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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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Calamita AG, Stimolo D, Puccini S, Innocenti M, Campanacci DA. Garrè Sclerosing Osteomyelitis of the Clavicle: Clinical Results after Clavicular Resection. Healthcare (Basel) 2024; 12:202. [PMID: 38255092 PMCID: PMC10815155 DOI: 10.3390/healthcare12020202] [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: 11/06/2023] [Revised: 12/27/2023] [Accepted: 01/05/2024] [Indexed: 01/24/2024] Open
Abstract
(1) Background: Chronic non-bacterial osteomyelitis (CNO), also known as sclerosing osteomyelitis of Garrè, is a rare inflammatory bone disease with a specific clinical picture, uncertain pathogenesis, and no consensus on an effective treatment. Most frequently affecting other long bones, CNO may rarely involve the clavicle. The aim of this study was to present the results of a series of patients affected by CNO of the clavicle treated with total and partial clavicula resection. In addition, a literature review of different types of treatment of CNO was performed. (2) Methods: We retrospectively reviewed three patients with Sclerosing Osteomyelitis of Garre' of the clavicle treated with partial resection of the clavicle (one) and with total clavicular resection (two). (3) Results: Patients (two female and one male) were an average age of 35.7 years at the time of the operation. At the 4-year follow-up, the mean active ROM was: 143° forward flexion, 133° abduction, 42° external rotation with an internal rotation of two patients at the interscapular level and one patient at the lumbosacral junction. The mean ASES score was 92/100 (range 87-100). In the literature review, after screening the abstracts and full texts for eligibility, 34 studies met the inclusion criteria. Conclusions: Partial or total clavicular resection resulted an effective treatment of CNO of the clavicle. The procedure seems to be particularly indicated after the failure of more conservative treatments.
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Affiliation(s)
- Andrea Gabriele Calamita
- Department of Orthopaedic Oncology, Careggi University Hospital, 50134 Firenze, Italy; (D.S.); (M.I.); (D.A.C.)
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Ramachandran S, Zhao Y, Ferguson PJ. Update on treatment responses and outcome measure development in chronic nonbacterial osteomyelitis (CNO). Curr Opin Rheumatol 2023:00002281-990000000-00062. [PMID: 37433220 DOI: 10.1097/bor.0000000000000954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
PURPOSE OF REVIEW To review recent trends in treatment and recent progress in developing outcome measures needed for chronic nonbacterial osteomyelitis (CNO) clinical trials. RECENT FINDINGS CNO is an autoinflammatory bone disease. In a minority of patients, the disease is genetically driven, and diagnosis can be made by DNA sequencing. However, for nonsyndromic CNO there is no diagnostic test. The number of children with CNO appears to be increasing and damage is common. Increases in CNO diagnosis is due to raised awareness, increased availability of whole-body magnetic resonance imaging and rising incidence. Treatment remains empiric and it is unclear which second line treatment is superior. Tumor necrosis factor inhibitors (TNFi) and bisphosphonates continue to be used as second line agents for nonsteroidal anti-inflammatory drugs (NSAID) refractory CNO; newer immune modulatory medications are used if this fails. Validated classification criteria, clinical outcome measures and imaging scoring standards are needed for successful clinical trials. SUMMARY Best treatment for NSAID refractory CNO remains unclear. Classification criteria, clinical outcomes measures and standardized imaging scoring have been developed or are near completion. This will facilitate robust clinical trials in CNO with the goal of having approved medications for this painful disease.
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Affiliation(s)
- Shwetha Ramachandran
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Yongdong Zhao
- Department of Pediatrics, Seattle Children's Hospital. Seattle, Washington, USA
| | - Polly J Ferguson
- Stead Family Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa
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Fraleigh R, Wei XC, Yu W, Miettunen PM. Chronic recurrent multifocal osteomyelitis with a comprehensive approach to differential diagnosis of paediatric skull pain. BMJ Case Rep 2023; 16:e252471. [PMID: 36599493 PMCID: PMC9815035 DOI: 10.1136/bcr-2022-252471] [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] [Indexed: 01/05/2023] Open
Abstract
A girl in middle childhood was referred to rheumatology with a 1-month history of progressive skull pain, preceded by fleeting musculoskeletal symptoms. Apart from a scaly rash on her scalp, she was well, with moderately elevated inflammatory markers. Skull imaging (radiographs, CT and MRI) revealed osteolytic lesions, soft tissue swelling and pachymeningeal enhancement at frontal and temporal convexities. Langerhans cell histiocytosis, bone infection/inflammation or malignancy was considered. Skin and bone biopsies eventually ruled out mimicking diseases and confirmed the diagnosis of chronic recurrent multifocal osteomyelitis (CRMO). She was treated with intravenous pamidronate (IVPAM) for 9 months, with rapid resolution of pain and gradual resolution of bony abnormalities. She remains in remission at 15-month follow-up. While CRMO can affect any bone, skull involvement is extremely rare, with a broad differential diagnosis. We recommend bone biopsy to confirm skull CRMO. The patient achieved excellent clinical and radiological response to IVPAM.
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Affiliation(s)
- Ross Fraleigh
- Pediatric Rheumatology, Alberta Children's Hospital, Calgary, Alberta, Canada
- Pediatrics, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Xing-Chang Wei
- Diagnostic Imaging, Alberta Children's Hospital, Calgary, Alberta, Canada
- Pediatrics, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Weiming Yu
- Pediatrics, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Pathology and Laboratory Medicine, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Paivi Maria Miettunen
- Pediatric Rheumatology, Alberta Children's Hospital, Calgary, Alberta, Canada
- Pediatrics, Alberta Children's Hospital, Calgary, Alberta, Canada
- Pediatrics, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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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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Kim MC, Kim KO, Kang MK, Jang BI. Chronic recurrent multifocal osteomyelitis of the left femur associated with ulcerative colitis: a case report. J Int Med Res 2021; 49:3000605211042996. [PMID: 34510962 PMCID: PMC8442495 DOI: 10.1177/03000605211042996] [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] [Indexed: 12/02/2022] Open
Abstract
Chronic recurrent multifocal osteomyelitis (CRMO) is a rare condition characterized by
chronic relapsing noninfectious bone inflammation of unknown etiology. Although CRMO is
considered an extraintestinal manifestation in patients with inflammatory bowel disease,
most cases of CRMO are associated with Crohn’s disease; very few are associated with
ulcerative colitis (UC). We herein describe a 21-year-old patient with UC who developed
recurrent left thigh pain. The patient was diagnosed with CRMO associated with UC, which
was well controlled with azathioprine treatment.
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Affiliation(s)
- Min Cheol Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Kyeong Ok Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Min Kyu Kang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Byung Ik Jang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
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