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Ożga J, Mężyk E, Kmiecik W, Wojciechowski W, Żuber Z. Coexisting Sacroiliac Arthritis and Chronic Nonbacterial Osteomyelitis in an Adolescent with Ehlers-Danlos Syndrome: A Case Report and Treatment Success. AMERICAN JOURNAL OF CASE REPORTS 2024; 25:e943579. [PMID: 39306669 PMCID: PMC11426177 DOI: 10.12659/ajcr.943579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2024]
Abstract
BACKGROUND Chronic nonbacterial osteomyelitis (CNO) is a multifocal autoinflammatory bone disease mainly affecting children and adolescents. Sacroiliitis is an inflammation of the sacroiliac joint, diagnosed with the use of musculoskeletal MRI due to its ability to visualize active inflammatory lesions. Ehlers-Danlos syndrome (EDS) is non-inflammatory hereditary disorder of connective tissue. Here, we report the case of a 17.5-year-old female patient with classical EDS and long-term course of the CNO with coexistence of sacroiliac arthritis. CASE REPORT On admission, a patient with CNO reported pain in the scapula, thoracic spine, shoulders, and iliac region, with morning stiffness present for 5 months. Physical examination revealed knee and elbow joint hyperextension, hypermobility of the phalanges, increased range of motion of the hip joints, and the presence of reticular rash on the face. In the laboratory blood tests, minor leukocytosis was reported. During hospitalization, a whole-body MRI was performed, detecting bone marrow edema in the Th3, Th4, and Th7 vertebral bodies and the head of seventh rib on the left side, as well as bilaterally in the sacroiliac joints. The patient was diagnosed with sacroiliitis and EDS and successfully treated with risedronate sodium, methotrexate with folic acid, sulfasalazine, and meloxicam, achieving CNO remission and reduced severity of axial skeleton pain. CONCLUSIONS The coexistence of these 3 diseases - CNO, sacroiliac arthritis, and EDS - in the same patient is rare and requires interphysician collaboration to determine the correct diagnosis and subsequently arrange multi-speciality therapeutic management to achieve remission.
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Affiliation(s)
- Joanna Ożga
- Department of Pediatrics, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Cracow University, Cracow, Poland
- Clinical Department of Pediatrics and Rheumatology, St. Louis Regional Specialised Children's Hospital, Cracow, Poland
| | - Elżbieta Mężyk
- Department of Pediatrics, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Cracow University, Cracow, Poland
- Clinical Department of Pediatrics and Rheumatology, St. Louis Regional Specialised Children's Hospital, Cracow, Poland
| | - Wojciech Kmiecik
- Department of Pediatrics, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Cracow University, Cracow, Poland
- Clinical Department of Pediatrics and Rheumatology, St. Louis Regional Specialised Children's Hospital, Cracow, Poland
| | - Wadim Wojciechowski
- Clinical Department of Pediatrics and Rheumatology, St. Louis Regional Specialised Children's Hospital, Cracow, Poland
- Department of Radiology, Jagiellonian University Medical College, Cracow, Poland
| | - Zbigniew Żuber
- Department of Pediatrics, Faculty of Medicine and Health Sciences, Andrzej Frycz Modrzewski Cracow University, Cracow, Poland
- Clinical Department of Pediatrics and Rheumatology, St. Louis Regional Specialised Children's Hospital, Cracow, Poland
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Robert M, Giolito A, Reumaux H, Rossi-Semerano L, Guillemin C, Biarrotte L, Leguevaques D, Belot A, Duquesne A, Frachette C, Laurent A, Desjonquères M, Larbre JP, Galeotti C, Koné-Paut I, Dusser P. Extra-osseous manifestations in chronic recurrent multifocal osteomyelitis: a retrospective study. Rheumatology (Oxford) 2024; 63:SI233-SI239. [PMID: 37698983 DOI: 10.1093/rheumatology/kead473] [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: 06/16/2023] [Revised: 08/10/2023] [Accepted: 08/23/2023] [Indexed: 09/14/2023] Open
Abstract
OBJECTIVES Extra-osseous (EO) manifestations are poorly characterized in chronic recurrent multifocal osteomyelitis (CRMO). This study aimed to further define the frequency, characteristics and treatment of EO events in CRMO and whether different phenotypes can be distinguished and benefit from special management. METHODS This multicentre retrospective study included CRMO patients followed in several paediatric rheumatology departments in France between 2015 and 2022. EO manifestations were defined as skin lesions, gastrointestinal manifestations, arthritis, enthesitis, sacroiliitis, uveitis, vasculitis and fever. At the last visit, the physician defined CRMO as active in the presence of clinical manifestations including both osseous and EO symptoms. RESULTS We included 133 patients; 87 (65.4%) were girls and the median age at first symptoms was 9.0 years (interquartile range 7.0-10.0). EO manifestations were described in 90 (67.7%) patients, with a predominance of skin lesions [n = 51/90 (56.7%)], followed by sacroiliitis [n = 38/90 (42.2%)], enthesitis [n = 21/90 (23.3%)], arthritis [n = 14/90 (15.6%)] and gastrointestinal manifestations [n = 6/90 (6.7%)]. The use of non-steroidal anti-inflammatory drugs and bisphosphonates did not differ by the presence or not of EO manifestations. Biologics were taken more frequently by patients with than without EO manifestations (P < 0.001); TNF inhibitors were used in 33 (36.7%) EO-positive patients. Under this treatment, 18 (54.5%) patients achieved complete remission of osseous and EO manifestations. At the last visit, more EO+ than EO- patients were on treatment (P = 0.009), with active disease in 58 (64.4%) patients. CONCLUSION The analysis of EO manifestations in CRMO delineates two groups of patients in terms of severity and treatments used. Our study opens up new pathophysiological leads that may underlie the wide range of CRMO phenotypes.
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Affiliation(s)
- Marie Robert
- Service de Rhumatologie Pédiatrique, Centre de Référence des Maladies Auto-Inflammatoires et des Amyloses Inflammatoires (CEREMAIA), Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
- Université Paris-Cité, Paris, France
| | - Anna Giolito
- Service de Rhumatologie Pédiatrique, Centre de Référence des Maladies Auto-Inflammatoires et des Amyloses Inflammatoires (CEREMAIA), Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
- Université Paris-Cité, Paris, France
| | - Heloise Reumaux
- Service de Rhumatologie Pédiatrique, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Linda Rossi-Semerano
- Service de Rhumatologie Pédiatrique, Centre de Référence des Maladies Auto-Inflammatoires et des Amyloses Inflammatoires (CEREMAIA), Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
- Réseau Rhumatismes Inflammatoires Pédiatriques (RESRIP), Bourg-La-Reine, France
| | - Claire Guillemin
- Service de Rhumatologie Pédiatrique, Centre de Référence des Maladies Auto-Inflammatoires et des Amyloses Inflammatoires (CEREMAIA), Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
- Université Paris-Cité, Paris, France
| | - Louis Biarrotte
- Service de Rhumatologie Pédiatrique, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Damia Leguevaques
- Service de Rhumatologie Pédiatrique, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Alexandre Belot
- Service de Néphrologie-Rhumatologie-Dermatologie Pédiatriques, Hôpital Femme-Mère-Enfant, Hospices Civils de Lyon, Bron, France
- Centre de Référence des Rhumatismes Inflammatoires et Maladies Auto-Immunes Rares de l'Enfant (RAISE), France
| | - Agnès Duquesne
- Service de Néphrologie-Rhumatologie-Dermatologie Pédiatriques, Hôpital Femme-Mère-Enfant, Hospices Civils de Lyon, Bron, France
- Centre de Référence des Rhumatismes Inflammatoires et Maladies Auto-Immunes Rares de l'Enfant (RAISE), France
| | - Cécile Frachette
- Service de Néphrologie-Rhumatologie-Dermatologie Pédiatriques, Hôpital Femme-Mère-Enfant, Hospices Civils de Lyon, Bron, France
- Centre de Référence des Rhumatismes Inflammatoires et Maladies Auto-Immunes Rares de l'Enfant (RAISE), France
| | - Audrey Laurent
- Service de Néphrologie-Rhumatologie-Dermatologie Pédiatriques, Hôpital Femme-Mère-Enfant, Hospices Civils de Lyon, Bron, France
- Centre de Référence des Rhumatismes Inflammatoires et Maladies Auto-Immunes Rares de l'Enfant (RAISE), France
| | - Marine Desjonquères
- Service de Néphrologie-Rhumatologie-Dermatologie Pédiatriques, Hôpital Femme-Mère-Enfant, Hospices Civils de Lyon, Bron, France
- Centre de Référence des Rhumatismes Inflammatoires et Maladies Auto-Immunes Rares de l'Enfant (RAISE), France
| | - Jean-Paul Larbre
- Service de Rhumatologie, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre-Bénite, France
| | - Caroline Galeotti
- Service de Rhumatologie Pédiatrique, Centre de Référence des Maladies Auto-Inflammatoires et des Amyloses Inflammatoires (CEREMAIA), Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
| | - Isabelle Koné-Paut
- Service de Rhumatologie Pédiatrique, Centre de Référence des Maladies Auto-Inflammatoires et des Amyloses Inflammatoires (CEREMAIA), Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
- Université Paris-Saclay, Paris, France
| | - Perrine Dusser
- Service de Rhumatologie Pédiatrique, Centre de Référence des Maladies Auto-Inflammatoires et des Amyloses Inflammatoires (CEREMAIA), Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, France
- Réseau Rhumatismes Inflammatoires Pédiatriques (RESRIP), Bourg-La-Reine, France
- Université Paris-Saclay, Paris, France
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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; 168:191-199. [PMID: 38682664 DOI: 10.5507/bp.2024.007] [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: 02/22/2024] [Accepted: 02/28/2024] [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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Lanckoroński M, Gietka P, Mańczak M, Sudoł-Szopińska I. Whole-Body MRI at Initial Presentation of Chronic Recurrent Multifocal Osteomyelitis, Juvenile Idiopathic Arthritis, Their Overlapping Syndrome, and Non-Specific Arthropathy. J Clin Med 2024; 13:998. [PMID: 38398312 PMCID: PMC10888598 DOI: 10.3390/jcm13040998] [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: 01/05/2024] [Revised: 02/02/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
(1) Background: Whole-body magnetic resonance imaging (WB-MRI) is central to defining total inflammatory burden in juveniles with arthritis. Our aim was to determine and compare the initial distribution of lesions in the WB-MRI in patients with chronic recurrent multifocal osteomyelitis (CRMO), juvenile idiopathic arthritis (JIA), their overlapping syndrome (OS), and with Non-specific Arthropathy (NA). (2) Methods: This retrospective single center study was performed on an Avanto 1.5-T MRI scanner with a dedicated multichannel surface coil system. A total of 173 pediatric patients were included with the following final diagnoses: CRMO (15.0%), JIA (29.5%), OS (4.6%), and NA (50.9%). (3) Results: Bone marrow edema (BME) was the most common abnormality, being seen in 100% patients with CRMO, 88% with OS, 55% with JIA, and 11% with NA. The bones of the lower extremities were the most affected in all compared entities. Effusion was seen in 62.5% children with OS, and in 52.9% with JIA, and in CRMO and NA, the exudate was sporadic. Enthesitis was found in 7.8% of patients with JIA and 3.8% with CRMO, and myositis was seen in 12.5% of patients with OS and in 3.9% with JIA. (4) Conclusions: The most frequent indication for WB-MRI in our center was JIA. The most common pathology in all rheumatic entities was BME, followed by effusion mainly seen in in OS and JIA. Enthesitis and myositis were less common; no case was observed in NA.
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Affiliation(s)
- Michał Lanckoroński
- Department of Radiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 1 Spartańska Street, 02-637 Warsaw, Poland
| | - Piotr Gietka
- Clinic of Paediatric Rheumatology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 1 Spartańska Street, 02-637 Warsaw, Poland;
| | - Małgorzata Mańczak
- Department of Gerontology, Public Health and Didactics, National Institute of Geriatrics, Rheumatology and Rehabilitation in Warsaw, 1 Spartańska Street, 02-637 Warsaw, Poland;
| | - Iwona Sudoł-Szopińska
- Department of Radiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, 1 Spartańska Street, 02-637 Warsaw, Poland
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Abstract
Chronic recurrent multifocal osteomyelitis (CRMO) is an underrecognized autoinflammatory disease affecting the skeletal system. Its vague symptoms are often first attributed to growing pains, infection, or malignancy, which can lead to a delay in diagnosis for days to years. Untreated CRMO has the potential to cause debilitating skeletal deformities, arthritis, and chronic pain; hence early recognition and treatment are paramount. MRI is the gold standard for diagnosis. Treatment consists of various antiinflammatory medications and may also include bisphosphonates if vulnerable skeletal sites are involved. Even when treated, the disease may have a relapsing course lasting years.
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Affiliation(s)
- Bridget A Rafferty
- Medical College of Wisconsin, 8701 W. Watertown Plank Road, Milwaukee, WI 53226, USA
| | - Pooja Thakrar
- Medical College of Wisconsin/Children's Wisconsin, 9000 W. Wisconsin Avenue, MS-721, Milwaukee, WI 53226, USA.
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