Abstract
Chronic recurrent multifocal osteomyelitis (CRMO), also known as chronic non-bacterial osteomyelitis (CNO), is a rare inflammatory disorder that primarily affects children. It is characterized by pain, local bone expansion, and radiological findings suggestive of osteomyelitis, usually at multiple sites. CRMO predominantly affects the metaphyses of long bones, but involvement of the clavicle or mandible are suggestive of the diagnosis. CRMO is a diagnosis of exclusion, and its pathogenesis remains unknown. Differential diagnosis includes infection, malignancies, benign bone tumors, metabolic disorders, and other autoinflammatory disorders. Biopsy of the bone lesion is not often required but could be necessary in unclear cases, especially for differentiation from bone neoplasia. Non-steroidal anti-inflammatory drugs (NSAIDs) are the first-line treatment. Alternative therapies have been used, including corticosteroids, methotrexate, bisphosphonates, and tumor necrosis factor (TNF)-α inhibitors. No guidelines have been established regarding diagnosis and treatment options. This manuscript gives an overview of the most recent findings on the pathogenesis of CRMO and clinical approaches for patients with the condition.
Similar content being viewed by others
References
Majeed HA, Kalaawi M, Mohanty D, Teebi AS, Tunjekar MF, Al-Gharbawy F, et al. Congenital dyserythropoietic anemia and chronic recurrent multifocal osteomyelitis in three related children and the association with Sweet syndrome in two siblings. J Pediatr. 1989;115:730–4.
Giedion A, Holthusen W, Masel LF, Vischer D. Subacute and chronic “symmetrical” osteomyelitis. Ann Radiol (Paris). 1972;15:329–42.
Bjorksten B, Boquist L. Histopathological aspects of chronic recurrent multifocal osteomyelitis. J Bone Jt Surg Br. 1980;62:376–80.
Stern SM, Ferguson PJ. Autoinflammatory bone diseases. Rheum Dis Clin North Am. 2013;39:735–49.
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;36:1737–45.
Gamble JG, Rinsky LA. Chronic recurrent multifocal osteomyelitis: a distinct clinical entity. J Pediatr Orthop. 1986;6:579–84.
Scianaro R, Insalaco A, Bracci Laudiero L, De Vito R, Pezzullo M, Teti A, et al. Deregulation of the IL-1β axis in chronic recurrent multifocal osteomyelitis. Pediatr Rheumatol Online J. 2014;17(12):30.
Hofmann SR, Kubasch AS, Ioannidis C, Rosen-Wolff A, Girschick HJ, Morbach H, et al. 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.
Papadaki ME, Lietman SA, Levine MA, Olsen BR, Kaban LB, Reichenberge EJ. Cherubism: best clinical practice. Orphanet J Rare Dis. 2012;7(suppl 1):S6.
Whyte MP. Physiological role of alkaline phosphatase explored in hypophosphatasia. Ann NY Acad Sci. 2010;1192:190–200.
Castori M, Sinibaldi L, Mingarelli R, Lachman RS, Rimoin DL, Dallapiccola B. Pachydermoperiostosis: an update. Clin Genet. 2005;68:6477–86.
Smith EJ, Allantaz F, Bennett L, Zhang D, Gao X, Wood G, et al. Clinical, molecular, and genetic characteristics of PAPA syndrome: a review. Curr Genomics. 2010;11:519–27.
Aksentijevich I, Masters SL, Ferguson PJ, Dancey P, Frenkel J, van Royen-Kerkhoff A, et al. N Engl J Med. 2009;360:2426–37.
Golla A, Jansson A, Ramser J, Hellebrand H, Zahn R, Meitinger T, et al. Chronic recurrent multifocal osteomyelitis (CRMO): evidence for a susceptibility gene located on chromosome 18q21.3-18q22. Eur J Hum Genet. 2002;10:217–21.
Wipff J, Costantino F, Lemelle I, Pajot C, Duquesne A, Lorrot M, et al. A large national cohort of French patients with chronic recurrent multifocal osteitis. Arthritis Rheumatol. 2015;67:1128–37.
Ben Becher S, Essaddam H, Nahali N, Ben Hamadi F, Mouelhi MH, Hammou A, et al. Recurrent multifocal periostosis in children. Report of a familial form. Ann Pediatr (Paris). 1991;38:345–9.
Bousvaros A, Marcon M, Treem W, Waters P, Issenman R, Couper R, et al. Chronic recurrent multifocal osteomyelitis associated with chronic inflammatory bowel disease in children. Dig Dis Sci. 1999;44:2500–7.
Hamel J, Paul D, Gahr M, Hedrich CM. Pilot study: possible association of IL10 promoter polymorphisms with CRMO. Rheumatol Int. 2012;32:555–6.
Hofmann SR, Morbach H, Schwarz T, Rösen-Wolff A, Girschick HJ, Hedrich CM. Attenuated TLR4/MAPK signaling in monocytes from patients with CRMO results in impaired IL-10 expression. Clin Immunol. 2012;145:69–76.
Ferguson PJ, Bing X, Vasef MA, Ochoa LA, Mahgoub A, Waldschmidt TJ, et al. A missense mutation in pstpip2 is associated with the murine autoinflammatory disorder chronic multifocal osteomyelitis. Bone. 2006;38:41–7.
Grosse J, Chitu V, Marquardt A, Hanke P, Schmittwolf C, Zeitlmann L, et al. Mutation of mouse Mayp/Pstpip2 causes a macrophage autoinflammatory disease. Blood. 2006;107:3350–8.
Beck C, Girschick HJ, Morbach H, Schwarz T, Yimam T, Frenkel J, et al. Mutation screening of the IL-1 receptor antagonist gene in chronic non-bacterial osteomyelitis of childhood and adolescence. Clin Exp Rheumatol. 2011;29:1040–3.
Huber AM, Lam PY, Duffy CM, Yeung RS, Ditchfield M, Laxer D, et al. Chronic recurrent multifocal osteomyelitis: clinical outcomes after more than five years of follow-up. J Pediatr. 2002;141:198–203.
Jansson A, Renner ED, Ramser J, Mayer A, Habad M, Meindl A, et al. Classification of non-bacterial osteitis: retrospective study of clinical, immunological and genetic aspects in 89 patients. Rheumatology (Oxford). 2007;46:154–60.
Beretta-Piccoli BC, Sauvain MJ, Gal I, Schibler A, Saurenmann T, Kressebuch H, et al. Synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome in childhood: a report of ten cases and review of the literature. Eur J Pediatr. 2000;159:594–601.
Prose NS, Fahrner LJ, Miller CR, Lay-field L. Pustulas psoriasis with chronic recurrent multifocal osteomyelitis and spontaneous fractures. J Am Acad Dermatol. 1994;31:376–9.
Bjorksten B, Gustavson KH, Ericksson B, Lindholm A, Nordstrom S. Chronic recurrent multifocal osteomyelitis and pustulosis palmoplantaris. J Pediatr. 1978;93:227–31.
Jurik AG, Helmig O, Ternowitz T, Moller BN. Chronic recurrent multifocal osteomyelitis: a follow-up study. J Pediatr Orthop. 1988;8:49–58.
Andersson R. Effective treatment with interferon-α in chronic recurrent multi-focal osteomyelitis. J Interferon Cytokine Res. 1995;15:837–8.
Catalano-Pons C. Clinical outcome in children with chronic recurrent multifocal osteomyelitis. Rheumatology (Oxford). 2008;47:1397–9.
Wipff J, Adamsbaum C, Kahan A, Job-Deslandre C. Chronic recurrent multifocal osteomyelitis. Jt Bone Spine. 2011;78:555–60.
Guérin-Pfyffer S, Guillaume-Czitrom S, Tammam S, Koné-Paut I. Evaluation of chronic recurrent multifocal osteitis in children by whole-body magnetic resonance imaging. Jt Bone Spine. 2012;79:616–20.
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.
Jansson AF, Müller TH, Gliera L, Ankerst DP, Wintergest U, Belohradsky BH, et al. Clinical score for nonbacterial osteitis in children and adults. Arthritis Rheum. 2009;60:1152–9.
Hofmann SR, Kubasch AS, Range U, Laass MW, Morbach H, Girschick HJ, et al. Serum biomarkers for the diagnosis and monitoring of chronic recurrent multifocal osteomyelitis (CRMO). Rheumatol Int. 2016;36:769–79.
Handrick W, Hörmann D, Voppmann A, Schille R, Reichardt P, Tröbs RB, et al. Chronic recurrent multifocal osteomyelitis–report of eight patients. Pediatr Surg Int. 1998;14:195–8.
Pastore S, Ferrara G, Monasta L, Meini A, Cattalini M, Martino S, et al. Chronic nonbacterial osteomyelitis may be associated with renal disease and bisphosphonates are a good option for the majority of patients. Acta Paediatr. 2016;105:e328–33.
Job-Deslandre C, Krebs S, Kahan A. Chronic recurrent multifocal osteomyelitis: five-year outcomes in 14 pediatric cases. Jt Bone Spine. 2001;68:245–51.
Abril JC, Ramirez A. Successful of treatment of Chronic Recurrent Multifocal Osteomyelitis with indomethacin. J Ped Orthop. 2007;27:587–91.
Beck C, Morbach H, Beer M, Stenzel M, Tappe D, Gattenlöhner S, et al. Chronic nonbacterial osteomyelitis in childhood: prospective follow-up during the first year of anti-inflammatory treatment. Arthritis Res Ther. 2010;12:R74.
Van der Velden VH. Glucocorticoids: mechanism of action and anti-inflammatory potential in asthma. Mediators Inflamm. 1998;7:229–37.
Ishikawa-Nakayama K, Sugiyama E, Sawazaki S, Taki H, Kobayashi M, Koizumi F, et al. Chronic recurrent multifocal osteomyelitis showing marked improvement with corticosteroid treatment. J Rheumatol. 2000;27:1318–9.
Kaiser D, Bolt I, Hofer M, Relly C, Berthet G, Bolz D, et al. Chronic nonbacterial osteomyelitis in children: a retrospective multicenter study. Pediatr Rheumatol Online J. 2015;13:25.
Borzutzky A, Stern S, Reiff A, Zurakowski D, Steinberg EA, Dedeoglu F, et al. Pediatric Chronic nonbacterial osteomyelitis. Pediatrics. 2012;130:e1190–7.
Iannitti T, Rosini S, Lodi D, Frediani B, Rottigni V, Palmieri B. Bisphosphonates: focus on Inflammation and Bone Loss. Am J Ther. 2012;19:228–46.
Coinde E, David L, Cottalorda J, Allard D, Bost M, Lucht F, et al. Chronic recurrent multifocal osteomyelitis in children: report of 17 cases. Arch Pediatr. 2001;8:577–83.
Simm PJ, Allen RC, Zacharin MR. Bisphosphonate treatment in chronic recurrent multifocal osteomyelitis. J Pediatr. 2008;152:571–5.
Miettunen PM, Wei X, Kaura D, Reslan WA, Aguirre AN, Kellner JD. Dramatic pain relief and resolution of bone inflammation following pamidronate in 9 pediatric patients with persistent chronic recurrent multifocal osteomyelitis (CRMO). Pediatr Rheumatol Online J. 2009;7:2.
Hospach T, Langendoerfer M, von Kalle T, Maier J, Dannecker GE. Spinal involvement in chronic recurrent multifocal osteomyelitis (CRMO) in childhood and effect of pamidronate. Eur J Pediatr. 2010;169:1105–11.
Compeyrot-Lacassagne S, Rosenberg AM, Babyn P, Laxer RM. Pamidronate treatment of chronic noninfectious inflammatory lesions of the mandible in children. J Rheumatol. 2007;34:1585–9.
De Cunto A, Maschio M, Lepore L, Zennaro F. A case of chronic recurrent multifocal osteomyelitis successfully treated with neridronate. J Pediatr. 2009;154:154–5.
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;43:1956–64.
Zhao B, Grimes SN, Li S, Hu X, Ivashkiv LB. TNF-induced osteoclastogenesis and inflammatory bone resorption are inhibited by transcription factor RBP-J. J Exp Med. 2012;209:319–34.
Deutschmann A, Mache CJ, Bodo K, Zebedin D, Ring E. Successful treatment of chronic recurrent multifocal osteomyelitis with tumor necrosis factor-alpha blockage. Pediatrics. 2005;116:1231–3.
Eisenstein EM, Syverson GD, Vora SS, Williams CB. Combination therapy with methotrexate and etanercept for refractory chronic recurrent multifocal osteomyelitis. J Rheumatol. 2011;38:782–3.
Barral Mena 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. An Pediatr (Barc). 2016;85:18–25.
Ferguson PJ, Laxer RM. New discoveries in CRMO: IL-1β, the neutrophil, and the microbiome implicated in disease pathogenesis in Pstpip2-deficient mice. Semin Immunopathol. 2015;37:407–12.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflicts of interest
Andrea Taddio, Floriana Zennaro, Serena Pastore, and Rolando Cimaz have no conflicts of interest.
Funding
No sources of funding were used to conduct this study or prepare this manuscript.
Rights and permissions
About this article
Cite this article
Taddio, A., Zennaro, F., Pastore, S. et al. An Update on the Pathogenesis and Treatment of Chronic Recurrent Multifocal Osteomyelitis in Children. Pediatr Drugs 19, 165–172 (2017). https://doi.org/10.1007/s40272-017-0226-4
Published:
Issue Date:
DOI: https://doi.org/10.1007/s40272-017-0226-4