Dr Jerin K John, Dr Suma Balan (Paediatric Rheumatology), Dr C Jayakumar
Ten -year-old boy presented with pain over the sternum for the last 3 months, following that he developed lower back ache and pain over hips. Pain was dull, non-radiating, more at night and decreased on taking acetaminophen.
Auxology Normal General and physical examination was normal .He had no extraosseous comorbidities such as psoriasis or inflammatory bowel disease.
Labs Tc:12 K/UL, N:55%, L:33%, PLT:565K/UL, CRP:8.9 mg/L.
ESR 53 mm/hr. Serum levels of electrolytes, CK, creatinine, transaminases and urinalysis were within normal limits.
Differential diagnosis
– Osteomyelitis
– Pauciarticular Rheumatoid arthritis
Leukaemia,
osteoporosis,
Vitamin D deficiency,
eosinophilic granuloma
Whole body MRI showed foci of bone oedema and enhancement with periosteal reaction in the roof of right acetabulum, posterior column of left acetabulum, left femur neck, S2, S3, S4 and D7 vertebral bodies.
He was started on an anti-inflammatory (Naproxon) which showed a good response. As there was vertebral involvement Pamidronate was given.
Discussion
● Chronic nonbacterial osteomyelitis (CNO)/chronic recurrent multifocal osteomyelitis (CRMO) is a chronic inflammatory bone disorder primarily affecting children. Both terms are used, although CRMO is often perceived as the more severe form, and CNO is the general term for the condition. CRMO has been reported worldwide with female predominance. It is a rare disease, but a lack of awareness of the condition has contributed to underdiagnosis and reporting. The exact pathogenesis is unknown. Both genetic and environmental factors are thought to contribute.
● Clinical manifestation – The cardinal feature of CRMO is bone pain of insidious onset as in our case
CRMO is also associated with other conditions such as psoriasis, palmoplantar pustulosis (PPP), inflammatory bowel disease (IBD), and spondyloarthropathy.
● Investigations: testing – The diagnosis of suspected CNO/CRMO involves obtaining laboratory studiesCBC
ESR
Imaging;
bone biopsy.
Whole-body magnetic resonance imaging (WBMRI) is the gold-standard imaging modality for diagnostic and staging purposes.
Carry home message
CRMO is an eminently treatable condition and all invasive procedures could be postponed if we want clinical diagnosis supported non invasive investigations
In some the prognosis is good
Some others may need prolonged medications and physical therapy
