Chronic Recurrent Multifocal Osteomyelitis: Comparison of Whole-Body MR Imaging with Radiography and Correlation with Clinical and Laboratory Data

Fritz, Jan; Tzaribatchev, Nikolay; Claussen, Claus D.; Carrino, John A.; Horger, Marius

doi:10.1148/radiol.2523081335

Cited by 185 publications

(172 citation statements)

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“…Whole-body MRI is a useful modality for the evaluation of this disease; symmetric involvement is highly suggestive of this condition [40], which responds to antiinflammatory agents rather than antibiotics. Chronic osteomyelitis due to S. aureus should also be differentiated from disease caused by other organisms such as tuberculosis and Bartonella hensealae (cat-scratch disease) [41].…”

Section: Imaging Of Complicationsmentioning

confidence: 99%

Infection: musculoskeletal

Jaramillo

2011

Pediatr Radiol

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The imaging approach to osteomyelitis has evolved in the past two decades. Advances in MRI allow for whole body imaging, decreasing the need for scintigraphy when symptoms are not localized or the disease may be multifocal. There is an increasing clinical need for depiction of abscesses in the soft tissues and subperiosteal space, particularly because methicillin-resistant Staphylococcus aureus infections constitute more than one-third of all the infections. The increasing emphasis on radiation dose reduction has also led away from scintigraphy and computed tomography. MR imaging has become the advanced imaging modality of choice in osteomyelitis. There is an increasing understanding of the appropriate role for gadolinium enhancement, which is not indicated when the pre-gadolinium images are normal. Other related infections, including pyomyositis, are best imaged with MRI.Keywords Infection . Musculoskeletal . Children . MRI EpidemiologyAcute hematogenous osteomyelitis is the most common form of musculoskeletal infection [1]. Its incidence is difficult to determine, but it has been reported to be 1 per 5,000 [2]. There is conflicting data regarding the change of the disease over time. A study in 1998 found that the incidence in Norway ranged between 70 and 160 per million and that the incidence had remained stable between 1965 and 1994 [3]. An American study, however, found that in the last 20 years the incidence of osteomyelitis had increased 2.8-fold, whereas that of septic arthritis was stable. Methicillin-resistant Staphylococcus aureus (MRSA) was the causative organism in 30% of the children [4]. More than half of the cases occur before 5 years of age, and it appears to be more frequent in boys. Approximately 70% of infections involve the lower extremities and onethird affect the knee [2]. PathophysiologyHematogenous osteomyelitis results from the seeding of bacteria, usually Staphylococcus aureus (S. aureus) in the metaphysis of a long bone (Fig. 1) or in the metaphyseal equivalents of the axial skeleton (Fig. 2). S. aureus bacteria, which are present in the skin or mucosal membranes, enter the bloodstream and lodge in the bone, usually at sites where blood flow is abundant and slow. The metaphyses are richly vascularized and the valveless sinusoidal loops of the metaphyseal venules have sluggish flow and discontinuous endothelium which facilitates bacterial invasion. During childhood, the metaphyses that grow the fastest, such as those around the knee, are the most richly vascularized in order to produce new bone at a rapid rate. These rapidly growing metaphyses also tend to be affected more frequently by infection. S. aureus has the capacity to attach to the bony matrix and produce proteolytic enzymes that destroy the surrounding tissues, allowing the spread of the infection. From the bone, the infection extends through the porous metaphyseal cortex into the subperiosteal space. The periosteum in children is loosely attached to the bone and separates easily from it, creating a space that allows ...

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Section: Imaging Of Complicationsmentioning

confidence: 99%

Infection: musculoskeletal

Jaramillo

2011

Pediatr Radiol

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“…[1][2][3] It represents up to 2-5% of the cases of osteomyelitis, 2 with an approximate incidence of up to 4/1,000,000 individuals, 4 and average age of disease onset estimated between 8-11 years, predominantly in females (64-83%). 1,[4][5][6] Signs and symptoms include local inflammation with pain and edema, episodes of mild fever, which do not profoundly affect the general condition of the patient, and common asymptomatic lesions (17-56%). 1 Positive personal or family history of psoriasis, palmoplantar pustules, chronic inflammatory bowel disease or other autoimmune diseases are also common (up to 50% of cases).…”

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confidence: 99%

“…Histological findings are nonspecific and often similar to those found in septic osteomyelitis, but with no evidence of infection by any microorganism. 1,[2][3][4][5][6][7][8][9][10] Imaging tests such as radiography, CT, magnetic resonance imaging (MRI) and scintigraphy are some of the diagnostic tools. The latter two are most commonly used to rule out other diseases and to detect asymptomatic sites employing whole body screening techniques.…”

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confidence: 99%

“…The latter two are most commonly used to rule out other diseases and to detect asymptomatic sites employing whole body screening techniques. 1,[4][5][6]12 Long and tubular bones are preferentially affected, especially the lower limbs. 1,[4][5][6] In a study by von Kalle et al, the frequencies found for lesions by bone segment were: meta-epiphyseal (31%), metaphyseal (30%), epiphyseal (19%), meta-diaphyseal (10%), diaphyseal (1.8%), apophyseal (1.8%), and epimetadiaphyseal (1.4%).…”

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confidence: 99%

“…4 According to a study by Fritz et al, diaphyseal involvement can reach 14%. 6 A predilection for regions in the metaphysis next to the growth plate is noted, and there is symmetry in at least 25% of the lesions. 1,[4][5][6] The most common articular findings are joint effusion and synovitis, most often in the knees and ankles, often bilaterally, sometimes with affections in the sacroiliac joints.…”

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Chronic recurrent multifocal osteomyelitis exhibiting predominance of periosteal reaction

Queiroz¹,

Rocha²,

Lauar

et al. 2017

Rev. Assoc. Med. Bras.

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Chronic recurrent multifocal osteomyelitis is an idiopathic nonpyogenic autoinflammatory bone disorder involving multiple sites, with clinical progression persisting for more than 6 months and which may have episodes of remission and exacerbation in the long term. It represents up to 2-5% of the cases of osteomyelitis, with an approximate incidence of up to 4/1,000,000 individuals, and average age of disease onset estimated between 8-11 years, predominantly in females. The legs are the most affected, with a predilection for metaphyseal regions along the growth plate. We describe the case of a female patient, aged 2 years and 5 months, with involvement of the left ulna, right jaw and left tibia, showing a predominance of periosteal reaction as main finding.Keywords: osteomyelitis, chronic, multifocal, recurrent, periosteal.case report A female patient aged 2 years and 5 months, being investigated due to pain and swelling in the left forearm for one month. Her parents denied episodes of fever, trauma, and other comorbidities. On physical examination, the child presented normal weight, normal skin color, she was well-hydrated, acyanotic, breathing normally and in good general conditions. Blood counts analyzed in the previous month revealed mild leukocytosis and normocytic normochromic anemia. Levels of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were slightly elevated.Computed tomography (CT) of the left forearm without intravenous contrast revealed a periosteal reaction and a small area of loss of cortical compaction, especially in the ulna ( Figure 1A).A biopsy of the left ulna was performed with results describing signs suggestive of chronic osteomyelitis. Culture of the biopsy material did not show growth of microorganisms.Empirical antibiotic therapy was used starting one month after diagnosis, but there was no change in clinical status. A new biopsy was performed in the third month, showing the same findings associated with negative blood culture. Radiographs of the left forearm from the second to the fifth month showed progression of the multilamellar periosteal reaction to a solid type ( Figure 1B).Chest radiography, echocardiography, levels of TSH, T4, IgG, IgA, IgM and complement components were all normal. A hypothesis of chronic recurrent multifocal osteomyelitis (CRMO) was suggested and thus treated with ibuprofen combined with methotrexate, later replaced with sulfasalazine.Between the eighth and ninth month, pain and swelling appeared in the right mandibular region and in the left leg. A facial CT scan showed mainly periosteal reaction at the right mandibular angle with mild bone sclerosis (Figure 2). CT scan of the left leg also characterized a periosteal reaction in the tibial diaphysis with a small area of cortical alteration (Figure 3), similar to that found in the ulna.After 6 months of therapy, there was clinical and general laboratory improvement, with left forearm radiography in the 11 th month showing a regression of the periosteal reaction, despite persistence of corti...

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