High prevalence of autoimmune disease in the rare inflammatory bone disorder sternocostoclavicular hyperostosis: survey of a Dutch cohort

Immunological Characterization of Chronic Nonbacterial Osteomyelitis (CNO) in Adults: A Cross-Sectional Exploratory Study

Chronic nonbacterial osteomyelitis (CNO) is a rare disease spectrum affecting children and adults. Adult CNO may occur as isolated bone inflammation, or with a broad range of extraskeletal features. CNO pathophysiology, including the key drivers of inflammation, remains largely unknown. For pediatric CNO, a role for pro-inflammatory cytokine dysregulation has been proposed, but studies in adults are scarce. We therefore provide immunological characterization of adult CNO. Cross-sectional study in our referral center including adult CNO patients (n = 172) and healthy controls (n = 65). Inflammation parameters and systemic inflammatory based scores(SIBS, including neutrophil/lymphocyte ratio [NLR] and systemic immune inflammation index [SII]) were compared between groups. Cytokine expression was explored with electrochemiluminescent immunoassays in 33 patients, eight healthy controls and 21 osteoporosis patients. Routine inflammation markers were higher in patients than in controls, but generally remained within reference range. Systemic inflammation was more pronounced in patients with additional vertebral involvement as compared to those osteitis in the anterior chest wall alone, in patients with comorbid pustulosis palmoplantaris or psoriasis, and in patients with strongly rather than moderately increased lesional uptake on nuclear imaging. SII was elevated in CNO patients too, but NLR was not. Cytokine expression was generally nondifferential between patients and both control groups, and patients displayed low absolute concentrations of pro-inflammatory cytokines. In this adult CNO cohort, systemic inflammation was generally subtle, but more pronounced in patients with vertebral lesions, associated skin disease, and strongly increased uptake on nuclear imaging. SII was increased in patients compared to healthy controls. Contrasting pediatric studies, we found no increased expression of the pro-inflammatory cytokines that have been proposed to drive the inflammatory cascade, like interleukin-6, -8, and -17 (IL-6, IL-8, and IL-17), and tumor necrosis α (TNF-α). Further studies are needed to evaluate the use of SII in diagnosis and monitoring of CNO, and elucidate the role of cytokine dysregulation in adult disease. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC. on behalf of American Society for Bone and Mineral Research.

Chronic Nonbacterial Osteomyelitis of the Sternocostoclavicular Region in Adults: A Single-Center Dutch Cohort Study

Sternocostoclavicular hyperostosis (SCCH) is a rare autoinflammatory bone disorder caused by chronic nonbacterial osteomyelitis (CNO), which is associated with sclerosis and hyperostosis primarily affecting the sternum, the medial end of the clavicles, and the first ribs. Other areas of the axial skeleton may also be affected. The more severe synovitis–acne–pustulosis–hyperostosis–osteitis (SAPHO) syndrome is additionally associated with dermatoses and joint manifestations. This Dutch retrospective cross‐sectional single‐center cohort study characterizes the spectrum of clinical features in adult CNO/SCCH patients at the time of diagnosis. The only inclusion criteria was the availability of complete sets of clinical and imaging data systematically collected over three decades using in‐house protocols. Data from 213 predominantly female patients (88%) with a median age of 36 years at presentation were studied. The mean diagnostic delay was 5 ± 5 years. The main symptoms were chronic pain (92%), bony swelling (61%), and restricted shoulder girdle function (46%); 32% had palmoplantar pustulosis and 22% had autoimmune disease. The majority (73%) had isolated SCCH; 59 (27%) had additional localizations in vertebrae (19%), the mandible (9%), or both (2%); 4 had SAPHO. The prevalence of current or past smoking was high (58%), particularly for patients with palmoplantar pustulosis (76%). There was a significant relationship between delay in diagnosis and both the extent of affected skeletal sites (p = 0.036) and erythrocyte sedimentation rate levels (p = 0.023). Adult‐onset CNO is characterized by distinctive clinical and radiological features, but diverse aspects of its spectrum are currently not fully captured by a comprehensive classification. Delayed diagnosis is still common and potentially associated with irreversible structural changes and debilitating chronic symptoms, increasing the burden of illness and negatively impacting on quality of life. It is hoped that findings from this study will dispel confusion about nomenclature and classification of adult‐onset CNO and increase awareness of its distinctive clinical and radiological features, and thus facilitate early diagnosis and referral for treatment, which should positively impact prognosis by preventing disease progression, although this remains to be established. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Coexistence of Sjögren syndrome in patients with synovitis, acne, pustulosis, hyperostosis, and osteitis syndrome: A retrospective observational study

To identify the prevalence and clinical characteristics of Sjögren syndrome (SS) in a Chinese single-center cohort of synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome.Patients diagnosed with SS were screened out from a cohort of 164 cases of SAHPO syndrome. Information regarding the patients' gender, age at onset, clinical features, laboratory tests, bone scintigraphy, and treatment was reviewed.Five patients were screened out. The prevalence of SS in SAPHO patients was 3.05% The mean onset age of SS was 48.0 ± 12.0 years old and no apparent time order in the occurrence of SAPHO and SS was observed. Compared with the general SAPHO cohort, the 5 SS patients exhibited no significant difference in the SAPHO related clinical features or inflammatory markers, except for a higher prevalence of peripheral joints and bones involvement in bone scintigraphy. Objective evidence of dryness and positive salivary gland biopsy were found in all the patients. However, the positive rates of SSA and SSB antibody were only 20%. Anti-inflammatory treatment for SS was recorded in 3 patients (ESSDAI score: 3 in 2 patients; 12 in 1 patient) with extra-glandular manifestations, severe complications or poor response to the basic treatment.The prevalence of SS is higher in the SAPHO cohort than in the general Chinese population. Objective tests or biopsy might be more indicative than the antibody detection for SS diagnosis. Anti-inflammatory treatment should be prescribed in consideration of both the severity of SS and the demand for disease activity control of SAPHO.

Serum interleukin-23 protects, whereas methotrexate treatment stimulates selected components of the metabolic syndrome in patients with SAPHO syndrome

INTRODUCTION

The aim of the study was to evaluate the impact of disease activity, selected serum cytokines, and therapy on metabolic syndrome (MetS) components in patients with synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome.

MATERIAL AND METHODS

We studied 46 SAPHO patients (40 women, 6 men). We recorded age, sex, disease duration, arthritis localization, type of skin changes, bone scintigraphy results, comorbidities, BASDAI, VAS, and treatment. We measured erythrocyte sedimentation rate, C-reactive protein, lipid profile, serum IL-6, IL-18, IL-23, endothelin-1, vascular endothelial growth factor, and epidermal growth factor (EGF).

RESULTS

97.8% of patients had sternoclavicular joint arthritis, 91.3% of patients palmoplantar pustulosis. In 65.2% of SAPHO patients skin changes and arthritis started simultaneously. Apart from non-steroidal anti-inflammatory drugs, patients were treated with methotrexate (41.3%), sulfasalazine (41.3%), and antibiotics (39.1%). 19.5% of patients met MetS criteria. Serum IL-23 correlated positively with total cholesterol (TC; p = 0.02) and high-density lipoprotein cholesterol (HDL-C) (p = 0.01) in the SAPHO group. There was a negative correlation between HDL-C and BASDAI (p = 0.02). Patients treated with methotrexate had higher triglyceride (p = 0.01) and low-density lipoprotein cholesterol (LDL-C) (p = 0.01) levels. There was a negative correlation between TC and EGF (p = 0.03). Increased prevalence of autoimmune diseases and depression was observed in SAPHO patients.

CONCLUSIONS

Serum IL-23 protects, whereas methotrexate treatment stimulates selected components of the MetS in patients with SAPHO syndrome.

Characteristics of Japanese patients with pustulotic arthro-osteitis associated with palmoplantar pustulosis: a multicenter study

BACKGROUND

Pustulotic arthro-osteitis (PAO) is a major comorbidity of palmoplantar pustulosis (PPP), which is frequently seen in Japanese patients. To determine the characteristics of Japanese patients with PAO, we conducted a multicenter, retrospective epidemiologic survey at four university hospitals.

METHODS

Clinical features including age, gender, duration of disease, extrapalmoplantar lesion, smoking habit, focal infection, site of joint pain, bone scintigraphy with Technetium⁹⁹ , and therapies were retrospectively evaluated.

RESULTS

In total, 165 patients with PAO were identified among 576 patients with PPP (28.6%). The male to female ratio was 1 : 3.7, and the mean age was 50.2 years. The mean disease duration of PAO was 6.0 years. Smoking habit was observed in 104 patients. Focal infection was detected in 74 patients, who developed tonsillar infection (n = 41), sinusitis (8), odontogenic infection (40), and others (2). Fifteen patients had multifocal infection. Technetium bone scintigraphy was performed in 97 cases. Increased uptake was most frequently observed in the sternocostoclavicular regions, followed by wrist and ankle, sacroiliac joint, knee and elbow, finger and toe, lumbar spine, thoracic spine, scapula, and thigh. Patients were mainly treated with nonsteroidal anti-inflammatory drugs, methotrexate, cyclosporine, antibiotics, and biologics, as well as tonsillectomy and dental treatment.

CONCLUSION

PAO frequently involves the anterior chest wall of middle-aged women with smoking habit and is closely associated with focal infection.

Stress fracture of the midshaft clavicle associated with sternocostoclavicular hyperostosis-Case report

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Stress fractures of the midshaft of the clavicle caused by sternocostoclavicular hyperostosis are very rare.

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The differential diagnosis of sternocostoclavicular hyperostosis might be difficult.

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Sternocostoclavicular hyperostosis in the patient was suspected of having either SAPHO syndrome or ankylosing spondylitis.

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The patient was treated conservatively and the shoulder function was satisfactory at the final follow-up.

Introduction

Stress fracture is generally a result of cumulative and repetitive stress in athletes, which accelerates the normal remodeling process of bones, and the most frequently involved areas are the tibia and metatarsal bones. Therefore, stress fractures of the midshaft of the clavicle are very rare.

Presentation of case

A 58-year-old female was admitted to our hospital because of pain in the middle of the right clavicle. Based on laboratory and radiographic inspection, it was concluded that the stress fracture of the midshaft of the clavicle in this case was caused by sternocostoclavicular hyperostosis (SCCH). Because the clavicular fracture had no displacement or callus formation, conservative treatment with a clavicle band was undertaken. Shoulder function at the final follow-up visit was satisfactory.

Discussion

SCCH is a rare chronic inflammatory disorder of the axial skeleton and ossifying diathesis associated with a predominantly osteogenic response. Synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome and ankylosing spondylitis (AS) should be considered in the differential diagnosis of SCCH. If a patient with this type of fracture has no history of traumatic injury or sports activity, the differential diagnosis might be very difficult.

Conclusion

We report the case of a female who had a stress fracture of the midshaft of the clavicle associated with SCCH in SAPHO or AS. Although the patient was treated conservatively, and the shoulder function was satisfactory at the final follow-up visit, re-fracture may occur in the future.