Chronic Recurrent Multifocal Osteomyelitis

Dangerous Errors in the Diagnosis and Treatment of Bony Tuberculosis by Dr. med. Alexander Herzog in volume 36/20090

Herzog’s article is of particularly topical interest, as the author has drawn renewed attention to tuberculosis (TB), which over the past 50 years seems to have disappeared and has therefore been forgotten as a differential diagnosis (1). TB—including TB of the bone—is threatening to make a comeback and be included, as a pathomorphosis, in a confusing array of differential diagnoses, such as was shown in this case report of bony tuberculosis. The range of differential diagnoses should also include the generally little known “chronic recurrent multifocal (also monofocal) osteomyelitis” (CRMO) as an important possible diagnosis. However, this diagnosis is hampered by the erroneous interpretation of results. Consequently, the rare “primary chronic osteomyelitis” might remain unrecognized as a result of such an indirectly didactic approach.

CRMO does not manifest in sterile abscesses—which by definition do not actually exist—but in larger areas of sometimes “migrating” sterile inflammation of the bone, the localization being age dependent. These inflammations develop in three stages are and primarily lymphoplasmacellular, not “purulent”—that is, never granular leukocyte related. Magnetic resonance tomography and biopsy specimens usually provide unequivocal findings that morphologically depend on which stage of development the pathological process has reached. Further, the localization of the focus does not correspond to any of the 6 CRMO types, where none of the foci reside in the skullcap of CRMO patients. Corticosteroids are not indicated therapeutically.

A recently discovered common radiological feature may, however, erroneously link TB and CRMO in terms of the differential diagnosis: a potential paraosseous, especially paravertebral, inflammation of the soft tissues with a tendency to ossification, which may result in vertebral CRMO being mistaken for TB.

However, this specific differential diagnosis is not likely to be common. In our SAPHO/CRMO project in Mainz, there was only one case among 183 patients.
DOI: 10.3238/arztebl.2010.0148a

Prof. Dr. med. Fritz Schilling
Hebbelstr. 20
55127 Mainz, Germany

References

1. Herzog A: Case report: dangerous errors in the diagnosis and treatment of bony tuberculosis [Gefährliche Fehler in Diagnostik und Therapie einer Knochentuberkulose]. Dtsch Arztebl Int 2009; 106(36): 573–7.

2. Schilling F: Abschiedsvorlesung „CRMO“ , Univ.-Klinik Mainz 2003.