Chronic Recurrent Multifocal Osteomyelitis: A Comprehensive Literature Review

Abstract

Chronic recurrent multifocal osteomyelitis (CRMO) is a non-infectious, inflammatory disorder of the bones. CRMO typically affects children, with a predisposition to females. Bone-related pain is often felt in the metaphysis of long bones, particularly of the lower extremities, but it can also target other sites at varied time intervals. Patients are likely to complain of tenderness and swelling that may cause considerable disability and adversely impact quality of life. There are three main pathophysiological mechanisms that have been hypothesized to drive CRMO including imbalanced cytokine expression, increased inflammasome activation, and enhanced osteoclast differentiation. Therapies have been based on targeting and suppressing these key players in CRMO patients. The first step in management involves pain control. Non-steroidal anti-inflammatory drugs should provide initial relief, albeit temporarily. It is imperative to initiate immunosuppressive medication that will help limit bone involvement and thereby prevent the development of fractures or leg-length discrepancies, for example. The purpose of this literature review is to study the pathophysiology of CRMO and carefully dissect the agents that have been previously employed in the management of CRMO patients. This could allow for the purposeful formulation of individualized care plans and improving the overall well-being of patients. The authors included a multitude of PubMed-indexed articles published from 2000 onwards in this review.

Chronic Nonbacterial Osteomyelitis in Inflammatory Bowel Disease

“…While the molecular pathophysiology remains partially understood, it is intriguingly linked to other auto-inflammatory conditions like inflammatory bowel disease (IBD), psoriasis, Wegener's disease, and SAPHO syndrome. Chronic nonbacterial osteomyelitis (CNO) may manifest several years before the symptoms of the associated disease, and the bone remodeling induced by CNO can lead to lasting disability [46,47].…”

“…For example, patients with IBD may experience extraintestinal symptoms like joint inflammation (arthritis), skin conditions (psoriasis), and eye inflammation (uveitis). Similarly, CNO can lead to musculoskeletal symptoms beyond bone inflammation [28,46,47]. Furthermore, patients presenting with both CNO and IBD often respond positively to immunosuppressive medications that help control inflammation.…”

“…Furthermore, patients presenting with both CNO and IBD often respond positively to immunosuppressive medications that help control inflammation. Medications such as corticosteroids, immunomodulators, and biologic factors are commonly used in the treatment of both conditions [46,52].…”

“…In many cases, patients have received antibiotic therapy before an official diagnosis of CNO is made. As the first-line treatment for CNO, NSAIDs are often utilized, with naproxen being the most chosen option [46,57]. NSAIDs can provide significant pain relief and reduce the number of bone lesions seen on MRI within as early as three months.…”