Complete resolution and remodeling of chronic recurrent multifocal osteomyelitis on MRI and radiographs
Chronic recurrent multifocal osteomyelitis (CRMO) is a rare condition thought to be under-diagnosed, with a true prevalence of more than the 1 in 10,000 estimated. It is a condition that is classically described as polyostotic with a relapsing and remitting course, preferentially affecting the metaphyses of tubular bones in the pediatric population. Lesions have characteristic appearances of cortical hyperostosis and mixed lytic/sclerotic medullary appearances radiographically, with active osteitis and periostitis best seen with fluid-sensitive sequences on magnetic resonance imaging (MRI). There are reports of lesions resolving on follow-up radiographs and MRI scans, but no supporting images. In particular, although the marrow appearances and degree of osteitis have been shown to improve on MRI, complete resolution and remodeling back to normal has never been demonstrated. We present a case of a lesion that has completely healed and remodeled back to normal appearances on both radiographs and MRI, and consider this the standard for the often loosely used terms “normalization” and “resolution”. We discuss the implications of this for our understanding of the natural history of CRMO, and how this adds weight to the condition being significantly under-diagnosed. It provides a “gold standard” to be aimed for when assessing treatments for CRMO, and the optimal outcomes that are possible. It also provides further insight into the potential of pediatric bone to recover and remodel when affected by inflammatory conditions.
KeywordsChronic recurrent multifocal osteomyelitis Magnetic resonance imaging MRI Radiographs Non-bacterial osteitis Resolution Remodeling
We would like to thank our colleagues at the Robert Jones and Agnes Hunt Orthopedic Hospital.
No funding received.
Compliance with ethical standards
Conflicts of interest
The authors declare that they have no conflicts of interest.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.
Informed consent was obtained from the patient and her legal guardians.
- 3.Giedion A, Holthusen W, Masel LF, Vischer D. Subacute and chronic “symmetrical” osteomyelitis. Ann Radiol (Paris). 1972;15(3):329–42.Google Scholar
- 4.Probst FP, Björksten B, Gustavson KH. Radiological aspect of chronic recurrent multifocal osteomyelitis. Ann Radiol (Paris). 1978;21(2–3):115–25.Google Scholar
- 29.Morbach H, Schneider P, Schwarz T, Hofmann C, Raab P, Neubauer H, et al. Comparison of magnetic resonance imaging and 99mTechnetium-labelled methylene diphosphonate bone scintigraphy in the initial assessment of chronic non-bacterial osteomyelitis of childhood and adolescents. Clin Exp Rheumatol. 2012;30(4):578–82.PubMedGoogle Scholar
- 34.Van Onna M, van Tubergen A, van der Heijde DM, Jurik AG, Landewé R. Bone marrow edema on magnetic resonance imaging (MRI) of the sacroiliac joints is associated with development of fatty lesions on MRI over a 1-year interval in patients with early inflammatory low back pain: a 2-year followup study. J Rheumatol 2014;41(6):1088–1094.CrossRefPubMedGoogle Scholar
- 40.Caffey J, Silverman WA. Infantile cortical hyperostosis. Preliminary report on a new syndrome. Am J Roentgenol. 1945;54:1–16.Google Scholar