[Chronic recurrent multifocal osteomyelitis (CRMO)]

A systematic review of SAPHO syndrome and inflammatory bowel disease association

BACKGROUND

The association between inflammatory bowel disease (IBD) and synovitis, acne, pustulosis, hyperostosis, osteitis syndrome (SAPHO syndrome) was first reported in 1992. To date, only case reports and short series have been published.

AIMS

The purpose of this study was to report new cases and systematically review the literature on this association.

MATERIALS AND METHODS

All patients with concomitant diagnosis of SAPHO syndrome and IBD were identified from the databases of the rheumatology and gastroenterology departments of our institution. In addition, we systematically searched for published full articles in Medlars Online International Literature via PubMed. Relevant information of each positive match was collected and all authors were contacted for additional clinical data.

RESULTS

Three patients sharing both SAPHO syndrome and IBD were identified among the 62 patients with SAPHO syndrome (4.8 % of the SAPHO cohort) and the 1,309 patients with IBD (0.2 % of the IBD cohort) from our hospital database. After a systematic review, a total of 39 reported patients with concomitant diagnosis of SAPHO syndrome and IBD were identified. There was a female predominance and most had Crohn's disease with colonic involvement.

CONCLUSIONS

The association of SAPHO syndrome and IBD seems to be rare among IBD patients but not so among SAPHO patients. SAPHO could be underdiagnosed because of the similarity of its clinical manifestations and some more common extraintestinal manifestations or drug-related side effects in IBD.

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.

Schnitzler's disease as an important differential diagnosis of chronic recurrent multifocal osteomyelitis: a case report

Introduction. At first sight, chronic recurrent multifocal osteomyelitis (CRMO) and Schnitzler's disease are diagnoses of exclusion and can be similar in their manifestation. Methods. In this paper we present the reevaluation of the 13-year-old diagnosis of chronic recurrent osteomyelitis of a 58-year-old man with chronic ostealgia, night sweat, and pruritic urticarial lesions on the extremities and trunk. For further examination, we performed blood analysis, bone and skin biopsies, CT scans, and magnetic resonance imaging. Results. Laboratory findings showed increased inflammation parameters. Magnetic resonance imaging (MRI) revealed a diffuse bone marrow infiltration. A bone and skin biopsy showed a sclerotic bone marrow involvement and a superficial dermal and perivascular infiltrate of neutrophils. Based on these findings, the diagnosis of Schnitzler's disease was made. Conclusion. Here, we want to present Schnitzler's disease as an important differential diagnosis to CRMO in adults presenting with signs suggestive of CRMO.

[Infectious bone diseases]

Bacterial infection of the bone is a severe disease with complications, potentially including long-term physical disability. The diagnosis and therapy of osteomyelitis include several elements: histopathology, microbiology, radiologic imagining, as well as antibiotic and surgical therapy. Histopathologists differentiate between acute osteomyelitis (infiltration of cancellous bone with neutrophil granulocytes); specific osteomyelitis (epithelioid-like granulomatous inflammation, tuberculosis, mycotic infections); primary/secondary chronic osteomyelitis (lymphocytic infiltration); and special forms of chronic osteomyelitis (varying histomorphology, Brodie abscess, SAPHO syndrome). Another important task in the histopathological diagnosis of inflammatory bone diseases is to differentiate osteomyelitis from malignant entities (sarcoma, lymphoma). Therefore, biopsy samples should be of sufficient size for safe diagnosis. Clinical information and imaging as well as interdisciplinary teamwork between radiologists, microbiologists, orthopedic surgeons and pathologists is mandatory to verify these diagnoses.

Chronic nonbacterial osteomyelitis in childhood: prospective follow-up during the first year of anti-inflammatory treatment

Introduction

Chronic nonbacterial osteomyelitis (CNO) is an inflammatory disorder of unknown etiology. In children and adolescents CNO predominantly affects the metaphyses of the long bones, but lesions can occur at any site of the skeleton. Prospectively followed cohorts using a standardized protocol in diagnosis and treatment have rarely been reported.

Methods

Thirty-seven children diagnosed with CNO were treated with naproxen continuously for the first 6 months. If assessment at that time revealed progressive disease or no further improvement, sulfasalazine and short-term corticosteroids were added. The aims of our short-term follow-up study were to describe treatment response in detail and to identify potential risk factors for an unfavorable outcome.

Results

Naproxen treatment was highly effective in general, inducing a symptom-free status in 43% of our patients after 6 months. However, four nonsteroidal anti-inflammatory drug (NSAID) partial-responders were additionally treated with sulfasalazine and short-term corticosteroids. The total number of clinical detectable lesions was significantly reduced. Mean disease activity estimated by the patient/physician and the physical aspect of health-related quality of life including functional ability (global assessment/childhood health assessment questionnaire and childhood health assessment questionnaire) and pain improved significantly. Forty-one percent of our patients showed radiological relapses, but 67% of them were clinically silent.

Conclusions

Most children show a favorable clinical course in the first year of anti-inflammatory treatment with NSAIDs. Relapses and new radiological lesions can occur at any time and at any site in the skeleton but may not be clinically symptomatic. Whole-body magnetic resonance imaging proved to be very sensitive for initial and follow-up diagnostics.

Imaging of chronic recurrent multifocal osteomyelitis

Chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory disorder of children and young adults that is characterized by nonbacterial osteomyelitis. Patients typically present with multifocal bone pain secondary to sterile osseous inflammation, and the disease has a relapsing and remitting course. The cause of CRMO remains unclear, although the results of several studies have suggested a genetic component. The typical imaging findings of CRMO include lytic and sclerotic lesions in the metaphyses of long bones and the medial clavicles. Other common sites of disease are the vertebral bodies, pelvis, ribs, and mandible. CRMO is often bilateral and multifocal at presentation. Owing to the lack of a diagnostic test, CRMO remains a diagnosis of exclusion. Although generally a self-limiting disease, CRMO can have a prolonged course and result in significant morbidity. Radiologists can be the first to suggest this diagnosis given its characteristic radiographic appearance and distribution of disease. Radiologists should be familiar with the typical imaging findings of CRMO to prevent unnecessary multiple biopsies and long-term antibiotic treatment in children with CRMO.

Biopsy of osteoporotic vertebral compression fractures during kyphoplasty: unsuspected histologic findings of chronic osteitis without clinical evidence of osteomyelitis

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To evaluate biopsy results obtained during vertebral augmentation (kyphoplasty) for presumed/confirmed osteoporotic vertebral compression fractures (VCFs).

SUMMARY OF BACKGROUND DATA

Kyphoplasty to augment vertebrae in osteoporotic VCFs is well established. When VCF etiology is in question, bone biopsy can be performed at that time. Biopsy results, however, can be misleading without careful clinical correlation.

METHODS

From July 2003 to July 2006, 94 vertebral biopsies were obtained from 66 patients during kyphoplasty for VCFs. Average patient age was 73 (range, 22-99), including 47 females and 19 males. There were 48 one-level, 17 two-level, and 4 three-level biopsies. Biopsy levels included: T6 (3), T7 (7), T8 (7), T9 (3), T10 (3), T11 (8), T12 (21), L1 (18), L2 (13), L3 (8), L4 (2), L5 (1). Histologic/immunohistochemical evaluations were performed.

RESULTS

All specimens showed features of fracture in various stages of bony healing. Initially, 13 of 66 (19.7%) cases were read by a surgical pathologist as chronic inflammation, with 6 having features suggestive of chronic osteomyelitis, including polyclonal plasma cells, necrosis, and lymphoplasmacytic infiltrate. For this study, these biopsies were evaluated by an independent surgical pathologist (N.W.). Re-review showed 7 of the 13 cases were consistent with osteoporotic VCF healing in various stages with adjacent trilineage hematopoiesis. Six of 13 (46%), were read as containing fragmented bony spicules, fibrotic and fatty marrow, lymphoplasmacytic inflammation, and aggregates of mature, polyclonal plasma cells, suggesting the possibility of chronic osteomyelitis. However, at average follow-up of 37 months (range, 21-57 months), no patient demonstrated clinical and/or laboratory evidence of infection. Additionally, biopsies from 4 patients confirmed suspected or unsuspected malignancy, or confirmed no recurrence of malignant disease.

CONCLUSION

Patients undergoing first-time vertebral augmentation should be considered for vertebral biopsy. Tissue examination is useful and may reveal pathologic fracture or possible infection. However, if infection is reported, clinical and laboratory correlation are important to make a diagnosis of osteomyelitis.