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.


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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