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Updated: Jun 13 2021

Chronic Recurrent Multifocal Osteomyelitis (CRMO)


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  • summary
    • Chronic Recurrent Multifocal Osteomyelitis (CRMO) is a condition characterized by idiopathic inflammatory disease of the skeleton that is associated with multiple sites of apparent osteomyelitis with negative cultures and no response to antibiotics. 
    • Diagnosis is one of exclusion and can be suspected with multiple eccentric metaphyseal lesions with sclerosis and new bone formation, with negative culture and pathology results.
    • Treatment is usually symptomatic treatment with NSAIDS and pamidronate.
  • Epidemiology
    • Incidence
      • incidence
        • 1 in 250,000
      • prevalence
        • 1 in 160,000
    • Demographics
      • age
        • primarily occurs in children/adolescents
        • peak age of onset is 10 years old
      • male: female ratio
        • girls more common than boys
    • Location
      • the tubular long bones and clavicle are most frequently affected
  • Etiology
    • Pathophysiology
      • poorly understood
    • Criteria 
      • multiple sites of apparent osteomyelitis
      • pathology and cultures are negative
      • no response to antibiotics
    • Associated conditions
      • Pustulosis palmoplantaris syndrome
        • a rare chronic relapsing condition causing red patches and pustules on the soles of the feet and palms of the hands
        • considered a rheumatologic condition and no infectious agents have been identified
        • following the outbreak of the lesions, desquamation occurs several days later
        • associated with CRMO
      • SAPHO Syndrome
        • CRMO associated with: synovitis, acne, pustulosis, hypersotosis, osteitis
  • Presentation
    • Symptoms
      • episodic fever
      • malaise
      • localized pain, swelling
    • Physical exam
      • focal tenderness in region of involvement
  • Imaging
    • Plain radiography
      • findings
        • eccentric lytic metaphyseal lesions with surrounding sclerosis and new bone formation
    • Bone scan
      • indications
        • Can help determine other sites of disease
    • MRI
      • indications
        • If concerned for malignancy, MRI can help determine presence or absence of soft tissue involvement
  • Studies
    • Laboratory values
      • WBC typically normal
      • ESR and CRP may be elevated
    • Biopsy
      • biopsy and bone cultures negative
      • important to establish diagnosis which is one of exclusion
  • Treatment
    • Nonoperative
      • symptomatic treatment with NSAIDS and pamidronate
        • indications
          • treat during exacerbations
        • medications
          • NSAIDs
          • corticosteroids
          • pamidronate can provide symptomatic improvement and stimulate vertebral remodeling
  • Complications
    • Growth disturbance
      • rare but may occur
  • Prognosis
    • Natural history
      • characterized by periods of remission and exacerbation
      • typically resolves in 3-5 years
    • Prognosis
      • traditionally thought as having a relatively benign sequelae
      • several case reports of growth disturbance have been reported.
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