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Xu Y, Wang G, Wang Y, Wang W, Kan Y, Yang J. Diagnostic Role of FDG PET/CT in Pediatric Patients With Chronic Recurrent Multifocal Osteomyelitis. Clin Nucl Med 2024; 49:536-539. [PMID: 38598512 DOI: 10.1097/rlu.0000000000005216] [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: 04/12/2024]
Abstract
PURPOSE Chronic recurrent multifocal osteomyelitis (CRMO), or chronic nonbacterial osteomyelitis, is difficult to diagnose. The accurate diagnosis of CRMO relies on comprehensive imaging examinations because of its multifocal nature. In this regard, 18 F-FDG PET/CT has demonstrated significant utility in inflammatory diseases. This study tries to determine the value of FDG PET/CT in the evaluation of CRMO. PATIENTS AND METHODS We retrospectively collected imaging data from pediatric CRMO patients who underwent FDG PET/CT scans. Lesions exhibiting abnormal metabolism with/without structural abnormalities on FDG PET/CT were identified as CRMO lesions, and their location and SUV max were recorded. RESULTS A total of 21 pediatric patients with CRMO were included in this study. The median age at diagnosis was 9.4 years. Total 131 foci of abnormal activity were identified using FDG PET/CT imaging. The distribution pattern showed a higher prevalence of lower limbs and pelvis involvement. Among all identified lesions, abnormalities were detected on both PET and CT images of 93 lesions, whereas exclusively positive findings on 18 F-FDG PET alone were observed for 38 of them. CONCLUSIONS Our study findings suggest a higher prevalence of lesions in the bones of the lower limbs and pelvis among children with CRMO. Compared with CT scans, FDG PET exhibits superior sensitivity in detecting these lesions.
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Affiliation(s)
- Yanfeng Xu
- From the Department of Nuclear Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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2
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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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3
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Zeng W, Wu Y, Liang X, Cun D, Ma L, Zhang J, Huang F, Jiang Z. Causal associations between human gut microbiota and osteomyelitis: a Mendelian randomization study. Front Cell Infect Microbiol 2024; 14:1338989. [PMID: 38655282 PMCID: PMC11035795 DOI: 10.3389/fcimb.2024.1338989] [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: 11/16/2023] [Accepted: 03/26/2024] [Indexed: 04/26/2024] Open
Abstract
Background Recent studies have emphasized the role of gut microbiota in the onset and progression of osteomyelitis. However, the exact types of gut microbiota and their mechanisms of action remain unclear. Additionally, there is a lack of theoretical support for treatments that improve osteomyelitis by altering the gut microbiota. Methods In our study, we utilized the largest genome-wide association study (GWAS) meta-analysis to date from the MiBioGen consortium, involving 13,400 participants. The GWAS data for osteomyelitis were sourced from the UK Biobank, which included 4,836 osteomyelitis cases and 486,484 controls. We employed a two-sample Mendelian randomization framework for a detailed investigation into the causal relationship between gut microbiota and osteomyelitis. Our methods included inverse variance weighting, MR-Egger, weighted median, and weighted mode approaches. Additionally, we applied Cochran's Q statistic to assess the heterogeneity of the instrumental variable. Results At the class level, Bacilli and Bacteroidia were positively correlated with the risk of osteomyelitis. At the order level, only Bacteroidales showed a positive association with osteomyelitis. At the genus level, an increased abundance of Butyricimonas, Coprococcus3, and Tyzzerella3 was positively associated with the risk of osteomyelitis, whereas Lachnospira was negatively associated. Sensitivity analyses showed no evidence of heterogeneity or pleiotropy. Conclusion This study reveals that classes Bacilli and Bacteroidia, order Bacteroidales, and genera Butyricimonas, Coprococcus3, and Tyzzerella3 are implicated in increasing the risk of osteomyelitis, while the genus Lachnospira is associated with a reduced risk. Future investigations are warranted to elucidate the precise mechanisms through which these specific bacterial groups influence the pathophysiology of osteomyelitis.
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Affiliation(s)
- Wenxing Zeng
- First Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yuheng Wu
- First Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
- Seventh Clinical Medical College of Guangzhou University of Chinese Medicine, Shenzhen, China
| | - Xiaoye Liang
- First Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Dejun Cun
- First Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Luyao Ma
- First Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jingtao Zhang
- First Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Feng Huang
- First Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Traumatology and Orthopedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ziwei Jiang
- First Clinical Medical College of Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Traumatology and Orthopedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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4
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Saffarzadeh M, Haydar S, Chan D, Andrews G, Ouellette H, Mallinson P, Munk PL, Sheikh A. A clinico-radiological review of chronic non-bacterial osteomyelitis in paediatrics, adolescents, and adults: demystifying a forgotten differential. Clin Radiol 2024; 79:170-178. [PMID: 38160105 DOI: 10.1016/j.crad.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 12/05/2023] [Indexed: 01/03/2024]
Abstract
Chronic non-bacterial osteomyelitis (CNO), also known as non-bacterial osteitis, is a chronic autoinflammatory disease of unknown aetiology that primarily occurs in the paediatric population, although rare cases of adult-onset disease also exist. CNO has non-specific clinical and radiological presentations, and the affected population often present with bone pain of insidious onset secondary to sterile bony inflammation that can be associated with swelling, focal tenderness, and warmth at the affected sites. The pattern of bony involvement appears to be dependent on the age of onset, with adults frequently having axial skeletal lesions and children and adolescents often being affected in the appendicular skeletal sites. CNO is a diagnosis of exclusion, and imaging is heavily relied on to identify and characterise the bony lesions in addition to exclude diseases that can mimic CNO. Magnetic resonance imaging is often the reference standard with biochemical and histopathological findings being complementary. Although combining imaging methods can be used to facilitate the diagnosis, a single technique could be adequate depending on the clinical picture. Given the relatively rare incidence of CNO, limited awareness of the disease among care providers, and its similarity in clinical and radiological presentation to various bony diseases, there are often long delays in diagnosis, with adults being unfavourably affected compared to paediatrics and adolescents. This review of CNO will describe the condition, overview its clinical presentation, highlight the radiological features, and emphasise clinical pearls that can aid in diagnosis and ruling out the mimics.
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Affiliation(s)
- M Saffarzadeh
- Faculty of Medicine, The University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada.
| | - S Haydar
- Department of Radiology, Vancouver General Hospital, 2775 Laurel St, Vancouver, BC V5Z 1M9, Canada
| | - D Chan
- Department of Radiology, Vancouver General Hospital, 2775 Laurel St, Vancouver, BC V5Z 1M9, Canada
| | - G Andrews
- Faculty of Medicine, The University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada; Department of Radiology, Vancouver General Hospital, 2775 Laurel St, Vancouver, BC V5Z 1M9, Canada
| | - H Ouellette
- Faculty of Medicine, The University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada; Department of Radiology, Vancouver General Hospital, 2775 Laurel St, Vancouver, BC V5Z 1M9, Canada
| | - P Mallinson
- Faculty of Medicine, The University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada; Department of Radiology, Vancouver General Hospital, 2775 Laurel St, Vancouver, BC V5Z 1M9, Canada
| | - P L Munk
- Faculty of Medicine, The University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada; Department of Radiology, Vancouver General Hospital, 2775 Laurel St, Vancouver, BC V5Z 1M9, Canada
| | - A Sheikh
- Faculty of Medicine, The University of British Columbia, 317 - 2194 Health Sciences Mall, Vancouver, BC V6T 1Z3, Canada; Department of Radiology, Vancouver General Hospital, 2775 Laurel St, Vancouver, BC V5Z 1M9, Canada
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5
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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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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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7
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Okay E, Ulu K, Demir F, Sari T, Zeynalov S, Toksoz Yildirim AN, Baysal B, Zenginkinet T, Reddy K, Akpinar F, Sozeri B, Ozkan K. Chronic recurrent multifocal osteomyelitis: A multidisciplinary experience of 22 pediatric cases with a mean follow-up of 27 months. J Orthop Sci 2023; 28:438-445. [PMID: 34895795 DOI: 10.1016/j.jos.2021.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/23/2021] [Accepted: 11/21/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Chronic recurrent multifocal osteomyelitis (CRMO) is not a well known disorder among nonpediatricians. The aim of this study is to retrospectively evaluate the clinical outcomes of twenty-two CRMO patients presenting to two referral centres. METHODS This retrospective study included twenty-two children (12 males, 10 females; mean age 13 years; range 7-17 years). The diagnosis was based on clinical, radiological, and pathological findings. Data were retrieved from hospital charts. RESULTS The mean delay in diagnosis was 26 months (range, 0-96 months). The mean follow-up after diagnosis was 27.4 months (range, 6-47 months). Symptoms included pain, limping, local swelling, morning stiffness, and fever. 18 patients had multifocal and 4 patients had unifocal disease. Bone lesions were detected with whole-body or local MRI (Magnetic Resonance Imaging). The mean number of bone lesions was 2.5 (range, 1-8). Ten cases underwent biopsy to exclude malignancy and infection. Prior to diagnosis, cast immobilization or curettage was erroneously performed in four patients. One patient suffered from vertebral compression fracture. There is no growth disturbance or deformity in any patient. CONCLUSION This study demonstrated that early recognition of the disease can be improved by using Bristol criteria which should be evaluated by a multidisciplinary team rather than one single specialist. In this way, the reliability of these criteria is improved and the treatment could be given earlier with decreased delay in diagnosis. This multidisciplinary approach is also important for decision for biopsy, timely aggressive medical treatment, and follow-up of the disease to minimise possible complications.
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Affiliation(s)
- Erhan Okay
- Istanbul Goztepe Prof.Dr.Suleyman Yalcin City Hospital, Department of Orthopaedics, Istanbul, Turkey.
| | - Kadir Ulu
- University of Health Sciences, Ümraniye Education and Research Hospital, Department of Pediatric Rheumatology, Istanbul, Turkey
| | - Ferhat Demir
- University of Health Sciences, Ümraniye Education and Research Hospital, Department of Pediatric Rheumatology, Istanbul, Turkey
| | - Tarık Sari
- Istanbul Goztepe Prof.Dr.Suleyman Yalcin City Hospital, Department of Orthopaedics, Istanbul, Turkey
| | - Samir Zeynalov
- Istanbul Afiyet Hospital, Department of Orthopaedics, Istanbul, Turkey
| | - Ayse Nur Toksoz Yildirim
- Istanbul Goztepe Prof.Dr.Suleyman Yalcin City Hospital, Department of Pathology, Istanbul, Turkey
| | - Begumhan Baysal
- Istanbul Goztepe Prof.Dr.Suleyman Yalcin City Hospital, Department of Radiology, Istanbul, Turkey
| | - Tulay Zenginkinet
- Istanbul Goztepe Prof.Dr.Suleyman Yalcin City Hospital, Department of Pathology, Istanbul, Turkey
| | - Krishna Reddy
- University of Cincinnati Medical Center, Department of Orthopedic Surgery, Cincinnati, OH, United States
| | - Fuat Akpinar
- Istanbul Goztepe Prof.Dr.Suleyman Yalcin City Hospital, Department of Orthopaedics, Istanbul, Turkey
| | - Betul Sozeri
- University of Health Sciences, Ümraniye Education and Research Hospital, Department of Pediatric Rheumatology, Istanbul, Turkey
| | - Korhan Ozkan
- Istanbul Goztepe Prof.Dr.Suleyman Yalcin City Hospital, Department of Orthopaedics, Istanbul, Turkey
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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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9
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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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10
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Ma L, Liu H, Tang H, Zhang Z, Zou L, Yu H, Sun L, Li X, Tang X, Lu M. Clinical characteristics and outcomes of chronic nonbacterial osteomyelitis in children: a multicenter case series. Pediatr Rheumatol Online J 2022; 20:1. [PMID: 34980193 PMCID: PMC8722093 DOI: 10.1186/s12969-021-00657-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 11/29/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate demographic, clinical, laboratory, imaging, histopathology characteristics, and treatment responses of children with Chronic nonbacterial osteomyelitis (CNO). METHODS Retrospective multi-center case series study of pediatric patients diagnosed with CNO treated at five tertiary centers in south China. RESULTS Totally there were 18 patients diagnosed as CNO between 2014 and 2020. The median age of onset was 9.2 years (range 3.7-13.1) and 55.6% were female. Median delay in diagnosis was 10.9 months (range 1.0-72.0). The most frequent presenting symptoms were bone pain (100%) and fever (44.4%). Most patients had more than one lesion (median of 5, range 1-7). Most frequently affected bones were tibiofibula (88.9%) and femur (77.8%). The MRI characteristics mainly presented as bone edema and hyperintensity in bone marrow. Bone biopsy was conducted in 11 patients (61.1%) with inflammatory cells infiltration manifested as chronic osteomyelitis, and none showed bacterial infection or tumor. In treatment, non-steroid anti-inflamatory drugs (NSAIDs) is used as the first-line drug followed by steriods, methotexate (MTX), salazosulfadimidine (SASP), Bisphosphonates and TNF-α inhibitor. Two refractory cases received combination therapy with Bisphosphonates and TNF-α inhibitor, and achieved good therapeutic effect. CONCLUSIONS The present study described a multicenter series of CNO from south China and highlighted the clinical features, laboratory tests, imaging characteristics and treatment outcomes. Increasing awareness of this disease is important to decrease time to diagnosis, improve access to treatment, and reduce complications.
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Affiliation(s)
- Le Ma
- grid.452511.6Department of Rheumatology and Immunology, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Haimei Liu
- grid.411333.70000 0004 0407 2968Department of rheumatology, Children’s Hospital of Fudan University, Shanghai, China
| | - Hanyun Tang
- grid.452253.70000 0004 1804 524XDepartment of Nephrology and Immunology, Children’s Hospital of Soochow University, Suzhou, China
| | - Zhiyong Zhang
- grid.488412.3Department of Rheumatology and Immunology, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Lixia Zou
- grid.411360.1Department of Allergy Immunology and Rheumatology, Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Haiguo Yu
- Department of Rheumatology and Immunology, Children's Hospital of Nanjing Medical University, Nanjing, China.
| | - Li Sun
- grid.411333.70000 0004 0407 2968Department of rheumatology, Children’s Hospital of Fudan University, Shanghai, China
| | - Xiaozhong Li
- grid.452253.70000 0004 1804 524XDepartment of Nephrology and Immunology, Children’s Hospital of Soochow University, Suzhou, China
| | - Xuemei Tang
- grid.488412.3Department of Rheumatology and Immunology, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Meiping Lu
- grid.411360.1Department of Allergy Immunology and Rheumatology, Children’s Hospital of Zhejiang University School of Medicine, Hangzhou, China
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11
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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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12
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Salaffi F, Ceccarelli L, Carotti M, Di Carlo M, Polonara G, Facchini G, Golfieri R, Giovagnoni A. Differentiation between infectious spondylodiscitis versus inflammatory or degenerative spinal changes: How can magnetic resonance imaging help the clinician? Radiol Med 2021; 126:843-859. [PMID: 33797727 PMCID: PMC8154816 DOI: 10.1007/s11547-021-01347-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 03/14/2021] [Indexed: 12/19/2022]
Abstract
Spondylodiscitis is a complex disease whose diagnosis and management are still challenging. The differentiation between infectious and non-infectious aetiology is mandatory to avoid delays in the treatment of life-threatening infectious conditions. Imaging methods, in particular magnetic resonance imaging (MRI), play a key role in differential diagnosis. MRI provides detailed anatomical information, especially regarding the epidural space and spinal cord, and may allow differential diagnosis by assessing the characteristics of certain infectious and inflammatory/degenerative lesions. In this article, we provide an overview of the radiological characteristics and differentiating features of non-infectious inflammatory spinal disorders and infectious spondylodiscitis, focussing on MRI results and presenting relevant clinical and pathological features that help early diagnosis.
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Affiliation(s)
- Fausto Salaffi
- Clinica Reumatologica, Ospedale "Carlo Urbani", Dipartimento Di Scienze Cliniche E Molecolari, Università Politecnica Delle Marche, Via Aldo Moro, 25, 60035, Jesi, Ancona, Italy
| | - Luca Ceccarelli
- Unità di Radiologia, Dipartimento di Medicina Specialistica, Diagnostica E Sperimentale, Ospedale Sant'Orsola, Università Di Bologna, Via Albertoni 15, 40138, Bologna, Italy.,Radiologia Diagnostica ed Interventistica, IRCCS Istituto Ortopedico Rizzoli, Via GC Pupilli 1, 40136, Bologna, Italia
| | - Marina Carotti
- Dipartimento di Scienze Radiologiche, Ospedali Riuniti, Università Politecnica Delle Marche, Ancona, Italia
| | - Marco Di Carlo
- Clinica Reumatologica, Ospedale "Carlo Urbani", Dipartimento Di Scienze Cliniche E Molecolari, Università Politecnica Delle Marche, Via Aldo Moro, 25, 60035, Jesi, Ancona, Italy.
| | - Gabriele Polonara
- Dipartimento di Scienze Radiologiche, Ospedali Riuniti, Università Politecnica Delle Marche, Ancona, Italia
| | - Giancarlo Facchini
- Radiologia Diagnostica ed Interventistica, IRCCS Istituto Ortopedico Rizzoli, Via GC Pupilli 1, 40136, Bologna, Italia
| | - Rita Golfieri
- Unità di Radiologia, Dipartimento di Medicina Specialistica, Diagnostica E Sperimentale, Ospedale Sant'Orsola, Università Di Bologna, Via Albertoni 15, 40138, Bologna, Italy
| | - Andrea Giovagnoni
- Dipartimento di Scienze Radiologiche, Ospedali Riuniti, Università Politecnica Delle Marche, Ancona, Italia
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13
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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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14
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Sato TS, Ferguson PJ. Whole-body MRI Imaging Is an Essential Tool in Diagnosing and Monitoring Patients With Sterile Osteomyelitis. J Rheumatol 2021; 48:635-637. [PMID: 33649064 DOI: 10.3899/jrheum.201507] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Takashi Shawn Sato
- T.S. Sato, Clinical Assistant Professor, Divisions of Pediatric Radiology and Neuroradiology, Department of Radiology, Carver College of Medicine, University of Iowa
| | - Polly J Ferguson
- P.J. Ferguson, Professor, Division of Pediatric Rheumatology, Allergy and Immunology, Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA.
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15
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Karunaratne YG, Davies J, Carty CP, Graham D. Chronic Recurrent Multifocal Osteomyelitis of the Hand: A Rare Pediatric Condition. Hand (N Y) 2021; 16:213-222. [PMID: 31137982 PMCID: PMC8041419 DOI: 10.1177/1558944719846599] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Chronic recurrent multifocal osteomyelitis (CRMO) is a rare autoinflammatory condition characterized by bone pain and swelling, secondary to sterile bone osteolytic lesions. Estimated incidence is 1:1 000 000, with ~2% involving the hand. We present a case series of CRMO of the hand and review the available literature, with the aim of educating and raising awareness of this condition. Methods: A retrospective chart review was conducted for all patients presenting to the institution diagnosed with CRMO involving the hands. Subsequently, a literature review was performed. Results/Case Series: Three cases of CRMO of the hand were identified. Age ranged from 20 months to 6 years, with 1 female. Time from presentation to diagnosis ranged from 3 to 15 months. Two had a single lesion, with the remaining patient having a second lesion on full-body magnetic resonance imaging (MRI). Three lesions involved phalanges, and one involved a metacarpal. Two received antibiotics without improvement prior to diagnosis. After diagnosis of CRMO, two received intravenous pamidronate. They both later showed improvement on MRI. Conclusion: CRMO is a rare disease with scarce literature to guide management. We present a series of CRMO specifically of the hand. The cases educate key stakeholders, raise awareness of the diagnosis, and illustrate challenging aspects of managing these patients. This includes the special functional and anatomical consideration essential in managing cases involving the hand.
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Affiliation(s)
| | | | | | - David Graham
- Queensland Children’s Hospital, Brisbane, Australia,David Graham, Department of Orthopaedic Surgery, Queensland Children’s Hospital, Children’s Health Queensland Hospital and Health Service, 501 Stanley Street, South Brisbane, QLD 4101, Australia.
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16
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Buch K, Thuesen ACB, Brøns C, Schwarz P. Chronic Non-bacterial Osteomyelitis: A Review. Calcif Tissue Int 2019; 104:544-553. [PMID: 30456556 DOI: 10.1007/s00223-018-0495-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 11/12/2018] [Indexed: 10/27/2022]
Abstract
Chronic non-bacterial osteomyelitis (CNO) is a rare auto-inflammatory bone disorder, with a prevalence of around one in a million patients. In the more severe form, it is referred to as chronic recurrent multifocal osteomyelitis (CRMO). We present the current knowledge on epidemiology, pathophysiology as well as diagnostic options and treatment regimens. CNO/CRMO most commonly affects children and lesions are often seen in the metaphyseal plates of the long bones, but cases have been described affecting all age groups as well as lesions in almost every bone. It is, therefore, a disease that clinicians can encounter in many different settings. Diagnosis is mainly a matter of exclusion from differential diagnoses such as bacterial osteomyelitis and cancer. Magnetic resonance imaging is the best radiological method for diagnosis coupled with a low-grade inflammation and a history of recurring episodes. Treatment is based on case reports and consists of alleviating symptoms with non-steroidal anti-inflammatory drugs since the disease is often self-limiting. Recently, more active treatments using either bisphosphonates or biological treatment are becoming more common, to prevent long term bone damage. In general, due to its rarity, much remains unclear regarding CNO/CRMO. We review the known literature on CNO/CRMO and propose areas of interest as well as possible ways to make current diagnostic criteria more detailed. We also find unifocal cases of the jaw to be a possible sub-type that may need its own set of criteria.
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Affiliation(s)
- Kristian Buch
- Department of Endocrinology, Diabetes and Bone-metabolic Research Unit, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Anne Cathrine Baun Thuesen
- Department of Endocrinology, Diabetes and Bone-metabolic Research Unit, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Charlotte Brøns
- Department of Endocrinology, Diabetes and Bone-metabolic Research Unit, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Peter Schwarz
- Department of Endocrinology, Diabetes and Bone-metabolic Research Unit, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.
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17
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Schwarzkopf E, Agaram NP, Ha S, Prince DE. Chronic recurrent multifocal osteomyelitis-case report of two patients and review of literature. ACTA ACUST UNITED AC 2019; 14:24-30. [PMID: 31031824 DOI: 10.4172/1758-4272.1000220] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background Chronic Recurrent Multifocal Osteomyelitis (CRMO) is an autoinflammatory skeletal disease characterized by unifocal or multifocal nonbacterial inflammatory bone lesions in the metaphysis of long bones. Common sites of CRMO are tibia, pelvis, proximal femur, clavicle, calcaneum and vertebrae. However, unifocal presentation or presentation in adults, atypical locations, and absence of recurrence have also been reported. Methods and Findings We describe two cases of female patients with unifocal presentation of nonbacterial inflammatory bone lesions in the upper and lower extremity. Furthermore, a review of literature is presented. Conclusion Although CRMO is seen primarily in children and adolescents, and usually occurs in a multifocal pattern, our cases illustrate that this disease can arise in adult patients and in a single location. The diagnosis of CRMO should be made in a multi-disciplinary approach amongst orthopedic surgeons, radiologists and pathologists.
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Affiliation(s)
| | - Narasimhan P Agaram
- Department of Pathology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
| | - Spencer Ha
- Tufts University, Medford, MA 02155, USA
| | - Daniel E Prince
- Orthopaedic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA
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18
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Kim SM, Lee SK. Chronic non-bacterial osteomyelitis in the jaw. J Korean Assoc Oral Maxillofac Surg 2019; 45:68-75. [PMID: 31106134 PMCID: PMC6502749 DOI: 10.5125/jkaoms.2019.45.2.68] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/13/2018] [Accepted: 08/21/2018] [Indexed: 12/29/2022] Open
Abstract
Chronic recurrent multifocal osteomyelitis (CRMO) is one of the most severe form of chronic non-bacterial osteomyelitis (CNO), which could result in bone and related tissue damage. This autoinflammatory bone disorder (ABD) is very difficult for its clinical diagnosis because of no diagnostic criteria or biomarkers. CRMO in the jaw must be suspected in the differential diagnosis of chronic and recurrent bone pain in the jaw, and a bone biopsy should be considered in chronic and relapsing bone pain with swelling that is unresponsive to treatment. The early diagnosis of CRMO in the jaw will prevent unnecessary and prolonged antibiotic usage or unnecessary surgical intervention. The updated researches for the identification of genetic and molecular alterations in CNO/CRMO should be studied more for its correct pathophysiological causes and proper treatment guidelines. Although our trial consisted of reporting items from Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), there are very few articles of randomized controlled trials. This article was summarized based on the author's diverse clinical experiences. This paper reviews the clinical presentation of CNO/CRMO with its own pathogenesis, epidemiology, recent research studies, and general medications. Treatment and monitoring of the jaw are essential for the clear diagnosis and management of CNO/CRMO patients in the field of dentistry and maxillofacial surgery.
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Affiliation(s)
- Soung Min Kim
- Oral and Maxillofacial Microvascular Reconstruction LAB, Brong Ahafo Regional Hospital, Sunyani, Ghana.,Department of Oral and Maxillofacial Surgery, School of Dentistry and Dental Research Institute, Seoul National University, Seoul, Korea
| | - Suk Keun Lee
- Department of Oral Pathology, College of Dentistry and Institute of Oral Science, Gangneung-Wonju National University, Gangneung, Korea
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19
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Girschick H, Finetti M, Orlando F, Schalm S, Insalaco A, Ganser G, Nielsen S, Herlin T, Koné-Paut I, Martino S, Cattalini M, Anton J, Mohammed Al-Mayouf S, Hofer M, Quartier P, Boros C, Kuemmerle-Deschner J, Pires Marafon D, Alessio M, Schwarz T, Ruperto N, Martini A, Jansson A, Gattorno M. The multifaceted presentation of chronic recurrent multifocal osteomyelitis: a series of 486 cases from the Eurofever international registry. Rheumatology (Oxford) 2018; 57:1203-1211. [PMID: 29596638 DOI: 10.1093/rheumatology/key058] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 02/08/2018] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES Chronic non-bacterial osteomyelitis (CNO) or chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory disorder characterized by sterile bone osteolytic lesions. The aim of this study was to evaluate the demographic data and clinical, instrumental and therapeutic features at baseline in a large series of CNO/CRMO patients enrolled in the Eurofever registry. METHODS A web-based registry collected retrospective data on patients affected by CRMO/CNO. Both paediatric and adult centres were involved. RESULTS Complete baseline information on 486 patients was available (176 male, 310 female). The mean age of onset was 9.9 years. Adult onset (>18 years of age) was observed in 31 (6.3%) patients. The mean time from disease onset to final diagnosis was 1 year (range 0-15). MRI was performed at baseline in 426 patients (88%), revealing a mean number of 4.1 lesions. More frequent manifestations not directly related to bone involvement were myalgia (12%), mucocutaneous manifestations (5% acne, 5% palmoplantar pustulosis, 4% psoriasis, 3% papulopustular lesions, 2% urticarial rash) and gastrointestinal symptoms (8%). A total of 361 patients have been treated with NSAIDs, 112 with glucocorticoids, 61 with bisphosphonates, 58 with MTX, 47 with SSZ, 26 with anti-TNF and 4 with anakinra, with a variable response. CONCLUSION This is the largest reported case series of CNO patients, showing that the range of associated clinical manifestations is rather heterogeneous. The study confirms that the disease usually presents with an early teenage onset, but it may also occur in adults, even in the absence of mucocutaneous manifestations.
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Affiliation(s)
- Hermann Girschick
- Paediatric and Adolescent Medicine, Perinatal Centre, Clinic for Paediatric and Adolescent Medicine, Vivantes Klinikum Berlin, Germany
- Section of Paediatric Rheumatology, Children's Hospital, Osteology, Immunology and Infectious Diseases, University of Wuerzburg, Germany
| | - Martina Finetti
- Istituto Giannina Gaslini, Pediatria II, Reumatologia, Genoa
| | - Francesca Orlando
- Istituto Giannina Gaslini, Pediatria II, Reumatologia, Genoa
- Dipartimento di Pediatria, Università di Napoli Federico II, Naples
| | - Susanne Schalm
- Klinikum der Universität, von Haunersches Kinderspital, Munich, Germany
| | | | - Gerd Ganser
- Clinic of Paediatric Rheumatology, St. Josef-Stift Hospital, Sendenhorst, Germany
| | - Susan Nielsen
- Paediatric Rheumatology, Rigshospitalet, Copenhagen, Denmark
| | - Troels Herlin
- Skejby Sygehus, Aarhus University Hospital, Aarhus, Denmark
| | - Isabelle Koné-Paut
- Service de rhumatologie pédiatrique, Le Kremlin-Bicêtre University Hospital, Paris-Sud University, Paris, France
| | - Silvana Martino
- Dipartimento di Scienze Pediatriche e dell'Adolescenza, University of Torino, Torino, Italy
| | - Marco Cattalini
- Unita di Immunologia e Reumatologia Pediatrica, Clinica Pediatrica dell'Universita di Brescia, Spedali Civili, Brescia, Italy
| | - Jordi Anton
- Paediatric Rheumatology, Hospital Sant Joan de Déu. Universitat de Barcelona, Spain
| | | | - Michael Hofer
- Centre Multisite Romand de Rhumatologie Pediatrique/Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Pierre Quartier
- IMAGINE Institute, Paris-Descartes University, Necker Children's Hospital, Paris, France
| | - Christina Boros
- Paediatrics and Reproductive Health, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | | | | | - Maria Alessio
- Dipartimento di Pediatria, Università di Napoli Federico II, Naples
| | - Tobias Schwarz
- Section of Paediatric Rheumatology, Children's Hospital, Osteology, Immunology and Infectious Diseases, University of Wuerzburg, Germany
- Clinic of Paediatric Rheumatology, St. Josef-Stift Hospital, Sendenhorst, Germany
| | | | - Alberto Martini
- Direzione Scientifica, Istituto Giannina Gaslini, Genoa, Italy
| | - Annette Jansson
- Klinikum der Universität, von Haunersches Kinderspital, Munich, Germany
| | - Marco Gattorno
- Istituto Giannina Gaslini, Pediatria II, Reumatologia, Genoa
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20
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Hofmann SR, Kapplusch F, Mäbert K, Hedrich CM. The molecular pathophysiology of chronic non-bacterial osteomyelitis (CNO)-a systematic review. Mol Cell Pediatr 2017; 4:7. [PMID: 28685269 PMCID: PMC5500598 DOI: 10.1186/s40348-017-0073-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 06/27/2017] [Indexed: 02/07/2023] Open
Abstract
Chronic non-bacterial osteomyelitis (CNO) belongs to the growing spectrum of autoinflammatory diseases and primarily affects the skeletal system. Peak onset ranges between 7 and 12 years of age. The clinical spectrum of CNO covers sometimes asymptomatic inflammation of single bones at the one end and chronically active or recurrent multifocal osteitis at the other.Despite the intense scientific efforts, the exact molecular mechanisms of CNO remain unknown. Recent data suggest CNO as a genetically complex disorder with dysregulated TLR4/MAPK/inflammasome signaling cascades resulting in an imbalance between pro- and anti-inflammatory cytokine expression, leading to osteoclast activation and osteolytic lesions.In this manuscript, the current understanding of molecular patho-mechanisms in CNO will be discussed.
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Affiliation(s)
- Sigrun Ruth Hofmann
- Pediatric Rheumatology and Immunology, Children's Hospital Dresden, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, D-01307, Dresden, Germany
| | - Franz Kapplusch
- Pediatric Rheumatology and Immunology, Children's Hospital Dresden, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, D-01307, Dresden, Germany
| | - Katrin Mäbert
- Pediatric Rheumatology and Immunology, Children's Hospital Dresden, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, D-01307, Dresden, Germany
| | - Christian Michael Hedrich
- Pediatric Rheumatology and Immunology, Children's Hospital Dresden, Faculty of Medicine Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, D-01307, Dresden, Germany.
- 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, Liverpool, UK.
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21
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Hofmann SR, Kapplusch F, Girschick HJ, Morbach H, Pablik J, Ferguson PJ, Hedrich CM. Chronic Recurrent Multifocal Osteomyelitis (CRMO): Presentation, Pathogenesis, and Treatment. Curr Osteoporos Rep 2017; 15:542-554. [PMID: 29080202 PMCID: PMC5705736 DOI: 10.1007/s11914-017-0405-9] [Citation(s) in RCA: 133] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Chronic non-bacterial osteomyelitis (CNO) with its most severe form chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory bone disorder. We summarize the clinical presentation, diagnostic approaches, most recent advances in understanding the pathophysiology, and available treatment options and outcomes in CNO/CRMO. RECENT FINDINGS Though the exact molecular pathophysiology of CNO/CRMO remains somewhat elusive, it appears likely that variable defects in the TLR4/MAPK/inflammasome signaling cascade result in an imbalance between pro- and anti-inflammatory cytokine expressions in monocytes from CNO/CRMO patients. In this context, we present previously unpublished data on cytokine and chemokine expression in monocytes and tissues. CNO/CRMO is an autoinflammatory bone disorder resulting from imbalanced cytokine expression from innate immune cells. Though the exact molecular pathophysiology remains unclear, variable molecular defects appear to result in inflammasome activation and pro-inflammatory cytokine expression in monocytes from CNO/CRMO patients. Recent advances suggest signaling pathways and single molecules as biomarkers for CNO/CRMO as well as future treatment targets.
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Affiliation(s)
- Sigrun R Hofmann
- Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Franz Kapplusch
- Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | | | - Henner Morbach
- Pediatric Rheumatology and Immunology, Children's Hospital, University of Würzburg, Würzburg, Germany
| | - Jessica Pablik
- Division of Pathology, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Polly J Ferguson
- Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - Christian M Hedrich
- Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
- Department of Women's and Children's Health, Institute of Translational Medicine (Child Health), University of Liverpool, East Prescott Road, Liverpool, L14 5AB, UK.
- Department of Pediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK.
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Monofocal Chronic Nonbacterial Osteomyelitis in the Mandible Accompanied With Mucocutaneous Disease. J Craniofac Surg 2017; 28:e547-e551. [PMID: 28692524 DOI: 10.1097/scs.0000000000003840] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Chronic nonbacterial osteomyelitis (CNO) is a bone disease with nonbacteria osteitis of unknown etiology. Symptoms, including pain, swelling, fever, etc, always result in misdiagnosis and wrong therapy. This study aims to introduce the clinical features and the therapy of patients with CNO accompanied with mucocutaneous disease. The authors retrospectively reviewed the patients who presented to our hospital from 2000 to 2016, the final sample including 3 patients with CNO accompanied with mucocutaneous disease, who presented repeated severe pain of bone, swelling, tenderness, and fever during attack stage with no evidence of bacterial infections. One patient underwent surgery, and all of them took the therapy of nonsteroidal anti-inflammatory drugs and immunosuppressive agents. There was no significant effect after taken surgery, but good results with drugs. The study suggested us that medical therapy sometimes better than surgery in CNO accompanied with mucocutaneous disease.
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Ata Y, Inaba Y, Choe H, Kobayashi N, Machida J, Nakamura N, Saito T. Bone metabolism and inflammatory characteristics in 14 cases of chronic nonbacterial osteomyelitis. Pediatr Rheumatol Online J 2017; 15:56. [PMID: 28693592 PMCID: PMC5504748 DOI: 10.1186/s12969-017-0183-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 07/03/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Chronic nonbacterial osteomyelitis (CNO) is a multifocal autoinflammatory disease that often impairs daily life in children. This study aimed to investigate the bone metabolic and inflammatory characteristics of patients with CNO, and to assess the differences between responders and nonresponders to conservative treatment. METHODS We investigated the clinical symptoms; laboratory data including inflammatory and bone metabolic biomarkers; and imaging findings from plain radiography, magnetic resonance imaging (MRI), fluorodeoxyglucose-positron emission tomography (FDG-PET), and dual-energy x-ray absorption (DEXA) in 14 patients with CNO. All patients underwent first-line treatment comprising systemic nonsteroidal anti-inflammatory drugs with or without bisphosphonate. According to the response to the first-line treatment, the patients were divided into the clinical remission/partial response group and the no response group. The differences in bone metabolic and inflammatory characteristics between the two groups were assessed. RESULTS All patients had low bone mineral density assessed with DEXA. The bone metabolic biomarkers (bone-specific alkaline phosphatase and tartrate-resistant acid phosphatase 5b) were increased in boys of all ages and in young girls. Multiple inflammatory regions were detected in all patients by using FDG-PET including asymptomatic regions. The no response group had higher immunoglobulin G (IgG) and a greater number of bone inflammatory lesions detected on MRI than the clinical remission/partial response group. CONCLUSION Our data indicate the involvement of abnormal bone turnover, necessity of whole-body scanning, and association of higher serum IgG levels and greater numbers of inflammatory lesions with prolonged disease activity in patients with CNO.
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Affiliation(s)
- Yurika Ata
- 0000 0001 1033 6139grid.268441.dDepartment of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan ,0000 0004 0377 7528grid.414947.bDepartment of Orthopaedic Surgery, Kanagawa Children’s Medical Center, 2-138-4 Mutsukawa, Minami-ku, Yokohama, Japan
| | - Yutaka Inaba
- Department of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan.
| | - Hyonmin Choe
- 0000 0001 1033 6139grid.268441.dDepartment of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Naomi Kobayashi
- 0000 0001 1033 6139grid.268441.dDepartment of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
| | - Jiro Machida
- 0000 0004 0377 7528grid.414947.bDepartment of Orthopaedic Surgery, Kanagawa Children’s Medical Center, 2-138-4 Mutsukawa, Minami-ku, Yokohama, Japan
| | - Naoyuki Nakamura
- 0000 0004 0377 7528grid.414947.bDepartment of Orthopaedic Surgery, Kanagawa Children’s Medical Center, 2-138-4 Mutsukawa, Minami-ku, Yokohama, Japan
| | - Tomoyuki Saito
- 0000 0001 1033 6139grid.268441.dDepartment of Orthopaedic Surgery, Yokohama City University, 3-9 Fukuura, Kanazawa-ku, Yokohama, Japan
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Bacterial Osteomyelitis or Nonbacterial Osteitis in Children: A Study Involving the German Surveillance Unit for Rare Diseases in Childhood. Pediatr Infect Dis J 2017; 36:451-456. [PMID: 28403046 DOI: 10.1097/inf.0000000000001469] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Although bacterial osteomyelitis (BO) is a commonly recognized diagnosis in pediatrics, it is often difficult to distinguish from nonbacterial osteitis (NBO). The goal of our study was to distinguish between the 2 disease entities and better define NBO. METHODS Using the German Surveillance Unit for Rare Diseases in Childhood (Erhebungseinheit für Seltene Paediatrische Erkrankungen in Deutschland), this prospective study during a 5-year period captured 657 patients at first diagnosis of either BO (n = 378) or NBO (n = 279) while analyzing epidemiologic, clinical and radiologic data. RESULTS BO was reported in 1.2 per 100,000 children with a higher prevalence in younger male patients (58%), and NBO was reported in 0.45 per 100,000 children. BO patients tended to present with fevers (68%), elevated inflammation markers (82%) and local swelling (62%) but a shorter course of symptoms than NBO patients. NBO patients presented in good general health (86%) and were more likely to have multifocal lesions (66%). Staphylococcus aureus was the most prominent pathogen (83%), with only one methicillin-resistant S. aureus reported. Complications ranged from arthritis adjacent to the lesion to hyperostosis and vertebral fractures. CONCLUSIONS BO and NBO can be distinguished based on symptoms, associated diseases and inflammation markers. NBO should always be considered in pediatric patients presenting with bone lesions and pain, especially in young female patients presenting with good general health, minimal inflammation markers and multifocal lesions in the vertebrae, clavicle and sternum.
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Schnabel A, Range U, Hahn G, Berner R, Hedrich CM. Treatment Response and Longterm Outcomes in Children with Chronic Nonbacterial Osteomyelitis. J Rheumatol 2017; 44:1058-1065. [DOI: 10.3899/jrheum.161255] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2017] [Indexed: 12/28/2022]
Abstract
Objective.The autoinflammatory bone disorder chronic nonbacterial osteomyelitis (CNO) covers a wide clinical spectrum, ranging from mild self-limited presentations to chronically active or recurrent courses, which are then referred to as chronic recurrent multifocal osteomyelitis (CRMO). Little is known about treatment options and longterm outcomes. We investigated treatment responses and outcomes in children with CNO.Methods.A retrospective chart review was conducted in a tertiary referral center, covering 2004–2015. Disease activity was measured at 0, 3, 6, 12, and 24 months after treatment initiation, and at the last recorded visit.Results.Fifty-six patients with CNO were identified; 44 had multifocal CNO. Fifty percent of patients relapsed after a median of 2.4 years, and as few as 40% remained relapse-free after 5 years. Nonsteroidal antiinflammatory drugs were used as first-line treatment in 55 patients, inducing remission after 3 months in all individuals with relapse rates of 50% after 2 years. Further treatment included corticosteroids (n = 23), tumor necrosis factor-α (TNF-α) inhibitors (n = 7), and bisphosphonates (n = 8). While 47% of patients with CNO relapsed within 1 year after corticosteroid therapy, favorable outcomes were achieved with TNF-α inhibitors or bisphosphonates (pamidronate).Conclusion.CNO is a chronic disease with favorable outcomes within the first year, but high relapse rates in longterm followup. Particularly, patients with CRMO with long-lasting, uncontrolled inflammation were at risk for the development of arthritis. Our findings underscore the importance of a timely diagnosis and treatment initiation. Prospective studies are warranted to establish evidence-based diagnostic and therapeutic approaches to CNO.
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Hofmann SR, Böttger F, Range U, Lück C, Morbach H, Girschick HJ, Suttorp M, Hedrich CM. Serum Interleukin-6 and CCL11/Eotaxin May Be Suitable Biomarkers for the Diagnosis of Chronic Nonbacterial Osteomyelitis. Front Pediatr 2017; 5:256. [PMID: 29250517 PMCID: PMC5716982 DOI: 10.3389/fped.2017.00256] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 11/16/2017] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES Chronic recurrent multifocal osteomyelitis (CRMO), the most severe form of chronic nonbacterial osteomyelitis (CNO), is an autoinflammatory bone disorder. In the absence of diagnostic criteria or biomarkers, CNO/CRMO remains a diagnosis of exclusion. The aim of this study was to identify biomarkers for diagnosing multifocal disease (CRMO). STUDY DESIGN Sera from 71 pediatric CRMO patients, 11 patients with osteoarticular infections, 62 patients with juvenile idiopathic arthritis (JIA), 7 patients with para-infectious or reactive arthritis, and 43 patients with acute leukemia or lymphoma, as well as 59 healthy individuals were collected. Multiplex analysis of 18 inflammation- and/or bone remodeling-associated serum proteins was performed. Statistical analysis included univariate ANOVA, discriminant analysis, univariate receiver operating characteristic (ROC) analysis, and logistic regression analyses. RESULTS For 14 of 18 blood serum proteins, significant differences were determined between CRMO patients, at least one alternative diagnosis, or healthy controls. Multi-component discriminant analysis delivered five biomarkers (IL-6, CCL11/eotaxin, CCL5/RANTES, collagen Iα, sIL-2R) for the diagnosis of CRMO. ROC analysis allowed further reduction to a core set of 2 biomarkers (CCL11/eotaxin, IL-6) that are sufficient to discern between CRMO, healthy controls, and alternative diagnoses. CONCLUSION Serum biomarkers CCL11/eotaxin and IL-6 differentiate between patients with CRMO, healthy controls, and alternative diagnoses (leukemia and lymphoma, osteoarticular infections, para-infectious arthritis, and JIA). Easily accessible biomarkers may aid in diagnosing CRMO. Further studies testing biomarkers in larger unrelated cohorts are warranted.
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Affiliation(s)
- Sigrun Ruth Hofmann
- Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Fanny Böttger
- Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Ursula Range
- Institute for Medical Informatics and Biometry, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Christian Lück
- Institute for Medical Microbiology, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Henner Morbach
- University Children's Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | | | - Meinolf Suttorp
- Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Christian Michael Hedrich
- Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, United Kingdom.,Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, United Kingdom
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Schnabel A, Range U, Hahn G, Siepmann T, Berner R, Hedrich CM. Unexpectedly high incidences of chronic non-bacterial as compared to bacterial osteomyelitis in children. Rheumatol Int 2016; 36:1737-1745. [PMID: 27730289 DOI: 10.1007/s00296-016-3572-6] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 09/28/2016] [Indexed: 12/19/2022]
Abstract
Historically, osteomyelitis was considered an infectious disorder. More recently, inflammatory mechanisms were recognized causing a significant proportion of pediatric osteomyelitis. This study was to compare characteristics of children with chronic non-bacterial (CNO) and bacterial osteomyelitis (BOM). A chart review of osteomyelitis patients from the departments of pediatrics, pediatric surgery, orthopedic surgery, and oral and maxillofacial surgery was conducted in a tertiary referral center, covering the years 2004-2014. Institutional incidences of CNO (n = 49) and BOM (n = 56) were comparable. Differentiation between CNO and BOM based on clinical or laboratory findings was mostly impossible. However, children with BOM more frequently presented with local inflammatory signs (47 vs. 68 %, p = 0.040), fever (12 vs. 38 %, p = 0.003), and abscesses (0 vs. 39 %, p < 0.001). Peripheral arthritis (14 vs. 0 %, p < 0.001), inflammatory bowel disease (10 vs. 2 %, p = ns), and hyperostosis (29 vs. 4 %, p = 0.001) were more common in CNO. Whole-body MRI was performed in 76 % of CNO patients, unveiling multifocal lesions in 80 % (CRMO). Though considered a rare disorder, institutional incidences of CNO were comparable to BOM, and the discrimination between CNO and BOM solely based on clinical aspects was mostly impossible. This is of special interest, since a correct and timely diagnosis is of utmost importance for long-term outcomes in both disorders. Whole-body MRIs should be considered in chronic osteomyelitis to (1) detect clinically inapparent lesions in CNO and (2) indirectly exclude (usually unifocal) chronic bacterial infections. Prospective studies are warranted to establish evidence-based diagnostic and therapeutic approaches to CNO.
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Affiliation(s)
- A Schnabel
- Pediatric Rheumatology and Immunology, Children's Hospital Dresden, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
| | - U Range
- Institute for Medical Informatics and Biometry, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - G Hahn
- Department of Radiology, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - T Siepmann
- Division of Health Care Sciences, Center for Clinical Research and Management Education, Dresden International University, Freiberger Str. 37, 01067, Dresden, Germany
| | - R Berner
- Pediatric Rheumatology and Immunology, Children's Hospital Dresden, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - C M Hedrich
- Pediatric Rheumatology and Immunology, Children's Hospital Dresden, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307, Dresden, Germany.
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Hofmann SR, Schnabel A, Rösen-Wolff A, Morbach H, Girschick HJ, Hedrich CM. Chronic Nonbacterial Osteomyelitis: Pathophysiological Concepts and Current Treatment Strategies. J Rheumatol 2016; 43:1956-1964. [PMID: 27585682 DOI: 10.3899/jrheum.160256] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2016] [Indexed: 12/22/2022]
Abstract
Chronic nonbacterial osteomyelitis (CNO) is an autoinflammatory bone disorder, covering a clinical spectrum with asymptomatic inflammation of single bones at the one end, and chronic recurrent multifocal osteomyelitis (CRMO) at the other end. The exact molecular pathophysiology of CNO remains largely unknown. Provided familial clusters and the association with inflammatory disorders of the skin and intestine suggest a genetic predisposition. Recently, profound dysregulation of cytokine responses was demonstrated in CRMO. Failure to produce antiinflammatory cytokines interleukin (IL)-10 and IL-19 contributes to activation of inflammasomes and subsequent IL-1β release. In IL-10-deficient and in CNO-prone chronic multifocal osteomyelitis mice, IL-1β was linked to bone inflammation. Further, alterations to the gut microbiome were suggested in contributing to IL-1β release from innate immune cells in mice, offering an interesting target in the search for molecular mechanisms in CNO. Here, we summarize clinical presentation and treatment options in CNO/CRMO, current pathophysiological concepts, available mouse models, and promising future scientific directions.
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Affiliation(s)
- Sigrun R Hofmann
- From the Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden; Department of Pediatrics, University of Würzburg, Würzburg; Children's Hospital, Vivantes Klinikum-Friedrichshain, Berlin, Germany.,S.R. Hofmann, MD, PhD, Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden; A. Schnabel, MD, Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden; A. Rösen-Wolff, MD, PhD, Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden; H. Morbach, MD, PhD, Department of Pediatrics, University of Würzburg; H.J. Girschick, MD, PhD, Children's Hospital, Vivantes Klinikum-Friedrichshain; C.M. Hedrich, MD, PhD, Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden
| | - Anja Schnabel
- From the Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden; Department of Pediatrics, University of Würzburg, Würzburg; Children's Hospital, Vivantes Klinikum-Friedrichshain, Berlin, Germany.,S.R. Hofmann, MD, PhD, Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden; A. Schnabel, MD, Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden; A. Rösen-Wolff, MD, PhD, Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden; H. Morbach, MD, PhD, Department of Pediatrics, University of Würzburg; H.J. Girschick, MD, PhD, Children's Hospital, Vivantes Klinikum-Friedrichshain; C.M. Hedrich, MD, PhD, Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden
| | - Angela Rösen-Wolff
- From the Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden; Department of Pediatrics, University of Würzburg, Würzburg; Children's Hospital, Vivantes Klinikum-Friedrichshain, Berlin, Germany.,S.R. Hofmann, MD, PhD, Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden; A. Schnabel, MD, Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden; A. Rösen-Wolff, MD, PhD, Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden; H. Morbach, MD, PhD, Department of Pediatrics, University of Würzburg; H.J. Girschick, MD, PhD, Children's Hospital, Vivantes Klinikum-Friedrichshain; C.M. Hedrich, MD, PhD, Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden
| | - Henner Morbach
- From the Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden; Department of Pediatrics, University of Würzburg, Würzburg; Children's Hospital, Vivantes Klinikum-Friedrichshain, Berlin, Germany.,S.R. Hofmann, MD, PhD, Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden; A. Schnabel, MD, Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden; A. Rösen-Wolff, MD, PhD, Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden; H. Morbach, MD, PhD, Department of Pediatrics, University of Würzburg; H.J. Girschick, MD, PhD, Children's Hospital, Vivantes Klinikum-Friedrichshain; C.M. Hedrich, MD, PhD, Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden
| | - Hermann J Girschick
- From the Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden; Department of Pediatrics, University of Würzburg, Würzburg; Children's Hospital, Vivantes Klinikum-Friedrichshain, Berlin, Germany.,S.R. Hofmann, MD, PhD, Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden; A. Schnabel, MD, Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden; A. Rösen-Wolff, MD, PhD, Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden; H. Morbach, MD, PhD, Department of Pediatrics, University of Würzburg; H.J. Girschick, MD, PhD, Children's Hospital, Vivantes Klinikum-Friedrichshain; C.M. Hedrich, MD, PhD, Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden
| | - Christian M Hedrich
- From the Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden; Department of Pediatrics, University of Würzburg, Würzburg; Children's Hospital, Vivantes Klinikum-Friedrichshain, Berlin, Germany. .,S.R. Hofmann, MD, PhD, Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden; A. Schnabel, MD, Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden; A. Rösen-Wolff, MD, PhD, Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden; H. Morbach, MD, PhD, Department of Pediatrics, University of Würzburg; H.J. Girschick, MD, PhD, Children's Hospital, Vivantes Klinikum-Friedrichshain; C.M. Hedrich, MD, PhD, Pediatric Rheumatology and Immunology, Department of Pediatrics, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden.
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Osteomielitis crónica no bacteriana: experiencia en un hospital terciario. An Pediatr (Barc) 2016; 85:18-25. [DOI: 10.1016/j.anpedi.2015.08.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 08/14/2015] [Indexed: 11/23/2022] Open
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Barral E, Freire Gómez X, Enríquez Merayo E, Casado Picón R, Bello Gutierrez P, de Inocencio Arocena J. Non-bacterial chronic osteomyelitis: experience in a tertiary hospital. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.anpede.2015.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Hofmann SR, Kubasch AS, Range U, Laass MW, Morbach H, Girschick HJ, Hedrich CM. Serum biomarkers for the diagnosis and monitoring of chronic recurrent multifocal osteomyelitis (CRMO). Rheumatol Int 2016; 36:769-79. [DOI: 10.1007/s00296-016-3466-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2015] [Accepted: 03/12/2016] [Indexed: 11/29/2022]
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Hedrich CM. Shaping the spectrum - From autoinflammation to autoimmunity. Clin Immunol 2016; 165:21-8. [PMID: 26948930 DOI: 10.1016/j.clim.2016.03.002] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Revised: 03/02/2016] [Accepted: 03/02/2016] [Indexed: 12/15/2022]
Abstract
Historically, autoimmune-inflammatory disorders were subdivided into autoinflammatory vs. autoimmune diseases. About a decade ago, an immunological continuum was proposed, placing "classical" autoinflammatory disorders, characterized by systemic inflammation in the absence of high-titer autoantibodies or autoreactive T lymphocytes, at the one end, and autoimmune disorders at the other end. We provide an overview of recent developments and observations, filling in some of the gaps and showing strong interconnections between innate and adaptive immune mechanisms, indicating that disorders from both ends of the immunological spectrum indeed share key pathomechanisms. We focus on three exemplary disorders: i) systemic juvenile idiopathic arthritis representing "classical" autoinflammatory disorders; ii) psoriasis, a mixed pattern disease; and iii) systemic lupus erythematosus, a prototypical autoimmune disease. We summarize scientific observations suggesting that, depending on disease stages and/or duration, individualized treatment targeting innate or adaptive immune mechanisms in disorders from either end of the immunological spectrum may control disease activity.
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Affiliation(s)
- Christian M Hedrich
- Pediatric Rheumatology and Immunology Section, Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 74, 01307 Dresden, Germany.
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Hofmann SR, Kubasch AS, Ioannidis C, Rösen-Wolff A, Girschick HJ, Morbach H, Hedrich CM. Altered expression of IL-10 family cytokines in monocytes from CRMO patients result in enhanced IL-1β expression and release. Clin Immunol 2015; 161:300-7. [PMID: 26404542 DOI: 10.1016/j.clim.2015.09.013] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 09/16/2015] [Accepted: 09/19/2015] [Indexed: 02/08/2023]
Abstract
Chronic recurrent multifocal osteomyelitis (CRMO) is characterized by reduced activation of protein kinases ERK1 and 2 in monocytes resulting in impaired IL-10 expression. IL10 and its homologs IL19 and IL20 are organized in the IL10 cluster on chromosome 1q32. IL-10 and IL-19 are immune-regulatory cytokines, while IL-20 acts in a pro-inflammatory manner. The NLRP3 inflammasome, a multi-protein complex forming in response to innate stimuli, mediates IL-1β cleavage and release. Here, we investigated IL-10-related cytokine expression in CRMO monocytes, underlying molecular events, and effects on inflammatory responses. We observed reduced anti-inflammatory IL-10 and IL-19 expression, and enhanced IL-20 expression in CRMO monocytes. Reduced IL-10 and IL-19 expression was associated with impaired Sp-1 recruitment to regulatory regions, contributing to NLRP3 inflammasome activation, which may induce inflammatory bone-loss. Our findings underscore the importance of balanced receptor-, cell-, and tissue-specific cytokine expression for immune homeostasis, providing additional arguments for cytokine blocking strategies in CRMO.
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Affiliation(s)
- S R Hofmann
- Pediatric Rheumatology and Immunology, Children's Hospital, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - A S Kubasch
- Pediatric Rheumatology and Immunology, Children's Hospital, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - C Ioannidis
- Division of Rheumatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - A Rösen-Wolff
- Pediatric Rheumatology and Immunology, Children's Hospital, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - H J Girschick
- Vivantes Klinikum Friedrichshain, Children's Hospital, Berlin, Germany
| | - H Morbach
- Pediatric Rheumatology and Immunology, Children's Hospital, University of Würzburg, Würzburg, Germany
| | - C M Hedrich
- Pediatric Rheumatology and Immunology, Children's Hospital, Universitätsklinikum Carl Gustav Carus, TU Dresden, Dresden, Germany; Division of Rheumatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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Current understanding of the pathophysiology of systemic juvenile idiopathic arthritis (sJIA) and target-directed therapeutic approaches. Clin Immunol 2015; 159:72-83. [DOI: 10.1016/j.clim.2015.04.018] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 04/16/2015] [Accepted: 04/19/2015] [Indexed: 01/21/2023]
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Hedrich CM, Hofmann SR, Pablik J, Morbach H, Girschick HJ. Autoinflammatory bone disorders with special focus on chronic recurrent multifocal osteomyelitis (CRMO). Pediatr Rheumatol Online J 2013; 11:47. [PMID: 24359092 PMCID: PMC3881012 DOI: 10.1186/1546-0096-11-47] [Citation(s) in RCA: 111] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Accepted: 12/14/2013] [Indexed: 01/19/2023] Open
Abstract
Sterile bone inflammation is the hallmark of autoinflammatory bone disorders, including chronic nonbacterial osteomyelitis (CNO) with its most severe form chronic recurrent multifocal osteomyelitis (CRMO). Autoinflammatory osteopathies are the result of a dysregulated innate immune system, resulting in immune cell infiltration of the bone and subsequent osteoclast differentiation and activation. Interestingly, autoinflammatory bone disorders are associated with inflammation of the skin and/or the intestine. In several monogenic autoinflammatory bone disorders mutations in disease-causing genes have been reported. However, regardless of recent developments, the molecular pathogenesis of CNO/CRMO remains unclear.Here, we discuss the clinical presentation and molecular pathophysiology of human autoinflammatory osteopathies and animal models with special focus on CNO/CRMO. Treatment options in monogenic autoinflammatory bone disorders and CRMO will be illustrated.
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Affiliation(s)
- Christian M Hedrich
- Division of Pediatric Rheumatology and Immunology, Children's Hospital Dresden, University Medical Center Carl Gustav Carus, TU Dresden, Dresden, Germany.
| | - Sigrun R Hofmann
- Division of Pediatric Rheumatology and Immunology, Children’s Hospital Dresden, University Medical Center Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Jessica Pablik
- Division of Pathology, University Medical Center Carl Gustav Carus, TU Dresden, Dresden, Germany
| | - Henner Morbach
- Department of Pediatrics, University of Würzburg, Würzburg, Germany
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