Disclosures: Sharon R. Ong, MD: No financial relationships or conflicts of interest

Case Diagnosis: Chronic Recurrent Multifocal Osteomyelitis (CRMO)

Case Description: A previously healthy 5 year old boy with no inciting event presented to his pediatrician for acute inability to bear weight on his lower extremities for three weeks. He had pain at the bottom of his feet and refused to walk. Motrin provided relief, but he continued to be non-weight bearing. He was referred to orthopedic surgery where no abnormalities were found on imaging. He was subsequently referred to the emergency department as his pain had progressed. Based on further lab/imaging, patient was diagnosed with Crohn’s and CRMO. Within a week of IV steroids and infliximab treatments, he was medically cleared for inpatient rehabilitation.

Setting: Inpatient rehabilitationAssessment/

Results: X-rays of bilateral hips/knees were unremarkable. MRI of lumbar spine and bilateral lower extremities showed periosteal reaction. Labs were notable for WBC 17.6, elevated ESR and CRP. Fecal calprotectin elevated. Serum cobalamin was also high, >2000. Bone marrow aspirate showed hypercellular but nonmalignant bone marrow with lineages intact. Whole-body MRI showed signal abnormality in the intertrochanteric femurs and proximal left tibia epiphysis and metaphysis with periosteal edema, suggestive of non-chronic, non-infectious osteomyelitis. MRI also noted mild thickening, edema with restricted diffusion of the ascending colon, compatible with colitis. EGD/colonoscopy confirmed diagnosis of Crohn’s disease.

Discussion: CRMO is a rare inflammatory disease that presents with similar findings to other more common diseases/conditions. This condition is often misdiagnosed early in its course, delaying proper treatment. It is often associated with autoimmune disorders, including irritable bowel syndrome, and can precede gastrointestinal symptoms by up to 5 years. Early diagnosis not only allows timely treatment with steroids/biologics, but can also detect other autoimmune conditions that have not yet become symptomatic.

Conclusion: CRMO is difficult to diagnose given its overlapping symptoms with other conditions. Proper diagnosis allows timely treatment and management of the condition.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/chronic-recurrent-multifocal-osteomyelitis/