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Bouchalova K, Pytelova Z. Chronic non-bacterial osteomyelitis (CNO) and chronic recurrent multifocal osteomyelitis (CRMO) with a focus on pamidronate therapy. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2024. [PMID: 38682664 DOI: 10.5507/bp.2024.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2024] Open
Abstract
Chronic recurrent multifocal osteomyelitis (CRMO), also called chronic nonbacterial osteomyelitis (CNO) or nonbacterial osteomyelitis (NBO), is a rare autoinflammatory bone disease of unknown etiology. However, the number of patients properly diagnosed would increase with better knowledge of the disease. In this regard, whole-body magnetic resonance imaging (WB MRI) has been found to be a better predictor of active lesions than clinical examination. Importantly, the RINBO index (radiologic index for NBO) quantifies the involvement based on the WB MRI. Further, a chronic nonbacterial osteomyelitis MRI scoring (CROMRIS) has been developed as an online tool for assessing WB MRI. The therapy consists of non-steroidal anti-inflammatory drugs (NSAIDs), bisphosphonates (pamidronate, zoledronate, etc.) and other drugs, including biologics. Pamidronate is an appropriate and safe therapy. The first pilot prospective randomised controlled trial (RCT) on pamidronate vs. placebo was carried out in adults. No RCT has been done in children yet. Besides RCTs, there are a number of issues to be explored in future, i.e. predictors of therapy effect, optimal therapy duration, predictors of therapy discontinuation and evaluation of optimal therapy protocol. Recently, the CNO clinical disease activity score (CDAS) was constructed and validated but the classification criteria are still being developed. As collaboration on this rare disease is essential, a prospective Chronic Nonbacterial Osteomyelitis International Registry (CHOIR) was established to generate future comparative effectiveness research data.
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Affiliation(s)
- Katerina Bouchalova
- Department of Pediatrics, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic
| | - Zuzana Pytelova
- Department of Pediatrics, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic
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Martinez Suarez YP, Amador Gutiérrez JA. Chronic recurrent multifocal osteomyelitis, a rare disease. Case report. CASE REPORTS 2022. [DOI: 10.15446/cr.v8n1.91304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Introduction: Chronic recurrent multifocal osteomyelitis (CRMO) is a rare inflammatory bone disease usually observed in children and adolescents. It is caused by an imbalance between proinflammatory and anti-inflammatory factors. To establish its diagnosis, it is necessary to integrate clinical and laboratory elements that are typically aimed at ruling out other conditions, constituting a diagnosis of exclusion. Treatment is based on non-steroidal anti-inflammatory drugs and other drugs in specific cases.
Case presentation: A 16-year-old female patient with a 1-year history of joint pain, especially in the knees, accompanied by signs of local inflammation was admitted to the emergency department of a quaternary care hospital due to a fever >38.5°, odynophagia, asthenia, and adynamia over the last two days. The patient underwent multiple extension studies, including laboratory, imaging and histopathological tests, which ruled out various etiologic causes. She received empirical antibiotic treatment without remission of symptoms, so a diagnosis of CRMO was finally established and outpatient treatment with non-steroidal anti-inflammatory drugs and corticosteroids was indicated, obtaining a favorable response.
Conclusions: CRMO should be considered in children and adolescents with bone pain and a poorly defined clinical history with non-specific laboratory, imaging and histopathological findings. To date, little is known about CRMO, so it is necessary to carry out research and expand the knowledge related to this disease.
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St Jeor JD, Thomas KB, Thacker PG, Hull NC. Multifocal subacute osteomyelitis in adjacent bones in the ankle without septic joint. Radiol Case Rep 2020; 15:1927-1930. [PMID: 32874386 PMCID: PMC7452080 DOI: 10.1016/j.radcr.2020.07.073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/24/2020] [Accepted: 07/25/2020] [Indexed: 11/27/2022] Open
Abstract
Osteomyelitis is an inflammation involving bone and/or bone marrow most often the result of bacterial infection of the bone. In children, osteomyelitis most often has an acute presentation and is caused by hematogenous spread. When osteomyelitis is seen in the extremities, conventional radiography is the first-line imaging modality preformed for diagnosis with magnetic resonance imaging employed for further delineation or as a problem-solving tool. A healthy 6-year-old female presented with a history of nonspecific left leg pain for 3-5 weeks which gradually progressed to focal left ankle pain and swelling. Further workup revealed multifocal subacute osteomyelitis with Brodie's abscesses seen on imaging in the absence of a septic joint. This was an uncommon presentation for the following reasons: Patients with multifocal osteomyelitis usually present in the acute setting, as opposed to the subacute setting. When osteomyelitis is multifocal or Brodie's abscesses are present adjacent to the joint capsule, concomitant septic joint is commonly seen.
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Affiliation(s)
- Jeffery D St Jeor
- Mayo Clinic School of Medicine, 200 1st St SW, Rochester, MN 55902, USA
| | | | - Paul G Thacker
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Nathan C Hull
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
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Abstract
BACKGROUND Chronic recurrent multifocal osteomyelitis (CRMO) is a rare auto-inflammatory disease of the bone. It tends to be multifocal and usually the symptoms tend to run for months and years before diagnosis is usually made. The objective of our study was to understand the clinical presentation and short-term response to treatment of CRMO patients. MATERIALS AND METHODS A retrospective analysis of patients diagnosed with CRMO between 2011 and 2016 was done. Case records of these were retrospectively reviewed for clinical features, investigations and treatment received. RESULTS Six patients were diagnosed with CRMO. The median age of onset and time to diagnosis from onset of symptoms was 8 and 3.5 years respectively. Lower limb bones were the most commonly involved. CONCLUSIONS There is significant delay in diagnosis of CRMO and this could be because of a lack of awareness of this condition amongst clinicians. Our case series with only male affection is rather unique as compared to other case series reported in medical literature which tend to have more female predilection. Pain with or without swelling was the most common symptom. Most of patients responded to combination therapy.
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Affiliation(s)
- Anand Prahalad Rao
- Pediatric Rheumatology Clinic, Manipal Hospital and Vijaya Children's Clinic, Indira Gandhi Institute of Child Health, Bengaluru, Karnataka, India
| | - Pooja Prakash Mallya
- Department of Pediatric Hemato-Oncology, Mazumdar Shaw Cancer Center, Bengaluru, Karnataka, India,Address for correspondence: Dr. Pooja Prakash Mallya, 46, 2nd Cross, Panduranga Nagar, Bannerghatta Road, Bengaluru - 560 076, Karnataka, India. E-mail:
| | - Shashi Ranjani
- Department of Pediatric Hemato-Oncology, Healthcare Global Enterprises, Bengaluru, Karnataka, India
| | - Jyothi Raghuram
- Pediatric Rheumatology Clinic, Indira Gandhi Institute of Child Health and Columbia Asia Hospital, Bengaluru, Karnataka, India
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Tronconi E, Miniaci A, Baldazzi M, Greco L, Pession A. Biologic treatment for chronic recurrent multifocal osteomyelitis: report of four cases and review of the literature. Rheumatol Int 2017; 38:153-160. [PMID: 29127574 DOI: 10.1007/s00296-017-3877-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 11/04/2017] [Indexed: 12/20/2022]
Abstract
Chronic recurrent multifocal osteomyelitis (CRMO) is a rare non-infectious inflammatory disorder with unpredictable clinical course, characterized by acute exacerbations and spontaneous remissions. There are no randomized-controlled trials about treatment options. Non-steroidal anti-inflammatory drugs (NSAID) are the first-line treatment option; glucocorticoids seem to be effective; positive outcomes have been obtained with bisphosphonates. In the last few years successful use of biologic agents like anti-TNF agents has been reported. We report the cases of 3 children suffering from CRMO who were treated with NSAID, steroid, bisphosphonates and eventually received etanercept and 1 case without vertebral involvement treated with etanercept after NSAID and steroid; all cases showed clinical improvement. The mean ages at symptoms onset and diagnosis were 8 and 10 years and 10 months, respectively. Two patients presented with back pain and three had vertebral lesions. Mean interval from diagnosis to the onset of anti-TNF treatment was 14 months. According to our small experience, we suggest considering therapy with etanercept for the treatment of severe cases with persistently active disease despite multiple treatments.
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Affiliation(s)
- Elena Tronconi
- Pediatric Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 9, Bologna, Italy.
| | - Angela Miniaci
- Pediatric Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 9, Bologna, Italy
| | - Michelangelo Baldazzi
- Pediatric Radiology Unit, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Laura Greco
- Pediatric Radiology Unit, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Andrea Pession
- Pediatric Unit, Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 9, Bologna, Italy
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Taddio A, Zennaro F, Pastore S, Cimaz R. An Update on the Pathogenesis and Treatment of Chronic Recurrent Multifocal Osteomyelitis in Children. Paediatr Drugs 2017; 19:165-172. [PMID: 28401420 DOI: 10.1007/s40272-017-0226-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Chronic recurrent multifocal osteomyelitis (CRMO), also known as chronic non-bacterial osteomyelitis (CNO), is a rare inflammatory disorder that primarily affects children. It is characterized by pain, local bone expansion, and radiological findings suggestive of osteomyelitis, usually at multiple sites. CRMO predominantly affects the metaphyses of long bones, but involvement of the clavicle or mandible are suggestive of the diagnosis. CRMO is a diagnosis of exclusion, and its pathogenesis remains unknown. Differential diagnosis includes infection, malignancies, benign bone tumors, metabolic disorders, and other autoinflammatory disorders. Biopsy of the bone lesion is not often required but could be necessary in unclear cases, especially for differentiation from bone neoplasia. Non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment. Alternative therapies have been used, including corticosteroids, methotrexate, bisphosphonates, and tumor necrosis factor (TNF)-α inhibitors. No guidelines have been established regarding diagnosis and treatment options. This manuscript gives an overview of the most recent findings on the pathogenesis of CRMO and clinical approaches for patients with the condition.
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Affiliation(s)
- Andrea Taddio
- Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", via dell'Istria 65/1, 34100, Trieste, Italy. .,University of Trieste, Piazzale Europa, 1, 34100, Trieste, Italy.
| | - Floriana Zennaro
- Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", via dell'Istria 65/1, 34100, Trieste, Italy
| | - Serena Pastore
- Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", via dell'Istria 65/1, 34100, Trieste, Italy
| | - Rolando Cimaz
- Rheumatology Unit, Anna Meyer Children's Hospital, University of Florence, Viale Pieraccini 24, 50139, Florence, Italy
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Ariza Jiménez AB, Núñez Cuadros E, Galindo Zavala R, Núñez Caro L, Díaz-Cordobés Rego G, Urda Cardona A. Recurrent multifocal osteomyelitis in children: Experience in a tertiary care center. ACTA ACUST UNITED AC 2017; 14:334-338. [PMID: 28528870 DOI: 10.1016/j.reuma.2017.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 02/25/2017] [Accepted: 04/06/2017] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Chronic recurrent multifocal osteomyelitis is a rare aseptic bone inflammation that affects pediatric patients. Its management and treatment have not yet been standardized. METHODS Retrospective, descriptive study of patients under 14 years of age diagnosed with chronic nonbacterial osteomyelitis (CNBO) in a tertiary hospital. We included patients diagnosed over the last 6 years (2010-2015) who met the Jansson criteria. The clinical and radiological characteristics of CNBO were analyzed, as was the outcome after different therapeutic options. RESULTS We report 12 patients, with a mean age of 11 years (±1.6 standard deviation [SD]) and female predominance (10:2). The mean number of foci was 3.5 (±2.2 SD). The most common locations were ankle (58%), clavicle (50%), sternum (33%) and hip (25%). The mean disease duration was 10.5 months (±10.3 SD), and the median time to diagnosis was 2.38 months (range 0.17-16). Bone scintigraphy detected asymptomatic foci in 33% and we detected lytic lesions in 50% through magnetic resonance imaging. Biopsy was performed in 60%; 2/12 (16%) were associated with inflammatory disease and 1/12 (8.3%) later developed lymphoma. In all, 58% received antibiotic therapy with little response, 100% anti-inflammatory agents, 50% systemic corticosteroids, 41.6% methotrexate/pamidronate and 16% anti-tumor necrosis factor (TNF) α. The mean duration of treatment was 14.8 months (±12.4 SD) and 66% had recurrences. Currently, 83% are in clinical remission without treatment. CONCLUSIONS When CNBO is refractory to treatment with anti-inflammatory drugs, intravenous pamidronate can be an alternative. Anti-TNF drugs can be considered in patients who fail with pamidronate, as can agents associated with other autoimmune conditions.
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Affiliation(s)
| | | | - Rocío Galindo Zavala
- Unidad de Reumatología Pediátrica, Hospital Materno-Infantil de Málaga, Málaga, España
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Rivas Felice J, González Herranz P, Mejía Casado A, Pérez Navarro R, Hernández Díaz R. Chronic recurrent osteomyelitis: A diagnostic and therapeutic challenge. Rev Esp Cir Ortop Traumatol (Engl Ed) 2017. [DOI: 10.1016/j.recote.2016.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Rivas Felice J, González Herranz P, Mejía Casado A, Pérez Navarro R, Hernández Díaz R. Chronic recurrent osteomyelitis: A diagnostic and therapeutic challenge. Rev Esp Cir Ortop Traumatol (Engl Ed) 2016; 61:35-42. [PMID: 27514713 DOI: 10.1016/j.recot.2016.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Revised: 07/03/2016] [Accepted: 07/06/2016] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Chronic recurrent osteomyelitis (CRO) is a rare disease characterised by unifocal or multifocal aseptic inflammatory bony lesions. OBJECTIVE To evaluate clinical features and response to treatment with non-steroidal anti-inflammatory drugs in patients with CRO. MATERIALS AND METHODS A retrospective assessment was conducted on 5 children with OCR over a period of 8 years. They had been diagnosed based on clinical, laboratory findings, histological study of injuries, and imaging test. RESULTS Multifocal disease was observed in 40% of cases, and unifocal in 60%. The large majority (80%) were male, with a mean age at diagnosis of 13 years (range: 11-15 years). The bones most frequently affected were the clavicle and tibia, representing 18.2%. The most common presenting symptom was pain in all patients, with fever being present in 20% of cases. Imaging studies such as CT and MRI were effective in 100%, and in all cases the biopsy reported a lymphoplasmacytic infiltrate. After a mean follow-up of 5.9 years, there was a good treatment response in 100%, with a mean recurrence at 5.25 months being observed. CONCLUSIONS The anodyne results of most clinical studies to assess CRO, and the similarity in clinical presentation of this with many infectious or tumour diseases makes its diagnosis a real challenge. On the other hand treatment with NSAIDs can be considered a good initial therapeutic option.
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Affiliation(s)
- J Rivas Felice
- Servicio de Cirugía Ortopédica y Traumatología, Hospital General de La Palma, Breña Alta, España.
| | | | - A Mejía Casado
- Servicio de Cirugía Ortopédica y Traumatología, Hospital Royo Villanova, Zaragoza, España
| | - R Pérez Navarro
- Servicio de Cirugía Ortopédica y Traumatología, Hospital General de La Palma, Breña Alta, España
| | - R Hernández Díaz
- Servicio de Cirugía Ortopédica y Traumatología, Hospital General de La Palma, Breña Alta, España
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