MRI Can Diagnose Chronic Recurrent Multifocal Osteomyelitis

Kate Johnson

June 13, 2012

June 13, 2012 (Berlin, Germany) — Despite its name, chronic recurrent multifocal osteomyelitis (CRMO) need not be multifocal, and is best investigated with whole-body magnetic resonance imaging (MRI), rather than computed tomography (CT), according to research reported here at the European League Against Rheumatism Congress 2012.

"CRMO must be considered in children with not only chronic multifocal osteomyelitis, but also in those with monofocal disease," said Agnes Ziobrowska Bech, MD, an intern at Aarhus University Hospital Skejby, in Denmark.

"Our study contributes to the discussion of the diagnostic criteria of CRMO. We did not find any substantial differences in the clinical presentation of monofocal and multifocal lesions, and the clinical presentation and the radiologic and histologic characteristics were comparable," she reported.

The retrospective study involved 31 children (19 girls and 12 boys) diagnosed with CRMO at Aarhus University Hospital Skejby from January 2001 to June 2011.

Mean age at disease onset was 10.3 years, and overall mean delay in diagnosis was 17.3 months. There were no differences in the clinical characteristics of these 2 groups, said Dr. Ziobrowska Bech.

In the cohort, 21 patients (67.7%) had 2 or more lesions and 10 (32.3%) had only 1 lesion; 22 patients had undergone bone biopsy. "Although histologic findings are nonspecific, a bone biopsy is often necessary to rule out bone tumor and infection; this is especially important in monofocal cases," she said.

Although 94% of the cohort eventually underwent diagnostic MRI (28% of these being whole-body MRI), the majority initially underwent other diagnostic procedures (87.1% x-rays, 67.7% scintigraphy, and 32% CT).

MRI and CT were more sensitive for detecting lesions than x-ray and scintigraphy. CT registered more sclerotic, hyperostotic, and lytic lesions, whereas MRI registered more edema, Dr. Ziobrowska Bech explained.

Nonskeletal inflammation was seen in 64.5% of patients (81% of patients with multifocal and 30% of those with monofocal lesions), she said.

All patients were treated with nonsteroidal anti-inflammatory drugs and 54.8% were treated with prednisone; both are considered first-line therapies.

In addition, patients with severe or refractory disease were treated with methotrexate (29.1%), pamidronate (9.7%), or remicade (3.2%).

MRI Should Be First-Line Investigation

CRMO is a diagnosis of exclusion. Dr. Ziobrowska Bech recommends that whole-body MRI be considered early in the process, because "it is a noninvasive investigation with no radiation hazard and it is very sensitive in detecting early subclinical lesions."

Session moderator Hermann Girschick, MD, PhD, said the study is a good reminder to clinicians not to rule out CRMO in the case of monofocal lesions. Dr. Girschick is director of the Klinik für Kinder- und Jugendmedizin in Berlin, Germany

It also underscores the value of whole-body MRI, he said. "It's more sensitive and has fewer side effects.... In Europe, MRI is used more frequently to diagnose CRMO. In the United States, CT or conventional radiographics are first-line; MRI would be third line," he said in an interview.

"Some leading pediatric radiologists in America who were trained in Europe are bringing the idea of MRI in children more and more, especially in the case of bone inflammation, but this is certainly a changing topic," said Dr. Girschick.

Dr. Ziobrowska-Bech and Dr. Girschick have disclosed no relevant financial relationships.

European League Against Rheumatism (EULAR) Congress 2012: Abstract OP0002. Presented June 6, 2012.

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