Presentation
Left thigh pain and swelling.
Patient Data
Left femoral shaft diaphyseal intramedullary sclerosis of persistent dark signal with surrounding marrow edema signal. Cortical thickening with periosteal reaction is noted.
Right femoral lower shaft small intramedullary marrow edema signal.
DWI sequence is marked degraded.
Left femoral mid-shaft intramedullary sclerosis with overlying cortical thickneing and subtle periosteal reaction.
Similar changes are seen at both mid-tibial shafts (more on the right) as well as the left fibula showing intramedullary marrow edema signal with mild overlying cortical thickening and periosteal reaction.
Left ulnar intramedullary edema signal with cortical thickening and periosteal reaction, associated with surrounding periosseous soft tissue edema signal.
5 months before MRI thighs
Multifocal increased tracer uptake in the right lower humerus, right forearm (radius and ulna), and both tibial shafts (more on the left) as well as the left calcaneus.
Case Discussion
The patient had a long history of recurrent osteomyelitis mainly of both legs, he had undergone multiple surgeries, negative culture on biopsy specimens (aseptic osteomyelitis), and prolonged antibiotic therapy at outside hospitals with no improvement.
The histopathologic, clinical, and culture findings were compatible with chronic recurrent multifocal osteomyelitis (CRMO).
CRMO occurs mainly in childhood, the commonest age of presentation ranges between 9 and 14 years.
The cause of CRMO is still unknown. Initial reports suggested an infectious origin, however, more extensive studies have shown no common infectious agent responsible for CRMO, our case had negative cultures on repeated biopsy specimens. CRMO is associated with skin lesions including palmoplantar pustulosis, psoriasis vulgaris, Sweet syndrome, pyoderma gangrenosum, and inflammatory bowel disease suggesting an autoimmune etiology.
Common sites of skeletal involvement include the long tubular bones (mainly the tibia) and also the clavicles, but, other sites which could be involved include the spine, pelvis, sacroiliac joint, ribs, sternum, scapula, mandible, hands, and feet.
The most common sites of disease are the metaphyses or metaphyseal equivalents.
Bone scintigraphy showed uptake in these lesions.
MR findings include marrow edema during the active phase. Associated periostitis, soft-tissue inflammation, and transphyseal disease.