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Ramautar AIE, Navas A, Winter EM, Kroon HM, Smit F, Vriens D, Hamdy NAT, Appelman-Dijkstra NM. Defining the imaging diagnostic criteria for adult chronic non-bacterial osteitis. JBMR Plus 2024; 8:ziae024. [PMID: 38606147 PMCID: PMC11008733 DOI: 10.1093/jbmrpl/ziae024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 01/19/2024] [Accepted: 01/30/2024] [Indexed: 04/13/2024] Open
Abstract
Osteitis of the sternocostoclavicular (SCC) region, referred to as sternocostoclavicular hyperostosis (SCCH), is the clinical expression of chronic non-bacterial osteitis (CNO) in adults with this rare chronic auto-inflammatory disorder of the axial skeleton. The diagnosis is based on distinctive computerized tomography (CT) features of sclerosis and hyperostosis of the SCC region, and local increases in osteoid formation visualized by high radiopharmacon uptake on skeletal scintigraphy but clear radiologic diagnostic criteria are lacking. In a cross-sectional study, CT scans and whole-body skeletal scintigraphy images obtained in 169 patients seen at the Center for Bone Quality of the Leiden University Medical Center between 2008 and 2018 with a suspected diagnosis of CNO of the SCC region were re-evaluated by 2 skeletal radiologists and 2 nuclear physicians. The diagnosis was confirmed in 118 (70%) predominantly female patients (n = 103, 89.2%); median age at first symptoms 45 years (range 20-73). The diagnosis was excluded in the remaining 51 "non-CNO" patients. Increased radiopharmacon uptake at the SCC region was observed in 82% CNO patients, with the manubrium sterni having the highest predictive ability to discriminate on both imaging modalities. The prevalence of sclerosis of the clavicles, manubrium and first ribs was significantly higher in CNO patients (P < 0.001). Hyperostosis was not observed in non-CNO patients. 46 CNO versus only 2 non-CNO patients had costoclavicular ligament calcification. Our findings identify CT scan features of sclerosis and hyperostosis of manubrium sterni, medial end of clavicles and first ribs, and calcification of costoclavicular ligaments, associated with increased tracer uptake on skeletal scintigraphy at the SCC region, specifically manubrium sterni, as well-defined imaging diagnostic criteria for adult CNO. Pitfalls encountered in the diagnosis of CNO are highlighted. These defined imaging diagnostic criteria for adult CNO should facilitate the diagnosis of this rare auto-inflammatory bone disease across the spectrum of its early to late stages.
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Affiliation(s)
- Ashna I E Ramautar
- Centre for Bone Quality, Division of Endocrinology, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Ana Navas
- Section of Musculoskeletal Radiology, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Elizabeth M Winter
- Centre for Bone Quality, Division of Endocrinology, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Herman M Kroon
- Section of Musculoskeletal Radiology, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frits Smit
- Section of Nuclear Medicine, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Nuclear Medicine, Alrijne Hospital, Leiderdorp, The Netherlands
| | - Dennis Vriens
- Section of Nuclear Medicine, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Neveen A T Hamdy
- Centre for Bone Quality, Division of Endocrinology, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Natasha M Appelman-Dijkstra
- Centre for Bone Quality, Division of Endocrinology, Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands
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Dierckx S, Nisolle JF, Boutsen Y. Dramatic response of synovitis, acne, pustulosis, hyperostosis, and osteitis syndrome to tofacitinib monotherapy: a case report. J Med Case Rep 2024; 18:57. [PMID: 38360816 PMCID: PMC10870493 DOI: 10.1186/s13256-024-04366-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 01/05/2024] [Indexed: 02/17/2024] Open
Abstract
INTRODUCTION The synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome is a rare condition. Its treatment remains a challenge for clinicians, and often yields mixed results. CASE We report the case of a 51-year-old Caucasian woman who presented with SAPHO syndrome with mainly axial involvement. She had been treated with sulfasalazine and anti-inflammatory drugs for many years without any success. A few weeks after starting treatment with tofacitinib, both clinical and biological parameters dramatically improved. Imaging also showed considerable regression of the vertebral and pelvic lesions. However, tofacitinib had to be discontinued due to the occurrence of pulmonary embolism. Consequently, recurrence of bone pain and biologic inflammation was rapidly observed. CONCLUSIONS Anti-JAKs are an interesting treatment option in the management of SAPHO syndrome that need further clinical trials and assessment for validating response.
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Affiliation(s)
- Stéphanie Dierckx
- Department of Rheumatology, CHU UCL Namur, Mont-Godinne, 1 Avenue Gaston Therasse, 5530, Yvoir, Belgium.
| | - Jean-François Nisolle
- Department of Radiology, CHU UCL Namur, Mont-Godinne, 1 Avenue Gaston Therasse, 5530, Yvoir, Belgium
| | - Yves Boutsen
- Department of Rheumatology, CHU UCL Namur, Mont-Godinne, 1 Avenue Gaston Therasse, 5530, Yvoir, Belgium
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Awadh NI, Gorial FI, Al-Obaidi AD, Hashim HT, Al-Obaidi MN, Hammadi RA. Unusual cause of inflammatory backache: SAPHO syndrome. Int J Rheum Dis 2024; 27:e14878. [PMID: 37592395 DOI: 10.1111/1756-185x.14878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 07/18/2023] [Accepted: 08/03/2023] [Indexed: 08/19/2023]
Abstract
Synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) is a rare chronic inflammatory disease that develops in adults. We present a case of SAPHO syndrome in a 37-year-old male presenting with gradually worsening back and neck pain for a 7-year period. The episodes were preceded by a history of pustular skin eruptions, which first appeared on the upper trunk and then involved his face and were pustular and scarring. The purpose of presenting this case report from Iraq is to raise awareness about this rare condition, which is frequently misdiagnosed and under-recognized.
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Affiliation(s)
- Nabaa Ihsan Awadh
- Rheumatology Unit, Department of Internal Medicine, Baghdad Teaching Hospital, Baghdad, Iraq
| | - Faiq I Gorial
- Rheumatology Unit, Department of Medicine, College of Medicine, University of Baghdad, Baghdad, Iraq
| | | | | | | | - Reem Abbas Hammadi
- Rheumatology Unit, Department of Internal Medicine, Baghdad Teaching Hospital, Baghdad, Iraq
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Leerling AT, Clunie G, Koutrouba E, Dekkers OM, Appelman-Dijkstra NM, Winter EM. Diagnostic and therapeutic practices in adult chronic nonbacterial osteomyelitis (CNO). Orphanet J Rare Dis 2023; 18:206. [PMID: 37480122 PMCID: PMC10362746 DOI: 10.1186/s13023-023-02831-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 07/12/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND Chronic nonbacterial osteomyelitis (CNO) is a rare, and impactful auto-inflammatory bone disease occurring in children and adults. Clinical care for CNO is challenging, as the condition lacks validated classification criteria and evidence-based therapies. This study aimed to map the current diagnostic and therapeutic practices for CNO in adults, as a first step towards a standardized disease definition and future consensus treatment plans. METHODS A primary survey was spread among global rheumatological/bone networks and 57 experts as identified from literature (May 2022), covering terminology, diagnostic tools (clinical, radiological, biochemical) and treatment steps. A secondary survey (sent to primary survey responders in August 2022) further queried key diagnostic features, treatment motivations, disease activity and treatment response monitoring. RESULTS 36 and 23 physicians completed the primary and secondary survey respectively. Diagnosis was mainly based on individual physician assessment, in which the combination of chronic relapsing-remitting bone pain with radiologically-proven osteitis/osteomyelitis, sclerosis, hyperostosis and increased isotope uptake on bone scintigraphy were reported indicative of CNO. Physicians appeared more likely to refer to the condition as synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome in the presence of joint and skin pathology. MRI was most frequently performed, and the preferred diagnostic test for 47%. X-rays were second-most frequently used, although considered least informative of all available tools. Typical imaging features reported were hyperostosis, osteitis, osteosclerosis, bone marrow edema, while degeneration, soft tissue calcification, and ankylosis were not regarded characteristic. Inflammation markers and bone markers were generally regarded unhelpful for diagnostic and monitoring purposes and physicians infrequently performed bone biopsies. Management strategies diverged, including indications for treatment, response monitoring and declaration of remission. Step-1 treatment consisted of non-steroidal anti-inflammatory drugs/COX-2 inhibitors (83%). Common step 2-3 treatments were pamidronate, methotrexate, and TNF-a-inhibition (anti-TNFα), the latter two regarded especially convenient to co-target extra-skeletal inflammation in SAPHO syndrome. Overall pamidronate and anti-TNFα and were considered the most effective treatments. CONCLUSIONS Following from our survey data, adult CNO is a broad and insufficiently characterized disease spectrum, including extra-osseous features. MRI is the favoured imaging diagnostic, and management strategies vary significantly. Overall, pamidronate and anti-TNFα are regarded most successful. The results lay out current practices for adult CNO, which may serve as backbone for a future consensus clinical guideline.
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Affiliation(s)
- A T Leerling
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
- Center for Bone Quality, Leiden University Medical Center, Leiden, the Netherlands
| | - G Clunie
- Department of Rheumatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - E Koutrouba
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
- Center for Bone Quality, Leiden University Medical Center, Leiden, the Netherlands
| | - O M Dekkers
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - N M Appelman-Dijkstra
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands
- Center for Bone Quality, Leiden University Medical Center, Leiden, the Netherlands
| | - E M Winter
- Department of Internal Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, the Netherlands.
- Center for Bone Quality, Leiden University Medical Center, Leiden, the Netherlands.
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Reijnierse M. Axial Skeleton Bone Marrow Changes in Inflammatory Rheumatologic Disorders. Semin Musculoskelet Radiol 2023; 27:91-102. [PMID: 36868247 PMCID: PMC9984269 DOI: 10.1055/s-0043-1761496] [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] [Indexed: 03/05/2023]
Abstract
Magnetic resonance imaging (MRI) of the axial skeleton, spine, and sacroiliac (SI) joints is critical for the early detection and follow-up of inflammatory rheumatologic disorders such as axial spondyloarthritis, rheumatoid arthritis, and SAPHO/CRMO (synovitis, acne, pustulosis, hyperostosis, and osteitis/chronic recurrent multifocal osteomyelitis). To offer a valuable report to the referring physician, disease-specific knowledge is essential. Certain MRI parameters can help the radiologist provide an early diagnosis and lead to effective treatment. Awareness of these hallmarks may help avoid misdiagnosis and unnecessary biopsies. A bone marrow edema-like signal plays an important role in reports but is not disease specific. Age, sex, and history should be considered in interpreting MRI to prevent overdiagnosis of rheumatologic disease. Differential diagnoses-degenerative disk disease, infection, and crystal arthropathy-are addressed here. Whole-body MRI may be helpful in diagnosing SAPHO/CRMO.
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Affiliation(s)
- Monique Reijnierse
- Musculoskeletal Radiology, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
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Furer V, Kishimoto M, Tomita T, Elkayam O, Helliwell PS. Pro and contra: is synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) a spondyloarthritis variant? Curr Opin Rheumatol 2022; 34:209-217. [PMID: 35699334 DOI: 10.1097/bor.0000000000000884] [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: 11/26/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to present the up-to-date evidence on the epidemiology, pathogenesis, musculoskeletal manifestations, and imaging of the synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome and to discuss its relationship with spondyloarthritis (SpA). RECENT FINDINGS SAPHO is a rare inflammatory disorder of bone, joints, and skin, with a worldwide distribution that predominantly affects the middle-age adults. The hallmark of the syndrome is a constellation of sterile inflammatory osteitis, hyperostosis, and synovitis involving the anterior chest wall, associated with acneiform and neutrophilic dermatoses, such as palmoplantar pustulosis and severe acne. The axial skeleton, sacroiliac, and peripheral joints can be involved in a similar fashion to SpA. The pathogenesis of the syndrome is multifactorial. The diagnosis is mainly based on the clinical and typical radiological features. The treatment approach is based on the off-label use of antibiotics, bisphosphonates, disease-modifying antirheumatic drugs, and anticytokine biologics. SUMMARY The SAPHO syndrome shares common features with SpA-related diseases, yet also shows some unique pathogenetic and clinical features. The nosology of SAPHO remains a subject of controversy, awaiting further research into the pathogenetic and clinical aspects of this syndrome. A better understanding of these aspects will improve the diagnostics and clinical care of patients with SAPHO.
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Affiliation(s)
- Victoria Furer
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mitsumasa Kishimoto
- Department of Nephrology and Rheumatology, Kyorin University School of Medicine, Tokyo
| | - Tetsuya Tomita
- Department of Orthopaedic Biomaterial Science, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Ori Elkayam
- Rheumatology Department, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Philip S Helliwell
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
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Xu T, Huang Y, Zhao Y, Wang P, Chen Y. 68Ga-DOTA-FAPI-04 PET/CT Imaging in a Case of SAPHO Syndrome. Clin Nucl Med 2022; 47:246-248. [PMID: 34560692 DOI: 10.1097/rlu.0000000000003901] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT A 66-year-old woman presented with anterior chest wall and knee joints pain and multiple skin lesions. 99mTc-MDP bone scintigraphy showed increased bone density in the sternal angle with abnormal bone metabolism. The patient was enrolled in a 68Ga-DOTA-FAPI-04 PET/CT tumor clinical trial, and it showed increased tracer uptake in the sternum and right knee joint. Subsequently, ultrasound of the right knee joint confirmed the existence of synovitis, and no malignant components were found in sternal biopsy. The patient's final diagnosis was synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome. The case confirmed that 68Ga-DOTA-FAPI-04 imaging is helpful for evaluating the involved sites of SAPHO syndrome.
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Affiliation(s)
- Tingting Xu
- From the Department of Nuclear Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, PR China; Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, Sichuan, PR China; and Academician (Expert) Workstation of Sichuan Province, PR China
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Maranini B, Ciancio G, Rinaldi R, Borrelli M, Pugliatti M, Govoni M. SAPHO Syndrome Presenting With Atlo-Epistrophic Synovitis and Left Vocal Cord Paresis: A Challenging Diagnosis. CLINICAL MEDICINE INSIGHTS: ARTHRITIS AND MUSCULOSKELETAL DISORDERS 2022; 15:11795441221118918. [PMID: 36090594 PMCID: PMC9459495 DOI: 10.1177/11795441221118918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Accepted: 07/21/2022] [Indexed: 11/16/2022]
Abstract
SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) is a rare
syndrome mainly characterized by cutaneous and osteoarticular
manifestations. The most typical osteoarticular manifestations are
localized to the anterior chest wall and include a usually
noninfectious osteitis, hyperostosis, and synovitis of the
sternoclavicular joints. However, clinical presentation of SAPHO
syndrome can be quite heterogeneous. Several clinical and radiological
features are shared with other well-defined pathological entities, and
clinical signs and symptoms often occur at different timepoints.
Mainly due to this complexity and its rarity, there are currently no
validated diagnostic criteria for SAPHO syndrome. Inflammation of the
soft tissues around the bones and possible nerve compression could
contribute to dysphagia, hypophonia, or obstruction of the airways.
Neurologic manifestations could therefore be part of this multiorgan
involvement. Here, we present a case of SAPHO syndrome with atypical
onset symptoms, characterized by left vocal cord paralysis, acute neck
pain due to osteolytic atlantoepistrophic lesion, and an unusual
cutaneous manifestation, diagnosed as mid-dermal elastolysis. The
latest two, to the best of our knowledge, have been here first
described in a case of SAPHO syndrome.
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Affiliation(s)
- Beatrice Maranini
- Rheumatology Unit, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Giovanni Ciancio
- Rheumatology Unit, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Rosa Rinaldi
- Pathology Unit, ASST Mantova, Ospedale Carlo Poma, Mantova, Italy
| | - Massimo Borrelli
- Neurororadiology Unit, Department of Radiology, Azienda Ospedaliero-Universitaria Sant’Anna, Ferrara, Italy
| | - Maura Pugliatti
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
| | - Marcello Govoni
- Rheumatology Unit, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
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