Diffuse chronic sclerosing osteomyelitis and the synovitis, acne, pustolosis, hyperostosis, osteitis (SAPHO) syndrome in two sisters

Pro and contra: is synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) a spondyloarthritis variant?

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.

The effectiveness of treatments for patients with SAPHO syndrome: a follow-up study of 24 cases from a single center and review of literature

OBJECTIVES

To evaluate the effectiveness of current treatments for SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, and osteitis) by delineating the therapeutic choices and the outcome of patients in a medical center of China and review of the literature.

METHOD

An observational study was performed on patients diagnosed as SAPHO syndrome in the Peking University First Hospital from 2009 to 2015. Clinical data including osteoarticular and cutaneous manifestations, laboratory and medical imaging findings, treatments, and outcomes were analyzed retrospectively. A literature detailing the usage of medicines and SAPHO syndrome patient responses to treatment were selected.

RESULTS

Clinical data of 24 patients were analyzed in this study. The mean age was 42.4 ± 15.5 years old at the time of diagnosis. Of a total of 17 patients that received the combination treatments of NSAIDs and DMARDs, 15 of them experienced an improvement in their symptoms. Bisphosphonates were given to 18 patients. Four patients were treated with TNF blockers, and one of them had adalimumab ineffective and then improved by add-on of DMARDs. The mean follow-up period was 2.5 years. Twenty-one patients (87.5%) had a favorable outcome and exhibited improved disease condition in the last follow-up.

CONCLUSIONS

The majority of patients with SAPHO syndrome respond well to combination therapy of NSAIDs, DMARDs, and bisphosphonates. TNF blockers are effective in a patient refractory to NSAID and DMARDs. However, in case TNF blockers are ineffective, add-on of DMARDs may be effective. Thus, the proper application of conventional DMARDs is still worth a position in the treatment of SAPHO syndrome. Key Points •NSAIDs and DMARDs and/or bisphosphonates can alleviate symptoms of the majority of patients with SAPHO syndrome. •TNF blockers are effective in patients who do not respond well to NSIADs and DMARDs. •In case TNF blockers are ineffective, add-on of conventional DMARDs may be effective.

SAPHO syndrome of the temporomandibular joint associated with trismus: a case report and review of the literature

Synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome is a disorder characterized by pustular skin lesions and osteoarticular lesions. Mandibular involvement occurs in approximately 10% of the cases, and is often seen as recurrent mandibular osteitis with bone sclerosis, mainly involving the body of the mandible in the head and neck region. Middle cranial base with temporomandibular joint (TMJ) involvement in SAPHO syndrome can be diagnostically challenging because of its rarity. Herein, we present a case of a 37-year-old man who suffered from trismus and dull pain in the left TMJ region. The initial panoramic image revealed spotty osteolysis around the left condylar head. Computed tomography (CT) images showed an osteosclerotic change in the middle cranial base including the TMJ. Magnetic resonance images showed a cortical bone change in the left TMJ without anterior disk displacement, with spotty low signal intensity in the left condyle bone marrow on T2- weighted images. Our initial diagnosis was osteomyelitis of the middle cranial base including the TMJ region. However, antimicrobial therapy, training for TMJ opening, and a surgical procedure were not effective. A detailed medical interview, careful check for skin lesions, and further imaging examinations including bone scintigraphy and chest CT led to the diagnosis of SAPHO syndrome. The possibility of SAPHO syndrome should be considered in patients suspected of osteomyelitis of the middle cranial base including the TMJ with unknown etiology.

Pediatric Chronic Nonbacterial Osteomyelitis of the Jaw: Clinical, Radiographic, and Histopathologic Features

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.

SAPHO syndrome: a review

INTRODUCTION

Synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) is an acronym for various osteoarticular and dermatological manifestations that can appear in the same patient. It is a rare syndrome, but since its awareness has increased, there have been more and more such reports in the literature.

AIMS

The objectives of this review are to summarize the current state of knowledge on pediatric and adult-onset SAPHO syndrome, and to discuss treatment strategies that should be considered.

RESULTS

The SAPHO syndrome can affect patients of any age, and its etiology is still not known. The syndrome has its cognizable radiological characteristics that are most important in making the diagnosis. There are several diagnostic criteria as well, but they need further validation. No standard treatment protocols are available and current treatment options are not evidenced-based due to the rarity of the syndrome. Therapy is empirical and aimed at easing pain and modifying the inflammatory process. It includes nonsteroidal anti-inflammatory drugs (NSAIDs) as the first-line agents. Antibiotics, corticosteroids, disease-modifying anti-rheumatic drugs, biologicals targeting tumor necrosis factor alpha or interleukin-1, and bisphosphonates have all been used with variable success. Surgery is reserved to treat complications. Even though it is a disease with good long-term prognosis, its treatment remains a challenge and the results are known to be disappointing, especially with the skin component of the disease.

CONCLUSION

It is expected that these patients present at the time of diagnosis and the treatment should be as early, effective, and safe as possible in order to prevent osteoarticular progression and to limit the adverse events associated with pharmacological drugs.

Diffuse sclerosing osteomyelitis (DSO) of the mandible in SAPHO syndrome: a novel approach with anti-TNF therapy. Systematic review

Diffuse sclerosing osteomyelitis of the mandible is now considered a local manifestation of SAPHO syndrome. This rare condition is thought to be of auto-inflammatory origin. The myriad of treatments shown in the literature, are basically empirical and reflect its unknown origin. We present a clinical case of refractory DSO treated with an anti-TNF drug (etanercept) with complete clinical remission. We advise against radical surgery and an interdisciplinary approach is recommended. A systematic literature review was also conducted.

Severe destruction of the temporomandibular joint with complete resorption of the condyle associated with synovitis, acne, pustulosis, hyperostosis, and osteitis syndrome

The synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome consists of a combination of inflammatory bone disorders and dermatologic pathology. Bone lesions as a form of diffuse sclerosing osteomyelitis in the mandible occur in the posterior body and ramus. Bone lesions rarely spread to the temporomandibular joint (TMJ) where ankylosis may result. Herein we present an unusual case of SAPHO syndrome with TMJ involvement in which severe destruction of the TMJ occurred. We observed an extension of the invasive soft tissue lesion into the infratemporal fossa from the TMJ with complete resorption of the condyle. In contrast to other previously reported cases, in our case the condyle was strongly suspected as the primary site of the bone lesion with subsequent extension to the ramus and infratemporal fossa. The destructive nature and related symptoms resembled a malignant tumor.

The SAPHO syndrome

OBJECTIVE

To review the epidemiology, presentation, diagnosis, treatment, pathogenesis, and genetics of the syndrome known under the acronym of SAPHO for Synovitis, Acne, Pustulosis, Hyperostosis, and Osteitis to heighten awareness of this entity.

METHODS

We conducted a Medline search using SAPHO syndrome, chronic recurrent multifocal osteitis/osteomyelitis, and related terms as keywords and extracted further relevant articles from the retrieved references.

RESULTS

The SAHPO acronym identifies a syndrome encompassing a variety of osteoarticular disorders that are frequently accompanied by dermatoses characterized by neutrophilic pseudoabscesses, but can also occur in isolation. SAPHO syndrome is rare, although probably underrecognized because its diagnosis may be challenging because of the wide variability in its musculoskeletal and cutaneous manifestations. This is especially true when atypical sites are involved and when specific skin lesions are absent. There are no standardized treatment protocols available. Current treatments are empirical and have the objective of providing relief from the at times debilitating pain associated with SAPHO syndrome. They include nonsteroidal anti-inflammatory drugs and analgesics as first-line agents. Systemic corticosteroids, disease-modifying anti-rheumatic drugs, biologicals targeting tumor necrosis factor alpha and interleukin-1, and bisphosphonates have all been beneficial in some patients, but ineffective in others. This suggests that the pathogenesis of SAPHO syndrome is multifactorial, but this aspect remains poorly explored, although bacteria and immunological dysfunction are hypothesized to play a role.

CONCLUSIONS

The early recognition, diagnosis, and prompt treatment of SAPHO syndrome can prevent the unnecessary use of long-term antibiotics or invasive procedures, while rapidly alleviating pain in a majority of affected patients.

Alveolar osteitis and osteomyelitis of the jaws

Postoperative bone healing after oral surgical procedures occurs uneventfully in most cases. However, in certain patients, the normal process of healing can be delayed and, in some cases, often because of multiple coexisting factors, the sites can become infected, with extension of the infection into medullary bone. This process is termed osteomyelitis. This article outlines the pathogenesis, microbiology, and surgical and medical therapies of this condition and specifically addresses osteomyelitis cases related to patients with no documented history of radiation or bisphosphonate exposure and in whom the principal factor in the development of the condition is infection by pyogenic microorganisms.

SAPHO syndrome with TMJ involvement: review of the literature and case presentation

Synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome is a rare group of sterile, inflammatory osteoarticular disorders classically associated with skin manifestations. The etiology is unknown but probably involves genetic, infectious, and immunological components. The characteristic feature of the disease is found in the bone lesions, which typically involve the anterior chest wall and axial skeleton. In the literature review, six case reports discussed involvement of the TMJ. Treatment of SAPHO is geared toward symptom management as there is no cure. Surgery for mandibular lesions is usually a last resort as results are reported to be temporary with symptoms recurring within a year. Surgery appears to be performed early after diagnosis of TMJ related pathology; probably because lesions affecting the TMJ involve some limitation in mouth opening with varying degrees of ankylosis. The authors provide a literature review and describe a case of SAPHO syndrome with ankylosis of the left TMJ. The patient was treated with joint reconstruction using a patient-fitted total joint prosthesis (TMJ Concepts Inc., Ventura CA) in single stage surgery. This paper is the first to report maxillary involvement in SAPHO syndrome.

SAPHO syndrome with affection of the mandible: diagnosis, treatment, and review of literature

The synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome is a rare syndrome of unknown etiology. Involvement of the mandible is found in almost 10% of cases. In the literature, conservative treatment is recommended most often, because decortication and partial resection are found to be ineffective and of temporary profit. We report a case of SAPHO syndrome in a 44-year-old women with unilateral hyperostosis of the mandible and massive painful swelling of the surrounding soft tissues. Owing to facial disfiguration and pain, resection of the affected bone followed by immediate reconstruction with a microvascular iliac crest flap were performed. The aim of this paper was to present the necessity of surgical intervention in SAPHO syndrome of the mandible in cases of esthetic and functional limitation.

Genetic Susceptibility Factors in a Cohort of 38 Patients with SAPHO Syndrome: A Study of PSTPIP2, NOD2, and LPIN2 Genes

Objective.

The SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, and osteitis) is a rare disorder that mainly affects bone and skin. Chronic multifocal osteitis is the main diagnostic feature. Genetic studies of HLA genes have shown no role for these class II antigens, whereas studies of 2 mouse models (cmo and Lupo) point to a role of the PSTPIP2 gene. We analyzed the PSTPIP2 gene in patients with SAPHO syndrome.

Methods.

In a cohort of 38 patients with SAPHO we analyzed PSTPIP2 and 2 other candidate genes, NOD2/CARD15 (Crohn's disease occurs in about 10% of SAPHO patients), and LPIN2 (clinical similarities of SAPHO with Majeed syndrome).

Results.

Rare variants of the 3 genes observed in patients with SAPHO were not specific or were not found more frequently compared to controls, suggesting no major pathogenetic role of these genes in the SAPHO syndrome.

Conclusion.

We found no association between PSTPIP2, NOD2, and LPIN2 variants and the SAPHO syndrome.

SAPHO syndrome with ankylosis of the temporomandibular joint

SAPHO syndrome is a rare combination of different symptoms with unknown aetiology. A complete ankylosis of the temporomandibular joint (TMJ) in a patient with SAPHO syndrome has not been described previously. The goal of this case report is to present the disease, give an overview about the frequency of mandibular involvement and describe different therapeutic strategies. The complication of an ankylosis of the TMJ is noted and the literature is reviewed. The authors report a 42-year-old patient with SAPHO syndrome and recurrent swelling of the right mandible and the soft tissue. The persisting involvement of the mandible resulted in a complete osseous ankylosis of the right TMJ and required resection with alloplastic replacement of the right condyle. SAPHO syndrome should be suspected in some cases of 'therapy resistant osteomyelitis' of the mandible. Smaller joints, such as the TMJ may also be affected. Treatment of SAPHO syndrome should include antibiotics and NSAIDs; corticosteroids may be helpful. Surgery is the ultimate treatment.

SAPHO syndrome with temporomandibular joint ankylosis: clinical, radiological, histopathological, and therapeutical correlations

The SAPHO syndrome is characterized by specific clinical manifestations of synovitis, acne pustulosis, hyperostosis, and osteitis. It is a rare disease with a combination of osseous and articular manifestations associated with skin lesions. We describe a patient with SAPHO syndrome of the mandible and involvement of the temporomandibular joint (TMJ ankylosis). The findings from orthopantomography, computed tomography (CT), and clinical and histopathological examinations are compared and analyzed to improve the final diagnosis. Our patient was submitted to a bilateral high condylectomy and coronoidectomy to correct the open mouth limitation. No previous report of SAPHO syndrome associated with secondary TMJ ankylosis was found in the literature.