Practice Based Learning: Chronic recurrent multifocal osteomyelitis – what is it and how is it treated?

Allison Rose

Presented by Allison Rose, MD PGY-2

Clinical Questions:

  • What is Chronic Recurrent Multifocal Osteomyelitis (CRMO)?
  • How does it present?
    • What are differences between CRMO and acute osteomyelitis?
    • How do I know this isn’t malignancy?
  • Is a biopsy necessary?
  • How is it managed?

Basic Info:

  • CNO (Chronic nonbacterial osteomyelitis)
    • Unifocal CNO
    • Multifocal CNO =? CRMO
    • SAPHO Syndrome (synovitis, acne, pustulosis, hyperostosis and osteitis) = adult version
  • Diagnosis of Exclusion:
    • Bacterial osteomyelitis (acute, subacute, chronic)
    • Malignancy (osteosarcoma, Ewing sarcoma, neuroblastoma, lymphoma, leukemia)
    • Benign bone tumor (osteoid osteoma, osteoblastoma)
    • Osteonecrosis

CRMO goes beyond bone:

  • Associate with dermatological skin findings (~30%)
    • Palmoplanta pustulosis
    • Psoriasis / psoriatic nail changes
    • Acne conglobata
  • Associated withIBD (~10%)
    • Crohn’s > Collitis
  • Associated with hypophosphatasia

CRMO Typical Findings / Presentation:

  • Bone pain that may be worse at night
    • May be unifocal or multifocal
  • Swelling of affected region
  • Arthritis
  • Skin findings
  • Inflammatory bowel disease
  • Mildly elevated ESR / CRP
  • Normal WBC

Conclusions from Beck, C. et al. (2010):

  • NSAIDs are currently first line therapy and in this cohort 62% were clinically free from lesions at 12 months of treatment.
  • ESR did correlate to radiographic lesions suggesting inflammation without clinical correlate
  • ESR may be used as a marker of disease progression but some pts with normal ESR throughout
  • All clinically significant lesions had radiographic findings
  • Are radiographic lesions that are clinical silent important? Probably. Pathologic fractures, growth changes
  • CHAQ is used with JIA – may not be as applicable to this population
  • Clinical/radiologic assessment at 6 months including WB-MRI to assess treatment effects, detect new lesions and progressive disease

Conclusions from Abril, JC. et al. (2007):

  • Indomethacin for anti-inflammatory and anti-ossification properties
  • “Complete remission” in 4 of 5 patients with normalization ofradiographs
    • Plain films vs MRI
    • Miniscule population

Final Summary:

  • CRMO is rare
  • Diagnosis of exclusion with clinical picture combined with radiographic data as main contributors to diagnosis
  • WB-MRI is first line imaging (over bone scan)
  • NSAIDs are first line treatment
  • Any concern for alternative diagnosis esp. malignancy, bone tumor, bacterial osteomyelitis should warrant biopsy. If treatment moving beyond NSAID, would consider biopsy.

References:

Abril JC, Ramirez A. Successful treatment of chronic recurrent multifocal osteomyelitis with indomethacin: a preliminary report of five cases. J Pediatr Orthop. 2007 Jul-Aug;27(5):587-91.

Beck C, Morbach H, Beer M, Stenzel M, Tappe D, Gattenlöhner S, Hofmann U, Raab P, Girschick HJ. Chronic nonbacterial osteomyelitis in childhood: prospective follow-up during the first year of anti-inflammatory treatment. Arthritis Res Ther. 2010;12(2):R74.

Ferguson PJ, Sandu M. Current understanding of the pathogenesis and management
of chronic recurrent multifocal osteomyelitis. Curr Rheumatol Rep. 2012 Apr;14(2):130-41.

Girschick HJ, Zimmer C, Klaus G, Darge K, Dick A, Morbach H. Chronic recurrent
multifocal osteomyelitis: what is it and how should it be treated? Nat Clin Pract Rheumatol. 2007 Dec;3(12):733-8.

Twilt M, Laxer RM. Clinical care of children with sterile bone inflammation. Curr Opin Rheumatol. 2011 Sep;23(5):424-31.

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