Working Diagnosis:
Chronic Recurrent Multifocal Osteomyelitis of left humerus

Treatment:
Following biopsy results, the patient had curettage and allograft packing of the lesion. He was then placed on naproxen twice a day for three months.

Outcome:
At the three month follow up, the patient had repeat imaging which revealed maturation of the previous periosteal reaction with no evidence of progression or new lesions of the proximal diaphysis of humerus. An MRI of his whole body was negative for any other skeletal lesions. He was pain free and was able to return to sport at that time.

Author's Comments:
Chronic recurrent multifocal osteomyelitis is a rare autoinflammatory bone disorder. It mostly affects children with an average age of 9 to 10 years old. Reported incidence is estimated to be 1 in 1,000,000. The median time between initial symptoms and diagnosis is two years. It usually presents as bone pain with or without fever and objective swelling at the site. Most patients are negative for constitutional symptoms. Osteolytic, sclerotic bone changes may be seen on radiographs, and MRI may demonstrate associated bone lesion, marrow edema, and periostitis. Laboratory studies are often normal, and a bone biopsy reveals sterile osteomyelitis. Whole body MRI is important in monitoring the disease. Initial treatment with NSAID's such as naproxen is considered first line therapy. Several second line options include corticosteroids, bisphosphonates, and DMARD's. Studies ahve shown a 40 percent remission rate, but a 50 percent recurrence rate after two years. Close follow up is needed with a pediatric rheumatologist.

Editor's Comments:
The goal of treatment is to decrease pain and allow for normal function of the affected area. Limiting damage to the underlying bone and maintaining growth potential should also be considered in choosing treatment options. As noted above, this can often be achieved with NSAID's or other medications. In this case, the surgeon took an aggressive approach with curettage and debridement of the area. Side effects to consider with this apprach include bone integrity issues as well as risk of infection.

References:
Hofmann SR, Kapplusch F, Girschick HJ, Morbach H, Pablik J, Ferguson PJ, Hedrich CM. Chronic Recurrent Multifocal Osteomyelitis (CRMO): Presentation, Pathogenesis, and Treatment. Curr Osteoporos Rep. 2017 Dec;15(6):542-554.

Zhao Y, Ferguson PJ. Chronic Nonbacterial Osteomyelitis and Chronic Recurrent Multifocal Osteomyelitis in Children. Pediatr Clin North Am. 2018 Aug;65(4):783-800.

Gicchino MF, Diplomatico M, Granato C, Capalbo D, Marzuillo P, Olivieri AN, Miraglia Del Giudice E. Chronic recurrent multifocal osteomyelitis: a case report. Ital J Pediatr. 2018 Feb 17;44(1):26.

Roderick MR, Sen ES, Ramanan AV. Chronic recurrent multifocal osteomyelitis in children and adults: current understanding and areas for development. Rheumatology (Oxford). 2018 Jan 1;57(1):41-48.

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