatics analysis has been utilized to seek key genes and pathways in CNO, only a few bioinformatics studies that focus on CNO pathogenesis and mechanisms have been reported. This study aimed to identify key biomarkers that could serve as early diagnostic or therapeutic markers for CNO. Two RNA-seq datasets (GSE133378 and GSE187429) were obtained from the Gene Expression Omnibus (GEO). Weighted gene coexpression network analysis (WGCNA) and differentially expressed gene (DEG) analysis were conducted to identify the genes associated with CNO. Then, the autoinflammatory genes most associated with CNO were identified based on the GeneCards database and a CNO prediction model, which was created by the LASSO machine learning algorithm. The accuracy of the model and effects of the autoinflammatory genes according to receiver operating characteristic (ROC) curves were verified in external datasets (GSE7014). Finally, we performed clustering analysis with ConsensusClusterPlus. In total, eighty CNO-related genes were identified and were significantly enriched in the biological processes regulation of actin filament organization, cell-cell junction organization and gamma-catenin binding. The main enriched pathways were adherens junctions, viral carcinogenesis and systemic lupus erythematosus. Two autoinflammatory genes with high expression in CNO samples were identified by combining an optimal machine learning algorithm (LASSO) with the GeneCards database. An external validation dataset (GSE187429) was utilized for ROC analysis of the prediction model and two genes, and the results indicated good efficiency. Then, based on consensus clustering analysis, we found that the expression of UTS2 and MPO differed between clusters. Finally, the ceRNA network of lncRNAs and the small molecule compounds targeting the two autoinflammatory genes were predicted. The identification of two autoinflammatory genes, the HCG18/has-mir-147a/UTS2/MPO axis and signalling pathways in this study can help us understand the molecular mechanism of CNO formation and provides candidate targets for the diagnosis and treatment of CNO.
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Affiliation(s)
- Zhuodong Fu
- Department of Orthopedic Surgery, the First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, Dalian, China
| | - Xingkai Wang
- Department of Orthopedic Surgery, the First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, Dalian, China
| | - Linxuan Zou
- Department of Orthopedic Surgery, the First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, Dalian, China
| | - Zhe Zhang
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, China
| | - Ming Lu
- Trauma and Tissue Repair Surgery Department, Dalian Municipal Central Hospital, Dalian, China.
| | - Junwei Zong
- Department of Orthopedic Surgery, the First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, Dalian, China.
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, China.
| | - Shouyu Wang
- Department of Orthopedic Surgery, the First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, Dalian, China.
- Institute (College) of Integrative Medicine, Dalian Medical University, Dalian, Liaoning, China.
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Perry KM, Enders BD, Negrão Watanabe TT. Refractory shock, hypercoagulability, and multiorgan thrombosis associated with hypertrophic osteodystrophy in a dog. J Vet Emerg Crit Care (San Antonio) 2023; 33:257-262. [PMID: 36799891 DOI: 10.1111/vec.13280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 02/07/2022] [Accepted: 02/26/2022] [Indexed: 02/18/2023]
Abstract
OBJECTIVE To describe the clinical findings and case progression in a dog presenting with severe systemic inflammatory response, refractory shock, progressive metabolic acidosis, and respiratory failure that was ultimately diagnosed with hypertrophic osteodystrophy (HOD). CASE SUMMARY A 4-month-old male intact Mastiff presented with a 24-hour history of lethargy and generalized ostealgia. On examination, the dog was recumbent, febrile, and tachycardic with pain on palpation of the abdomen, right femur, and mandible. Appendicular joint radiographs showed changes consistent with osteochondrosis and ulnar-retained cartilaginous cores, with no overt evidence of HOD. Initial treatment included IV fluid therapy, multimodal analgesia, and broad-spectrum antimicrobials. Vasopressor therapy was initiated following hemodynamic decompensation. Synovial fluid cytological analysis and culture revealed nonseptic suppurative inflammation and no bacterial growth, respectively. Blood and urine cultures also yielded no growth. Viscoelastic testing was consistent with hypercoagulability. The dog initially had a metabolic acidosis with appropriate respiratory compensation that progressed to a mixed metabolic and respiratory acidosis despite aggressive therapies that included antimicrobials, vasopressors, positive inotropes, and corticosteroids. Humane euthanasia was elected approximately 32 hours after admission. Necropsy yielded a diagnosis of HOD. NEW OR UNIQUE INFORMATION PROVIDED This is the first report detailing the occurrence of refractory shock and hypercoagulability associated with HOD in a dog without evidence of another identified comorbidity. HOD should be considered in any young, large-breed dog with generalized ostealgia and signs of systemic illness, even in the absence of classic radiographic abnormalities. Further investigation of coagulation status in dogs with HOD and a secondary systemic inflammatory response is warranted.
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Affiliation(s)
- Kayla M Perry
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Brittany D Enders
- Small Animal Emergency and Triage Services, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
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Beck NA, Roudnitsky E, Nuzzi LC, Padwa BL, Dedeoglu F. How Have the Diagnosis and Treatment of Chronic Recurrent Multifocal Osteomyelitis Changed Over Time? J Oral Maxillofac Surg 2023; 81:238-247. [PMID: 36372159 DOI: 10.1016/j.joms.2022.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/28/2022] [Accepted: 10/12/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Chronic recurrent multifocal osteomyelitis (CRMO) is a rare inflammatory condition characterized by sterile bone lesions. There appears to be a shift in the diagnostic modalities and treatment over the past decades despite insufficient published data. The purpose of this study was to document: 1) the number of patients diagnosed with CRMO, 2) patient demographics, 3) disease characteristics at presentation, 4) diagnostic modalities employed, and 5) treatments prescribed at our institution over a 30-year period. METHODS This single-center, retrospective cohort study included children diagnosed with CRMO who presented between 1990 and 2020. The electronic medical records were queried using numerous search terms. Patients were excluded if CRMO was included in the differential diagnosis but was not confirmed at the time of chart review or if CRMO was suspected early in the disease course but the patient was ultimately diagnosed with another condition. The predictor (time in years) and outcome variables (diagnostic modalities and treatment types) were tested using bivariate analyses using IBM SPSS, Version 27 (IBM Corp., Armonk, NY). RESULTS A total of 224 patients were diagnosed with CRMO during the observation period (68.3% female; 67.4% white). The number of patients diagnosed over the past decade rose by 215%, as compared to the previous 2 decades (1990 to 2010). Regional magnetic resonance imaging (83.8%) and biopsy (66.5%) were the most utilized diagnostic modalities over the past decade, with a statistically significant decline in the proportion of biopsies performed (66.5% during the past decade vs 84.9% in the previous 2 decades, P = .01). Over the past decade, nonsteroidal anti-inflammatory drugs (40.1%), disease-modifying antirheumatic drugs (27.1%), and tumor necrosis factor inhibitors (21.1%) were the most commonly used treatments, with a statistically disproportionate increase in the use of tumor necrosis factor inhibitors (21.1% during the past decade vs 3.8% in the previous 2 decades, P < .001). CONCLUSIONS This is one of the largest CRMO cohort studies and the only study to observe changes in diagnostic modalities and treatment over a 30-year period. Future studies should assess the impact of variations in clinical presentation, time to diagnosis, diagnostic modalities, and management as predictors of disease outcomes.
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Affiliation(s)
- Nicole A Beck
- Oral and Maxillofacial Surgery Resident, Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Boston, MA
| | - Emily Roudnitsky
- Oral and Maxillofacial Surgery Resident, Department of Oral and Maxillofacial Surgery, University of Medicine and Dentistry of New Jersey, Newark, NJ
| | - Laura C Nuzzi
- Clinical Research Manager, Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA
| | - Bonnie L Padwa
- Professor, Harvard School of Dental Medicine, and Oral Surgeon in Chief, Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA.
| | - Fatma Dedeoglu
- Associate Professor, Harvard Medical School, Division of Immunology, Rheumatology Program, Boston Children's Hospital, Boston, MA
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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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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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Mechanisms of bone pain: Progress in research from bench to bedside. Bone Res 2022; 10:44. [PMID: 35668080 PMCID: PMC9170780 DOI: 10.1038/s41413-022-00217-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 04/29/2022] [Accepted: 05/09/2022] [Indexed: 12/27/2022] Open
Abstract
AbstractThe field of research on pain originating from various bone diseases is expanding rapidly, with new mechanisms and targets asserting both peripheral and central sites of action. The scope of research is broadening from bone biology to neuroscience, neuroendocrinology, and immunology. In particular, the roles of primary sensory neurons and non-neuronal cells in the peripheral tissues as important targets for bone pain treatment are under extensive investigation in both pre-clinical and clinical settings. An understanding of the peripheral mechanisms underlying pain conditions associated with various bone diseases will aid in the appropriate application and development of optimal strategies for not only managing bone pain symptoms but also improving bone repairing and remodeling, which potentially cures the underlying etiology for long-term functional recovery. In this review, we focus on advances in important preclinical studies of significant bone pain conditions in the past 5 years that indicated new peripheral neuronal and non-neuronal mechanisms, novel targets for potential clinical interventions, and future directions of research.
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Kostik MM, Makhova MA, Maletin AS, Magomedova SM, Sorokina LS, Tsukasaki M, Okamoto K, Takayanagi H, Vasiliev DS, Kozlova DI, Mushkin AY. Cytokine profile in patients with chronic non-bacterial osteomyelitis, juvenile idiopathic arthritis, and insulin-dependent diabetes mellitus. Cytokine 2021; 143:155521. [PMID: 33863633 DOI: 10.1016/j.cyto.2021.155521] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Our study aimed to evaluate the cytokine levels in pediatric chronic non-bacterial osteomyelitis (CNO) patients and compare these with other immune-mediated diseases and healthy controls. METHODS In this prospective study, we included 42 children with CNO, 28 patients with non-systemic juvenile idiopathic arthritis (JIA), 17 children with insulin-dependent diabetes mellitus (IDDM), and 30 healthy age-matched controls. In each of the CNO patients and comparison groups, the levels of 14-3-3-η protein, S100A8/A9 protein, interleukin-4 (IL-4), interleukin-17 (IL-17), interleukin-18 (IL-18), interleukin-1β (IL-1β), tumor necrosis factor-α (TNF-α) were measured by ELISA assay. RESULTS All studied cytokines in the CNO patients were significantly higher than controls, and IDDM, 14-3-3-η protein, IL-18, IL-4, IL-17, IL-1β, and TNF-α were less than in JIA patients. In the discriminant analysis, ESR, 14-3-3 protein, S100A8/A9, IL-18, IL-4, and TNF-α can discriminate CNO from JIA, and 14-3-3 protein, S100A8/A9, IL-18, IL-17, IL-4, and TNF-α can distinguish CNO from other diseases and HC. CONCLUSION The increased level of pro-inflammatory cytokines confirms the role of monocyte-driven inflammation in CNO patients. Cytokines may prove valuable as biomarkers and potential therapeutic targets for CNO.
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Affiliation(s)
- Mikhail M Kostik
- Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russian Federation.
| | - Maria A Makhova
- Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russian Federation
| | - Alexei S Maletin
- Science Research Institute of Phthisiopulmonology, Saint-Petersburg, Russian Federation
| | - Shamai M Magomedova
- Republican Children's Clinical Hospital, Makhachkala, Russian Federation; Dagestan State Medical University, Makhachkala, Russian Federation
| | - Lybov S Sorokina
- Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russian Federation
| | - Masayuki Tsukasaki
- Department of Immunology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, 113-0033 Tokyo, Japan
| | - Kazuo Okamoto
- Department of Osteoimmunology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, 113-0033 Tokyo, Japan
| | - Hiroshi Takayanagi
- Department of Immunology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, 113-0033 Tokyo, Japan
| | - Dmitriy S Vasiliev
- Sechenov Institute of Evolutionary Physiology and Biochemistry, Saint Petersburg, Russian Federation
| | - Darya I Kozlova
- Department of Osteoimmunology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, 113-0033 Tokyo, Japan
| | - Alexander Yu Mushkin
- Science Research Institute of Phthisiopulmonology, Saint-Petersburg, Russian Federation
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Karunaratne YG, Davies J, Carty CP, Graham D. Chronic Recurrent Multifocal Osteomyelitis of the Hand: A Rare Pediatric Condition. Hand (N Y) 2021; 16:213-222. [PMID: 31137982 PMCID: PMC8041419 DOI: 10.1177/1558944719846599] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Chronic recurrent multifocal osteomyelitis (CRMO) is a rare autoinflammatory condition characterized by bone pain and swelling, secondary to sterile bone osteolytic lesions. Estimated incidence is 1:1 000 000, with ~2% involving the hand. We present a case series of CRMO of the hand and review the available literature, with the aim of educating and raising awareness of this condition. Methods: A retrospective chart review was conducted for all patients presenting to the institution diagnosed with CRMO involving the hands. Subsequently, a literature review was performed. Results/Case Series: Three cases of CRMO of the hand were identified. Age ranged from 20 months to 6 years, with 1 female. Time from presentation to diagnosis ranged from 3 to 15 months. Two had a single lesion, with the remaining patient having a second lesion on full-body magnetic resonance imaging (MRI). Three lesions involved phalanges, and one involved a metacarpal. Two received antibiotics without improvement prior to diagnosis. After diagnosis of CRMO, two received intravenous pamidronate. They both later showed improvement on MRI. Conclusion: CRMO is a rare disease with scarce literature to guide management. We present a series of CRMO specifically of the hand. The cases educate key stakeholders, raise awareness of the diagnosis, and illustrate challenging aspects of managing these patients. This includes the special functional and anatomical consideration essential in managing cases involving the hand.
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Affiliation(s)
| | | | | | - David Graham
- Queensland Children’s Hospital, Brisbane, Australia,David Graham, Department of Orthopaedic Surgery, Queensland Children’s Hospital, Children’s Health Queensland Hospital and Health Service, 501 Stanley Street, South Brisbane, QLD 4101, Australia.
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Chronic recurrent multifocal osteomyelitis (CRMO) involving spine: A case report and literature review. J Orthop Sci 2021; 26:300-305. [PMID: 30153963 DOI: 10.1016/j.jos.2018.06.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Accepted: 06/27/2018] [Indexed: 02/09/2023]
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Nepal P, Alam SI, Sajid S, Sapire J, Ojili V. Rare presentation of chronic recurrent multifocal osteomyelitis of the Iliac wing mimicking Ewing's sarcoma. SA J Radiol 2021; 25:2030. [PMID: 33824748 PMCID: PMC8008083 DOI: 10.4102/sajr.v25i1.2030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 11/26/2020] [Indexed: 11/02/2022] Open
Abstract
This report describes a case of chronic recurrent multifocal osteomyelitis (CRMO) in an 11-year-old girl, involving the iliac bone as an initial, solitary site. Atypical imaging features were suspicious of a bone tumour, such as Ewing's sarcoma. Chronic recurrent multifocal osteomyelitis is a great masquerader and can present atypically. Radiologists should be familiar with both typical and atypical presentations, to determine an accurate diagnosis and guide appropriate management. Timely diagnosis may avoid invasive bone biopsy and inappropriate long-term antibiotic prescription for children.
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Affiliation(s)
- Pankaj Nepal
- Department of Radiology, Faculty of Sciences, St. Vincent's Medical Center, Bridgeport, United States of America
| | - Syed I Alam
- Department of clinical imaging, Faculty of Sciences, Hamad medical corporation, Doha, Qatar
| | - Sadia Sajid
- Department of clinical imaging, Faculty of Sciences, Hamad medical corporation, Doha, Qatar
| | - Joshua Sapire
- Department of Radiology, Faculty of Sciences, St. Vincent's Medical Center, Bridgeport, United States of America
| | - Vijayanadh Ojili
- Department of Radiology, University of Texas Health, San Antonio, Texas, United States of America
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14
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Andronikou S, Kraft JK, Offiah AC, Jones J, Douis H, Thyagarajan M, Barrera CA, Zouvani A, Ramanan AV. Whole-body MRI in the diagnosis of paediatric CNO/CRMO. Rheumatology (Oxford) 2021; 59:2671-2680. [PMID: 32648576 DOI: 10.1093/rheumatology/keaa303] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/16/2020] [Accepted: 05/02/2020] [Indexed: 11/13/2022] Open
Abstract
Chronic recurrent multifocal osteomyelitis (CRMO) is an auto-inflammatory disorder affecting the skeleton of children and adolescents. Whole-body MRI (WBMRI) is key in the diagnosis and follow-up of CRMO. Imaging protocols should include sagittal short Tau inversion recovery of the spine, imaging of the hands and feet, and T1 images for distinguishing normal bone marrow. CRMO lesions can be metaphyseal, epiphyseal and physeal-potentially causing growth disturbance and deformity. Spinal lesions are common, important and can cause vertebral collapse. Lesion patterns include multifocal tibial and pauci-focal patterns that follow a predictable presentation and course of disease. Common pitfalls of WBMRI include haematopoietic marrow signal, metaphyseal signal early on in bisphosphonate therapy and normal high T2 signal in the hands and feet. Pictorial reporting assists in recording lesions and follow-up over time. The purpose of this paper is to review the different WBMRI protocols, imaging findings, lesion patterns and common pitfalls in children with CRMO.
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Affiliation(s)
- Savvas Andronikou
- Department of Radiology, The Children's Hospital of Philadelphia.,Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeannette K Kraft
- Clarendon Wing Radiology Department, Leeds Children's Hospital at The Leeds General Infirmary, Leeds
| | - Amaka C Offiah
- Department of Radiology, Academic Unit of Child Health, University of Sheffield, Sheffield Children's NHS Foundation Trust, Sheffield.,Department of Radiology, Sheffield Children's NHS Foundation Trust, Sheffield
| | - Jeremy Jones
- Department of Radiology, Royal Hospital for Sick Children, Edinburgh
| | - Hassan Douis
- Department of Radiology, University Hospital Birmingham NHS Foundation Trust, Birmingham
| | - Manigandan Thyagarajan
- Department of Radiology, Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham
| | | | - Andrea Zouvani
- School of Clinical Sciences, School of Medicine, University of Glasgow, Glasgow
| | - Athimalaipet V Ramanan
- School of Clinical Sciences, Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, UHB Education Centre, Bristol.,School of Clinical Sciences, University of Bristol, Bristol, UK
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15
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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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16
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Panwar J, Tolend M, Lim L, Tse SM, Doria AS, Laxer RM, Stimec J. Whole-body MRI Quantification for Assessment of Bone Lesions in Chronic Nonbacterial Osteomyelitis Patients Treated With Pamidronate: A Prevalence, Reproducibility, and Responsiveness Study. J Rheumatol 2020; 48:751-759. [PMID: 32934131 DOI: 10.3899/jrheum.200329] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The purpose of this study was (1) to assess the interreader reliability in detecting and scoring the inflammatory bone lesions in pediatric patients with chronic nonbacterial osteomyelitis (CNO) by using whole-body magnetic resonance imaging (WB-MRI), and (2) to evaluate the responsiveness of the MRI-detected CNO lesions to pamidronate therapy. METHODS Eighty-eight WB-MRI examinations were independently reviewed and scored by 2 radiologists blinded to clinical details in 32 retrospectively enrolled pediatric patients with CNO. Inflammatory bone lesions, soft tissue abnormality, and bony structural changes were scored before and after pamidronate therapy. Lesion responsiveness was calculated by using standardized response mean and interreader reliability was assessed by k statistics. RESULTS There was good to excellent interreader agreement for the detection and quantification of bone lesions. After the first cycle of pamidronate in all 32 patients, 96 of the 279 lesions (34%; after excluding 108 lesions of hand and feet) resolved, whereas in a subset of 11 patients with 2 or more cycles, 76% of lesions resolved after the second cycle. Twenty-one (7.5%) lesions worsened and 46 (16.4%) new lesions developed after 1 cycle in all 32 patients. In these 11 patients, the number of worsened lesions reduced to 2 (2%) and new lesions to 14 (14.9%) after the second cycle as detected on MRI. Vertebral lesions had the highest response to treatment. CONCLUSION WB-MRI is a reliable tool for objective quantification and assessment of response to treatment of pediatric CNO bone lesions and could be used to monitor disease activity for clinical and research purposes.
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Affiliation(s)
- Jyoti Panwar
- J. Panwar, MD, FRCR, Department of Radiodiagnosis, Christian Medical College and Hospital, Vellore, India and Department of Diagnostic Imaging, The Hospital for Sick Children, Department of Medical Imaging, University of Toronto, Toronto, Ontario;
| | - Mirkamal Tolend
- M. Tolend, BSc, A.S. Doria, MD, PhD, MSc, MBA, J. Stimec, MD, FRCPC, Department of Diagnostic Imaging, The Hospital for Sick Children, Department of Medical Imaging, University of Toronto, Toronto, Ontario
| | - Lillian Lim
- L. Lim, MD, FRCPC, Division of Pediatric Rheumatology, Department of Pediatrics, University of Alberta, Edmonton, Alberta
| | - Shirley M Tse
- S.M. Tse, MD, FRCPC, R.M. Laxer, MDCM, FRCPC, Division of Rheumatology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Andrea S Doria
- M. Tolend, BSc, A.S. Doria, MD, PhD, MSc, MBA, J. Stimec, MD, FRCPC, Department of Diagnostic Imaging, The Hospital for Sick Children, Department of Medical Imaging, University of Toronto, Toronto, Ontario
| | - Ronald M Laxer
- S.M. Tse, MD, FRCPC, R.M. Laxer, MDCM, FRCPC, Division of Rheumatology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Stimec
- M. Tolend, BSc, A.S. Doria, MD, PhD, MSc, MBA, J. Stimec, MD, FRCPC, Department of Diagnostic Imaging, The Hospital for Sick Children, Department of Medical Imaging, University of Toronto, Toronto, Ontario
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17
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Wu N, Shao Y, Huo J, Zhang Y, Cao Y, Jing H, Zhang F, Yu C, Yu Y, Li C, Song H, Zhang W. Clinical characteristics of pediatric synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome: the first Chinese case series from a single center. Clin Rheumatol 2020; 40:1487-1495. [PMID: 32929648 DOI: 10.1007/s10067-020-05393-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/04/2020] [Accepted: 09/09/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Pediatric SAPHO syndrome is regarded as the equivalent of chronic recurrent multifocal osteomyelitis or chronic non-bacterial osteomyelitis. This study aimed to evaluate the clinical features and treatment options for Chinese pediatric patients with SAPHO syndrome. METHOD We conducted a single-center, retrospective study on a sample of 24 pediatric patients with SAPHO syndrome who were diagnosed at Peking Union Medical College Hospital from April 2014 to August 2018. The demographic, clinical, laboratory, imaging, histological, and therapeutic data were collected and analyzed. RESULTS A total of 15 boys and 9 girls were included. The mean age of onset of bone and skin symptoms was 11.7 ± 3.8 and 14.4 ± 2.7 years, respectively. The mean follow-up period was 39.2 months. Seventeen patients had skin manifestations (46% had severe acne, 100% were boys; 21% had palmoplantar pustulosis, 100% were girls). Bone lesions were localized in four of the following major regions: anterior chest wall (42%), mandible (29%), peripheral bones (50%), and spine and sacroiliac joints (21%). Six patients had been treated with non-steroidal anti-inflammatory drugs, 10 with bisphosphonate, 10 with a tumor necrosis factor-α antagonist, and 1 with glucocorticoids, with variable responses. A total of 70% of the patients had complete remission after bisphosphonate or TNF-α antagonist therapy. CONCLUSION Pediatric patients with SAPHO syndrome have different characteristics from other cohorts in the sex ratio, frequency of mandibular involvement, and sex distribution of skin lesions. Bisphosphonate and TNF-α antagonists show a favorable response in pediatric SAPHO syndrome treatment. Key points •Being the first study that describes an Asian pediatric SAPHO case series. •Chinese pediatric patients with SAPHO syndrome have different characteristics from Chinese adult patients and Caucasian pediatric patients.
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Affiliation(s)
- Nan Wu
- Department of Orthopedic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,Department of genetic research, Beijing Key Laboratory for Genetic Research of Skeletal Deformity, Beijing, China.,Medical Research Center of Orthopedics, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuming Shao
- Institute of Clinical Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jianwei Huo
- Department of Radiology, Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China
| | - Yanan Zhang
- Department of Radiology, Beijing Hospital of Traditional Chinese Medicine Affiliated to Capital Medical University, Beijing, China
| | - Yihan Cao
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Hongli Jing
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Fa Zhang
- Institute of Clinical Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Chenyang Yu
- Institute of Clinical Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yanying Yu
- Institute of Clinical Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Chen Li
- Department of Traditional Chinese Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China, No. 1 Shuaifuyuan, Beijing, 100730, China.
| | - Hongmei Song
- Department of Pediatrics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Wen Zhang
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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18
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The peculiarities and treatment outcomes of the spinal form of chronic non-bacterial osteomyelitis in children: a retrospective cohort study. Rheumatol Int 2019; 40:97-105. [DOI: 10.1007/s00296-019-04479-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 11/12/2019] [Indexed: 01/08/2023]
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19
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Andronikou S, Mendes da Costa T, Hussien M, Ramanan A. Radiological diagnosis of chronic recurrent multifocal osteomyelitis using whole-body MRI-based lesion distribution patterns. Clin Radiol 2019; 74:737.e3-737.e15. [DOI: 10.1016/j.crad.2019.02.021] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 02/28/2019] [Indexed: 11/25/2022]
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20
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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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21
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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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22
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Heath MS, Ortega-Loayza AG. Insights Into the Pathogenesis of Sweet's Syndrome. Front Immunol 2019; 10:414. [PMID: 30930894 PMCID: PMC6424218 DOI: 10.3389/fimmu.2019.00414] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 02/15/2019] [Indexed: 12/15/2022] Open
Abstract
Sweet's syndrome, also known as Acute Febrile Neutrophilic Dermatosis, is a rare inflammatory condition. It is considered to be the prototype disease of neutrophilic dermatoses, and presents with acute onset dermal neutrophilic lesions, leukocytosis, and pyrexia. Several variants have been described both clinically and histopathologically. Classifications include classic Sweet's syndrome, malignancy associated, and drug induced. The cellular and molecular mechanisms involved in Sweet's syndrome have been difficult to elucidate due to the large variety of conditions leading to a common clinical presentation. The exact pathogenesis of Sweet's syndrome is unclear; however, new discoveries have shed light on the role of inflammatory signaling, disease induction, and relationship with malignancy. These findings include an improved understanding of inflammasome activation, malignant transformation into dermal infiltrating neutrophils, and genetic contributions. Continued investigations into effective treatments and targeted therapy will benefit patients and improve our molecular understanding of inflammatory diseases, including Sweet's syndrome.
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Affiliation(s)
- Michael S Heath
- Oregon Health and Science University, Department of Dermatology, Portland, OR, United States
| | - Alex G Ortega-Loayza
- Oregon Health and Science University, Department of Dermatology, Portland, OR, United States
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23
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Snipaitiene A, Sileikiene R, Klimaite J, Jasinskiene E, Uktveris R, Jankauskaite L. Unusual case of chronic recurrent multifocal osteomyelitis. Pediatr Rheumatol Online J 2018; 16:49. [PMID: 30053822 PMCID: PMC6062932 DOI: 10.1186/s12969-018-0267-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 07/19/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Chronic recurrent multifocal osteomyelitis (CRMO) is a rare auto-inflammatory bone disorder that primarily affects young girls, with a mean age of 10 years at onset. Generally, it is a self-limited disease. However, recent data indicate that more than 50% of patients have a chronic persistent disease and about 20% a recurring course of this condition. Also, there are more cases reported with associated auto-inflammatory and autoimmune diseases. In this case report, we present a rare case of sporadic CRMO in which the patient eventually developed C-ANCA (cytoplasmic anti-neutrophil cytoplasmic antibodies)-associated renal vasculitis and hyperparathyroidism. CASE PRESENTATION A 14 year old female patient was brought to the emergency department with a sudden onset of left leg pain and oedema. After physical evaluation and initial investigation, she was diagnosed with femoral and pelvic deep vein thrombosis. While searching for possible thrombosis causes, osteomyelitis of the left leg was identified. Additional CT and MRI scans hinted at the CRMO diagnosis. Due to the multifocal lesions of CRMO, endocrinological evaluation of calcium metabolism was done. The results showed signs of hyperparathyroidism with severe hypocalcaemia. Moreover, when kidney damage occurred and progressed, a kidney biopsy was performed, revealing a C-ANCA associated renal vasculitis. Treatment was started with cyclophosphamide and prednisolone according to the renal vasculitis management protocol. Severe metabolic disturbances and hyperparathyroidism were treated with alfacalcidol, calcium and magnesium supplements. Secondary glomerulonephritis (GN) associated hypertension was treated with ACE (angiotenzine converting enzyme) inhibitors. Anticoagulants were prescribed for deep vein thrombosis. After 1.5 years of treatment, the patient is free of complaints. All microelement and parathormone levels are within normal range. Kidney function is now normal. To date, there are no clinical or diagnostic signs of deep vein thrombosis. CONCLUSIONS This case report presents a complex immunodysregulatory disorder with both auto-inflammatory and autoimmune processes. We hypothesize that the long lasting active inflammation of CRMO may induce an autoimmune response and result in concomitant diseases like C-ANCA-associated vasculitis in our patient. Any potential specific pathogenic relationships between these two rare pathologies may need to be further studied. Furthermore, there is a lack of specific biomarkers for CRMO and more studies are necessary to identify CRMO's characteristic patterns and how to best monitor disease progression.
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Affiliation(s)
- Ausra Snipaitiene
- The Lithuanian University of Health Sciences, A. Mickevičiaus g. 9, Kaunas, Lithuania. .,The Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Eiveniu g. 2, Kaunas, Lithuania.
| | - Rima Sileikiene
- 0000 0004 0432 6841grid.45083.3aThe Lithuanian University of Health Sciences, A. Mickevičiaus g. 9, Kaunas, Lithuania ,0000 0004 0575 8750grid.48349.32The Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Eiveniu g. 2, Kaunas, Lithuania
| | - Justina Klimaite
- 0000 0004 0575 8750grid.48349.32The Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Eiveniu g. 2, Kaunas, Lithuania
| | - Edita Jasinskiene
- 0000 0004 0432 6841grid.45083.3aThe Lithuanian University of Health Sciences, A. Mickevičiaus g. 9, Kaunas, Lithuania ,0000 0004 0575 8750grid.48349.32The Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Eiveniu g. 2, Kaunas, Lithuania
| | - Rimantas Uktveris
- 0000 0004 0432 6841grid.45083.3aThe Lithuanian University of Health Sciences, A. Mickevičiaus g. 9, Kaunas, Lithuania ,0000 0004 0575 8750grid.48349.32The Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Eiveniu g. 2, Kaunas, Lithuania
| | - Lina Jankauskaite
- 0000 0004 0432 6841grid.45083.3aThe Lithuanian University of Health Sciences, A. Mickevičiaus g. 9, Kaunas, Lithuania ,0000 0004 0575 8750grid.48349.32The Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Eiveniu g. 2, Kaunas, Lithuania
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24
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Le Saux N. Le diagnostic et la prise en charge des infections ostéoarticulaires aiguës chez les enfants. Paediatr Child Health 2018. [DOI: 10.1093/pch/pxy050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nicole Le Saux
- Société canadienne de pédiatrie, comité des maladies infectieuses et d’immunisation, Ottawa (Ontario)
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25
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Le Saux N. Diagnosis and management of acute osteoarticular infections in children. Paediatr Child Health 2018; 23:336-343. [PMID: 30653632 DOI: 10.1093/pch/pxy049] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Acute hematogenous osteomyelitis and septic arthritis are not uncommon infections in children and should be considered as part of the differential diagnosis of limb pain and pseudoparalysis. Most bone infections in children arise secondary to hematogenous seeding of bacteria into bone. The most common pathogens are Staphylococcus aureus and Kingella kingae. Children with septic arthritis should be evaluated promptly by orthopedic specialists for aspiration and possible debridement of concomitant osteomyelitis. Optimal empiric therapy after appropriate cultures continues to be intravenous cefazolin. In most cases, conversion to oral antimicrobials should occur when the patient has clinically improved and has decreasing inflammatory markers. For most uncomplicated cases of osteomyelitis, current recommendations are 3 to 4 weeks of antimicrobial therapy compared with the 6 weeks previously recommended.
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Affiliation(s)
- Nicole Le Saux
- Canadian Paediatric Society, Infectious Diseases and Immunization Committee, Ottawa, Ontario
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26
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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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Schaub S, Sirkis HM, Kay J. Imaging for Synovitis, Acne, Pustulosis, Hyperostosis, and Osteitis (SAPHO) Syndrome. Rheum Dis Clin North Am 2017; 42:695-710. [PMID: 27742022 DOI: 10.1016/j.rdc.2016.07.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Multifocal osteomyelitis and synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome constitute a spectrum of disease that includes inflammatory bone lesions and dermatologic findings. Radiographic features resemble those of the spondyloarthropathies with anterior chest wall involvement. Early radiographic findings are osteodestructive with lytic lesions. Bone scintigraphy of the sternoclavicular region classically yields a 'bull's head' pattern of radionuclide uptake. Magnetic resonance imaging (MRI) can demonstrate corner lesions of vertebral bodies. Ultrasound often reveals peripheral enthesitis. Late radiographic features are usually osteoproliferative. PET/CT can identify chronic lesions. Differential diagnostic considerations include osteomyelitis and malignancy, which often prompt bone biopsy.
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Affiliation(s)
- Steven Schaub
- Division of Rheumatology, Department of Medicine, UMass Memorial Medical Center and University of Massachusetts Medical School, 119 Belmont Street, Worcester, MA 01605, USA
| | - Hartley M Sirkis
- Division of Musculoskeletal Imaging, Department of Radiology, UMass Memorial Medical Center and University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655, USA
| | - Jonathan Kay
- Division of Rheumatology, Department of Medicine, UMass Memorial Medical Center and University of Massachusetts Medical School, 119 Belmont Street, Worcester, MA 01605, USA.
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Kim SM, Eo MY, Cho YJ, Kim YS, Lee SK. Immunoprecipitation high performance liquid chromatographic analysis of healing process in chronic suppurative osteomyelitis of the jaw. J Craniomaxillofac Surg 2017; 46:119-127. [PMID: 29191501 DOI: 10.1016/j.jcms.2017.10.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Revised: 09/16/2017] [Accepted: 10/19/2017] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Chronic suppurative osteomyelitis (CSO) of the jaw is one of the most difficult infectious diseases to manage, because it causes progressive bony destruction and is associated with bacterial inhabitation of the sequestra. A combination of antibiotic therapy and surgical debridement is often used to treat CSO. Nevertheless, various systemic conditions can lead to life-threatening complications. METHODS The present study aimed to explore the wound healing progress in 16 cases of CSO through protein expression analysis of postoperative exudates (POE) that were collected 6 h, 1 day, and 2 days after saucerization and/or decortication. A bony lesion was removed during surgery and then examined pathologically, and the CSO POE was examined by immunoprecipitation thus high performance chromatography (IP-HPLC). The POE at 6 h was used as a comparative control. RESULTS Histologically the CSO lesion showed a necrotic granulomatous lesion heavily infiltrated with polymorphonuclear leukocytes, macrophages, and plasma cells, admixed with multiple sequestra inhabited by bacterial colonies. The IP-HPLC analysis displayed a slight increase in innate immunity-related proteins, i.e., NFkB, TNFα, IL-1, IL-6, IL-28, and LL-37, but a gradual decrease of bacteria-related inflammatory proteins, i.e., IL-8, IL-12, CD31, CD68, and lysozyme. The angiogenesis-related proteins, i.e., VEGF-A and VEGF-C, were slightly decreased but TGF-β1 and bFGF were markedly increased on day 2. The osteogenesis-related proteins, i.e., OPG and ALP, were slightly increased, while the osteoclastogenesis-related protein, RANKL was slightly decreased compared to the control. CONCLUSION These findings indicate that the infected CSO undergoes a rapid wound healing process with active osteogenesis and a gradual decrease in bacteria-related inflammation, predicting a favorable prognosis after surgery. Moreover, IP-HPLC can be useful in monitoring the POE and wound healing processes during the postoperative period.
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Affiliation(s)
- Soung Min Kim
- Department of Oral and Maxillofacial Surgery, Dental Research Institute, School of Dentistry, Seoul National University, Seoul, South Korea.
| | - Mi Young Eo
- Department of Oral and Maxillofacial Surgery, Dental Research Institute, School of Dentistry, Seoul National University, Seoul, South Korea.
| | - Yun Ju Cho
- Department of Oral and Maxillofacial Surgery, Dental Research Institute, School of Dentistry, Seoul National University, Seoul, South Korea.
| | - Yeon Sook Kim
- Department of Dental Hygiene, Cheongju University, Cheongju, South Korea.
| | - Suk Keun Lee
- Department of Oral Pathology, College of Dentistry, Gangneung-Wonju National University, Gangneung, South Korea.
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Mihara M, Hara H, Kikuchi K. Lymph node transfer for refractory infectious sites caused by trauma. SAGE Open Med Case Rep 2017; 5:2050313X17711631. [PMID: 28616231 PMCID: PMC5459457 DOI: 10.1177/2050313x17711631] [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: 11/12/2016] [Accepted: 05/02/2017] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE In this report, we placed focus on the immunological function of lymph nodes and performed lymph node transfer via a free flap to a site of refractory infection. CASE AND RESULTS Case 1 describes a 34-year-old male suffering from compound fractures with severe crush injuries and burns in the right ankle joint. A 20 × 15 cm skin defect was observed around the right malleolus medialis, along with denuded tendons with bacterial infection. After conservative treatment, we transferred a lymph-node-containing free superficial circumflex iliac artery perforator flap to the region, with minimum debridement. No recurrence of wound infection appeared. Case 2 describes a 73-year-old male patient suffering from extensive contused wound in the right crus. Despite conservative treatment, the tibia gradually became denuded with computed tomography and magnetic resonance imaging revealing degeneration of the tibial cortex. We performed a free superficial circumflex iliac artery perforator flap containing lymph nodes to the chronic infection area. The wound area healed successfully. CONCLUSION In conclusion, lymph node transfer has a potential of treatment infection sites.
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Affiliation(s)
- Makoto Mihara
- Department of Lymphatic and Reconstructive Surgery, Saiseikai Kawaguchi General Hospital, Saitama, Japan.,Department of Plastic and Reconstructive Surgery, Nadogaya Hospital, Chiba, Japan
| | - Hisako Hara
- Department of Lymphatic and Reconstructive Surgery, Saiseikai Kawaguchi General Hospital, Saitama, Japan
| | - Kazuki Kikuchi
- Department of Plastic and Reconstructive Surgery, Nadogaya Hospital, Chiba, Japan
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Zhang P, Jia XY, Zhang Y, Morelli J, Zhang ZK. Chronic recurrent multifocal osteomyelitis beginning with a solitary lesion of the ilium. BMC Musculoskelet Disord 2017; 18:245. [PMID: 28587611 PMCID: PMC5461680 DOI: 10.1186/s12891-017-1611-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 06/01/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chronic recurrent multifocal osteomyelitis (CRMO) is an idiopathic inflammatory disease. The initial lesions are typically found in the metaphyses, generally without periosteal reaction. CASE PRESENTATION We present a case of a 14-year-old female teenager with relapsing and remitting right iliac pain. There was no evidence of infectious organisms, neoplastic processes, or hematologic malignancy based on laboratory tests. Initial computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated atypical periosteal proliferation in the right ilium. Histopathology demonstrated only non-specific chronic inflammation compatible with CRMO. Two years later, this patient developed left humeral pain. MRI and CT images revealed thickening and marrow edema involving the humeral cortex. CONCLUSIONS This case highlights that CRMO can begin as a unifocal lesion and also possibly within the ilium, despite usually being multifocal and involving the long bone metaphysis.
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Affiliation(s)
- Ping Zhang
- Department of Radiology, The third Hospital of Hebei Medical University, Hebei Province Biomechanical Key Laborary of Orthopedics, No.139, Ziqiang Road, Shijiazhuang City, Hebei Province, 050051, China
| | - Xiao Ying Jia
- Department of Emergency, The Hebei general Hospital, Shijiazhuang, Hebei, 050051, China
| | - Yun Zhang
- Department of Outpatient, Chinese people's Armed Police Force 8640 hospital, Dingzhou, Hebei, China
| | - John Morelli
- Department of Radiology, St. Johns Medical Center, Tulsa, OK, USA
| | - Ze Kun Zhang
- Department of Radiology, The third Hospital of Hebei Medical University, Hebei Province Biomechanical Key Laborary of Orthopedics, No.139, Ziqiang Road, Shijiazhuang City, Hebei Province, 050051, China.
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[Acute haematogenous osteomyelitis in children : Diagnostic algorithm and treatment strategies]. DER ORTHOPADE 2017; 46:541-556. [PMID: 28534215 DOI: 10.1007/s00132-017-3431-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Acute haematogenous osteomyelitis (AHO) in children is a severe condition. A delay in diagnosis and insufficient treatment may result in deformities, chronicity and sepsis. Therefore a structured diagnostic workup has to be followed in order to diagnose or rule out osteomyelitis. To identify the causative agent for targeted antibiotic treatment, a bone biopsy or puncture should be performed. However, approximately 25% of cases are culture-negative even after biopsy. The knowledge of the typical age-dependent bacterial spectrum is essential for empirical antibiotic therapy. The principal causative organism is Staphylococcus aureus. Surgery is not routinely required in paediatric acute osteomyelitis but surgical intervention is indicated if an abscess is detected. Secondary septic arthritis is a serious complication which has to be treated immediately by surgical intervention. Nevertheless, complete regeneration can be expected in up to 80% of children with AHO.
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Roderick MR, Sen ES, Ramanan AV. Chronic recurrent multifocal osteomyelitis in children and adults: current understanding and areas for development. Rheumatology (Oxford) 2017; 57:41-48. [DOI: 10.1093/rheumatology/kex066] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Indexed: 11/14/2022] Open
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Wurm MC, Brecht I, Lell M, Brunner K, Mitsimponas KT, Chada M, Jahn J, Neukam FW, von Wilmowsky C. Chronic recurrent multifocal osteomyelitis in association with pyoderma gangraenosum. BMC Oral Health 2016; 16:85. [PMID: 27585859 PMCID: PMC5009688 DOI: 10.1186/s12903-016-0275-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 08/12/2016] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Matthias Christian Wurm
- Department of Oral and Maxillofacial Surgery, University of Erlangen-Nürnberg, Glückstrasse 11, 91054, Erlangen, Germany.
| | - Ines Brecht
- Department of Paediatrics and Adolescent Medicine, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Michael Lell
- Department of Radiology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Kathrin Brunner
- Department of Pathology, University of Erlangen-Nürnberg, Erlangen, Germany
| | | | - Martin Chada
- Department of Paediatrics and Adolescent Medicine, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Julia Jahn
- Department of Dermatology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Friedrich-Wilhelm Neukam
- Department of Oral and Maxillofacial Surgery, University of Erlangen-Nürnberg, Glückstrasse 11, 91054, Erlangen, Germany
| | - Cornelius von Wilmowsky
- Department of Oral and Maxillofacial Surgery, University of Erlangen-Nürnberg, Glückstrasse 11, 91054, Erlangen, Germany
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34
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Zimmermann P, Curtis N. Synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome - A challenging diagnosis not to be missed. J Infect 2016; 72 Suppl:S106-14. [PMID: 27263075 DOI: 10.1016/j.jinf.2016.04.030] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
SAPHO syndrome manifests as chronic inflammation of bones and joints, which may or may not be accompanied by skin changes. The term SAPHO is an acronym that stands for synovitis, acne, pustulosis (usually palmoplantar), hyperostosis and osteitis. The bones most commonly affected are those in the anterior chest wall (mainly the sternum, clavicles and sternocostoclavicular joints), the vertebrae and the sacroiliac joints, but peripheral and flat bones may also be involved, especially in children. There are no validated diagnostic criteria for SAPHO, and diagnosis is based on clinical and radiological findings. One of the main challenges in diagnosis is that the clinical features may occur many years apart. Additionally, patients may not develop all manifestations. Delayed diagnosis, as a result of a lack of awareness of SAPHO, can lead to patients suffering ongoing pain and disfiguring skin manifestations. One theory is that Propionibacterium acnes (isolated from bone biopsies in many SAPHO patients) triggers an auto-immune mediated chronic inflammation in genetically predisposed individuals. Treatment involves the use of nonsteroidal anti-inflammatory drugs, intra-articular steroids, bisphosphonates and biologicals. The course of SAPHO is often prolonged but, despite the challenges in diagnosis and treatment, the long-term prognosis is good.
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Affiliation(s)
- Petra Zimmermann
- Infectious Diseases Unit, The Royal Children's Hospital Melbourne, Parkville, Australia
| | - Nigel Curtis
- Infectious Diseases Unit, The Royal Children's Hospital Melbourne, Parkville, Australia; Department of Paediatrics, The University of Melbourne, Parkville, Australia; Infectious Diseases & Microbiology Research Group, Murdoch Children's Research Institute, Parkville, Australia.
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35
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Padwa BL, Dentino K, Robson CD, Woo SB, Kurek K, Resnick CM. Pediatric Chronic Nonbacterial Osteomyelitis of the Jaw: Clinical, Radiographic, and Histopathologic Features. J Oral Maxillofac Surg 2016; 74:2393-2402. [PMID: 27318191 DOI: 10.1016/j.joms.2016.05.021] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 05/14/2016] [Accepted: 05/17/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Chronic nonbacterial osteomyelitis (CNO) is a focal sterile inflammatory osteitis in children that most commonly develops in the long bones, but can occur in any bone. The disease course is variable, ranging from acute and self-resolving isolated lesions to chronic recurrent multifocal osteomyelitis (CRMO), which is frequently associated with extraosseous inflammatory disease. The purpose of this study was to present our clinical experience with CNO of the mandible in children. The specific aims were to 1) document the clinical characteristics, radiographic findings, and histologic features of CNO and 2) determine the percentage of our sample with multifocal disease (CRMO). MATERIALS AND METHODS This is a retrospective case series of patients with mandibular CNO. To be included, patients had to have a mandibular lesion radiographically consistent with osteomyelitis without infection, onset before aged 18 years, and complete records. Medical records were reviewed for history, clinical features, imaging, and pathology. Descriptive data were summarized. RESULTS The sample included 22 patients (13 female and 9 male patients) with disease onset at a mean age of 9.05 ± 2.4 years. On presentation, all patients reported mandibular pain and swelling, and 45% had trismus. All had clinical and/or radiographic findings of multifocal intraosseous disease and/or extraosseous inflammatory lesions. Of the patients, 12 (54%) had a documented family history of autoimmune or autoinflammatory disease and 15 (68%) had elevated erythrocyte sedimentation rates during a flare. Computed tomography scans typically showed expansion of the affected mandible with sclerosis of the medullary space, small foci of poorly defined lytic destruction with a lamellated periosteal reaction, and swollen muscles of mastication. Four distinct histologic features were noted including parallel and interconnected osteoid seams, atypical osteoid, areas of woven bone and hypocellular fibroblastic stroma resembling fibrous dysplasia, and patchy nodular fibrosis. CONCLUSION Pediatric CNO of the mandible has characteristic radiographic and pathologic features and is usually found as one of multiple disease foci in CRMO rather than as an isolated lesion.
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Affiliation(s)
- Bonnie L Padwa
- Associate Professor, Harvard School of Dental Medicine, Oral Surgeon-in-Chief Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA.
| | - Kelley Dentino
- Research Assistant, Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA
| | - Caroline D Robson
- Associate Professor, Harvard Medical School, Division Chief, Neuroradiology, Department of Radiology, Boston Children's Hospital, Boston, MA
| | - Sook Bin Woo
- Associate Professor, Harvard School of Dental Medicine, Division of Oral Medicine and Dentistry, Brigham and Women's Hospital, Boston, MA
| | - Kyle Kurek
- Assistant Professor, Cummings School or Medicine, University of Calgary, Departments of Pathology and Medical Genetics, Alberta Children's Hospital & Research Institute, Boston, MA
| | - Cory M Resnick
- Instructor, Harvard School of Dental Medicine, Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA
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OKAMOTO YUKA, ISHIDA HAJIME, KIMURA RYOSUKE, SATO TAKEHIRO, TSUCHIYA NANAE, MURAYAMA SADAYUKI, FUKASE HITOSHI, NAGAOKA TOMOHITO, ADACHI NOBORU, YONEDA MINORU, WEBER ANDRZEJ, KATO HIROFUMI. An Okhotsk adult female human skeleton (11th/12th century AD) with possible SAPHO syndrome from Hamanaka 2 site, Rebun Island, northern Japan. ANTHROPOL SCI 2016. [DOI: 10.1537/ase.160608] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- YUKA OKAMOTO
- Department of Human Biology and Anatomy, Graduate School of Medicine, University of the Ryukyus, Nishihara-cho
| | - HAJIME ISHIDA
- Department of Human Biology and Anatomy, Graduate School of Medicine, University of the Ryukyus, Nishihara-cho
| | - RYOSUKE KIMURA
- Department of Human Biology and Anatomy, Graduate School of Medicine, University of the Ryukyus, Nishihara-cho
| | - TAKEHIRO SATO
- Department of Human Biology and Anatomy, Graduate School of Medicine, University of the Ryukyus, Nishihara-cho
| | - NANAE TSUCHIYA
- Department of Radiology, Graduate School of Medicine, University of the Ryukyus, Nishihara-cho
| | - SADAYUKI MURAYAMA
- Department of Radiology, Graduate School of Medicine, University of the Ryukyus, Nishihara-cho
| | - HITOSHI FUKASE
- Division of Human Evolution Studies, Graduate School of Medicine, Hokkaido University, Sapporo
| | - TOMOHITO NAGAOKA
- Department of Anatomy, St. Marianna University School of Medicine, Kawasaki
| | - NOBORU ADACHI
- Department of Legal Medicine, University of Yamanashi Interdisciplinary Graduate School of Medicine and Engineering, Chuo
| | | | - ANDRZEJ WEBER
- Department of Anthropology, University of Alberta, Edmonton
- Laboratoire Méditerranéen de Préhistoire Europe Afrique (LAMPEA)—UMR 7269, Aix-Marseille Université, Aix-en-Provence
| | - HIROFUMI KATO
- Hokkaido University Center for Ainu and Indigenous Studies, Sapporo
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Espirito Santo AI, Ersek A, Freidin A, Feldmann M, Stoop AA, Horwood NJ. Selective inhibition of TNFR1 reduces osteoclast numbers and is differentiated from anti-TNF in a LPS-driven model of inflammatory bone loss. Biochem Biophys Res Commun 2015; 464:1145-1150. [PMID: 26208457 DOI: 10.1016/j.bbrc.2015.07.094] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 07/20/2015] [Indexed: 12/28/2022]
Abstract
The treatment of autoimmune disorders has been revolutionised by the introduction of biologics such as anti-tumour necrosis factor (anti-TNF). Although in rheumatoid arthritis patients a bone sparing effect of anti-TNF has been shown, the mechanism is not fully understood. Anti-TNF molecules block tumour necrosis factor (TNF) and prevent signalling via both TNF receptor 1 (TNFR1; p55) and TNF receptor 2 (TNFR2; p75). However, signalling via TNFR2 is reported to have protective effects in a number of cell and organ systems. Hence we set out to investigate if pharmacological inhibition of TNFR1 had differential effects compared to pan-TNF inhibition in both an in vitro cell-based model of human osteoclast activity and an in vivo mouse model of lipopolysaccharide (LPS)-induced osteolysis. For the in vitro experiments the anti-human TNFR1 domain antibody (dAb) DMS5541 was used, whereas for the in vivo mouse experiments the anti-mouse TNFR1 dAb DMS5540 was used. We show that selective blocking of TNFR1 signalling reduced osteoclast formation in the presence of TNF. Subcutaneous LPS injection over the calvaria leads to the development of osteolytic lesions within days due to inflammation driven osteoclast formation. In this model, murine TNFR2 genetically fused with mouse IgG1 Fc domain (mTNFR2.Fc), an anti-TNF, did not protect from bone loss in contrast to anti-TNFR1, which significantly reduced lesion development, inflammatory infiltrate, and osteoclast number and size. These results support further exploring the use of TNFR1-selective inhibition in inflammatory bone loss disorders such as osteomyelitis and peri-prosthetic aseptic loosening.
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Affiliation(s)
- A I Espirito Santo
- Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Roosevelt Drive, Headington, Oxford, OX3 7FY, United Kingdom
| | - A Ersek
- Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Roosevelt Drive, Headington, Oxford, OX3 7FY, United Kingdom
| | - A Freidin
- Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Roosevelt Drive, Headington, Oxford, OX3 7FY, United Kingdom
| | - M Feldmann
- Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Roosevelt Drive, Headington, Oxford, OX3 7FY, United Kingdom
| | - A A Stoop
- GlaxoSmithKline, Biopharm R&D, Stevenage, UK
| | - N J Horwood
- Kennedy Institute of Rheumatology, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Roosevelt Drive, Headington, Oxford, OX3 7FY, United Kingdom.
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Chronic recurrent multifocal osteomyelitis with an atypical presentation in an adult man. Skeletal Radiol 2015; 44:1359-64. [PMID: 25771734 DOI: 10.1007/s00256-015-2130-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 02/20/2015] [Accepted: 02/26/2015] [Indexed: 02/02/2023]
Abstract
We present the case of a 33-year-old man with no significant medical history who developed right scapular pain, left-sided sacroiliac joint pain, and lower back pain, and was eventually diagnosed with chronic recurrent multifocal osteomyelitis (CRMO). Imaging demonstrated multiple scattered T2-hyperintense lesions on MRI at the spine and the left SI joint, some of which progressed and one regressed in size on follow-up. Histopathology demonstrated only non-specific chronic inflammation compatible with CRMO. No evidence of infectious organisms or neoplastic processes was found. The pain was relapsing and remitting in nature. Laboratory investigations were notable for no evidence of hematologic malignancy or infection, but only a mild increase in alkaline phosphatase. This case highlights that CRMO, despite being thought of as a childhood-onset disease, can present in adults as well, and also provides illustrative examples of imaging and histological findings.
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Baroncelli GI, Bertelloni S. The use of bisphosphonates in pediatrics. Horm Res Paediatr 2015; 82:290-302. [PMID: 25376487 DOI: 10.1159/000365889] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 07/09/2014] [Indexed: 11/19/2022] Open
Abstract
Bisphosphonates are widely used for the prevention and treatment of osteoporosis in adulthood. In the last years, bisphosphonates have been increasingly used in pediatric patients for the treatment of a growing number of disorders associated with osteoporosis, resistant hypercalcemia or heterotopic calcifications. The use of bisphosphonates in pediatric patients has been proven safe; however, the risk of potential severe consequences into adulthood should be kept in mind. Well-defined criteria for bisphosphonates treatment in pediatric patients are not specified, therefore an accurate selection of patients who could benefit from bisphosphonates is mandatory. A strict follow-up of pediatric patients receiving long-term bisphosphonate therapy is strongly recommended. The purpose of this mini review is to provide a summary of current knowledge on some main general aspects of the structure, mechanisms of action, pharmacokinetics, and bioavailability of bisphosphonates, and to focus on the latest advances of bisphosphonate treatment in pediatric patients. Particular attention has been paid to the common and potential adverse effects of bisphosphonate treatment, and some suggestions concerning the clinical approach and general measures for bisphosphonate treatment in pediatric patients are reported.
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Affiliation(s)
- Giampiero I Baroncelli
- Pediatric Unit I, Department of Obstetrics, Gynecology and Pediatrics, University Hospital, Pisa, Italy
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Batu ED, Ergen FB, Gulhan B, Topaloglu R, Aydingoz U, Ozen S. Etanercept treatment in five cases of refractory chronic recurrent multifocal osteomyelitis (CRMO). Joint Bone Spine 2015; 82:471-3. [PMID: 26184538 DOI: 10.1016/j.jbspin.2014.11.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 11/25/2014] [Indexed: 12/13/2022]
Affiliation(s)
- Ezgi Deniz Batu
- Department of Pediatric Rheumatology, Hacettepe University, Faculty of Medicine, Sıhhiye, 06100 Ankara, Turkey
| | - Fatma Bilge Ergen
- Department of Radiology, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Bora Gulhan
- Department of Pediatric Nephrology, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Rezan Topaloglu
- Department of Pediatric Nephrology, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Ustun Aydingoz
- Department of Radiology, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Seza Ozen
- Department of Pediatric Rheumatology, Hacettepe University, Faculty of Medicine, Sıhhiye, 06100 Ankara, Turkey.
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Chronic recurrent multifocal osteomyelitis: typical patterns of bone involvement in whole-body bone scintigraphy. Nucl Med Commun 2015; 35:797-807. [PMID: 24736329 DOI: 10.1097/mnm.0000000000000126] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory bone disease of unknown etiology. It affects children and adolescents predominantly and occurs mostly in the female population. It is characterized by the insidious onset of pain and swelling, with a fluctuating clinical course of relapses and remissions. Typically, several bones are affected, either synchronously or metachronously, and bilateral involvement is common. CRMO most commonly affects the metaphysis of long bones, especially the tibia, femur, and clavicle. The spine, pelvis, ribs, sternum, and mandible may also be affected. Although lesions are mostly multiple, patients may present with a single symptomatic focus. Radiographic findings may be negative early in the course of the disease. Bone scintigraphy is useful in determining the presence of abnormality and the extent of disease. The imaging and clinical features of CRMO overlap with those of infectious osteomyelitis, bone malignancy, and inflammatory arthritis. Nonetheless, CRMO can be confidently diagnosed with the recognition of typical imaging patterns in the appropriate clinical setting. This article reviews imaging findings with special emphasis on bone scintigraphy and specific disease sites.
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Chronic non-bacterial osteomyelitis in a patient with common variable immunodeficiency. Joint Bone Spine 2014; 81:193-4. [DOI: 10.1016/j.jbspin.2013.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 08/09/2013] [Indexed: 11/22/2022]
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