Summary: A previously healthy 7-year-old girl presented with 4 weeks of gradually
increasing back pain. An initial MRI of the thoracolumbar spine was
obtained (Figure 1). Two weeks later the patient presented with right
ankle pain. There was mild swelling of the right ankle and elevation of
the ESR to 40 mm/hr. Over the next 2 weeks, the patient’s symptoms
resolved completely and follow-up radiography and magnetic resonance
imaging (MRI) of the lower extremity was performed (Figure 2). She
remained asymptomatic until 15 months later, when she returned with a
low-grade fever and malaise. Mild swelling of the lower legs was
discovered on physical exam, and ESR was elevated at 61 mm/hr with
otherwise normal laboratory studies. MRI of the lower extremities was
obtained (Figure 3).
Chronic recurrent multifocal osteomyelitis
The sagittal T1 series of the thoracolumbar spine showed mild
superior end-plate compression of the T12 vertebral body with abnormal
marrow signal, initially presumed to be post-traumatic (Figure 1).
Plain film and coronal T1 (450/14) images of the right ankle
(Figure 2) demonstrated an osteolytic lesion in the right distal fibular
metaphysis. Coronal FSE IR (5400/63) showed a right proximal tibial
lesion (Figure 2). Given the concern for multifocal bacterial
osteomyelitis and malignancy, biopsy of the distal fibular metaphyseal
lesion was performed, revealing both acute and chronic osteomyelitis.
All bacterial and fungal cultures were negative. A bone marrow biopsy
concurrently performed at this time showed no findings of hematopoetic
malignancy. Conservative treatment was given, with the presumptive
diagnosis of chronic recurrent multifocal osteomyelitis.
Coronal FSE IR (5400/63) of the lower extremity, taken 15 months
later, showed new symmetric lesions in the distal tibial metaphyses, as
well as lesions in the left proximal tibial metaphysis (Figure 3). The
previously noted right proximal tibial metaphyseal lesion had resolved.
The patient was again treated conservatively with resolution of
Chronic recurrent multifocal osteomyelitis (CRMO) is an inflammatory
disease of bone that occurs primarily in children and adolescents.1
Though it generally has a benign, self-limited clinical course, its
variable clinical findings can often mimic more serious diseases such as
bacterial osteomyelitis and malignancy.2 Recognition of the imaging findings of this protean condition plays a crucial role in its diagnosis.
Symptoms may include low-grade fever and malaise, with local pain
and swelling of the affected bones, although this constellation of
findings is not consistently present.3,4 Laboratory findings
are relatively few and point to nonspecific inflammation, with elevation
of the erythrocyte sedimentation rate (ESR). Microbiologic cultures of
the blood are negative.5
The most characteristic features are recurrent episodes of active
disease followed by remission. Reactivation occurs either in previously
involved osseous locations or in different sites.1 The most common
locations are the metaphyses of long bones and clavicles. Less frequent
involvement is seen in the vertebrae and pelvis, while other locations
are uncommon.6 Symmetric lesions have been classically described, though this is an inconsistent finding.7
The radiographic findings appear similar to acute bacterial
osteomyelitis. Metaphyseal lesions are osteolytic, with a thin sclerotic
rim often seen in healing lesions.8 The degree of periosteal reaction can vary, as can the presence of soft tissue swelling.9 Bone scintigraphy is useful in identifying the presence of multifocal disease, which helps in making the correct diagnosis.
MR imaging is especially advantageous in detecting early disease
before radiographic findings are present. In addition to demonstrating
the characteristic findings of marrow edema, it is useful in excluding
stigmata associated with bacterial osteomyelitis such as soft tissue
abscesses, sinus tracts and sequestra.10
Though chronic recurrent multifocal osteomyelitis is a diagnosis of
exclusion, the clinical course, presence of multiple reactivating and
remitting lesions over time, and absence of positive microbiologic
results should suggest the diagnosis. As the disease is self-limiting,
knowledge of its characteristic appearance can prevent overly aggressive
medical and surgical evaluation and treatment.
- Jurriaans E, Singh NP, Finlay K, Friedman L. Imaging of chronic
recurrent multifocal osteomyelitis. Radiol Clin North Am.
- Chow LTC, Griffith Jf, Kumta SM, Leung PC. Chronic recurrent
multifocal osteomyelitis: A great clinical and radiologic mimic in need
of recognition by the pathologist. APMIS. 1999;107:369–379.
- Demharter J, Bohndorf K, Michl W, Vogt H. Chronic recurrent
multifocal osteomyelitis: A radiological and clinical investigation of
five cases. Skeletal Radiol. 1997;26:579–588.
- Gamble JG, Rinsky LA. Chronic recurrent multifocal osteomyelitis: A distinct clinical entity. J Pediatr Orthop. 1986;6:579–584, .
- Handrick W, Hörman D, Voppmann A, et al. Chronic recurrent multifocal osteomyelitis: Report of eight patients. Pediatr Surg Int. 1988;14:195–198, .
- Jurik AG. Chronic recurrent multifocal osteomyelitis. Semin Musculoskelet Radiol. 2004;8:243–253.
- Wiener MD, Newbold RG, Merten DF. Chronic recurrent multifocal osteomyelitis (case report). AJR Am J Roentgenol. 1986;147:87–88.
- Rosenberg ZS, Shankman S, Klein M,Lehman W. Chronic recurrent multifocal osteomyelitis. AJR Am J Roentgenol. 1988;151:142–44.
- Carr AJ, Cole WG, Roberton DM, Chow CW. Chronic multifocal osteomyelitis. J Bone Joint Surg Br. 1993;75:582–591.
- Jurik AG, Egund N. MRI in chronic recurrent multifocal osteomyelitis. Skeletal Radiol. 1997;26:230–238.