Working Diagnosis:
Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis (SAPHO) Syndrome

Treatment:
Osteomyelitis and malignancy were ruled out with bone biopsy. A short course of antibiotics (Augmentin) was started while biopsy results were pending. Cultures growing P acnes were initially thought to be a contaminant. However cultures positive for P acnes have been noted in other cases of SAPHO Syndrome.

Since there were no available standardized treatment protocols, empiric treatment options include: NSAIDs, antibiotics (doxycycline), systemic steroids, biologics targeting TNF alpha and IL-1.

Outcome:
The patient improved with a short course of NSAIDs. No additional interventions were needed and the patient had no further activity restrictions.

Author's Comments:
SAPHO syndrome is a rare inflammatory disorder of bone, joints, and skin with a prevalence estimated to be 1 in 10,000. This was first described as SAPHO syndrome in 1987 by Chamot et. al. but also had previously been described as Chronic Recurrent Multifocal Osteomyelitis (CRMO). The pathogenesis is not well understood and there are no current validated diagnostic criteria. The bone and joint manifestations are the hallmark and occur with or without dermatologic findings. Any joint can be involved but the anterior chest wall involvement is seen in 65-90% of all cases, most frequently involving the sternoclavicular joints and sternocostal joints. Synovitis is usually a non-erosive inflammatory arthritis while osteitis is commonly seen in the cortex or medullary cavity. Hyperostosis with bony overgrowth is commonly seen as a late disease manifestation.

Editor's Comments:
Aside from the anterior chest wall, the sacroiliac joints and spine are two additional regions which are often documented as sites of SAPHO syndrome involvement. The osteitis present in SAPHO syndrome can involve multiple sites. Bone scintigraphy may help identify additional sites of involvement. Dermatologic findings are not always present and diagnosis should be considered with bone and/or joint involvement concerning for SAPHO syndrome.

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