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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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2
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Hospach T, Kallinich T, Martin L, V Kalle T, Reichert F, Girschick HJ, Hedrich CM. [Arthritis and osteomyelitis in childhood and adolescence-Bacterial and nonbacterial]. Z Rheumatol 2024:10.1007/s00393-024-01504-z. [PMID: 38653784 DOI: 10.1007/s00393-024-01504-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/29/2024] [Indexed: 04/25/2024]
Abstract
Bacterial arthritis and osteomyelitis are usually acute diseases, which in this way differ from the often insidious course of nonbacterial osteomyelitis; however, there is often an overlap both in less acute courses of bacterial illnesses and also in nonbacterial osteitis. The overlapping clinical phenomena can be explained by similar pathophysiological processes. In bacteria-related illnesses the identification of the pathogen and empirical or targeted anti-infectious treatment are prioritized, whereas no triggering agent is known for nonbacterial diseases. The diagnostics are based on the exclusion of differential diagnoses, clinical scores and magnetic resonance imaging (MRI). An activity-adapted anti-inflammatory treatment is indicated.
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Affiliation(s)
- T Hospach
- Zentrum für Pädiatrische Rheumatologie, Olgahospital, Klinikum Stuttgart (ZEPRAS), Kriegsbergstr 62, 70176, Stuttgart, Deutschland.
| | - T Kallinich
- Klinik für Pädiatrie m.S. Pneumologie, Immunologie und Intensivmedizin, Charité, Universitätsmedizin Berlin, Berlin, Deutschland
| | - L Martin
- Klinik für Pädiatrie m.S. Pneumologie, Immunologie und Intensivmedizin, Charité, Universitätsmedizin Berlin, Berlin, Deutschland
| | - T V Kalle
- Radiologisches Institut, Olgahospital, Klinikum Stuttgart, Stuttgart, Deutschland
| | - F Reichert
- Pädiatrische Infektiologie, Olgahospital, Klinikum Stuttgart, Stuttgart, Deutschland
| | - H J Girschick
- Vivantes Klinikum Friedrichshain, Berlin, Deutschland
| | - C M Hedrich
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, Großbritannien
- Department of Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, Großbritannien
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3
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Sgaglione J, Muran A, Rhode M, Goodman HJ, Edelman MC, Shah SA, Greenberg AS, Kenan S. Geriatric chronic recurrent multifocal osteomyelitis (CRMO) mimicking multifocal multiple myeloma: a first in an octogenarian. Skeletal Radiol 2024:10.1007/s00256-024-04653-z. [PMID: 38499893 DOI: 10.1007/s00256-024-04653-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 03/09/2024] [Accepted: 03/11/2024] [Indexed: 03/20/2024]
Abstract
Chronic recurrent multifocal osteomyelitis (CRMO), an autoinflammatory bone disorder characterized by non-bacterial osteomyelitis causing recurrent multifocal bone lesions, is a well-known, yet uncommon pediatric condition that rarely affects adults; to date, it has never been diagnosed over the age of 75. The following report will discuss the first octogenarian diagnosed with CRMO and therefore represents an exceptionally rare presentation of a rare disease. An 83-year-old woman presented with progressive right shoulder, forearm, and hip pain, with associated weight loss and global weakness, requiring a wheelchair for mobility. Imaging revealed a pathologic right ulna fracture in addition to lytic lesions of the right proximal humerus and proximal femur. The clinical picture was thus that of a patient with probable multiple myeloma versus metastatic disease. After an extensive workup, however, the lesions were not malignant; histologic findings were instead suggestive of chronic osteomyelitis with negative cultures. Given the multifocal nature of this condition, combined with a lack of clinical symptoms of infection, a diagnosis of CRMO was rendered. The patient underwent intramedullary nailing of the right femur and splinting of the ulna, with a subsequent remarkable recovery to painless ambulation, complete union of the right ulna fracture, and resolution of the lytic lesions without receiving any targeted medical treatment. This case highlights the importance of maintaining CRMO on the differential for multifocal skeletal lesions, regardless of age. Performing a thorough workup with necessary imaging, biopsy, and culture are critical to establishing this diagnosis, which can only made as a diagnosis of exclusion.
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Affiliation(s)
- Jonathan Sgaglione
- Donald and Barbara Zucker School of Medicine, Hofstra/Northwell 500 Hofstra Blvd, Hempstead, NY, 11549, USA
| | - Andrew Muran
- Donald and Barbara Zucker School of Medicine, Hofstra/Northwell 500 Hofstra Blvd, Hempstead, NY, 11549, USA
| | - Matthew Rhode
- Donald and Barbara Zucker School of Medicine, Hofstra/Northwell 500 Hofstra Blvd, Hempstead, NY, 11549, USA
| | - Howard J Goodman
- Northwell Health, Long Island Jewish Medical Center Department of Orthopaedic Surgery, 270-05 76th Avenue, New York, NY, 11040, USA
| | - Morris C Edelman
- Pediatric Pathology Division, Northwell Health, Long Island Jewish Medical Center Department of Pathology, 270-05 76th Avenue, New York, NY, 11040, USA
| | - Suhail Ahmed Shah
- Department of Internal Medicine, Northwell Health, Long Island Jewish Medical Center Department of Orthopaedic Surgery, 270-05 76th Avenue, New York, NY, 11040, USA
| | - Andrew S Greenberg
- Orthopaedic Associates of Manhasset, 600 Northern Blvd, Lake Success, NY, 11021, USA
| | - Shachar Kenan
- Northwell Health, Long Island Jewish Medical Center Department of Orthopaedic Surgery, 270-05 76th Avenue, New York, NY, 11040, USA.
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4
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Choi S, Kim MJ, Kang SH, Park IW. Pediatric mandibular chronic nonbacterial osteomyelitis: A case report with 12 years of radiologic follow-up. Imaging Sci Dent 2024; 54:93-104. [PMID: 38571777 PMCID: PMC10985518 DOI: 10.5624/isd.20230189] [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] [Received: 08/31/2023] [Revised: 12/08/2023] [Accepted: 12/14/2023] [Indexed: 04/05/2024] Open
Abstract
Chronic nonbacterial osteomyelitis (CNO) is histologically characterized by nonspecific osteitis. This inflammatory disorder, which lacks an infectious origin, typically presents with chronic pain and swelling at the affected site that can persist for months or even years. However, it is rare for CNO to affect the mandible. A 10-year-old girl presented with a primary complaint of pain in her left mandible. She had no significant medical or dental history. On examination, swelling was visible on the left buccal side, and imaging revealed radiolucent bone deterioration within the left mandible. This case report presents the radiological changes observed over a 12-year follow-up period. Variations in radiopacity, radiolucency, and periosteal reactions were noted periodically. This case highlights the radiological characteristics and findings that are crucial for the diagnosis of CNO, a condition for which no clear diagnostic criteria are currently available.
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Affiliation(s)
- Sehyun Choi
- Department of Oral and Maxillofacial Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Min-Ji Kim
- Department of Oral and Maxillofacial Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Sang-Hoon Kang
- Department of Oral and Maxillofacial Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - In-Woo Park
- Department of Oral and Maxillofacial Radiology, College of Dentistry, Gangneung-Wonju National University, Gangneung, Korea
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Izumikawa M, Kato M, Wakiya R, Kameda T, Nakashima S, Shimada H, Miyagi T, Sugihara K, Ushio Y, Mino R, Mizusaki M, Chujo K, Hiraishi T, Kadowaki N, Dobashi H. Colchicine-responsive chronic recurrent multifocal osteomyelitis associated with familial Mediterranean fever in the presence of MEFV mutation: A case report. Mod Rheumatol Case Rep 2023; 8:195-198. [PMID: 37235633 DOI: 10.1093/mrcr/rxad027] [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: 01/26/2023] [Revised: 02/05/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023]
Abstract
A 38-year-old female was referred with a history of fever, polyarthralgia, and bone pain. She was diagnosed with chronic recurrent multifocal osteomyelitis based on imaging and biopsy findings. Non-steroidal anti-inflammatory drugs and bisphosphonate caused no improvement. Then, she developed recurrent diarrhoea and abdominal pain. Genetic testing revealed MEFV mutation. Based on the symptoms and genetic mutation results that emerged during the course of these events, she was diagnosed with familial Mediterranean fever. All symptoms, including bone pain, improved with daily colchicine administration. This case was considered familial Mediterranean fever complicated with a clinical diagnosis of chronic recurrent multifocal osteomyelitis, which is included in the spectrum of pyrine autoinflammatory diseases. Considering this case, patients with chronic recurrent multifocal osteomyelitis with MEFV gene variants may respond to colchicine.
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Affiliation(s)
- Miharu Izumikawa
- Division of Haematology, Rheumatology and Respiratory Medicine, Department of Internal Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Mikiya Kato
- Division of Haematology, Rheumatology and Respiratory Medicine, Department of Internal Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Risa Wakiya
- Division of Haematology, Rheumatology and Respiratory Medicine, Department of Internal Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Tomohiro Kameda
- Division of Haematology, Rheumatology and Respiratory Medicine, Department of Internal Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Shusaku Nakashima
- Division of Haematology, Rheumatology and Respiratory Medicine, Department of Internal Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Hiromi Shimada
- Division of Haematology, Rheumatology and Respiratory Medicine, Department of Internal Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Taichi Miyagi
- Division of Haematology, Rheumatology and Respiratory Medicine, Department of Internal Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Koichi Sugihara
- Division of Haematology, Rheumatology and Respiratory Medicine, Department of Internal Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Yusuke Ushio
- Division of Haematology, Rheumatology and Respiratory Medicine, Department of Internal Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Rina Mino
- Division of Haematology, Rheumatology and Respiratory Medicine, Department of Internal Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Mao Mizusaki
- Division of Haematology, Rheumatology and Respiratory Medicine, Department of Internal Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Kanako Chujo
- Division of Haematology, Rheumatology and Respiratory Medicine, Department of Internal Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Takashi Hiraishi
- Department of Rheumatology, Kagawa Prefectural Central Hospital, Takamatsu, Japan
| | - Norimitsu Kadowaki
- Division of Haematology, Rheumatology and Respiratory Medicine, Department of Internal Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Hiroaki Dobashi
- Division of Haematology, Rheumatology and Respiratory Medicine, Department of Internal Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
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Li SWS, Roberts E, Hedrich C. Treatment and monitoring of SAPHO syndrome: a systematic review. RMD Open 2023; 9:e003688. [PMID: 38151265 PMCID: PMC10753757 DOI: 10.1136/rmdopen-2023-003688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/24/2023] [Indexed: 12/29/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Synovitis acne pustulosis hyperostosis osteitis (SAPHO) is a rare heterogeneous disease of unknown aetiopathology. Externally validated and internationally agreed diagnostic criteria or outcomes and, as a result, prospective randomised controlled trials in SAPHO are absent. Consequently, there is no agreed treatment standard. This study aimed to systematically collate and discuss treatment options in SAPHO. METHODS Following 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses' guidance, a systematic literature search was conducted using PubMed, Scopus and Web of Science databases. Prospective clinical studies and retrospective case collections discussing management and outcomes in SAPHO involving five or more participants were included. Articles not published in English, studies not reporting defined outcomes, and studies solely relying on patient-reported outcomes were excluded. RESULTS A total of 28 studies (20 observational, 8 open-label clinical studies) reporting 796 patients of predominantly European ethnicity were included. Reported therapies varied greatly, with many centres using multiple treatments in parallel. Most patients (37.1%) received non-steroidal anti-inflammatory drugs alone or in combination. Bisphosphonates (22.1%), conventional (21.7%) and biological (11.3%) disease-modifying antirheumatic drugs were the next most frequently reported treatments. Reported outcomes varied and delivered mixed results, which complicates comparisons. Bisphosphonates demonstrated the most consistent improvement of osteoarticular symptoms and were associated with transient influenza-like symptoms. Paradoxical skin reactions were reported in patients treated with TNF inhibitors, but no serious adverse events were recorded. Most treatments had limited or mixed effects on cutaneous involvement. A recent study investigating the Janus kinase inhibitor tofacitinib delivered promising results in relation to skin and nail involvement. CONCLUSIONS No single currently available treatment option sufficiently addresses all SAPHO-associated symptoms. Variable, sometimes descriptive outcomes and the use of treatment combinations complicate conclusions and treatment recommendations. Randomised clinical trials are necessary to generate reliable evidence.
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Affiliation(s)
- Sophie W S Li
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Eve Roberts
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Christian Hedrich
- Department of Women's & Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
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Tzaneti A, Athanasopoulou E, Fessatou S, Fotis L. Chronic Nonbacterial Osteomyelitis in Inflammatory Bowel Disease. Life (Basel) 2023; 13:2347. [PMID: 38137947 PMCID: PMC10745028 DOI: 10.3390/life13122347] [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: 11/04/2023] [Revised: 12/10/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023] Open
Abstract
Chronic nonbacterial osteomyelitis (CNO), also known as chronic recurrent multifocal osteomyelitis (CRMO), is a rare autoinflammatory bone disease primarily affecting children and adolescents. This review presents a comprehensive analysis of the intricate relationship between CNO and inflammatory bowel disease (IBD), shedding light on shared pathophysiological mechanisms and clinical management. A thorough literature review was conducted, encompassing 24 case reports involving 40 patients. The demographic distribution of patients revealed a near-equal gender ratio, with a median age of diagnosis at 12 years. The diagnosis patterns showed a higher proportion of CNO as the initial diagnosis, while Crohn's disease was more prevalent than ulcerative colitis. The time interval between the clinical presentations varied, ranging from simultaneous detection to a substantial 15-year gap. Treatment modalities included nonsteroidal anti-inflammatory drugs (NSAIDs), steroids, aminosalicylates, and biologic agents, such as infliximab, often overlapping in their use and suggesting shared pathophysiological pathways. Both conditions displayed systemic manifestations, and patients often responded well to immunosuppressive medications. The pathophysiology of CNO involves a genetic predisposition, cytokine dysregulation, and osteoclast activation. Dysregulated innate immunity results in immune cell infiltration into bones, causing sterile bone lesions. Notably, emerging evidence hints at a potential link between the microbiome and CNO. In contrast, IBD results from imbalanced mucosal immune responses to the intestinal microbiota. Polymorphisms in the promotor region of IL-10, common cytokines, immune cells, and genetic markers indicate shared immunological and genetic factors between CNO and IBD. Both conditions also involve extraintestinal symptoms. This analysis underscores the need for clinical awareness of the co-occurrence of CNO and IBD, especially among pediatric patients. A deepened understanding of the connections between these seemingly distinct diseases could lead to more effective management and improved patient outcomes.
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Affiliation(s)
- Ariadni Tzaneti
- Department of Pediatrics, Attikon General Hospital, National and Kapodistrian University of Athens, 124 62 Athens, Greece
| | - Elli Athanasopoulou
- Department of Pediatrics, Attikon General Hospital, National and Kapodistrian University of Athens, 124 62 Athens, Greece
| | - Smaragdi Fessatou
- Division of Pediatric Gastroenterology, Department of Pediatrics, Attikon General Hospital, National and Kapodistrian University of Athens, 124 62 Athens, Greece;
| | - Lampros Fotis
- Division of Pediatric Rheumatology, Department of Pediatrics, Attikon General Hospital, National and Kapodistrian University of Athens, 124 62 Athens, Greece
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8
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Sundqvist M, Christenson K, Wekell P, Björnsdottir H, Dahlstrand Rudin A, Sanchez Klose FP, Kallinich T, Welin A, Björkman L, Bylund J, Karlsson-Bengtsson A, Berg S. Severe chronic non-bacterial osteomyelitis in combination with total MPO deficiency and responsiveness to TNFα inhibition. Front Immunol 2023; 14:1233101. [PMID: 37954595 PMCID: PMC10637399 DOI: 10.3389/fimmu.2023.1233101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 10/10/2023] [Indexed: 11/14/2023] Open
Abstract
We describe a female patient suffering from severe chronic non-bacterial osteomyelitis (CNO) with systemic inflammation and advanced malnutrition and complete deficiency of myeloperoxidase (MPO). CNO is a rare autoinflammatory bone disorder associated with dysregulation of the innate immune system. MPO deficiency is a genetic disorder with partial or complete absence of the phagocyte peroxidase MPO. MPO deficiency has no established clinical phenotype but reports indicate increased susceptibility to infection and chronic inflammation. The patient's symptoms began at 10 years of age with pain in the thighs, systemic inflammation and malnutrition. She was diagnosed with CNO at 14 years of age. Treatment with nonsteroidal anti-inflammatory drugs, corticosteroids, bisphosphonates or IL1-receptor antagonists (anakinra) did not relieve the symptoms. However, the patient responded instantly and recovered from her clinical symptoms when treated with TNFα blockade (adalimumab). Three years after treatment initiation adalimumab was withdrawn, resulting in rapid symptom recurrence. When reintroducing adalimumab, the patient promptly responded and went into remission. In addition to clinical and laboratory profiles, neutrophil functions (reactive oxygen species, ROS; neutrophil extracellular traps, NETs; degranulation; apoptosis; elastase activity) were investigated both in a highly inflammatory state (without treatment) and in remission (on treatment). At diagnosis, neither IL1β, IL6, nor TNFα was significantly elevated in serum, but since TNFα blockade terminated the inflammatory symptoms, the disease was likely TNFα-driven. All neutrophil parameters were normal both during treatment and treatment withdrawal, except for MPO-dependent intracellular ROS- and NET formation. The role of total MPO deficiency for disease etiology and severity is discussed.
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Affiliation(s)
- Martina Sundqvist
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg, Sweden
| | - Karin Christenson
- Department of Oral Microbiology and Immunology, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Per Wekell
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Pediatrics, NU Hospital Group, Uddevalla, Sweden
- Department of Pediatric Rheumatology and Immunology, Queen Silvia Children’s Hospital, Gothenburg, Sweden
| | - Halla Björnsdottir
- Department of Oral Microbiology and Immunology, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Agnes Dahlstrand Rudin
- Department of Oral Microbiology and Immunology, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Felix P. Sanchez Klose
- Department of Oral Microbiology and Immunology, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Tilmann Kallinich
- Department of Pediatric Pneumology, Immunology and Critical Care Medicine, Charité Universitätsmedizin Berlin, Deutsches Rheuma-Forschungszentrum (DRFZ), Institute of the Leibniz Association, Berlin, Germany
| | - Amanda Welin
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg, Sweden
- Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Faculty of Medicine, Linköping University, Linköping, Sweden
| | - Lena Björkman
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg, Sweden
- Unit of Rheumatology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johan Bylund
- Department of Oral Microbiology and Immunology, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anna Karlsson-Bengtsson
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg, Sweden
- Division of Chemical Biology, Department of Life Sciences, Chalmers University of Technology, Gothenburg, Sweden
| | - Stefan Berg
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Pediatric Rheumatology and Immunology, Queen Silvia Children’s Hospital, Gothenburg, Sweden
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9
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Wu EY, Oliver M, Scheck J, Lapidus S, Akca UK, Yasin S, Stern SM, Insalaco A, Pardeo M, Simonini G, Marrani E, Wang X, Huang B, Kovalick LK, Rosenwasser N, Casselman G, Liau A, Shao Y, Yang C, Mosa DM, Tucker L, Girschick H, Laxer RM, Akikusa JD, Hedrich CM, Onel K, Dedeoglu F, Twilt M, Ferguson PJ, Ozen S, Zhao Y. Feasibility of Conducting Comparative Effectiveness Research and Validation of a Clinical Disease Activity Score for Chronic Nonbacterial Osteomyelitis. J Rheumatol 2023; 50:1333-1340. [PMID: 37399459 PMCID: PMC10543471 DOI: 10.3899/jrheum.2022-1323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2023] [Indexed: 07/05/2023]
Abstract
OBJECTIVE Prospective comparative effectiveness research (CER) in chronic nonbacterial osteomyelitis (CNO) is lacking. Our objectives were to (1) determine the use and safety of each consensus treatment plan (CTP) regimen for CNO, (2) assess the feasibility of using the Chronic Nonbacterial Osteomyelitis International Registry (CHOIR) data for CER, and (3) develop and validate a CNO clinical disease activity score (CDAS) using CHOIR. METHODS Consenting children or young adults with CNO were enrolled into CHOIR. Demographic, clinical, and imaging data were prospectively collected. The CNO CDAS was developed through a Delphi survey and nominal group technique. External validation surveys were administered to CHOIR participants. RESULTS One hundred forty (78.2%) CHOIR participants enrolled between August 2018 and September 2020 received at least 1 CTP regimen. Baseline characteristics from different CTP groups were well matched. Patient pain, patient global assessment, and clinical CNO lesion count were key variables included in the CNO CDAS. The CDAS showed a strong correlation with patient/parent report of difficulty using a limb, back, or jaw and patient/parent report of disease severity, but a weak correlation with patient/parent report of fatigue, sadness, and worry. The change in CDAS was significant in patients reporting disease worsening or improvement (P < 0.001). The CDAS significantly decreased after initiating second-line treatments from median 12.0 (IQR 8.0-15.5) to 5.0 (IQR 3.0-12.0; P = 0.002). Although second-line treatments were well tolerated, psoriasis was the most common adverse event. CONCLUSION The CNO CDAS was developed and validated for disease monitoring and assessment of treatment effectiveness. CHOIR provided a comprehensive framework for future CER.
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Affiliation(s)
- Eveline Y Wu
- E.Y. Wu, MD, MSCR, L.K. Kovalick, PNP, Division of Rheumatology, Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Melissa Oliver
- M. Oliver, MD, MS, Division of Pediatric Rheumatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Joshua Scheck
- J. Scheck, BS, N. Rosenwasser, MD, G. Casselman, BS, A. Liau, BS, Y. Shao, BS, C. Yang, BS, Y. Zhao, MD, PhD, Division of Pediatric Rheumatology, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Sivia Lapidus
- S. Lapidus, MD, Division of Rheumatology, Department of Pediatrics, Joseph M. Sanzari Children's Hospital, Hackensack University Medical Center and Hackensack Meridian School of Medicine, Hackensack, New Jersey, USA
| | - Ummusen Kaya Akca
- U. Kaya Akca, MD, S. Ozen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | - Shima Yasin
- S. Yasin, MD, MSc, P.J. Ferguson, MD, Division of Rheumatology, Allergy and Immunology, Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Sara M Stern
- S.M. Stern, MD, Division of Rheumatology, Department of Pediatrics, The University of Utah, Salt Lake City, Utah, USA
| | - Antonella Insalaco
- A. Insalaco, MD, M. Pardeo, MD, Division of Rheumatology, ERN RITA Center, IRCCS Ospedale Pediatrico Bambino Gesù, Roma, Italy
| | - Manuela Pardeo
- A. Insalaco, MD, M. Pardeo, MD, Division of Rheumatology, ERN RITA Center, IRCCS Ospedale Pediatrico Bambino Gesù, Roma, Italy
| | - Gabriele Simonini
- G. Simonini, MD, E. Marrani, MD, Rheumatology Unit, ERN ReCONNET Center, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Edoardo Marrani
- G. Simonini, MD, E. Marrani, MD, Rheumatology Unit, ERN ReCONNET Center, Meyer Children's Hospital IRCCS, Florence, Italy
| | - Xing Wang
- X. Wang, PhD, Biostatistics Epidemiology and Analytics in Research, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Bin Huang
- B. Huang, PhD, Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Leonard K Kovalick
- E.Y. Wu, MD, MSCR, L.K. Kovalick, PNP, Division of Rheumatology, Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Natalie Rosenwasser
- J. Scheck, BS, N. Rosenwasser, MD, G. Casselman, BS, A. Liau, BS, Y. Shao, BS, C. Yang, BS, Y. Zhao, MD, PhD, Division of Pediatric Rheumatology, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Gabriel Casselman
- J. Scheck, BS, N. Rosenwasser, MD, G. Casselman, BS, A. Liau, BS, Y. Shao, BS, C. Yang, BS, Y. Zhao, MD, PhD, Division of Pediatric Rheumatology, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Adriel Liau
- J. Scheck, BS, N. Rosenwasser, MD, G. Casselman, BS, A. Liau, BS, Y. Shao, BS, C. Yang, BS, Y. Zhao, MD, PhD, Division of Pediatric Rheumatology, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Yurong Shao
- J. Scheck, BS, N. Rosenwasser, MD, G. Casselman, BS, A. Liau, BS, Y. Shao, BS, C. Yang, BS, Y. Zhao, MD, PhD, Division of Pediatric Rheumatology, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Claire Yang
- J. Scheck, BS, N. Rosenwasser, MD, G. Casselman, BS, A. Liau, BS, Y. Shao, BS, C. Yang, BS, Y. Zhao, MD, PhD, Division of Pediatric Rheumatology, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA
| | - Doaa Mosad Mosa
- D.M. Mosa, MD, Rheumatology and Rehabilitation Department, Mansoura University Hospitals, Mansoura University, Mansoura City, Egypt
| | - Lori Tucker
- L. Tucker, MD, Division of Rheumatology, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hermann Girschick
- H. Girschick, Department of Pediatrics, Vivantes Clinic Friedrichshain, Berlin, Germany
| | - Ronald M Laxer
- R.M. Laxer, The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | | | - Christian M Hedrich
- C.M. Hedrich, MD, PhD, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, UK
| | - Karen Onel
- K. Onel, MD, Division of Pediatric Rheumatology, Hospital for Special Surgery, New York, New York, USA
| | - Fatma Dedeoglu
- F. Dedeoglu, MD, Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marinka Twilt
- M. Twilt, MD, Division of Rheumatology, Department of Paediatrics, Alberta Children's Hospital, Calgary, Alberta, Canada
| | - Polly J Ferguson
- S. Yasin, MD, MSc, P.J. Ferguson, MD, Division of Rheumatology, Allergy and Immunology, Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Seza Ozen
- U. Kaya Akca, MD, S. Ozen, MD, Division of Rheumatology, Department of Pediatrics, Hacettepe University, Ankara, Turkey
| | - Yongdong Zhao
- J. Scheck, BS, N. Rosenwasser, MD, G. Casselman, BS, A. Liau, BS, Y. Shao, BS, C. Yang, BS, Y. Zhao, MD, PhD, Division of Pediatric Rheumatology, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA;
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10
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Guariento A, Sharma P, Andronikou S. MRI features of spinal chronic recurrent multifocal osteomyelitis/chronic non-bacterial osteomyelitis in children. Pediatr Radiol 2023; 53:2092-2103. [PMID: 37204463 DOI: 10.1007/s00247-023-05688-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/26/2023] [Accepted: 04/29/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Spinal lesions in pediatric chronic recurrent multifocal osteomyelitis/chronic non-bacterial osteomyelitis (CRMO/CNO) can cause permanent sequelae; thus, early recognition of these is vital for management. OBJECTIVE To characterize the MR imaging features and patterns of pediatric spinal CRMO/CNO. MATERIALS AND METHODS This cross-section study received IRB approval. The first available MRI with documented spine involvement in children with CRMO/CNO was reviewed by a pediatric radiologist. Descriptive statistics were used to describe the characteristics of vertebral lesions, disc involvement, and soft tissue abnormality. RESULTS Forty-two patients were included (F:M, 30:12); median age was 10 years (range 4-17). At diagnosis, 34/42 (81%) had spine involvement. Kyphosis in 9/42 (21%) and scoliosis in 4/42 (9.5%) patients were present at the time of spinal disease recognition. Vertebral involvement was multifocal in 25/42 (59.5%). Disc involvement was found in 11/42 (26%) patients, commonly in the thoracic spine and often with adjacent vertebrae height loss. Posterior element abnormalities were present in 18/42 patients (43%) and soft tissue involvement in 7/42 (17%). One hundred nineteen vertebrae were affected, commonly the thoracic vertebrae (69/119; 58%). Vertebral body edema was focal in 77/119 (65%) and frequently superior (42/77; 54%). Sclerosis and endplate abnormality were present in 15/119 (13%) and 31/119 (26%) vertebrae, respectively. Height loss was present in 41/119 (34%). CONCLUSION Chronic non-bacterial osteomyelitis of spine is usually thoracic. Vertebral body edema is often focal at the superior vertebral body. Kyphosis and scoliosis occur in a quarter and vertebral height loss in a third of children at spinal disease recognition.
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Affiliation(s)
- Andressa Guariento
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Parth Sharma
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Savvas Andronikou
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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11
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Stojkic I, Rubin E, Lee J, Lee ASE, Ogbu EA. An unusual presentation of chronic recurrent multifocal osteomyelitis involving bones of the skull. Int J Rheum Dis 2023; 26:1579-1581. [PMID: 36843231 DOI: 10.1111/1756-185x.14629] [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: 02/01/2023] [Accepted: 02/09/2023] [Indexed: 02/28/2023]
Abstract
Chronic recurrent multifocal osteomyelitis is a rare, multisystemic inflammatory disease that affects children and adolescents. We present the case of an African-American adolescent male who presented with recurrent swelling of the temporal region with skull involvement on head imaging, which is atypical for chronic recurrent multifocal osteomyelitis. He had clinical and laboratory improvement after initiation of indomethacin and pamidronate.
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Affiliation(s)
- Ivana Stojkic
- Division of Rheumatology, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Eric Rubin
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jay Lee
- Division of Pediatric Orthopaedics, Department of Orthopaedic Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ashley Sang Eun Lee
- Department of Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Ekemini Akan Ogbu
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Division of Rheumatology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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12
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Hassan M, Assi H, Hassan M, Bies JJ, Prakash S, Hassan A, Alhariri S, Dihowm F. Chronic Recurrent Multifocal Osteomyelitis: A Comprehensive Literature Review. Cureus 2023; 15:e43118. [PMID: 37692753 PMCID: PMC10483435 DOI: 10.7759/cureus.43118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/08/2023] [Indexed: 09/12/2023] Open
Abstract
Chronic recurrent multifocal osteomyelitis (CRMO) is a non-infectious, inflammatory disorder of the bones. CRMO typically affects children, with a predisposition to females. Bone-related pain is often felt in the metaphysis of long bones, particularly of the lower extremities, but it can also target other sites at varied time intervals. Patients are likely to complain of tenderness and swelling that may cause considerable disability and adversely impact quality of life. There are three main pathophysiological mechanisms that have been hypothesized to drive CRMO including imbalanced cytokine expression, increased inflammasome activation, and enhanced osteoclast differentiation. Therapies have been based on targeting and suppressing these key players in CRMO patients. The first step in management involves pain control. Non-steroidal anti-inflammatory drugs should provide initial relief, albeit temporarily. It is imperative to initiate immunosuppressive medication that will help limit bone involvement and thereby prevent the development of fractures or leg-length discrepancies, for example. The purpose of this literature review is to study the pathophysiology of CRMO and carefully dissect the agents that have been previously employed in the management of CRMO patients. This could allow for the purposeful formulation of individualized care plans and improving the overall well-being of patients. The authors included a multitude of PubMed-indexed articles published from 2000 onwards in this review.
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Affiliation(s)
- Mariam Hassan
- Internal Medicine, Texas Tech University Health Sciences Center Paul L. Foster School of Medicine, El Paso, USA
| | - Heabah Assi
- Internal Medicine, Texas Tech University Health Sciences Center Paul L. Foster School of Medicine, El Paso, USA
| | - Maha Hassan
- Biomedical Sciences, Gulf Medical University, Ajman, ARE
| | - Jared J Bies
- Internal Medicine, Texas Tech University Health Sciences Center Paul L. Foster School of Medicine, El Paso, USA
| | - Swathi Prakash
- Internal Medicine, Texas Tech University Health Sciences Center Paul L. Foster School of Medicine, El Paso, USA
| | - Ali Hassan
- Emergency Medicine, Mercy Health St. Elizabeth Boardman Hospital, Boardman, USA
| | - Sara Alhariri
- Internal Medicine, Texas Tech University Health Sciences Center Paul L. Foster School of Medicine, El Paso, USA
| | - Fatma Dihowm
- Internal Medicine, Texas Tech University Health Sciences Center Paul L. Foster School of Medicine, El Paso, USA
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13
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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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14
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Singhal S, Landes C, Shukla R, McCann LJ, Hedrich CM. Classification and management strategies for paediatric chronic nonbacterial osteomyelitis and chronic recurrent multifocal osteomyelitis. Expert Rev Clin Immunol 2023; 19:1101-1116. [PMID: 37224535 DOI: 10.1080/1744666x.2023.2218088] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 05/04/2023] [Accepted: 05/22/2023] [Indexed: 05/26/2023]
Abstract
INTRODUCTION Chronic non-bacterial osteomyelitis (CNO) is an autoinflammatory bone disease that most commonly affects children and adolescents causing significant pain and damage to bones. The absence of diagnostic criteria and biomarkers, an incomplete understanding of the molecular pathophysiology, and lack of evidence from randomized and controlled trials make the diagnosis and care challenging. AREAS COVERED This review provides an overview of the clinical and epidemiological features of CNO and displays diagnostic challenges and how they can be addressed following strategies used internationally and by the authors. It summarizes the molecular pathophysiology, including pathological activation of the NLRP3 inflammasome and IL-1 secretion, and how these observations can inform future treatment strategies. Finally, it provides a summary of ongoing initiatives aiming at classification criteria (ACR/EULAR) and outcome measures (OMERACT) that will enable the generation of evidence through clinical trials. EXPERT OPINION Scientific efforts have linked molecular mechanisms to cytokine dysregulation in CNO, thereby delivering arguments for cytokine blocking strategies. Recent and ongoing collaborative international efforts are providing the basis to move toward clinical trials and target directed treatments for CNO that find approval by regulatory agencies.
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Affiliation(s)
- Shabnam Singhal
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Caren Landes
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
- Department of Paediatric Radiology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Rajeev Shukla
- Department of Paediatric Histopathology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Liza J McCann
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Christian M Hedrich
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
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15
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Hetrick R, Oliver M. Pediatric autoinflammatory bone disorders-a mini review with special focus on pathogenesis and inborn errors of immunity. Front Pediatr 2023; 11:1169659. [PMID: 37342528 PMCID: PMC10277822 DOI: 10.3389/fped.2023.1169659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 05/17/2023] [Indexed: 06/23/2023] Open
Abstract
Autoinflammatory bone disorders are a group of diseases characterized by sterile osteomyelitis. This includes chronic nonbacterial osteomyelitis and the monogenic forms, Majeed syndrome and deficiency of the interleukin-1 receptor antagonist. These disorders result from innate immune system dysregulation and cytokine imbalance that triggers inflammasome activation causing downstream osteoclastogenesis and excessive bone remodeling. In this review, we will summarize the immunopathogenesis of pediatric autoinflammatory bone diseases with a special focus on the genetics and inborn errors of immunity, while briefly touching on the clinical manifestations and management of each disease as well as areas for future research.
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16
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Alexeeva EI, Dvoryakovskaya TM, Tsulukiya IT, Kondrateva NM, Solomatina NM, Kondratiev GV, Peshekhonova LV, Kostik MM. Juvenile idiopathic arthritis with systemic onset with inflammatory bone lesions: two case reports of patients successfully treated with canakinumab and experience gained from literature. Front Pediatr 2023; 11:1163483. [PMID: 37325364 PMCID: PMC10266530 DOI: 10.3389/fped.2023.1163483] [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: 02/10/2023] [Accepted: 05/02/2023] [Indexed: 06/17/2023] Open
Abstract
Non-bacterial osteomyelitis (NBO) is a rare chronic inflammatory bone disease related to immune system dysregulation. This disease belongs to a family of autoinflammatory diseases. It often coexists with other TNF-α-mediated immune-mediated diseases such as juvenile idiopathic arthritis (JIA) and inflammatory bowel diseases. Previously, interleukin-1-driven inflammation was described predominantly in monogenic cases of NBO, such as DIRA syndrome or Majeed syndrome. However, the association between NBO and JIA with systemic onset (soJIA) has not been described yet. Herein, we describe the cases of two patients with soJIA with inflammatory bone lesions wherein canakinumab (anti-interleukin-1β antibodies) caused remission. Case descriptions Patient 1-A 6-month-old boy with typical soJIA suffered a destruction of the 7th to 9th ribs and the left pubic bone. Antibiotics, IVIG, and cyclosporine proved ineffective. Corticosteroids were effective, but due to the factor of corticosteroid dependence, which has some disadvantages, canakinumab with a dosage of 4 mg/kg was initiated every 4 weeks, which completely controlled the disease and allowed to taper corticosteroids.Patient 2-A 2-year-old girl developed chronic non-bacterial osteomyelitis of the 5th rib 2 months after taking corticosteroids prescribed for typical soJIA. She underwent surgical debridement removal, and several courses of antibiotics proved ineffective. She developed macrophage activation syndrome, following which anakinra was prescribed, which resulted in only temporary improvement. Therefore, this drug was switched to canakinumab, which caused corticosteroid-free remission. Conclusion This is the first description of a rare association of soJIA with inflammatory bone lesions with the proven efficacy of IL-1 blockade. The association of two autoinflammatory conditions should indicate IL-1-driven mechanisms and a possible genetic basis. Follow-up genetic and functional studies are required to better understand the pathogenesis of such overlapping diseases.
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Affiliation(s)
- Ekaterina I. Alexeeva
- Department of Rheumatology, National Medical Research Center of Children's Health, Moscow, Russia
- Russian Federation Department of Pediatrics, Sechenov First Moscow State Medical University, Moscow, Russia
- Association of Pediatric Rheumatologists, Moscow, Russia
| | - Tatyana M. Dvoryakovskaya
- Department of Rheumatology, National Medical Research Center of Children's Health, Moscow, Russia
- Russian Federation Department of Pediatrics, Sechenov First Moscow State Medical University, Moscow, Russia
- Association of Pediatric Rheumatologists, Moscow, Russia
| | - Irina T. Tsulukiya
- Department of Rheumatology, National Medical Research Center of Children's Health, Moscow, Russia
| | - Natalia M. Kondrateva
- Department of Rheumatology, National Medical Research Center of Children's Health, Moscow, Russia
| | - Natalia M. Solomatina
- Pediatric Pulmonology, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russia
| | - Gleb V. Kondratiev
- Pediatric Oncology, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russia
| | - Luliia V. Peshekhonova
- Pediatric Pulmonology, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russia
| | - Mikhail M. Kostik
- Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russia
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17
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Romagnuolo M, Moltrasio C, Iannone C, Gattinara M, Cambiaghi S, Marzano AV. Pyoderma gangrenosum following anti-TNF therapy in chronic recurrent multifocal osteomyelitis: drug reaction or cutaneous manifestation of the disease? A critical review on the topic with an emblematic case report. Front Med (Lausanne) 2023; 10:1197273. [PMID: 37324147 PMCID: PMC10264797 DOI: 10.3389/fmed.2023.1197273] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/15/2023] [Indexed: 06/17/2023] Open
Abstract
Chronic recurrent multifocal osteomyelitis (CRMO) is a rare autoinflammatory disease, clinically characterized by chronic and recurrent episodes of osteoarticular inflammation, that generally presents in children and adolescents. From a dermatological point-of-view, CMRO can be associated with skin rashes mainly including psoriasis, palmoplantar pustulosis and acne. Pyoderma gangrenosum (PG) is a rare immune-mediated inflammatory skin disease classified within the spectrum of neutrophilic dermatoses that, in some cases, has been reported as cutaneous manifestation in CMRO patients. This paper presents a 16-year female patient diagnosed with CMRO, who presented PG lesions located on the lower leg, that arose after the administration of the tumour necrosis factor (TNF)-α inhibitor adalimumab. Cases of PG have been reported in patients being treated with certain medications, including TNF-α antagonists, leading to classified them in a setting aptly termed "drug-induced PG." In this paper, we discuss the co-occurrence of PG and CRMO, in the light of recent evidence on the pathogenesis of both diseases and giving ample space to a literature review on drug induced PG. In our case, it is plausible that PG could be considered a cutaneous manifestation of CRMO, although the mechanisms underlying this intriguingly relationship remain to be fully unraveled.
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Affiliation(s)
- Maurizio Romagnuolo
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Chiara Moltrasio
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Claudia Iannone
- Division of Clinical Rheumatology, ASST Gaetano Pini-CTO Institute, Milan, Italy
| | - Maurizio Gattinara
- Department of Clinical Sciences and Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, University of Milan, Milan, Italy
| | - Stefano Cambiaghi
- Pediatric Dermatology Unit, Department of Clinical Sciences and Community Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Angelo Valerio Marzano
- Dermatology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
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18
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Hedrich CM, Beresford MW, Dedeoglu F, Hahn G, Hofmann SR, Jansson AF, Laxer RM, Miettunen P, Morbach H, Pain CE, Ramanan AV, Roberts E, Schnabel A, Theos A, Whitty L, Zhao Y, Ferguson PJ, Girschick HJ. Gathering expert consensus to inform a proposed trial in chronic nonbacterial osteomyelitis (CNO). Clin Immunol 2023; 251:109344. [PMID: 37098355 DOI: 10.1016/j.clim.2023.109344] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/23/2022] [Accepted: 04/07/2023] [Indexed: 04/27/2023]
Abstract
Chronic nonbacterial osteomyelitis (CNO) is an autoinflammatory bone disease that primarily affects children and adolescents. CNO is associated with pain, bone swelling, deformity, and fractures. Its pathophysiology is characterized by increased inflammasome assembly and imbalanced expression of cytokines. Treatment is currently based on personal experience, case series and resulting expert recommendations. Randomized controlled trials (RCTs) have not been initiated because of the rarity of CNO, expired patent protection of some medications, and the absence of agreed outcome measures. An international group of fourteen CNO experts and two patient/parent representatives was assembled to generate consensus to inform and conduct future RCTs. The exercise delivered consensus inclusion and exclusion criteria, patent protected (excludes TNF inhibitors) treatments of immediate interest (biological DMARDs targeting IL-1 and IL-17), primary (improvement of pain; physician global assessment) and secondary endpoints (improved MRI; improved PedCNO score which includes physician and patient global scores) for future RCTs in CNO.
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Affiliation(s)
- C M Hedrich
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK.
| | - M W Beresford
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, UK; Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - F Dedeoglu
- Boston Children's Hospital & Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - G Hahn
- Department of Radiology, University Medical Center Carl Gustav Carus, TU Dresden, Germany
| | - S R Hofmann
- Department of Paediatrics, University Medical Center Carl Gustav Carus, TU Dresden, Germany
| | - A F Jansson
- Department of Pediatrics, Dr von Hauner Children's Hospital, Ludwig Maximilian University, Munich, Germany
| | - R M Laxer
- The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - P Miettunen
- University of Calgary, Calgary, Alberta, Canada
| | - H Morbach
- Pediatric Immunology, University Childrens' Hospital Würzburg, Würzburg, Germany
| | - C E Pain
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - A V Ramanan
- Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol and Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - E Roberts
- CNO/CRMO Patient Partner, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - A Schnabel
- Department of Paediatrics, University Medical Center Carl Gustav Carus, TU Dresden, Germany
| | - A Theos
- CNO/CRMO Patient/parent Partner, Department of Human Science, Georgetown University, Washington, DC, USA
| | - L Whitty
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, UK
| | - Y Zhao
- Seattle Children's Hospital, University of Washington, Seattle, United States of America
| | - P J Ferguson
- University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - H J Girschick
- Vivantes Children's Hospital in Friedrichshain, Berlin, Germany
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19
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Costi S, Germinario S, Pandolfi M, Pellico MR, Amati A, Gattinara M, Chighizola CB, Caporali R, Marino A. Chronic Nonbacterial Osteomyelitis and Inflammatory Bowel Disease: A Literature Review-Based Cohort. CHILDREN 2023; 10:children10030502. [PMID: 36980060 PMCID: PMC10047775 DOI: 10.3390/children10030502] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 02/27/2023] [Accepted: 03/01/2023] [Indexed: 03/06/2023]
Abstract
Background: Chronic nonbacterial osteomyelitis (CNO) is a rare autoinflammatory bone disorder that mainly involves children and adolescents. The association with other inflammatory disorders, such as inflammatory bowel disease (IBD), psoriasis, and arthritis, has been reported in the literature. In particular, the relationship between bone and intestinal inflammation is still poorly understood. For this purpose, our review aims to describe the cases reported in the literature concerning this association and to compare them with data from our single-center cohort of patients. Methods: We conducted a literature review of published cases of CNO associated with IBD. Eligible articles were identified through a Medline search in the PubMed database until December 2022. We retrospectively reviewed medical records of patients with CNO referred to G. Pini Hospital and compared them with the literature-review-based cohort. Results: Fifty-seven patients with a defined diagnosis of CNO and associated IBD were described in the literature (female 55%). The median age of onset of the disease (CNO or IBD) was 11 years. In 32/53 (60%), a diagnosis of Crohn’s disease (CD) was made, while 18 (34%) patients were classified as suffering from ulcerative colitis (UC) and 3 (6%) from undifferentiated IBD. The diagnosis of CNO preceded the diagnosis of IBD in 59% of cases; while in 24%, IBD anticipated CNO; and in 17%, the two conditions appeared simultaneously. The median time between the two events was 24 months. In our Italian cohort (n = 23 patients), no diagnosis of IBD was made. No significant differences were found when comparing clinical and demographical characteristics of the Italian vs. review-based cohort, except for a significant involvement of rachis in the Italian group. Conclusions: The correlation between autoinflammatory bone disease and intestinal inflammation should be further investigated. It is essential to promote awareness among pediatric rheumatologists and gastroenterologists about this possible association to facilitate the diagnosis and better optimize treatment.
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Affiliation(s)
- Stefania Costi
- Unit of Pediatric Rheumatology, ASST G. Pini-CTO, 20122 Milan, Italy
| | | | | | | | | | | | - Cecilia Beatrice Chighizola
- Unit of Pediatric Rheumatology, ASST G. Pini-CTO, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, Research Center for Pediatric and Adult Rheumatic Diseases (RECAP.RD), University of Milan, 20122 Milan, Italy
| | - Roberto Caporali
- Unit of Pediatric Rheumatology, ASST G. Pini-CTO, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, Research Center for Pediatric and Adult Rheumatic Diseases (RECAP.RD), University of Milan, 20122 Milan, Italy
- Department of Rheumatology and Medical Sciences, ASST G. Pini-CTO, 20122 Milan, Italy
| | - Achille Marino
- Unit of Pediatric Rheumatology, ASST G. Pini-CTO, 20122 Milan, Italy
- Correspondence:
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20
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Salazar LM, Cone R, Morrey BF. Chronic nonbacterial monoarticular osteomyelitis of the elbow. JSES REVIEWS, REPORTS, AND TECHNIQUES 2022; 2:592-596. [PMID: 37588451 PMCID: PMC10426514 DOI: 10.1016/j.xrrt.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
| | - Robert Cone
- Department of Radiology, UT Health San Antonio, San Antonio, TX, USA
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21
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Chang E, Vickery J, Zaiat N, Sallam E, Hanan A, Baker S, Alhamar M, Poulik J, Demian E, Shehata BM. Chronic Recurrent Multifocal Osteomyelitis (CRMO): A Study of 12 Cases from One Institution and Literature Review. Fetal Pediatr Pathol 2022; 41:759-770. [PMID: 34542007 DOI: 10.1080/15513815.2021.1978602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND CRMO is a sterile auto inflammatory bone disease that affects the pediatric population. Recently, single gene mutations in LPIN2, DIRA, and IL1RN have been reported in murine models of CRMO. MATERIALS AND METHODS The medical records and histopathological slides of twelve patients were reviewed. RESULTS The diagnosis was determined by multiple lesions, imaging, negative cultures, bone biopsy, and lack of antibiotic response. Biopsy showed early neutrophilic infiltrates, and older lesions showed lymphoplasmacytic infiltrates and fibrosis. Patients were treated with anti-inflammatory medication with some lesions completely resolving. CONCLUSION Bone biopsy aids the diagnosis of CRMO in correlation with clinical presentation, imaging, and culture findings. Our findings indicate the kinetics of CRMO is not well defined and the fibrosis may be reached after months, in contrast to the previously reported several years. We hope that these genetic mutations can be further studied in human models to describe the genetics behind CRMO.
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Affiliation(s)
- Eric Chang
- Pathology, Children Hospital of Michigan, Detroit MI, USA
| | | | - Nadeen Zaiat
- Pathology, Children Hospital of Michigan, Detroit MI, USA
| | - Eman Sallam
- Pathology, Children Hospital of Michigan, Detroit MI, USA
| | - Abdul Hanan
- Pathology, Children Hospital of Michigan, Detroit MI, USA
| | - Scott Baker
- Pathology, Children Hospital of Michigan, Detroit MI, USA
| | | | - Janet Poulik
- Pathology, Children Hospital of Michigan, Detroit MI, USA
| | - Ereny Demian
- Pathology, Children Hospital of Michigan, Detroit MI, USA
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22
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Nico MAC, Araújo FF, Guimarães JB, da Cruz IAN, Silva FD, Carneiro BC, Filho AGO. Chronic nonbacterial osteomyelitis: the role of whole-body MRI. Insights Imaging 2022; 13:149. [PMID: 36114435 PMCID: PMC9481810 DOI: 10.1186/s13244-022-01288-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 08/24/2022] [Indexed: 11/12/2022] Open
Abstract
Background Chronic nonbacterial osteomyelitis (CNO), also known as chronic recurrent multifocal osteomyelitis, is a noninfectious autoinflammatory disorder that occurs primarily in children and adolescents and is characterized by episodic musculoskeletal pain with a protracted course. Main body Traditionally, the diagnosis of CNO is made by exclusion and commonly requires bone biopsy to rule out infection and malignancy. However, bone biopsy may be avoided when imaging and clinical characteristic features are present, such as multifocal bone lesions at typical sites, no constitutional symptoms and no signs of infection in laboratory test results. Whole-body magnetic resonance imaging (WB-MRI) can assess signs of acute and chronic inflammation and enables the detection of CNO typical patterns of lesion location and distribution, thereby helping to exclude differential diagnosis. The goal of the present study paper is to review the main clinical and imaging aspects of the disease with emphasis on the role of WB-MRI in the diagnosis, assessment of disease burden and follow-up monitoring. Conclusion Radiologists need to be familiar with the imaging features to suggest the diagnosis as the early therapy may help to avoid irreversible secondary damage of skeletal system.
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23
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Efthimiou P, Petryna O, Nakasato P, Kontzias A. New insights on multigenic autoinflammatory diseases. Ther Adv Musculoskelet Dis 2022; 14:1759720X221117880. [PMID: 36081748 PMCID: PMC9445512 DOI: 10.1177/1759720x221117880] [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] [Received: 12/22/2021] [Accepted: 07/14/2022] [Indexed: 11/16/2022] Open
Abstract
Autoinflammatory diseases are disorders of the innate immune system, which can be either monogenic due to a specific genetic mutation or complex multigenic due to the involvement of multiple genes. The aim of this review is to explore and summarize the recent advances in pathogenesis, diagnosis, and management of genetically complex autoinflammatory diseases, such as Schnitzler's syndrome; adult-onset Still's disease; synovitis, acne, pustulosis, hyperostosis, osteitis syndrome/chronic recurrent multifocal osteomyelitis/chronic non-bacterial osteomyelitis; Adamantiades-Behçet's disease; Yao syndrome; and periodic fever with aphthous stomatitis, pharyngitis, and adenitis syndrome. The PubMed database was screened for relevant articles using free text words and specific search strings. The search was limited to English-language articles, reporting the results of studies in humans, published through March 2021. Evidence from literature suggest that these rare multigenic autoinflammatory diseases can present with different clinical features and the diagnosis of these diseases can be challenging due to a combination of nonspecific manifestations that can be seen in a variety of other conditions. Diagnostic delays and disease complications may occur due to low disease awareness and the lack of pathognomonic markers. The pathogeneses of these diseases are complex and in some cases precise pathogenesis is not clearly understood. Conventional treatments are commonly used for the management of these conditions, but biologics have shown promising results. Biologics targeting proinflammatory cytokines including IL-1, IL-6, TNF-α, IL-17A and IL-18 have been shown to ameliorate signs and symptoms of different multigenic autoinflammatory diseases.
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Affiliation(s)
- Petros Efthimiou
- New York Rheumatology Care, Ross University School of Medicine, New York, USA
| | - Olga Petryna
- NYU Grossman School of Medicine, New York, NY, USA
| | | | - Apostolos Kontzias
- Department of Rheumatology, Stony Brook University School of Medicine, Stony Brook, NY, USA
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24
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Shamim H, Khan MR, Absah I. Chronic Neck Pain and Swelling in a Teenage Patient: An Unusual Association of Inflammatory Bowel Disease. Clin Pediatr (Phila) 2022; 61:503-506. [PMID: 35442118 DOI: 10.1177/00099228221088719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Huma Shamim
- Division of Pediatric Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Muhammad Rehan Khan
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, University of Illinois College of Medicine at Peoria, Children's Hospital of Illinois, Peoria, IL, USA
| | - Imad Absah
- Division of Pediatric Gastroenterology & Hepatology, Mayo Clinic, Rochester, MN, USA
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25
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Ferjani Hanene L, Makhlouf Y, Maatallah K, Triki W, Ben Nessib D, Kaffel D, Hamdi W. Management of chronic recurrent multifocal osteomyelitis: review and update on the treatment protocol. Expert Opin Biol Ther 2022; 22:781-787. [PMID: 35574685 DOI: 10.1080/14712598.2022.2078161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory disorder primarily affecting children. It is characterized by a peripheral involvement of the metaphysis of long bones rather than axial involvement. Due to the scarcity of the disease, there are no guidelines regarding its management. AREAS COVERED This review aims to provide an overview of the different therapeutic alternatives and recent protocols. For this reason, first-line and second-line treatment, as well as the impact of new therapies, are discussed in depth. We conducted a search through PubMed on the different aspects of CRMO. Outcomes were categorized as first and second-line treatments. EXPERT OPINION Non-steroidal anti-inflammatory drugs remain the keystone of CRMO management and are proposed as the first-line treatment. In the case of vertebral involvement, bisphosphonate should be considered, even as a first-line treatment. Several case series and retrospective studies highlight the efficacy of anti-TNF agents. Their use could be an optimal treatment choice for CRMO with comorbid immune-mediated diseases. The potentially favorable effect of interleukin-1 antagonists remains to be determined.
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Affiliation(s)
- Lassoued Ferjani Hanene
- Department of Rheumatology, Mohammed Kassab National Institute of Orthopedics Mannouba, Tunisia.,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia.,Research Unit UR17SP04, 2010 Ksar Said, Tunis, Tunisia
| | - Yasmine Makhlouf
- Department of Rheumatology, Mohammed Kassab National Institute of Orthopedics Mannouba, Tunisia.,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia
| | - Kaouther Maatallah
- Department of Rheumatology, Mohammed Kassab National Institute of Orthopedics Mannouba, Tunisia.,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia.,Research Unit UR17SP04, 2010 Ksar Said, Tunis, Tunisia
| | - Wafa Triki
- Department of Rheumatology, Mohammed Kassab National Institute of Orthopedics Mannouba, Tunisia.,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia.,Research Unit UR17SP04, 2010 Ksar Said, Tunis, Tunisia
| | - Dorra Ben Nessib
- Department of Rheumatology, Mohammed Kassab National Institute of Orthopedics Mannouba, Tunisia.,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia.,Research Unit UR17SP04, 2010 Ksar Said, Tunis, Tunisia
| | - Dhia Kaffel
- Department of Rheumatology, Mohammed Kassab National Institute of Orthopedics Mannouba, Tunisia.,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia.,Research Unit UR17SP04, 2010 Ksar Said, Tunis, Tunisia
| | - Wafa Hamdi
- Department of Rheumatology, Mohammed Kassab National Institute of Orthopedics Mannouba, Tunisia.,Faculty of Medicine of Tunis, University Tunis El Manar, Tunis, Tunisia.,Research Unit UR17SP04, 2010 Ksar Said, Tunis, Tunisia
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26
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Schnabel A, Nashawi M, Anderson C, Felsenstein S, Lamoudi M, Poole-Cowley J, Lindell E, Oates B, Fowlie P, Walsh J, Ellis T, Hahn G, Goldspink A, Martin N, Mahmood K, Hospach T, Lj M, Hedrich CM. TNF-inhibitors or bisphosphonates in chronic nonbacterial osteomyelitis? - Results of an international retrospective multicenter study. Clin Immunol 2022; 238:109018. [PMID: 35460903 DOI: 10.1016/j.clim.2022.109018] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 04/12/2022] [Accepted: 04/14/2022] [Indexed: 12/26/2022]
Abstract
Chronic nonbacterial osteomyelitis (CNO) can cause significant morbidity, including bone pain and damage. In the absence of clinical trials, treatments include non-steroidal anti-inflammatory drugs, corticosteroids, TNF-inhibitors (TNFi) and/or bisphosphonates. In a retrospective chart review in the United Kingdom and Germany, we investigated response to TNFi and/or pamidronate. Ninety-one patients were included, receiving pamidronate (n = 47), TNFi (n = 22) or both sequentially (n = 22). Patients with fatigue [p = 0.003] and/or arthritis [p = 0.002] were more frequently treated with TNFi than pamidronate. Both therapies were associated with clinical remission at 6 months, and reduction of bone lesions on MRI at 12 months. While not reaching statistical significance, pamidronate resulted in faster resolution of MRI lesions. Fewer flares were observed with TNFi. Failure to respond to pamidronate was associated with female sex [p = 0.027], more lesions on MRI [p = 0.01] and higher CRP levels [p = 0.03]. Randomized clinical trials are needed to confirm observations and generate evidence.
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Affiliation(s)
- A Schnabel
- Pädiatrische Rheumatologie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany.
| | - M Nashawi
- Pädiatrische Rheumatologie, Klinikum Stuttgart, Germany; Department of Pediatrics, King Abdulaziz University, Jeddah, Saudi Arabia
| | - C Anderson
- Royal Hospital for Children and Young People, Edinburgh, United Kingdom
| | - S Felsenstein
- Department of Infectious Disease and Immunology, Alder Hey Children's NHS Foundation Trust, United Kingdom
| | - M Lamoudi
- Royal Hospital for Children and Young People, Edinburgh, United Kingdom
| | - J Poole-Cowley
- Royal Hospital for Sick Children, Glasgow, United Kingdom
| | - E Lindell
- University Hospital Crosshouse, Kilmarnock, United Kingdom
| | - B Oates
- University Hospital Crosshouse, Kilmarnock, United Kingdom
| | - P Fowlie
- Ninewells Hospital, Dundee, United Kingdom
| | - J Walsh
- Royal Hospital for Sick Children, Glasgow, United Kingdom
| | - T Ellis
- Pädiatrische Rheumatologie, Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | - G Hahn
- Department of Radiology, Universitätsklinikum Carl Gustav Carus, Dresden, Germany
| | - A Goldspink
- Raigmore Hospital, Inverness, United Kingdom
| | - N Martin
- Royal Hospital for Sick Children, Glasgow, United Kingdom
| | - K Mahmood
- Department of Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | - T Hospach
- Pädiatrische Rheumatologie, Klinikum Stuttgart, Germany
| | - McCann Lj
- Department of Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | - C M Hedrich
- Department of Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom; Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, United Kingdom.
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27
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Rausch P, Hartmann M, Baines JF, von Bismarck P. Analysis of the fecal and oral microbiota in chronic recurrent multifocal osteomyelitis. Arthritis Res Ther 2022; 24:54. [PMID: 35193655 PMCID: PMC8862485 DOI: 10.1186/s13075-021-02711-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 12/20/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Chronic recurrent multifocal osteomyelitis (CRMO) is a rare autoinflammatory bone disease for which a lack of bacterial involvement is a key diagnostic feature to distinguish it from other symptomatically related diseases. However, the growing evidence suggesting an involvement of the host-associated microbiota in rheumatic disorders together with the now wide accessibility of modern culture-independent methods warrant a closer examination of CRMO. METHODS In this study, we show through bacterial 16S rRNA gene profiling that numerous features of the oral- and fecal microbial communities differentiate children with and without CRMO. RESULTS Notably, communities in diseased children are characterized by a lack of potential probiotic bacteria in the fecal community and an overabundance of known pathobionts in the oral microbial communities. Of special interest is the HACEK group, a set of commonly known oral pathogens that are implicated in the development of several acute and chronic diseases such as osteitis and rheumatoid arthritis. Furthermore, we observe that gut bacterial communities in the diseased children appear to reflect an altered host physiology more strongly than the oral community, which could suggest an oral disease origin followed by propagation and/or responses beyond the oral cavity. CONCLUSIONS Bacterial communities, in particular the oral microbiota, may serve as an indicator of underlying susceptibility to CRMO, or play a yet undefined role in its development.
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Affiliation(s)
- Philipp Rausch
- Institute for Clinical Molecular Biology (IKMB), Kiel University, Kiel, Germany
- Laboratory of Genomics and Molecular Biomedicine, Department of Biology, University of Copenhagen, Copenhagen, Denmark
| | - Meike Hartmann
- Clinic for General Pediatrics, University Hospital Schleswig-Holstein, Kiel, Germany
| | - John F Baines
- Max Planck Institute for Evolutionary Biology, Plön, Germany.
- Institute for Experimental Medicine, Kiel University, Kiel, Germany.
| | - Philipp von Bismarck
- Clinic for General Pediatrics, University Hospital Schleswig-Holstein, Kiel, Germany.
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28
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Yousaf A, Muhammad S, Zoghoul SBM, Alam SI, Elsyaed AM. Chronic Recurrent Multifocal Osteomyelitis and Its Management. Cureus 2021; 13:e18872. [PMID: 34804721 PMCID: PMC8598692 DOI: 10.7759/cureus.18872] [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] [Accepted: 10/18/2021] [Indexed: 11/15/2022] Open
Abstract
Chronic recurrent multifocal osteomyelitis (CRMO) is an inflammatory disorder of bones first reported by Giedion et al. in 1972. It is a disease of childhood, comparable to SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteitis) in adults. CRMO presents with pain and swelling overlying the involved bones. Inflammatory markers are usually raised and X-rays usually show sclerotic lesions. MRI demonstrates the extent of the lesions accurately and associated soft tissue changes. Nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids are the mainstays of the management. We report three patients who presented with bone pains. Extensive workup and radiological modalities along with clinical findings supported the diagnosis of CRMO. This article highlights important clinical presentations, radiological findings, and various management options.
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Affiliation(s)
- Amman Yousaf
- Internal Medicine, McLaren Flint, Michigan State University, Flint, USA.,Radiology, Services Institute of Medical Sciences, Lahore, PAK
| | - Shoaib Muhammad
- Urology, Ghulab Devi Hospital, Al-Aleem Medical College, Lahore, PAK
| | | | | | - Ahmed Mounir Elsyaed
- Orthopaedics Surgery, Hamad Medical Corporation, Doha, QAT.,Orthopaedics Surgery, Weill Cornell School of Medicine, Doha, QAT
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29
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Kentar Y, Schwarze M, Pepke W, Schiltenwolf M, Akbar M. Pediatric back pain-Diagnostic algorithm. DER ORTHOPADE 2021; 51:36-43. [PMID: 34767043 DOI: 10.1007/s00132-021-04189-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/07/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Back pain in the pediatric population is common. History and a thorough physical examination and a systematic work-up approach are key components to guide the physician in evaluating the possible causes of pain and providing appropriate treatment. OBJECTIVE The main aim of this review was to develop an algorithmic approach to assist physicians in the assessment of pediatric back pain. A comprehensive review of prevalence, differential diagnoses and proper management of pediatric back pain are also presented. MATERIAL AND METHODS An extensive literature search was performed in PubMed to gather articles on the prevalence, risk factors, diagnostic tools, differential diagnoses and appropriate management of pediatric back pain. RESULTS Available literature revealed that pediatric back pain is a common complaint. Although most cases are non-specific and self-limiting, there is a wide differential that should be considered including inflammatory, neoplastic, infectious and mechanical causes. Sedentary lifestyle, obesity and vigorous physical activity have been shown to increase the likelihood of developing back pain. We proposed an algorithm to guide the physician's decision about the next step in the diagnostic process. CONCLUSION A well-defined strategy in the diagnostic process is needed in approaching children/adolescents with back pain. This would have the benefit of minimizing costs, unnecessary tests and child/family anxiety as well as increasing the likelihood of early diagnosis and proper treatment.
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Affiliation(s)
- Y Kentar
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - M Schwarze
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - W Pepke
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - M Schiltenwolf
- Clinic for Orthopedics and Trauma Surgery, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Schlierbacher Landstraße 200a, 69118, Heidelberg, Germany
| | - M Akbar
- MEOCLINIC GmbH, Friedrichstraße 71, 10117, Berlin, Germany.
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30
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Shah A, Rosenkranz M, Thapa M. Review of spinal involvement in Chronic recurrent multifocal osteomyelitis (CRMO): What radiologists need to know about CRMO and its imitators. Clin Imaging 2021; 81:122-135. [PMID: 34710802 DOI: 10.1016/j.clinimag.2021.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 07/27/2021] [Accepted: 09/15/2021] [Indexed: 11/03/2022]
Abstract
Chronic recurrent multifocal osteomyelitis (CRMO) is a distinct disease entity of unknown etiology primarily affecting children and adolescents. It is an autoinflammatory process that typically affects multiple bones with a waxing and waning course. About one third of the patients diagnosed with CRMO have spinal involvement which can lead to long term morbidity. The clinical presentation and imaging features of CRMO involving the spine are nonspecific and can mimic other disease processes like infection or malignancy. Since imaging plays a very important role in the diagnosis and management of CRMO, we intend to highlight various imaging patterns of spinal CRMO alongside its clinical features and briefly discuss its imitators, management and outcomes.
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Affiliation(s)
- Amisha Shah
- Department of Radiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States of America.
| | - Margalit Rosenkranz
- Department of Rheumatology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, United States of America
| | - Mahesh Thapa
- Department of Radiology, Seattle Children's Hospital, Seattle, WA, United States of America
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31
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Diagnosis and Management of Osteomyelitis in Children. Curr Infect Dis Rep 2021. [DOI: 10.1007/s11908-021-00763-0] [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]
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32
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Nuruzzaman F, Zhao Y, Ferguson PJ. Chronic Nonbacterial Osteomyelitis: Insights into Pathogenesis, Assessment, and Treatment. Rheum Dis Clin North Am 2021; 47:691-705. [PMID: 34635299 DOI: 10.1016/j.rdc.2021.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Chronic nonbacterial osteomyelitis, or its most severe form, chronic recurrent multifocal osteomyelitis, is an autoinflammatory bone disease that causes skeletal inflammation characterized by bone pain and swelling that primarily affects children. It is a diagnosis of exclusion and its clinical presentation may mimic underlying infectious processes and malignancy. Clinical suspicion for this diagnosis and timely referral to pediatric rheumatology is crucial to achieve earlier diagnosis, appropriate treatment, and improved quality of life of affected patients and families. This article focuses on recent insights into the pathogenesis of chronic nonbacterial osteomyelitis and outlines recent advances and ongoing research.
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Affiliation(s)
- Farzana Nuruzzaman
- Pediatric Rheumatology, Stony Brook Children's Hospital, Renaissance School of Medicine at Stony Brook University, 101 Nicolls Road, Health Sciences Tower T11-060, Stony Brook, NY 11794, USA.
| | - Yongdong Zhao
- Pediatric Rheumatology, Seattle Children's Hospital, University of Washington, 4800 Sand Point Way NE, MA.7.110 - Rheumatology, Seattle, WA 98105, USA
| | - Polly J Ferguson
- Pediatrics - Rheumatology, Allergy and Immunology, University of Iowa Carver College of Medicine, Med Labs, 25 South Grand, Iowa City, IA 52242, USA
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33
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Capponi M, Pires Marafon D, Rivosecchi F, Zhao Y, Pardeo M, Messia V, Tanturri de Horatio L, Tomà P, De Benedetti F, Insalaco A. Assessment of disease activity using a whole-body MRI derived radiological activity index in chronic nonbacterial osteomyelitis. Pediatr Rheumatol Online J 2021; 19:123. [PMID: 34391458 PMCID: PMC8364123 DOI: 10.1186/s12969-021-00620-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Based on the recently developed ChRonic nonbacterial Osteomyelitis MRI Scoring tool (CROMRIS), we developed a radiological activity index (RAI-CROMRIS) to obtain a quantification of the overall bone involvement in individual patients. METHODS Whole Body Magnetic Resonance Imaging (WB-MRI) images were scored according to parameters included in the RAI-CROMRIS: bone marrow hyperintensity, signal extension, soft tissue/periosteal hyperintensity, bony expansion, vertebral collapse. These parameters were evaluated for each bone unit yielding a score from 0 to 7 and summed up as RAI-CROMRIS including all bone units. We assessed clinical disease activity using a physician global assessment (PGA) and radiological findings in 76 treatment-naïve patients; 46 of 76 were evaluated at 6 and 12 months after initial WB-MRI. Quantitative variables were compared using the Mann-Whitney U test for unmatched groups and the Wilcoxon signed-rank test for paired groups. Correlation was evaluated using Spearman's rank coefficient (rs). RESULTS There was a significant correlation between RAI-CROMRIS and PGA (rs = 0.32; p = 0.0055), between RAI-CROMRIS and presence of elevated erythrocyte sedimentation rate (p = 0.013) and C-reactive protein (p = 0.0001) at baseline. The RAI-CROMRIS decreased from a median of 17 at baseline to 12 at 6 months (p = 0.004) and remained stable (median 11) at 12 months. A correlation between the RAI-CROMRIS and the PGA was observed at baseline (rs = 0.41; p = 0.004) and during follow up at 6 months (rs = 0.33; p = 0.025) and 12 months (rs = 0.38; p = 0.010). The baseline RAI-CROMRIS (median 20) was significantly higher in patients who subsequently received bisphosphonates than in patients who received other treatments (median 12) and decreased significantly after bisphosphonates (p = 0.008). CONCLUSIONS The RAI-CROMRIS was correlated with clinical and laboratory measures of disease activity showing significant short-term changes following treatment with bisphosphonates. This tool could be used in clinical practice and clinical trials after validation.
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Affiliation(s)
- Martina Capponi
- grid.414125.70000 0001 0727 6809Division of Rheumatology, Ospedale Pediatrico Bambino Gesù, IRCCS (ERN-RITA center), Rome, Italy
| | - Denise Pires Marafon
- grid.414125.70000 0001 0727 6809Division of Rheumatology, Ospedale Pediatrico Bambino Gesù, IRCCS (ERN-RITA center), Rome, Italy
| | - Flaminia Rivosecchi
- grid.414603.4Division of Radiology, Ospedale Pediatrico Bambino Gesù, IRCCS (ERN-RITA center), Rome, Italy
| | - Yongdong Zhao
- grid.34477.330000000122986657Seattle Children’s Hospital, Department of Pediatrics, University of Washington, and Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, WA USA
| | - Manuela Pardeo
- grid.414125.70000 0001 0727 6809Division of Rheumatology, Ospedale Pediatrico Bambino Gesù, IRCCS (ERN-RITA center), Rome, Italy
| | - Virginia Messia
- grid.414125.70000 0001 0727 6809Division of Rheumatology, Ospedale Pediatrico Bambino Gesù, IRCCS (ERN-RITA center), Rome, Italy
| | - Laura Tanturri de Horatio
- grid.414603.4Division of Radiology, Ospedale Pediatrico Bambino Gesù, IRCCS (ERN-RITA center), Rome, Italy
| | - Paolo Tomà
- grid.414603.4Division of Radiology, Ospedale Pediatrico Bambino Gesù, IRCCS (ERN-RITA center), Rome, Italy
| | - Fabrizio De Benedetti
- grid.414125.70000 0001 0727 6809Division of Rheumatology, Ospedale Pediatrico Bambino Gesù, IRCCS (ERN-RITA center), Rome, Italy
| | - Antonella Insalaco
- Division of Rheumatology, Ospedale Pediatrico Bambino Gesù, IRCCS (ERN-RITA center), Rome, Italy.
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Kostik MM, Makhova MA, Maletin AS, Magomedova SM, Sorokina LS, Tsukasaki M, Okamoto K, Takayanagi H, Vasiliev DS, Kozlova DI, Mushkin AY. Cytokine profile in patients with chronic non-bacterial osteomyelitis, juvenile idiopathic arthritis, and insulin-dependent diabetes mellitus. Cytokine 2021; 143:155521. [PMID: 33863633 DOI: 10.1016/j.cyto.2021.155521] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Our study aimed to evaluate the cytokine levels in pediatric chronic non-bacterial osteomyelitis (CNO) patients and compare these with other immune-mediated diseases and healthy controls. METHODS In this prospective study, we included 42 children with CNO, 28 patients with non-systemic juvenile idiopathic arthritis (JIA), 17 children with insulin-dependent diabetes mellitus (IDDM), and 30 healthy age-matched controls. In each of the CNO patients and comparison groups, the levels of 14-3-3-η protein, S100A8/A9 protein, interleukin-4 (IL-4), interleukin-17 (IL-17), interleukin-18 (IL-18), interleukin-1β (IL-1β), tumor necrosis factor-α (TNF-α) were measured by ELISA assay. RESULTS All studied cytokines in the CNO patients were significantly higher than controls, and IDDM, 14-3-3-η protein, IL-18, IL-4, IL-17, IL-1β, and TNF-α were less than in JIA patients. In the discriminant analysis, ESR, 14-3-3 protein, S100A8/A9, IL-18, IL-4, and TNF-α can discriminate CNO from JIA, and 14-3-3 protein, S100A8/A9, IL-18, IL-17, IL-4, and TNF-α can distinguish CNO from other diseases and HC. CONCLUSION The increased level of pro-inflammatory cytokines confirms the role of monocyte-driven inflammation in CNO patients. Cytokines may prove valuable as biomarkers and potential therapeutic targets for CNO.
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Affiliation(s)
- Mikhail M Kostik
- Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russian Federation.
| | - Maria A Makhova
- Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russian Federation
| | - Alexei S Maletin
- Science Research Institute of Phthisiopulmonology, Saint-Petersburg, Russian Federation
| | - Shamai M Magomedova
- Republican Children's Clinical Hospital, Makhachkala, Russian Federation; Dagestan State Medical University, Makhachkala, Russian Federation
| | - Lybov S Sorokina
- Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russian Federation
| | - Masayuki Tsukasaki
- Department of Immunology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, 113-0033 Tokyo, Japan
| | - Kazuo Okamoto
- Department of Osteoimmunology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, 113-0033 Tokyo, Japan
| | - Hiroshi Takayanagi
- Department of Immunology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, 113-0033 Tokyo, Japan
| | - Dmitriy S Vasiliev
- Sechenov Institute of Evolutionary Physiology and Biochemistry, Saint Petersburg, Russian Federation
| | - Darya I Kozlova
- Department of Osteoimmunology, Graduate School of Medicine and Faculty of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, 113-0033 Tokyo, Japan
| | - Alexander Yu Mushkin
- Science Research Institute of Phthisiopulmonology, Saint-Petersburg, Russian Federation
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Chronic Nonbacterial Osteomyelitis in Children. CHILDREN-BASEL 2021; 8:children8070551. [PMID: 34202154 PMCID: PMC8303960 DOI: 10.3390/children8070551] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 06/22/2021] [Accepted: 06/22/2021] [Indexed: 12/26/2022]
Abstract
Chronic nonbacterial osteomyelitis (CNO) is an auto-inflammatory bone disorder with a wide spectrum of clinical manifestations, from unifocal to multifocal lesions. When it manifests with multifocal lesions, it is also referred to as chronic recurrent multifocal osteomyelitis (CRMO). CNO/CRMO can affect all age groups, with the pediatric population being the most common. Patients may present with systemic inflammation, but there is no pathognomonic laboratory finding. Magnetic resonance imaging (MRI) is the gold standard radiological tool for diagnosis. In the absence of validated diagnostic criteria, CNO/CRMO remains an exclusion diagnosis. Bone biopsy does not show a specific disease pattern, but it may be necessary in unifocal or atypical cases to differentiate it from malignancy or infection. First-line treatments are non-steroidal anti-inflammatory drugs (NSAIDs), while bisphosphonates or TNF-α blockers can be used in refractory cases. The disease course is unpredictable, and uncontrolled lesions can complicate with bone fractures and deformations, underlying the importance of long-term follow-up in these patients.
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Juszczak B, Sułko J. Patient-reported effectiveness and safety of Pamidronate in NSAIDs-refractory chronic recurrent multifocal osteomyelitis in children. Rheumatol Int 2021; 42:699-706. [PMID: 34018012 PMCID: PMC8940851 DOI: 10.1007/s00296-021-04886-4] [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: 01/15/2021] [Accepted: 05/03/2021] [Indexed: 12/03/2022]
Abstract
To evaluate patient-reported effectiveness, safety and social influence of Pamidronate in the therapy of NSAIDs-refractory Chronic Recurrent Multifocal Osteomyelitis in children. Authors reviewed self-created questionnaires, which asked patients for symptoms alleviation, adverse drug reactions frequency and degree of severity and daily activities self-reliance. Only surveys with complete answers, which were returned to authors by an e-mail from juvenile patients treated for NSAIDs-refractory Chronic Recurrent Multifocal Osteomyelitis at the University Children’s Hospital of Cracow were analyzed. Between 2010 and 2019, 61 children were diagnosed with NSAIDs-refractory Chronic Recurrent Multifocal Osteomyelitis at our department. Out of 61 requests sent, 42 complete replies (33 females, 9 males) were gathered and analyzed. All patients included in this research were administered with at least one set of Pamidronate intravenously in the dose of 1 mg/kg/day for 3 consecutive days. Our analysis shows remarkable in terms of patient’s impressions decrease of pain intensity after 2.5 series of Pamidronate on average, and total pain resolution after 5.9 series on average. Overall number of adverse drug reaction events reported by responders was 105. One patient developed drug-dependent renal insufficiency in the course of therapy. Outcome assessment indicates that nearly 50% of the studied population was more eager to participate in social life just after the first infusion of the drug. 95% of the surveyed unanimously agreed to recommend Pamidronate therapy to cure NSAIDs-refractory CRMO. 39 out of 42 (93%) patients considered Pamidronate effective at the end of the treatment. Onset of Pamidronate’s action is gradual and differs in terms of symptoms alleviation between sexes. The therapy can induce considerable number of adverse drug reactions (2.5 per patient). Only 3 out of 42 (7%) patients were free from any ADRs. To demonstrate the impact of the use of Pamidronate on daily activities more precisely, further research with quantification of the quality of life is warranted.
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Affiliation(s)
- Bartłomiej Juszczak
- Department of Orthopaedics, Children's University Hospital of Cracow, ul. Wielicka 265, 30-663, Cracow, Poland.
| | - Jerzy Sułko
- Department of Orthopaedics, Children's University Hospital of Cracow, ul. Wielicka 265, 30-663, Cracow, Poland
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Chronic nonbacterial osteomyelitis (CNO) and chronic recurrent multifocal osteomyelitis (CRMO). J Transl Autoimmun 2021; 4:100095. [PMID: 33870159 PMCID: PMC8040271 DOI: 10.1016/j.jtauto.2021.100095] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/22/2021] [Accepted: 03/10/2021] [Indexed: 01/01/2023] Open
Abstract
Chronic nonbacterial osteomyelitis (CNO) is an inflammatory bone disorder that most frequently affects children and adolescents. Chronic recurrent multifocal osteomyelitis (CRMO) is a severe form of CNO, usually characterized by symmetrical inflammatory bone lesions and its waxing and waning character. Sometimes severe and chronic pain can significantly affect the quality of life and psychosocial development of individuals affected. In the absence of prospectively tested and widely accepted diagnostic criteria or disease biomarkers, CNO remains a diagnosis of exclusion, and infections, malignancy and other differentials require consideration (1). The pathophysiology of CNO is not fully understood, but imbalanced cytokine expression and increased inflammasome activation in monocytes from CNO patients contribute to a pro-inflammatory phenotype that contributes to bone inflammation (2). Currently, no medications are licensed for the use in CNO. Most patients show at least some response to nonsteroidal anti-inflammatory drugs, others require more aggressive treatment that can include corticosteroids, cytokine-blocking agents and/or bisphosphonates (3). While under the care of an experienced team and sufficient treatment, the prognosis is good, but some patients will develop sequalae which can include vertebral compression fractures (1). CNO is an autoinflammatory bone disorder mostly affecting children and adolescents. Dysregulated cytokine expression and pathological activation of inflammasomes play a central role. Treatment is based on experience from case series and expert consensus treatment plans. Understanding the exact molecular pathophysiology will allow patient stratification and individualized treatment.
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Watahiki A, Hoshikawa S, Chiba M, Egusa H, Fukumoto S, Inuzuka H. Deficiency of Lipin2 Results in Enhanced NF-κB Signaling and Osteoclast Formation in RAW-D Murine Macrophages. Int J Mol Sci 2021; 22:ijms22062893. [PMID: 33809261 PMCID: PMC8001760 DOI: 10.3390/ijms22062893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 03/05/2021] [Accepted: 03/10/2021] [Indexed: 11/30/2022] Open
Abstract
Lipin2 is a phosphatidate phosphatase that plays critical roles in fat homeostasis. Alterations in Lpin2, which encodes lipin2, cause the autoinflammatory bone disorder Majeed syndrome. Lipin2 limits lipopolysaccharide (LPS)-induced inflammatory responses in macrophages. However, little is known about the precise molecular mechanisms underlying its anti-inflammatory function. In this study, we attempted to elucidate the molecular link between the loss of lipin2 function and autoinflammatory bone disorder. Using a Lpin2 knockout murine macrophage cell line, we showed that lipin2 deficiency enhances innate immune responses to LPS stimulation through excessive activation of the NF-κB signaling pathway, partly because of TAK1 signaling upregulation. Lipin2 depletion also enhanced RANKL-mediated osteoclastogenesis and osteoclastic resorption activity accompanied by NFATc1 dephosphorylation and increased nuclear accumulation. These results suggest that lipin2 suppresses the development of autoinflammatory bone disorder by fine-tuning proinflammatory responses and osteoclastogenesis in macrophages. Therefore, this study provides insights into the molecular pathogenesis of monogenic autoinflammatory bone disorders and presents a potential therapeutic intervention.
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Affiliation(s)
- Asami Watahiki
- Center for Advanced Stem Cell and Regenerative Research, Tohoku University Graduate School of Dentistry, Sendai 980-8575, Japan; (A.W.); (S.H.); (M.C.); (H.E.)
- Division of Molecular and Regenerative Prosthodontics, Tohoku University Graduate School of Dentistry, Sendai 980-8575, Japan
| | - Seira Hoshikawa
- Center for Advanced Stem Cell and Regenerative Research, Tohoku University Graduate School of Dentistry, Sendai 980-8575, Japan; (A.W.); (S.H.); (M.C.); (H.E.)
- Division of Pediatric Dentistry, Tohoku University Graduate School of Dentistry, Sendai 980-8575, Japan
| | - Mitsuki Chiba
- Center for Advanced Stem Cell and Regenerative Research, Tohoku University Graduate School of Dentistry, Sendai 980-8575, Japan; (A.W.); (S.H.); (M.C.); (H.E.)
- Division of Pediatric Dentistry, Tohoku University Graduate School of Dentistry, Sendai 980-8575, Japan
| | - Hiroshi Egusa
- Center for Advanced Stem Cell and Regenerative Research, Tohoku University Graduate School of Dentistry, Sendai 980-8575, Japan; (A.W.); (S.H.); (M.C.); (H.E.)
- Division of Molecular and Regenerative Prosthodontics, Tohoku University Graduate School of Dentistry, Sendai 980-8575, Japan
| | - Satoshi Fukumoto
- Center for Advanced Stem Cell and Regenerative Research, Tohoku University Graduate School of Dentistry, Sendai 980-8575, Japan; (A.W.); (S.H.); (M.C.); (H.E.)
- Division of Pediatric Dentistry, Tohoku University Graduate School of Dentistry, Sendai 980-8575, Japan
- Department of Pediatric Dentistry, Graduate School of Dental Science, Kyushu University, Fukuoka 812-8582, Japan
- Correspondence: (S.F.); (H.I.); Tel.: +81-22-717-8380 (S.F.); +81-22-717-8308 (H.I.)
| | - Hiroyuki Inuzuka
- Center for Advanced Stem Cell and Regenerative Research, Tohoku University Graduate School of Dentistry, Sendai 980-8575, Japan; (A.W.); (S.H.); (M.C.); (H.E.)
- Correspondence: (S.F.); (H.I.); Tel.: +81-22-717-8380 (S.F.); +81-22-717-8308 (H.I.)
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Genomic Expression Profiling and Bioinformatics Analysis of Chronic Recurrent Multifocal Osteomyelitis. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6898093. [PMID: 33628812 PMCID: PMC7888306 DOI: 10.1155/2021/6898093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 12/31/2020] [Accepted: 01/12/2021] [Indexed: 12/03/2022]
Abstract
Objective Chronic nonbacterial osteomyelitis (CNO) is an autoinflammatory bone disorder. Its most severe form is referred to as chronic recurrent multifocal osteomyelitis (CRMO). Currently, the exact molecular pathophysiology of CNO/CRMO remains unknown. No uniform diagnostic standard and treatment protocol were available for this disease. The aim of this study was to identify the differentially expressed genes (DEGs) in CRMO tissues compared to normal control tissues to investigate the mechanisms of CRMO. Materials Microarray data from the GSE133378 (12 CRMO and 148 matched normal tissue samples) data sets were downloaded from the Gene Expression Omnibus (GEO) database. DEGs were identified using the limma package in the R software. Gene Ontology (GO) analysis, Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis, and protein-protein interaction (PPI) network analysis were performed to further investigate the function of the identified DEGs. Results This study identified a total of 1299 differentially expressed mRNAs, including1177 upregulated genes and 122 downregulated genes, between CRMO and matched normal tissue samples. GO analyses showed that DEGs were enriched in immune-related terms. KEGG pathway enrichment analyses showed that the DEGs were mainly related to oxidative phosphorylation, ribosome, and Parkinson disease. Eight modules were extracted from the gene expression network, including one module constituted with immune-related genes and one module constituted with ribosomal-related genes. Conclusion Oxidative phosphorylation, ribosome, and Parkinson disease pathways were significantly associated with CRMO. The immune-related genes including IRF5, OAS3, and HLA-A, as well as numerous ribosomal-related genes, might be implicated in the pathogenesis of CRMO. The identification of these genes may contribute to the development of early diagnostic tools, prognostic markers, or therapeutic targets in CRMO.
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Abstract
PURPOSE OF REVIEW The aim of this article is to review recent findings regarding the diagnosis and treatment of chronic recurrent multifocal osteomyelitis (CRMO). RECENT FINDINGS An adequate understanding of pathophysiology along with the new advances in MRI imaging make it possible to determine the extent of disease and establish early treatment. TNF-α inhibitors and bisphosphonates have shown to be a well-tolerated and efficient treatment for CRMO providing both symptomatic relief and normalization of bone morphology. SUMMARY The results of recent studies suggest that a better knowledge of the genetic and molecular factors will allow early diagnosis and the development of more effective individualized treatments in the future.
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Murray GM, Schnabel A, Alessi M, Chopra M, Mahmood K, Killeen OG, Hedrich CM, Ramanan AV. Is chronic non-infectious osteomyelitis with mandibular involvement a distinct disease? THE LANCET. RHEUMATOLOGY 2021; 3:e90-e92. [PMID: 38279375 DOI: 10.1016/s2665-9913(20)30414-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/06/2020] [Accepted: 11/13/2020] [Indexed: 01/28/2024]
Affiliation(s)
- Grainne M Murray
- Department of Paediatric Rheumatology, University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8BJ, UK
| | - Anja Schnabel
- Pädiatrische Rheumatologie, Klinik und Poliklinik für Kinder und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Mutibah Alessi
- Department of Paediatric and Adolescent Rheumatology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Mark Chopra
- Department of Radiology, University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8BJ, UK
| | - Kamran Mahmood
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Orla G Killeen
- Department of Paediatric and Adolescent Rheumatology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Christian M Hedrich
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK; Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Athimalaipet V Ramanan
- Department of Paediatric Rheumatology, University Hospitals Bristol NHS Foundation Trust, Bristol BS2 8BJ, UK; Translational Health Sciences, University of Bristol, Bristol, UK.
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Assessing Knowledge and Promoting Awareness of Chronic Recurrent Multifocal Osteomyelitis Among Oral and Maxillofacial Surgeons. J Oral Maxillofac Surg 2021; 79:1689-1693. [PMID: 33617787 DOI: 10.1016/j.joms.2021.01.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE Chronic recurrent multifocal osteomyelitis (CRMO) is underdiagnosed and underreported because of a lack of awareness among providers. While patients with undiagnosed CRMO often present to oral and maxillofacial surgeons (OMSs) with a chief complaint of mandibular pain, to our knowledge, there is no literature regarding how well informed these providers are about this disease. Survey studies and educational efforts have been carried out among other specialists with the aim of raising awareness. The purpose of this study was to document current levels of understanding and determine knowledge gaps among OMSs regarding the diagnostic process for CRMO. MATERIALS AND METHODS For this cross-sectional cohort study, the investigators sent an anonymous and electronic survey to OMSs practicing in the United States. Using a clinical vignette, the survey captured respondents' ability to evaluate, diagnosis, and take appropriate next steps for a hypothetical patient with CRMO. RESULTS A total of 429 respondents completed the entire survey. The following proportion of respondents correctly answered questions pertaining to information gathering (10.3%), differential diagnosis (9.8%), overall diagnostic workup (76.7%), diagnostic imaging (78.8%), diagnostic laboratory tests (36.8%), biopsy and specimen (0.5%), and final diagnosis and next steps (9.6%). CONCLUSION Our findings demonstrate incomplete understanding of this disorder among OMSs and uncover knowledge deficiencies that can lead to misdiagnosis and/or delay in appropriate treatment. To improve patient outcomes, it is paramount to augment educational initiatives among practitioners regarding this disease.
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Kanda R, Nakano K, Miyagawa I, Iwata S, Nakayamada S, Tanaka Y. A case of bone destruction caused by chronic non-bacterial osteomyelitis (CNO) successfully repaired with a tumour necrosis factor-α (TNF-α) inhibitor, adalimumab. Mod Rheumatol Case Rep 2020; 4:196-201. [PMID: 33087018 DOI: 10.1080/24725625.2020.1749360] [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: 10/24/2022]
Abstract
Chronic Non-bacterial Osteomyelitis (CNO) is an autoinflammatory bone disorder that causes non-bacterial and non-neoplastic osteomyelitis. CNO appeared to the long bone, clavicle, pelvis, and spine on children commonly. This time, we report a case with osteomyelitis of the mandible for the adult-onset. A 25-year-old woman presented pustulosis palmaris/pustular psoriasis after the extraction of the lower right tooth 1 year before hospitalisation. She felt pain and swelling of the right jaw and an antibiotic, NSAIDs, and glucocorticoids were ineffective. The cortical osteotomy of right mandibular bone was carried out 2 months before hospitalisation, but the symptom was not improved and she was admitted to our hospital. For pustular psoriasis with CNO, we treated her with adalimumab and the pain and swelling in her right jaw disappeared immediately. One and two years after the treatment, osteolytic and sclerotic bone lesion and osteomyelitis were improved in both Computed Tomography (CT) and Magnetic Resonance Imaging (MRI). An anti-TNF-α antibody may be an effective therapy for CNO resistant to conventional treatment.
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Affiliation(s)
- Ryuichiro Kanda
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Kazuhisa Nakano
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Ippei Miyagawa
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Shigeru Iwata
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Shingo Nakayamada
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
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Hedrich CM, Morbach H, Reiser C, Girschick HJ. New Insights into Adult and Paediatric Chronic Non-bacterial Osteomyelitis CNO. Curr Rheumatol Rep 2020; 22:52. [PMID: 32705386 PMCID: PMC7378119 DOI: 10.1007/s11926-020-00928-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Purpose of Review To describe in detail the clinical synopsis and pathophysiology of chronic non-bacterial osteomyelitis and SAPHO syndrome. Recent Findings Chronic non-bacterial osteomyelitis (CNO) has been identified as a disease entity for almost 50 years. This inflammatory bone disorder is characterized by osteolytic as well as hyperostotic/osteosclerotic lesions. It is chronic in nature, but it can present with episodic flairs and phases of remission, which have led to the denomination “chronic recurrent osteomyelitis”, with its severe multifocal form “chronic recurrent multifocal osteomyelitis” (CRMO). For almost three decades, an infectious aetiology had been considered, since especially Propionibacterium acnes had been isolated from bone lesions of individual patients. However, this concept has been challenged since long-term antibiotic therapy did not alter the course of disease and modern microbiological techniques (including PCR) failed to confirm bone infection as an underlying cause. Over recent years, a profound dysregulation of cytokine expression profiles has been demonstrated in innate immune cells of CNO patients. A hallmark of monocytes from CNO patients is the failure to produce immune regulatory cytokines interleukin-10 (IL-10) and IL-19, which have been linked with genetic and epigenetic alterations. Subsequently, a significant upregulation of pro-inflammatory, NLRP3 inflammasome-dependent cytokines (IL-1β and TNF-α), has been demonstrated. Summary The current knowledge on CNO, the underlying molecular pathophysiology, and modern imaging strategies are summarized; differential diagnoses, treatment options, outcome measures, as well as quality of life studies are discussed.
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Affiliation(s)
- Christian M Hedrich
- Department of Women's & Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, East Prescot Road, Liverpool, L14 5AB, Great Britain, UK
| | - Henner Morbach
- Pediatric Rheumatology and Immunology, Department of Pediatrics, University of Würzburg, Josef-Schneider-Str.2, 98080, Würzburg, Germany
| | - Christiane Reiser
- Department of Pediatrics, Pediatric Rheumatology and Immunology, Landeskrankenhaus Bregenz, Carl-Pedenz-Straße 12, 6900, Bregenz, Austria
| | - Hermann J Girschick
- Vivantes Klinikum Friedrichshain, Children's Hospital, Landsberger Allee 49, 10249, Berlin, Germany. .,University Childrens Hospital, Julius Maximilians Universität Würzburg, Würzburg, Germany.
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45
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Zhao Y, Ferguson PJ. Chronic non-bacterial osteomyelitis and autoinflammatory bone diseases. Clin Immunol 2020; 216:108458. [PMID: 32389739 PMCID: PMC7338233 DOI: 10.1016/j.clim.2020.108458] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 05/04/2020] [Accepted: 05/04/2020] [Indexed: 12/23/2022]
Affiliation(s)
- Yongdong Zhao
- Department of Pediatrics, University of Washington, Seattle, WA, United States of America
| | - Polly J Ferguson
- Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA, United States of America.
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Roig-Abraham N, Méndez-Hernández M, Martínez-Morillo M. Chronic recurrent multifocal osteomyelitis in pediatrics: A diagnostic challenge. Rev Esp Cir Ortop Traumatol (Engl Ed) 2020; 63:447-450. [PMID: 29776891 DOI: 10.1016/j.recot.2018.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 03/19/2018] [Accepted: 03/26/2018] [Indexed: 11/15/2022] Open
Abstract
Chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory disease that presents with aseptic bone inflammation and can be accompanied by multisystemic symptoms. We present the case of a 14-year-old male with a 2-week history of pain located at the tibial metaphysis and fever. X-ray revealed a lytic lesion in the tibial metaphysis. MRI revealed an intramedullary bone lesion with perilesional bone oedema. CT-guided biopsy discounted malignancy and microbiological cultures were negative. The patient's symptoms and fever worsened after the biopsy; therefore antibiotherapy was commenced for a suspected superinfection. A body MRI was performed given the persistence of the fever, which found a second active lesion in the spine that was diagnosed as CRMO and progressed well with anti-inflammatories. CRMO is an entity that is difficult to diagnose. Differential diagnosis is extensive with infectious diseases, tumours and other autoinflammatory diseases. Prompt diagnosis and appropriate treatment are crucial to prevent sequelae.
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Affiliation(s)
- N Roig-Abraham
- Servicio de Pediatría, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España.
| | - M Méndez-Hernández
- Servicio de Pediatría, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España
| | - M Martínez-Morillo
- Servicio de Reumatología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España
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Gaal A, Basiaga ML, Zhao Y, Egbert M. Pediatric chronic nonbacterial osteomyelitis of the mandible: Seattle Children's hospital 22-patient experience. Pediatr Rheumatol Online J 2020; 18:4. [PMID: 31941491 PMCID: PMC6964064 DOI: 10.1186/s12969-019-0384-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 12/04/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Studies evaluating treatment responses for chronic nonbacterial osteomyelitis (CNO) are lacking. We aimed to measure and compare response rates of medical treatments, time to response of medical treatments among patients with CNO of the mandible, and describe bacterial contamination rates from biopsy. METHODS We conducted a retrospective chart review of all patients diagnosed with CNO of mandible between 2003 and 2017 and extracted demographic, clinical, laboratory, imaging and surgical data. Detailed medication use and response to medications were recorded. The primary outcome was response to medical treatments defined as improvement of presenting symptoms, inflammatory markers, and imaging if available. Medical treatments included nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, disease modifying anti rheumatic drugs (DMARDs), anti-tumor necrosis factor (TNF) therapy, and pamidronate. Descriptive analysis was performed when appropriate. Multivariable logistic regression and Kaplan-Meier curves were applied to compare the responses to medical treatments and time to full response. RESULTS We identified 22 patients with a median age of 11 and 36% were female. Four patients (18%) had multifocal bone lesions. CT findings (n = 21) showed lytic lesions (62%) and sclerosis (90%). MRI (n = 14) revealed hyperintensity within bone marrow (100%), soft tissue (71%) and bony expansion (71%). Non-antibiotic treatments including NSAIDs (n = 18), glucocorticoids (n = 10), DMARDs (n = 9), anti-TNF therapy (n = 5) and pamidronate (n = 6) were applied. Rates of full responses to anti-TNF therapy (60%) and pamidronate (67%) were higher than that to NSAIDs (11%) (p < 0.05). Patients receiving pamidronate responded more rapidly than those receiving anti-TNF therapy (median two vs 17 months, p = 0.01) when there was a full response. All had bone biopsies. Intraoral biopsy was performed in 12 of 13 operated in our center and the most common contaminants were Neisseria spp and Streptococcus viridians. CONCLUSION Both anti-TNF and pamidronate appeared superior to NSAIDs alone in treating mandibular CNO. Patients receiving pamidronate responded faster than those receiving anti-TNF therapy.
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Affiliation(s)
- Austin Gaal
- 0000000122986657grid.34477.33Department of Oral and Maxillofacial Surgery, University of Washington, 4800 Sand Point Way NE, Seattle, WA 98105 USA
| | - Matthew L. Basiaga
- 0000 0004 0459 167Xgrid.66875.3aPediatric Rheumatology, Mayo Clinic, Rochester, MN USA
| | - Yongdong Zhao
- 0000000122986657grid.34477.33Pediatric Rheumatology, Seattle Children’s Hospital, University of Washington, Seattle, WA USA
| | - Mark Egbert
- Pediatric Oral and Maxillofacial Surgery, Seattle Children's Hospital, University of Washington, Seattle, WA, USA.
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48
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Chronic recurrent multifocal osteomyelitis in pediatrics: A diagnostic challenge. Rev Esp Cir Ortop Traumatol (Engl Ed) 2019. [DOI: 10.1016/j.recote.2019.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Goenka A, Roderick M, Finn A, Ramanan AV. The jigsaw puzzle of chronic non-bacterial osteomyelitis: are anti-IL17 therapies the next piece? Rheumatology (Oxford) 2019; 59:459-461. [DOI: 10.1093/rheumatology/kez492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 08/10/2019] [Accepted: 09/17/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Anu Goenka
- Paediatric Immunology and Infectious Diseases Service, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust
- Bristol Children’s Vaccine Centre, Schools of Cellular and Molecular Medicine and of Population Heath Sciences, University of Bristol
| | - Marion Roderick
- Paediatric Immunology and Infectious Diseases Service, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust
| | - Adam Finn
- Paediatric Immunology and Infectious Diseases Service, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust
- Bristol Children’s Vaccine Centre, Schools of Cellular and Molecular Medicine and of Population Heath Sciences, University of Bristol
| | - Athimalaipet V Ramanan
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust
- Translational Health Sciences, University of Bristol, Bristol, UK
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50
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Świdrowska-Jaros J, Smolewska E. A complicated path to the CRMO diagnosis - case of a 9 year old girl whose story comes full circle. BMC Musculoskelet Disord 2019; 20:392. [PMID: 31470834 PMCID: PMC6717389 DOI: 10.1186/s12891-019-2776-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 08/22/2019] [Indexed: 11/18/2022] Open
Abstract
Background Chronic recurrent multifocal osteomyelitis (CRMO) is a rare idiopathic autoinflammatory bone disease that mostly affects children and adolescents. It is a diagnosis of exclusions since no clinical signs and symptoms are pathognomonic. Radiological tests are often essential, but bone biopsy may be needed in unclear cases. Case presentation A 9-year-old Caucasian girl with a history of bone pain. The data from the history and results of laboratory tests suggested osteomyelitis, but no adequate response to the treatment was observed. A number of imaging tests did not confirm the diagnosis, therefore a bone biopsy was necessary. Conclusions Differential diagnosis of CRMO is challenging and it is based on exclusions. Since it might be misdiagnosed or mistreated, bone biopsy should be considered in patients reporting bone pain who are unresponsive to treatment.
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Affiliation(s)
- Joanna Świdrowska-Jaros
- Department of Paediatric Cardiology and Rheumatology, Medical University of Lodz, Łódz, Poland.
| | - Elżbieta Smolewska
- Department of Paediatric Cardiology and Rheumatology, Medical University of Lodz, Łódz, Poland
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