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When is CRMO NOT CRMO?

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A 3 year old girl presented with a limp and a hot, swollen ankle. X-Ray showed active osteomyelitis. ESR > 60 mm/hr, Hb 11.3 g/dl, WCC 7.9 × 109/L, Platelets 808 × 109/L. Intravenous antibiotics were commenced. One week later, the left ankle became swollen, X-Ray showed osteomyelitis. Bone scan showed several areas of increased uptake, right femoral neck, both knees, both ankles, and scapula. A presumptive diagnosis of chronic recurrent multifocal osteomyelitis was made. Management was with intravenous followed by oral antibiotics. Upon rheumatology review 4 months later, she had clinically improved, non-steroidal anti-inflammatory agents were advised, it was felt a bone biopsy was not indicated.

2 months later, she had developed episodic lower back pain, both day and night. She did not like walking and had lost weight. She was pale and had developed a kyphosis in L2–3 region with a scoliosis. Spinal X-Ray revealed multiple crush fractures with marked osteopenia. Repeat bloods showed Hb 7.0 g/dl, WCC 17 × 109/L and platelet count of 200 × 109/L. Blood film demonstrated multiple lymphoblasts. Bone marrow examination revealed common acute lymphoblastic leukaemia.

At presentation, chronic recurrent multifocal osteomyelitis may mimic acute osteomyelitis; however, definitive diagnosis is with a bone biopsy. Bone scans can be useful to identify additional foci of involvement that can be present concurrently or sequentially. One case report of CRMO following ALL has been documented [1]. This case illustrates a rare presentation of CRMO clinical symptomatology and radiological findings with an underlying diagnosis of ALL.

References

  1. 1.

    Abril JC, Castillo F, Loewinsonh AF, Rivas C, Bernacer M: Chronic recurrent multifocal osteomyelitis after acute lymphoblastic leukaemia. Int Orthop. 1994, 18 (2): 126-8. 10.1007/BF02484425.

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Correspondence to A McMahon.

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Open Access This article is published under license to BioMed Central Ltd. This is an Open Access article is distributed under the terms of the Creative Commons Attribution 2.0 International License (https://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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McMahon, A., Pilkington, C. When is CRMO NOT CRMO?. Pediatr Rheumatol 6, P190 (2008) doi:10.1186/1546-0096-6-S1-P190

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Keywords

  • Lower Back Pain
  • Femoral Neck
  • Osteomyelitis
  • Acute Lymphoblastic Leukaemia
  • Bone Biopsy