Chronic recurrent osteomyelitis: A diagnostic and therapeutic challenge | Revista Española de Cirugía Ortopédica y Traumatología (English Edition)

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Rivas Felice, P. González Herranz, A. Mejía Casado, R. Pérez Navarro, R. Hernández Díaz" "autores" => array:5 [ 0 => array:4 [ "nombre" => "J." "apellidos" => "Rivas Felice" "email" => array:2 [ 0 => "jesusrivas_felice@hotmail.com" 1 => "jesusrivasf@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "P." "apellidos" => "González Herranz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "A." "apellidos" => "Mejía Casado" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "R." "apellidos" => "Pérez Navarro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "R." "apellidos" => "Hernández Díaz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Cirugía Ortopédica y Traumatología, Hospital General de La Palma, Breña Alta, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Ortopedia Infantil, Hospital Teresa Herrera, A Coruña, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Cirugía Ortopédica y Traumatología, Hospital Royo Villanova, Zaragoza, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Osteomielitis crónica recurrente: un reto diagnóstico y terapéutico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1024 "Ancho" => 1400 "Tamanyo" => 120324 ] ] "descripcion" => array:1 [ "en" => "Patient 1. Lytic lesion in axial and sagittal slices of MRI and CT scans of the lumbar spine. (A) MRI, note the oedema in L1. (B) CAT, note the lesion occupying 30% of L1." ] ] ] "textoCompleto" => "IntroductionChronic recurrent osteomyelitis (CRO) is a rare clinical entity characterised by the presence of aseptic inflammatory foci in one (chronic recurrent unifocal osteomyelitis) or several bones (chronic recurrent multifocal osteomyelitis) which principally affects the long bone metaphysis and is considered the most severe form of non-bacterial bone inflammation in infancy and adolescence.Although this disease has been known for more than 40 years, its pathogenesis has not been at all clarified. Currently the most accepted hypothesis is that it is a hereditary dysfunction of the immune system.Diagnosis poses a real challenge because imaging techniques show non-specific lesions which suggest multiple diagnostic possibilities and furthermore, most analytical tests (acute phase reactants, serology and microbiological cultures) return negative.The aim of the study is to present a case series of patients with chronic recurrent osteomyelitis, both unifocal and multifocal, treated in our unit to assess their clinical features and response to treatment with NSAIDs, and also present a review of the current references.Patients and methodsBetween the years 2007 and 2015, 5 patients were diagnosed and treated in our hospital for non-bacterial osteomyelitis, reviewed retrospectively and classified into 2 groups. The first group comprised patients diagnosed with chronic recurrent unifocal osteomyelitis (CRUO) and the second comprised patients with chronic recurrent multifocal osteomyelitis (CRMO), there were 4 male patients and one female patient, aged between 11 and 15 years.The patients had been referred to our centre with high initial clinical suspicion of neoplastic disease with bone involvement. The diagnosis of CRO was made after excluding other diseases such as infectious osteomyelitis, hypophosphatasia, histiocytosis, leukaemia, lymphoma, osteosarcoma, etc.All the patients were assessed by means of laboratory tests: blood count, acute phase reactants, rheumatoid factor, hepatitis A and B serology, Salmonella typhi, Brucella, cytomegalovirus, HIV, Epstein–Barr virus, rubeola, Toxoplasma gondii, Treponema pallidum, Mycoplasma pneumoniae, Legionella, Chlamydia pneumoniae, Borrellia, varicella zoster.The imaging tests performed were: plain X-rays, computerised axial tomography (CAT), magnetic nuclear resonance (MRI), bone gammagraphy and positron emission tomography (PET-CT) to assess the lesions causing these patients’ symptoms. Bone biopsies were also taken for anatomopathological and microbiological study.Once diagnosis had been confirmed, the patients were treated with NSAIDs (naproxen and ibuprofen), the patients were followed -up for a mean of 5.9 years during which time the response to treatment and rate of recurrence were monitored. Both clinical and radiographic improvement represented by a diminution or disappearance of pain and improved bone lesions was considered a favourable response.The Mann–Whitney U test was used for the statistical analysis to assess the clinical differences between the patients with CRMO and those with CRUO.ResultsFour of the 5 patients in the series were male and there was one female, 3 of the patients had been diagnosed with CRUO and 2 with CRMO, the mean age of the onset of symptoms was 12 (r: 10–13 years) with a mean diagnostic delay of 9.4 months (r: 2–24 month), and a mean age at time of diagnosis of 13 years (r: 11–15 years). A total of 11 bones were affected with a mean of 2 bones per patient (r: 1–4 bones); the most frequently affected bones were the clavicle and the tibia in 2 cases (18.2%), followed by the distal radius, fibula, sternum, calcaneus, the lumbar vertebrae (L1), and pelvis; the ribs were affected on one occasion (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The most common symptom in the 5 patients in terms of clinical presentation was local pain which presented in all cases. Arthritis was also present in one patient adjacent to the affected bone observed with a lesion in the proximal tibia and ipsilateral knee inflammation, and also one patient presented fever (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).Various imaging tests were used for diagnosis including plain X-ray, CAT and MRI which showed lytic bone lesions with areas of sclerosis in 5/5 (100%) of the patients which suggested a neoplastic process to be evaluated. Gammagraphy was positive in the 3/4 patients on whom it was performed (75%) however; in the case where the gammagraphy was negative when the PET-CT scan was performed it reported an increase in metabolic activity in the first lumbar vertebra, and xiphoid process (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia>The laboratory tests showed the following mean results: haemoglobin 12.94g/dl (r: 11.8–14g/dl), haematocrit 38.25% (r: 35.3–41.6%) mean corpuscular volume 80.2 (r: 77.7–82.9fL); the serology was also negative, no change was observed in C-reactive protein, however, globular sedimentation velocity (GSV) levels were elevated to 46mm/h and 28mm/h in 2 patients respectively, the first with CRMO and the second with CRUO during the active period of the disease, the mean of the group assessed was 20.94mm/h. No significant differences were observed between the groups (CRUO and CRMO) in elevated GSV levels (Z=−0.57, p>0.05, Mann–Whitney U test) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The lesions of the 5 patients in the series were biopsied in order to take cultures which were negative in 4 of the 5 cases, and positive in the female patient with chronic recurrent unifocal osteomyelitis in whom a few colonies were isolated of Propionibacterium acnes (P. acnes). Similarly, histopathological analysis showed inflammation characterised by interstitial infiltrates of mononuclear cells with a predominance of plasma cells and the presence of abundant lymphocytes, and accompanying fibrosis and remodelling of the bone trabeculae in all of the cases.On two occasions a subperisoteal resection of the lesions of 12cm and 14cm was performed on one of the patients with involvement of the tibia; the defect was reconstructed by bone transport surgery before the diagnosis of CRO had been reached. Despite these broad resections the lesion recurred on both occasions.Empirical antibiotic therapy was started in 3 of the 5 cases studied before a diagnosis of CRO had been made (2 had CRUO and one had CRMO); once the diagnosis had been established all the patients were treated with nonsteroidal anti-inflammatory drugs. Four out of the 5 (3 with CRUO and one with CRMO) patients received naproxen 15mg/kg/weight in cycles of 3–4 months reducing the dose to 250mg every 12h, depending on the response to prolonged treatment, until treatment had been given for 12–16 months. The other patient (CRUO) was treated with 400mg of ibuprofen every 8h according to pain level for 12 months, relief and/or disappearance of pain was considered a good response with or without radiographic improvement of the osteomyelitic foci.After a mean follow-up of 5.9 years recurrence of the lesions was observed in 3 patients with a mean recurrence at 7 months after discontinuing treatment with NSAIDs (2 with naproxen and one with ibuprofen); no recurrence of symptoms occurred in 2 of the 5 patients, these patients were in the CRUO group treated with naproxen, no statistical differences were observed in recurrence time of the disease between the 2 groups studied (Z=−0.28, p>0.05, Mann–Whitney U test).DiscussionCRO was first described by Giedion et al.<a class="elsevierStyleCrossRef" href="#bib0075">1</a> in 1972 and since then its aetiopathogenesis is yet to be established. It is believed that it might be a genetic condition which results in an autoimmune disorder in which the inflammatory response is altered.<a class="elsevierStyleCrossRef" href="#bib0080">2</a>With regard to epidemiology, CRO presents in the paediatric ages especially in the age range between 8 and 14 years; however cases have been described in 6-month-old infants and in adults aged over 50. It predominates in females at a female to male ratio of 2:1.<a class="elsevierStyleCrossRefs" href="#bib0085">3,4</a> These data coincide with our series, except that the male gender predominates in our study.The real prevalence of this disease is still unclear due to the few cases recorded in the literature, and the difficulty in diagnosis which might overlap with other autoimmune diseases.<a class="elsevierStyleCrossRefs" href="#bib0085">3,4</a>Recent studies suggest an imbalance between proinflammatory cytokines (interleukin-6 and tumour necrosis factor-alpha) and antiinflammatory cytokynes (interleukin-10) to the detriment of the latter, as the pathogenesis basis of CRO.<a class="elsevierStyleCrossRefs" href="#bib0095">5,6</a>This disorder can present in isolation or form part of other syndromes such as SAPHO (synovitis, acne, pustulosis, hyperostosis and osteitis) and Majeed syndrome (osteomyelitis, skin rash, dyserythropoietic microcytic anaemia).<a class="elsevierStyleCrossRefs" href="#bib0095">5–8</a> In our series, they presented in isolation and no skin lesions were observed. However, it is worth noting the positive cultures in one of the 5 patients in which a few colonies of P. acnes were isolated; this germ has been associated with other inflammatory syndromes such as SAPHO.The clinical symptoms are insidious involving pain in the affected bones, mainly at night, accompanied or otherwise by spiking fever and local manifestations of inflammation. Occasionally skin lesions can be observed that present with periods of remission and exacerbation.<a class="elsevierStyleCrossRefs" href="#bib0090">4–7</a>Diagnosis is principally based on clinical symptoms and a high degree of suspicion is required. Handrick<a class="elsevierStyleCrossRef" href="#bib0115">9</a> in 1998 and then Ramanan<a class="elsevierStyleCrossRef" href="#bib0120">10</a> in 2014 suggested criteria to serve as guidelines for diagnosis based on clinical-radiological findings (<a class="elsevierStyleCrossRefs" href="#tbl0015">Tables 3 and 4</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia>Laboratory tests only serve to rule out diseases with a similar clinical presentation but they do not provide a certain diagnosis since to date there are no genetic or analytical markers for CRO.Blood count is usually normal in patients with CRO, although in some cases disturbances such as anaemia with microcytosis and dyserythropoiesis appear, as mentioned by Hendrich.<a class="elsevierStyleCrossRef" href="#bib0095">5</a> These findings are similar to those observed in our series; the patient diagnosed with CRMO presented these changes in their blood count.The inflammatory markers (GSV, CRP, IL6 and TFN alpha) are usually slightly elevated and tests such as serology and cultures to rule out infectious diseases caused by various germs (Borrelia burgdorferi, Salmonella enteritidis, Yersinia enterocolitica and Campylobacter jejuni) are usually anodyne since this is not an infectious condition.<a class="elsevierStyleCrossRefs" href="#bib0095">5–7</a>Imaging studies (X-rays, bone gammagraphy con Tc99, CAT, MRI and PET-CT) are very useful in diagnosis and for staging and follow-up of the bone lesion outcomes. These are initially lytic lesions which subsequently turn sclerotic, with signs of bone remodelling.<a class="elsevierStyleCrossRef" href="#bib0085">3</a>In 1982, Roberts<a class="elsevierStyleCrossRef" href="#bib0125">11</a> proposed a topo-radiographic classification for subacute haematogenous osteomyelitis (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>) comprising 4 types and 9 subtypes, which reflects the difficulty in differentiating some of these benign lesions with images of differing appearance from malignant lesions such as osteosarcoma, Ewing's sarcoma and other bone neoplasms, as in type IIB of this classification where the malignant radiographic appearance might lead to errors in deciding treatment and subjecting CRO patients to unnecessary interventions. In our series the patient underwent broad resection of the tibia on two occasions because it was uncertain whether the condition was of possible tumour or septic origin.<elsevierMultimedia ident="tbl0025"></elsevierMultimedia>Most of the patients in the series were referred to our centre to assess the initial diagnostic possibility of neoplastic disease with bone involvement. Anatomopathological studies are useful in ruling out other diseases, but the findings in CRO are no more than non-specific inflammatory changes such as lymphoplasmacytic infiltrates and fibrosis in advanced stages.<a class="elsevierStyleCrossRefs" href="#bib0095">5,7</a>A differential diagnosis should be made with other disorders of a similar clinical presentation such as infectious osteomyelitis, hypophosphatasia, histiocytosis, leukaemia, lymphoma, osteosarcoma, deficiency of the interleukin-1-receptor antagonist (DIRA), etc.<a class="elsevierStyleCrossRefs" href="#bib0095">5,7,12</a>With regard to treatment, the first therapeutic option should be nonsteroidal anti-inflammatory drugs administered over long periods (12–18 months) with excellent results, especially the naproxen we used in our series, although good results have been reported with indomethacin as an NSAID of choice for these lesions. Other treatments such as sulfasalazine, glucocorticoids, and bisphosphonates. Interferon-alpha and tumour necrosis factor-alpha inhibitors are considered a second choice and are generally used as coadjuvant treatment, they require more long term studies to assess their effectiveness in isolation compared to their use with NSAIDs.<a class="elsevierStyleCrossRefs" href="#bib0095">5–7,11–14</a>Girschick et al.,<a class="elsevierStyleCrossRef" href="#bib0105">7</a> treated 27 patients with a dose of 15mg/kg/day of naproxen with good outcomes at 6 months in patients who had only had one relapse, recommending treatment up to 25 months for patients with multiple relapses, in 25% of the patients the treatment was not effective. Likewise, Beck<a class="elsevierStyleCrossRef" href="#bib0130">12</a> observed in another cohort study that in 43% of 37 patients treated with naproxen alone the treatment was effective at 6 months after it had been started. In our study 100% of the patients had good outcomes after treatment with NSAIDs; however, in 3 of the 5 cases there was a recurrence of clinical symptoms.With regard to the use of other NSAIDs such as indomethacin for the treatment CRO, Abril and Ramírez<a class="elsevierStyleCrossRef" href="#bib0140">14</a> observed excellent outcomes with 100% clinical improvement in their series of 5 patients followed up over a period of 4 years, the bone lesions persisted in one of the 5 patients. These results are comparable with those achieved using naproxen in our series, demonstrating that NSAIDs are the first option in designing a therapeutic strategy to tackle this disease.ConclusionsChronic recurrent osteomyelitis is a disease that poses a diagnostic challenge due to its natural history and clinical presentation which resembles other entities like infection or malignant disease such as Ewing's sarcoma, osteosarcoma or metastatic disease, amongst others. These factors in addition to most tests returning negative results often leads to an error in the initial diagnosis and consequently inappropriate treatment. For this reason, clinical suspicion is essential in order to guide diagnosis.The long term prognosis for this disease is very good and NSAIDs are the drugs of choice. They require prolonged periods of treatment which have demonstrated good outcomes (<a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 3–5</a>).<elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia>Level of evidenceLevel of evidence IV.Ethical disclosuresProtection of people and animalsThe authors declare that neither human nor animal testing have been carried out under this research.Confidentiality of dataThe authors declare that they have complied with their work centre protocols for the publication of patient data.Right to privacy and informed consentThe authors declare that no patients’ data appear in this article.Conflict of interestsThe authors have no conflict of interests to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres789245" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Materials and methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec787638" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres789244" "titulo" => "Resumen" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Materiales y métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec787639" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Patients and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Level of evidence" ] 10 => array:3 [ "identificador" => "sec0035" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Protection of people and animals" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Right to privacy and informed consent" ] ] ] 11 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflict of interests" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-05-08" "fechaAceptado" => "2016-07-06" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec787638" "palabras" => array:6 [ 0 => "Osteomyelitis" 1 => "Chronic" 2 => "Recurrent" 3 => "Osteitis" 4 => "Aseptic" 5 => "Treatment" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec787639" "palabras" => array:6 [ 0 => "Osteomielitis" 1 => "Crónica" 2 => "Recurrente" 3 => "Osteítis" 4 => "Aséptica" 5 => "Tratamiento" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionChronic recurrent osteomyelitis (CRO) is a rare disease characterised by unifocal or multifocal aseptic inflammatory bony lesions. ObjectiveTo evaluate clinical features and response to treatment with non-steroidal anti-inflammatory drugs in patients with CRO. Materials and methodsA retrospective assessment was conducted on 5 children with OCR over a period of 8 years. They had been diagnosed based on clinical, laboratory findings, histological study of injuries, and imaging test. ResultsMultifocal disease was observed in 40% of cases, and unifocal in 60%. The large majority (80%) were male, with a mean age at diagnosis of 13 years (range: 11–15 years). The bones most frequently affected were the clavicle and tibia, representing 18.2%. The most common presenting symptom was pain in all patients, with fever being present in 20% of cases. Imaging studies such as CT and MRI were effective in 100%, and in all cases the biopsy reported a lymphoplasmacytic infiltrate. After a mean follow-up of 5.9 years, there was a good treatment response in 100%, with a mean recurrence at 5.25 months being observed. ConclusionsThe anodyne results of most clinical studies to assess CRO, and the similarity in clinical presentation of this with many infectious or tumour diseases makes its diagnosis a real challenge. On the other hand treatment with NSAIDs can be considered a good initial therapeutic option." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Materials and methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLa osteomielitis crónica recurrente (OCR) es una rara enfermedad caracterizada por lesiones óseas inflamatorias asépticas uni- o multifocales. ObjetivoValorar características clínicas y la respuesta al tratamiento con AINE de los pacientes con OCR. Materiales y métodosCinco niños con OCR valorados de forma retrospectiva por un periodo de 8 años, los cuales fueron diagnosticados basándose en los hallazgos clínicos, analíticos, estudio anatomopatológico de las lesiones y pruebas de imagen. ResultadosEl 40% presentó afectación multifocal y el 60% unifocal. El 80% eran del sexo masculino (4/5), la edad media al momento del diagnóstico 13 años (r: 11-15 años), los huesos más frecuentemente afectados fueron la clavícula y la tibia representado el 18,2%, el síntoma más común fue el dolor presentándose en todos los pacientes, la fiebre apareció en el 20% de los casos. Los estudios de imagen como la TAC y la RM fueron eficaces en el 100% y en todos la biopsia objetivó infiltrado linfoplasmocitario. Después de un seguimiento medio de 5,9 años se observó una buena respuesta al tratamiento en el 100%, con una recurrencia media a los 5,25 meses. ConclusionesLos resultados anodinos de la mayoría de los estudios clínicos para valorar OCR y la similitud en la presentación clínica de esta con muchas patologías infecciosas o tumorales hace que su diagnóstico represente un verdadero reto, por otra parte el tratamiento con AINE puede considerarse una buena opción terapéutica inicial." "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0030" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0035" "titulo" => "Objetivo" ] 2 => array:2 [ "identificador" => "abst0040" "titulo" => "Materiales y métodos" ] 3 => array:2 [ "identificador" => "abst0045" "titulo" => "Resultados" ] 4 => array:2 [ "identificador" => "abst0050" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Rivas Felice J, González Herranz P, Mejía Casado A, Pérez Navarro R, Hernández Díaz R. Osteomielitis crónica recurrente: un reto diagnóstico y terapéutico. 2017;61:35–42." ] ] "multimedia" => array:10 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1024 "Ancho" => 1400 "Tamanyo" => 120324 ] ] "descripcion" => array:1 [ "en" => "Patient 1. Lytic lesion in axial and sagittal slices of MRI and CT scans of the lumbar spine. (A) MRI, note the oedema in L1. (B) CAT, note the lesion occupying 30% of L1." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 907 "Ancho" => 1400 "Tamanyo" => 146647 ] ] "descripcion" => array:1 [ "en" => "Patient 1. PET-CT images showing increased metabolic activity L1 and xiphoid process. (A) and (B) Three-dimensional reconstruction. (C) Hypermetabolism in L1. (D) Hypermetabolism in xiphoid process." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 542 "Ancho" => 1500 "Tamanyo" => 74443 ] ] "descripcion" => array:1 [ "en" => "Patient 3. Photographs of the clinical appearance of a chronic osteomyelitis focus in the left clavicle, (a) view from the front, (b) lateral view of the tumour, it should be highlighted that the patient was referred to our centre due suspected malignant neoplastic disease." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 894 "Ancho" => 1333 "Tamanyo" => 143892 ] ] "descripcion" => array:1 [ "en" => "Patient 3. CT, MRI and PET-CT images of a CRO focus in the left clavicle. (A) Three-dimensional reconstruction of the lesion in the clavicle. (B) MRI image. (C) and (D) PET-CT showing increased metabolism in the inflammatory focus in the left clavicle." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 832 "Ancho" => 1500 "Tamanyo" => 123230 ] ] "descripcion" => array:1 [ "en" => "Patient 5. Lesion in distal 1/3 of the radius. (A) X-ray showing well-defined radiolucent image in distal 1/3 of the radius with areas of sclerosis. (B) and (C) the MRI shows a lesion with a mixed-type intraosseous component, with lytic areas and other areas which seem to relate to bone formation, and adjacent soft tissue oedema." ] ] 5 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">3 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">4 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">5 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gender \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Female \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diagnostic delay (months) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diagnosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CRMO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CRMO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CRUO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CRUO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">CRUO \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Clinical symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pain, fever \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pain, inflammation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pain, inflammation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Location of lesions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Clavicle, sternum, calcaneus, L1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pelvis, ribs, fibula \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Clavicle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Distal third of radius \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Distal third of radius \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Naproxen 15mg/kg/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Naproxen 15mg/kg/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Naproxen 15mg/kg/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ibuprofen 1200mg/day \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Naproxen 15mg/kg/day \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duration of treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 months \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Recurrence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1316742.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical characteristics of patients with CRO." ] ] 6 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">1 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">3 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">4 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">5 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Haemoglobin (g/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.94 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Haematocrit (%)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">41.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">39.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">37.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">38.25 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">GSV (mm/h)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">46 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20.94 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">C-reactive protein (mg/l)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.78 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.84 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Biopsy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Non-specific<a class="elsevierStyleCrossRef" href="#tblfn0010">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Idem \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Idem \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Idem \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Idem \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cultures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Negative \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Idem \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Idem \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Idem \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Propionibacterium acnes \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1316741.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Mean levels." ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "Lymphoplasmacytic infiltrates." ] ] ] "descripcion" => array:1 [ "en" => "Laboratory tests performed on patients with chronic recurring osteomyelitis." ] ] 7 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Source: Handrick et al.<a class="elsevierStyleCrossRef" href="#bib0115">9</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Handrick's criteria for the diagnosis of CRO</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Good general condition • Afebrile or mild fever • Findings of local inflammation • Sometimes multifocal • Sometimes with skin involvement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Laboratory \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Increase in GSV • Normal blood count • CRP usually negative • Rheumatoid factor, antinuclear antibodies, HLA B27 usually undetectable • No evidence of infectious agents. Histology: nonspecific inflammation (initially neutrophilic then lymphomonocytic) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Imaging Dx. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• X-ray: initially osteolysis, then sclerosis (principally in the long bone metaphysis) • Gammagraphy: clear focal increase in activity in the joints involved. • Magnetic resonance: inflammatory activity-dependent changes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Treatment and outcome \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Antibiotics had no effect • Clinical improvement with NSAID • Recurrent and chronic outcome • Good prognosis \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1316743.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Clinical and paraclinical findings that indicate the presence of CRO." ] ] 8 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "Source: Ramanan et al.<a class="elsevierStyleCrossRef" href="#bib0120">10</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• The presence of typical clinical<a class="elsevierStyleCrossRef" href="#tblfn0015">a</a> and radiological findings of CRO<a class="elsevierStyleCrossRef" href="#tblfn0020">b</a> in more than one bone (or clavicle alone) without significantly raised inflammatory markers \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">• Typical clinical and radiological findings of CRO in one bone plus inflammatory changes (plasma cells, osteoclass, fibrosis or sclerosis on bone biopsy with no bacterial growth) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1316745.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "a" "nota" => "Typical clinical findings include pain with or without localised swelling. Absence of significant local or systemic features of inflammation or infection." ] 1 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "b" "nota" => "Typical radiological findings of CRO constitute: plain X-rays showing a combination of lytic areas, sclerosis and new bone formation or preferably STIR MRI showing bone marrow oedema, bone expansion, lytic areas and periosteal reaction." ] ] ] "descripcion" => array:1 [ "en" => "Bristol criteria for the diagnosis of CRO." ] ] 9 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Source: Roberts et al.<a class="elsevierStyleCrossRef" href="#bib0125">11</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type I (metaphyseal) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Type IA: central metaphyseal lesion • Type IIB: metaphyseal lesion with cortical erosion \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type II (diaphyseal) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• Type IIA: lesion with cortical and periosteal reaction • Type IIB: medullary abscess with onion skin periosteal reaction \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type III (epiphyseal) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• IIIA: lesion in the epiphysis alone • IIIB: metaphyseal-epiphyseal lesion \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">• IVA: erosive lesion in vertebral bodies • IVB: lesion in pelvic bones • IVC: lesion in small bones \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1316744.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Robert's classification of subacute haematogenous osteomyelitis." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0075" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Subacute and chronic symmetrical osteomyelitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A. Giedion" 1 => "W. Holthusen" 2 => "L.F. Masel" 3 => "D. Vischer" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Radiol" "fecha" => "1972" "volumen" => "15" "paginaInicial" => "329" "paginaFinal" => "342" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/4403064" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0080" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Current understanding of the pathogenesis and management of chronic recurrent multifocal osteomyelitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P.J. Ferguson" 1 => "M. Sandhu" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s11926-012-0239-5" "Revista" => array:6 [ "tituloSerie" => "Curr Rheumatol Rep" "fecha" => "2012" "volumen" => "14" "paginaInicial" => "130" "paginaFinal" => "141" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22359228" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0085" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Available at: <a class="elsevierStyleInterRef" id="intr0010" href="http://pubs.rsna.org/doi/10.1148/rg.294085244">http://pubs.rsna.org/doi/10.1148/rg.294085244</a> [accessed 11.05.09]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Imaging of chronic recurrent multifocal osteomyelitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "G. Khanna" 1 => "T.S. Sato" 2 => "P.J. Ferguson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1148/rg.294085244" "Revista" => array:6 [ "tituloSerie" => "RadioGraphics" "fecha" => "2014" "volumen" => "29" "paginaInicial" => "1159" "paginaFinal" => "1177" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19605663" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0090" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Caso clínico osteomielitis crónica multifocal recurrente (OCMR). Experiencia en nuestro Servicio" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S.L. Regueras" 1 => "B.I. Ledezma" 2 => "J. Ferrero de la Mano" 3 => "E. del Ri¿o González" 4 => "C.M. Fernández" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Bol Pediatr" "fecha" => "2007" "volumen" => "47" "paginaInicial" => "136" "paginaFinal" => "141" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0095" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Available at: <a class="elsevierStyleInterRef" id="intr0015" href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3881012">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3881012</a> [accessed 11.05.13]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Autoinflammatory bone disorders with special focus on chronic recurrent multifocal osteomyelitis (CRMO)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C.M. Hedrich" 1 => "S.R. Hofmann" 2 => "J. Pablik" 3 => "H. Morbach" 4 => "H.J. Girschick" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1546-0096-11-11" "Revista" => array:6 [ "tituloSerie" => "Pediatr Rheumatol Online J" "fecha" => "2014" "volumen" => "11" "paginaInicial" => "11" "paginaFinal" => "47" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23497068" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0100" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Update cytokine dysregulation in chronic nonbacterial osteomyelitis (CNO)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S.R. Hofmann" 1 => "A. Roesen-Wolff" 2 => "G. Hanh" 3 => "C.M. Hedrich" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Int J Rheumatol" "fecha" => "2012" "volumen" => "2012" "paginaInicial" => "1" "paginaFinal" => "7" ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0105" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chronic non-bacterial osteomyelitis in children" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H.J. Girschick" 1 => "P. Raab" 2 => "S. Surbaum" 3 => "A. Trusen" 4 => "S. Kirschner" 5 => "P. Schneider" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/ard.2004.023838" "Revista" => array:6 [ "tituloSerie" => "Ann Rheum Dis" "fecha" => "2005" "volumen" => "64" "paginaInicial" => "279" "paginaFinal" => "285" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15647436" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0110" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Osteomilitis crónica multifocal recurrente o síndrome SAPHO" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "B. Panero" 1 => "S. Allodi de la Hoz" 2 => "T. García de la Oliva" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Esp Cir Ortop Traumatol" "fecha" => "1998" "volumen" => "42" "paginaInicial" => "29" "paginaFinal" => "31" ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0115" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chronic recurrent multifocal osteomyelitis: report of eight patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "W. Handrick" 1 => "D. Hörmann" 2 => "A. Voppmann" 3 => "R. Schille" 4 => "P. Reichardt" 5 => "R.B. 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Original Article

Chronic recurrent osteomyelitis: A diagnostic and therapeutic challenge

Osteomielitis crónica recurrente: un reto diagnóstico y terapéutico

J. Rivas Felicea,

Corresponding author

jesusrivas_felice@hotmail.com
jesusrivasf@gmail.com

Corresponding author.

, P. González Herranzb, A. Mejía Casadoc, R. Pérez Navarroa, R. Hernández Díaza

a Servicio de Cirugía Ortopédica y Traumatología, Hospital General de La Palma, Breña Alta, Spain

b Unidad de Ortopedia Infantil, Hospital Teresa Herrera, A Coruña, Spain

c Servicio de Cirugía Ortopédica y Traumatología, Hospital Royo Villanova, Zaragoza, Spain

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most analytical tests &#40;acute phase reactants&#44; serology and microbiological cultures&#41; return negative&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The aim of the study is to present a case series of patients with chronic recurrent osteomyelitis&#44; both unifocal and multifocal&#44; treated in our unit to assess their clinical features and response to treatment with NSAIDs&#44; and also present a review of the current references&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Patients and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">Between the years 2007 and 2015&#44; 5 patients were diagnosed and treated in our hospital for non-bacterial osteomyelitis&#44; reviewed retrospectively and classified into 2 groups&#46; The first group comprised patients diagnosed with chronic recurrent unifocal osteomyelitis &#40;CRUO&#41; and the second comprised patients with chronic recurrent multifocal osteomyelitis &#40;CRMO&#41;&#44; there were 4 male patients and one female patient&#44; aged between 11 and 15 years&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patients had been referred to our centre with high initial clinical suspicion of neoplastic disease with bone involvement&#46; The diagnosis of CRO was made after excluding other diseases such as infectious osteomyelitis&#44; hypophosphatasia&#44; histiocytosis&#44; leukaemia&#44; lymphoma&#44; osteosarcoma&#44; etc&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">All the patients were assessed by means of laboratory tests&#58; blood count&#44; acute phase reactants&#44; rheumatoid factor&#44; hepatitis A and B serology&#44; <span class="elsevierStyleItalic">Salmonella typhi</span>&#44; <span class="elsevierStyleItalic">Brucella</span>&#44; cytomegalovirus&#44; HIV&#44; Epstein&#8211;Barr virus&#44; rubeola&#44; <span class="elsevierStyleItalic">Toxoplasma gondii</span>&#44; <span class="elsevierStyleItalic">Treponema pallidum</span>&#44; <span class="elsevierStyleItalic">Mycoplasma pneumoniae</span>&#44; <span class="elsevierStyleItalic">Legionella</span>&#44; <span class="elsevierStyleItalic">Chlamydia pneumoniae</span>&#44; <span class="elsevierStyleItalic">Borrellia</span>&#44; varicella zoster&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The imaging tests performed were&#58; plain X-rays&#44; computerised axial tomography &#40;CAT&#41;&#44; magnetic nuclear resonance &#40;MRI&#41;&#44; bone gammagraphy and positron emission tomography &#40;PET-CT&#41; to assess the lesions causing these patients&#8217; symptoms&#46; Bone biopsies were also taken for anatomopathological and microbiological study&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Once diagnosis had been confirmed&#44; the patients were treated with NSAIDs &#40;naproxen and ibuprofen&#41;&#44; the patients were followed -up for a mean of 5&#46;9 years during which time the response to treatment and rate of recurrence were monitored&#46; Both clinical and radiographic improvement represented by a diminution or disappearance of pain and improved bone lesions was considered a favourable response&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test was used for the statistical analysis to assess the clinical differences between the patients with CRMO and those with CRUO&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Results</span><p id="par0055" class="elsevierStylePara elsevierViewall">Four of the 5 patients in the series were male and there was one female&#44; 3 of the patients had been diagnosed with CRUO and 2 with CRMO&#44; the mean age of the onset of symptoms was 12 &#40;<span class="elsevierStyleItalic">r</span>&#58; 10&#8211;13 years&#41; with a mean diagnostic delay of 9&#46;4 months &#40;<span class="elsevierStyleItalic">r</span>&#58; 2&#8211;24 month&#41;&#44; and a mean age at time of diagnosis of 13 years &#40;<span class="elsevierStyleItalic">r</span>&#58; 11&#8211;15 years&#41;&#46; A total of 11 bones were affected with a mean of 2 bones per patient &#40;<span class="elsevierStyleItalic">r</span>&#58; 1&#8211;4 bones&#41;&#59; the most frequently affected bones were the clavicle and the tibia in 2 cases &#40;18&#46;2&#37;&#41;&#44; followed by the distal radius&#44; fibula&#44; sternum&#44; calcaneus&#44; the lumbar vertebrae &#40;L1&#41;&#44; and pelvis&#59; the ribs were affected on one occasion &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">The most common symptom in the 5 patients in terms of clinical presentation was local pain which presented in all cases&#46; Arthritis was also present in one patient adjacent to the affected bone observed with a lesion in the proximal tibia and ipsilateral knee inflammation&#44; and also one patient presented fever &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Various imaging tests were used for diagnosis including plain X-ray&#44; CAT and MRI which showed lytic bone lesions with areas of sclerosis in 5&#47;5 &#40;100&#37;&#41; of the patients which suggested a neoplastic process to be evaluated&#46; Gammagraphy was positive in the 3&#47;4 patients on whom it was performed &#40;75&#37;&#41; however&#59; in the case where the gammagraphy was negative when the PET-CT scan was performed it reported an increase in metabolic activity in the first lumbar vertebra&#44; and xiphoid process &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">The laboratory tests showed the following mean results&#58; haemoglobin 12&#46;94<span class="elsevierStyleHsp" style=""></span>g&#47;dl &#40;<span class="elsevierStyleItalic">r</span>&#58; 11&#46;8&#8211;14<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#41;&#44; haematocrit 38&#46;25&#37; &#40;<span class="elsevierStyleItalic">r</span>&#58; 35&#46;3&#8211;41&#46;6&#37;&#41; mean corpuscular volume 80&#46;2 &#40;<span class="elsevierStyleItalic">r</span>&#58; 77&#46;7&#8211;82&#46;9<span class="elsevierStyleHsp" style=""></span>fL&#41;&#59; the serology was also negative&#44; no change was observed in C-reactive protein&#44; however&#44; globular sedimentation velocity &#40;GSV&#41; levels were elevated to 46<span class="elsevierStyleHsp" style=""></span>mm&#47;h and 28<span class="elsevierStyleHsp" style=""></span>mm&#47;h in 2 patients respectively&#44; the first with CRMO and the second with CRUO during the active period of the disease&#44; the mean of the group assessed was 20&#46;94<span class="elsevierStyleHsp" style=""></span>mm&#47;h&#46; No significant differences were observed between the groups &#40;CRUO and CRMO&#41; in elevated GSV levels &#40;<span class="elsevierStyleItalic">Z</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;57&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#44; Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The lesions of the 5 patients in the series were biopsied in order to take cultures which were negative in 4 of the 5 cases&#44; and positive in the female patient with chronic recurrent unifocal osteomyelitis in whom a few colonies were isolated of <span class="elsevierStyleItalic">Propionibacterium acnes</span> &#40;<span class="elsevierStyleItalic">P&#46; acnes</span>&#41;&#46; Similarly&#44; histopathological analysis showed inflammation characterised by interstitial infiltrates of mononuclear cells with a predominance of plasma cells and the presence of abundant lymphocytes&#44; and accompanying fibrosis and remodelling of the bone trabeculae in all of the cases&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">On two occasions a subperisoteal resection of the lesions of 12<span class="elsevierStyleHsp" style=""></span>cm and 14<span class="elsevierStyleHsp" style=""></span>cm was performed on one of the patients with involvement of the tibia&#59; the defect was reconstructed by bone transport surgery before the diagnosis of CRO had been reached&#46; Despite these broad resections the lesion recurred on both occasions&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Empirical antibiotic therapy was started in 3 of the 5 cases studied before a diagnosis of CRO had been made &#40;2 had CRUO and one had CRMO&#41;&#59; once the diagnosis had been established all the patients were treated with nonsteroidal anti-inflammatory drugs&#46; Four out of the 5 &#40;3 with CRUO and one with CRMO&#41; patients received naproxen 15<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;weight in cycles of 3&#8211;4 months reducing the dose to 250<span class="elsevierStyleHsp" style=""></span>mg every 12<span class="elsevierStyleHsp" style=""></span>h&#44; depending on the response to prolonged treatment&#44; until treatment had been given for 12&#8211;16 months&#46; The other patient &#40;CRUO&#41; was treated with 400<span class="elsevierStyleHsp" style=""></span>mg of ibuprofen every 8<span class="elsevierStyleHsp" style=""></span>h according to pain level for 12 months&#44; relief and&#47;or disappearance of pain was considered a good response with or without radiographic improvement of the osteomyelitic foci&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">After a mean follow-up of 5&#46;9 years recurrence of the lesions was observed in 3 patients with a mean recurrence at 7 months after discontinuing treatment with NSAIDs &#40;2 with naproxen and one with ibuprofen&#41;&#59; no recurrence of symptoms occurred in 2 of the 5 patients&#44; these patients were in the CRUO group treated with naproxen&#44; no statistical differences were observed in recurrence time of the disease between the 2 groups studied &#40;<span class="elsevierStyleItalic">Z</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#8722;0&#46;28&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#44; Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0095" class="elsevierStylePara elsevierViewall">CRO was first described by Giedion et al&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> in 1972 and since then its aetiopathogenesis is yet to be established&#46; It is believed that it might be a genetic condition which results in an autoimmune disorder in which the inflammatory response is altered&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">With regard to epidemiology&#44; CRO presents in the paediatric ages especially in the age range between 8 and 14 years&#59; however cases have been described in 6-month-old infants and in adults aged over 50&#46; It predominates in females at a female to male ratio of 2&#58;1&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">3&#44;4</span></a> These data coincide with our series&#44; except that the male gender predominates in our study&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The real prevalence of this disease is still unclear due to the few cases recorded in the literature&#44; and the difficulty in diagnosis which might overlap with other autoimmune diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Recent studies suggest an imbalance between proinflammatory cytokines &#40;interleukin-6 and tumour necrosis factor-alpha&#41; and antiinflammatory cytokynes &#40;interleukin-10&#41; to the detriment of the latter&#44; as the pathogenesis basis of CRO&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">This disorder can present in isolation or form part of other syndromes such as SAPHO &#40;synovitis&#44; acne&#44; pustulosis&#44; hyperostosis and osteitis&#41; and Majeed syndrome &#40;osteomyelitis&#44; skin rash&#44; dyserythropoietic microcytic anaemia&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">5&#8211;8</span></a> In our series&#44; they presented in isolation and no skin lesions were observed&#46; However&#44; it is worth noting the positive cultures in one of the 5 patients in which a few colonies of <span class="elsevierStyleItalic">P&#46; acnes</span> were isolated&#59; this germ has been associated with other inflammatory syndromes such as SAPHO&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The clinical symptoms are insidious involving pain in the affected bones&#44; mainly at night&#44; accompanied or otherwise by spiking fever and local manifestations of inflammation&#46; Occasionally skin lesions can be observed that present with periods of remission and exacerbation&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">4&#8211;7</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Diagnosis is principally based on clinical symptoms and a high degree of suspicion is required&#46; Handrick<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">9</span></a> in 1998 and then Ramanan<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">10</span></a> in 2014 suggested criteria to serve as guidelines for diagnosis based on clinical-radiological findings &#40;<a class="elsevierStyleCrossRefs" href="#tbl0015">Tables 3 and 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall">Laboratory tests only serve to rule out diseases with a similar clinical presentation but they do not provide a certain diagnosis since to date there are no genetic or analytical markers for CRO&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Blood count is usually normal in patients with CRO&#44; although in some cases disturbances such as anaemia with microcytosis and dyserythropoiesis appear&#44; as mentioned by Hendrich&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">5</span></a> These findings are similar to those observed in our series&#59; the patient diagnosed with CRMO presented these changes in their blood count&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The inflammatory markers &#40;GSV&#44; CRP&#44; IL6 and TFN alpha&#41; are usually slightly elevated and tests such as serology and cultures to rule out infectious diseases caused by various germs &#40;<span class="elsevierStyleItalic">Borrelia burgdorferi</span>&#44; <span class="elsevierStyleItalic">Salmonella enteritidis</span>&#44; <span class="elsevierStyleItalic">Yersinia enterocolitica and Campylobacter jejuni</span>&#41; are usually anodyne since this is not an infectious condition&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">5&#8211;7</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Imaging studies &#40;X-rays&#44; bone gammagraphy con Tc<span class="elsevierStyleSup">99</span>&#44; CAT&#44; MRI and PET-CT&#41; are very useful in diagnosis and for staging and follow-up of the bone lesion outcomes&#46; These are initially lytic lesions which subsequently turn sclerotic&#44; with signs of bone remodelling&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">3</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">In 1982&#44; Roberts<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a> proposed a topo-radiographic classification for subacute haematogenous osteomyelitis &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41; comprising 4 types and 9 subtypes&#44; which reflects the difficulty in differentiating some of these benign lesions with images of differing appearance from malignant lesions such as osteosarcoma&#44; Ewing&#39;s sarcoma and other bone neoplasms&#44; as in type IIB of this classification where the malignant radiographic appearance might lead to errors in deciding treatment and subjecting CRO patients to unnecessary interventions&#46; In our series the patient underwent broad resection of the tibia on two occasions because it was uncertain whether the condition was of possible tumour or septic origin&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">Most of the patients in the series were referred to our centre to assess the initial diagnostic possibility of neoplastic disease with bone involvement&#46; Anatomopathological studies are useful in ruling out other diseases&#44; but the findings in CRO are no more than non-specific inflammatory changes such as lymphoplasmacytic infiltrates and fibrosis in advanced stages&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">5&#44;7</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">A differential diagnosis should be made with other disorders of a similar clinical presentation such as infectious osteomyelitis&#44; hypophosphatasia&#44; histiocytosis&#44; leukaemia&#44; lymphoma&#44; osteosarcoma&#44; deficiency of the interleukin-1-receptor antagonist &#40;DIRA&#41;&#44; etc&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">5&#44;7&#44;12</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">With regard to treatment&#44; the first therapeutic option should be nonsteroidal anti-inflammatory drugs administered over long periods &#40;12&#8211;18 months&#41; with excellent results&#44; especially the naproxen we used in our series&#44; although good results have been reported with indomethacin as an NSAID of choice for these lesions&#46; Other treatments such as sulfasalazine&#44; glucocorticoids&#44; and bisphosphonates&#46; Interferon-alpha and tumour necrosis factor-alpha inhibitors are considered a second choice and are generally used as coadjuvant treatment&#44; they require more long term studies to assess their effectiveness in isolation compared to their use with NSAIDs&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">5&#8211;7&#44;11&#8211;14</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Girschick et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">7</span></a> treated 27 patients with a dose of 15<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day of naproxen with good outcomes at 6 months in patients who had only had one relapse&#44; recommending treatment up to 25 months for patients with multiple relapses&#44; in 25&#37; of the patients the treatment was not effective&#46; Likewise&#44; Beck<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">12</span></a> observed in another cohort study that in 43&#37; of 37 patients treated with naproxen alone the treatment was effective at 6 months after it had been started&#46; In our study 100&#37; of the patients had good outcomes after treatment with NSAIDs&#59; however&#44; in 3 of the 5 cases there was a recurrence of clinical symptoms&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">With regard to the use of other NSAIDs such as indomethacin for the treatment CRO&#44; Abril and Ram&#237;rez<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a> observed excellent outcomes with 100&#37; clinical improvement in their series of 5 patients followed up over a period of 4 years&#44; the bone lesions persisted in one of the 5 patients&#46; These results are comparable with those achieved using naproxen in our series&#44; demonstrating that NSAIDs are the first option in designing a therapeutic strategy to tackle this disease&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusions</span><p id="par0180" class="elsevierStylePara elsevierViewall">Chronic recurrent osteomyelitis is a disease that poses a diagnostic challenge due to its natural history and clinical presentation which resembles other entities like infection or malignant disease such as Ewing&#39;s sarcoma&#44; osteosarcoma or metastatic disease&#44; amongst others&#46; These factors in addition to most tests returning negative results often leads to an error in the initial diagnosis and consequently inappropriate treatment&#46; For this reason&#44; clinical suspicion is essential in order to guide diagnosis&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">The long term prognosis for this disease is very good and NSAIDs are the drugs of choice&#46; They require prolonged periods of treatment which have demonstrated good outcomes &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3&#8211;5</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Level of evidence</span><p id="par0190" class="elsevierStylePara elsevierViewall">Level of evidence IV&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Ethical disclosures</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Protection of people and animals</span><p id="par0195" class="elsevierStylePara elsevierViewall">The authors declare that neither human nor animal testing have been carried out under this research&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Confidentiality of data</span><p id="par0200" class="elsevierStylePara elsevierViewall">The authors declare that they have complied with their work centre protocols for the publication of patient data&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Right to privacy and informed consent</span><p id="par0205" class="elsevierStylePara elsevierViewall">The authors declare that no patients&#8217; data appear in this article&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflict of interests</span><p id="par0210" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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            0 => "Osteomielitis"
            1 => "Cr&#243;nica"
            2 => "Recurrente"
            3 => "Oste&#237;tis"
            4 => "As&#233;ptica"
            5 => "Tratamiento"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chronic recurrent osteomyelitis &#40;CRO&#41; is a rare disease characterised by unifocal or multifocal aseptic inflammatory bony lesions&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To evaluate clinical features and response to treatment with non-steroidal anti-inflammatory drugs in patients with CRO&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Materials and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A retrospective assessment was conducted on 5 children with OCR over a period of 8 years&#46; They had been diagnosed based on clinical&#44; laboratory findings&#44; histological study of injuries&#44; and imaging test&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Multifocal disease was observed in 40&#37; of cases&#44; and unifocal in 60&#37;&#46; The large majority &#40;80&#37;&#41; were male&#44; with a mean age at diagnosis of 13 years &#40;range&#58; 11&#8211;15 years&#41;&#46; The bones most frequently affected were the clavicle and tibia&#44; representing 18&#46;2&#37;&#46; The most common presenting symptom was pain in all patients&#44; with fever being present in 20&#37; of cases&#46; Imaging studies such as CT and MRI were effective in 100&#37;&#44; and in all cases the biopsy reported a lymphoplasmacytic infiltrate&#46; After a mean follow-up of 5&#46;9 years&#44; there was a good treatment response in 100&#37;&#44; with a mean recurrence at 5&#46;25 months being observed&#46;</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The anodyne results of most clinical studies to assess CRO&#44; and the similarity in clinical presentation of this with many infectious or tumour diseases makes its diagnosis a real challenge&#46; On the other hand treatment with NSAIDs can be considered a good initial therapeutic option&#46;</p></span>"
        "secciones" => array:5 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Objective"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Materials and methods"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Results"
          ]
          4 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introducci&#243;n</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La osteomielitis cr&#243;nica recurrente &#40;OCR&#41; es una rara enfermedad caracterizada por lesiones &#243;seas inflamatorias as&#233;pticas uni- o multifocales&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Valorar caracter&#237;sticas cl&#237;nicas y la respuesta al tratamiento con AINE de los pacientes con OCR&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Materiales y m&#233;todos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Cinco ni&#241;os con OCR valorados de forma retrospectiva por un periodo de 8 a&#241;os&#44; los cuales fueron diagnosticados bas&#225;ndose en los hallazgos cl&#237;nicos&#44; anal&#237;ticos&#44; estudio anatomopatol&#243;gico de las lesiones y pruebas de imagen&#46;</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">El 40&#37; present&#243; afectaci&#243;n multifocal y el 60&#37; unifocal&#46; El 80&#37; eran del sexo masculino &#40;4&#47;5&#41;&#44; la edad media al momento del diagn&#243;stico 13 a&#241;os &#40;r&#58; 11-15 a&#241;os&#41;&#44; los huesos m&#225;s frecuentemente afectados fueron la clav&#237;cula y la tibia representado el 18&#44;2&#37;&#44; el s&#237;ntoma m&#225;s com&#250;n fue el dolor present&#225;ndose en todos los pacientes&#44; la fiebre apareci&#243; en el 20&#37; de los casos&#46; Los estudios de imagen como la TAC y la RM fueron eficaces en el 100&#37; y en todos la biopsia objetiv&#243; infiltrado linfoplasmocitario&#46; Despu&#233;s de un seguimiento medio de 5&#44;9 a&#241;os se observ&#243; una buena respuesta al tratamiento en el 100&#37;&#44; con una recurrencia media a los 5&#44;25 meses&#46;</p></span> <span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Los resultados anodinos de la mayor&#237;a de los estudios cl&#237;nicos para valorar OCR y la similitud en la presentaci&#243;n cl&#237;nica de esta con muchas patolog&#237;as infecciosas o tumorales hace que su diagn&#243;stico represente un verdadero reto&#44; por otra parte el tratamiento con AINE puede considerarse una buena opci&#243;n terap&#233;utica inicial&#46;</p></span>"
        "secciones" => array:5 [
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            "titulo" => "Objetivo"
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          2 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Materiales y m&#233;todos"
          ]
          3 => array:2 [
            "identificador" => "abst0045"
            "titulo" => "Resultados"
          ]
          4 => array:2 [
            "identificador" => "abst0050"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Please cite this article as&#58; Rivas Felice J&#44; Gonz&#225;lez Herranz P&#44; Mej&#237;a Casado A&#44; P&#233;rez Navarro R&#44; Hern&#225;ndez D&#237;az R&#46; Osteomielitis cr&#243;nica recurrente&#58; un reto diagn&#243;stico y terap&#233;utico&#46; 2017&#59;61&#58;35&#8211;42&#46;</p>"
      ]
    ]
    "multimedia" => array:10 [
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        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Patient 1&#46; Lytic lesion in axial and sagittal slices of MRI and CT scans of the lumbar spine&#46; &#40;A&#41; MRI&#44; note the oedema in L1&#46; &#40;B&#41; CAT&#44; note the lesion occupying 30&#37; of L1&#46;</p>"
        ]
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        "mostrarFloat" => true
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        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
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            "Tamanyo" => 146647
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Patient 1&#46; PET-CT images showing increased metabolic activity L1 and xiphoid process&#46; &#40;A&#41; and &#40;B&#41; Three-dimensional reconstruction&#46; &#40;C&#41; Hypermetabolism in L1&#46; &#40;D&#41; Hypermetabolism in xiphoid process&#46;</p>"
        ]
      ]
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        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
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            "imagen" => "gr3.jpeg"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Patient 3&#46; Photographs of the clinical appearance of a chronic osteomyelitis focus in the left clavicle&#44; &#40;a&#41; view from the front&#44; &#40;b&#41; lateral view of the tumour&#44; it should be highlighted that the patient was referred to our centre due suspected malignant neoplastic disease&#46;</p>"
        ]
      ]
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        "etiqueta" => "Figure 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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            "imagen" => "gr4.jpeg"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Patient 3&#46; CT&#44; MRI and PET-CT images of a CRO focus in the left clavicle&#46; &#40;A&#41; Three-dimensional reconstruction of the lesion in the clavicle&#46; &#40;B&#41; MRI image&#46; &#40;C&#41; and &#40;D&#41; PET-CT showing increased metabolism in the inflammatory focus in the left clavicle&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Figure 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr5.jpeg"
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            "Tamanyo" => 123230
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Patient 5&#46; Lesion in distal 1&#47;3 of the radius&#46; &#40;A&#41; X-ray showing well-defined radiolucent image in distal 1&#47;3 of the radius with areas of sclerosis&#46; &#40;B&#41; and &#40;C&#41; the MRI shows a lesion with a mixed-type intraosseous component&#44; with lytic areas and other areas which seem to relate to bone formation&#44; and adjacent soft tissue oedema&#46;</p>"
        ]
      ]
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gender&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diagnostic delay &#40;months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diagnosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CRMO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CRMO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CRUO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CRUO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CRUO&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Clinical symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pain&#44; fever&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pain&#44; inflammation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pain&#44; inflammation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Location of lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Clavicle&#44; sternum&#44; calcaneus&#44; L1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pelvis&#44; ribs&#44; fibula&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Clavicle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Distal third of radius&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Distal third of radius&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Naproxen 15<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Naproxen 15<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Naproxen 15<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ibuprofen 1200<span class="elsevierStyleHsp" style=""></span>mg&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Naproxen 15<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Duration of treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Recurrence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Clinical characteristics of patients with CRO&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Haemoglobin &#40;g&#47;dl&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#46;94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Haematocrit &#40;&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">35&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">41&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">39&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">37&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">38&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">GSV &#40;mm&#47;h&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#46;94&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">C-reactive protein &#40;mg&#47;l&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;36&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;84&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Biopsy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Non-specific<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Idem&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Idem&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Idem&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Idem&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cultures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Negative&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Idem&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Idem&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Idem&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Propionibacterium acnes</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Lymphoplasmacytic infiltrates&#46;</p>"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Laboratory tests performed on patients with chronic recurring osteomyelitis&#46;</p>"
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          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Source&#58; Handrick et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">9</span></a></p>"
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Handrick&#39;s criteria for the diagnosis of CRO</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Good general condition<br>&#8226; Afebrile or mild fever<br>&#8226; Findings of local inflammation<br>&#8226; Sometimes multifocal<br>&#8226; Sometimes with skin involvement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Laboratory&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Increase in GSV<br>&#8226; Normal blood count<br>&#8226; CRP usually negative<br>&#8226; Rheumatoid factor&#44; antinuclear antibodies&#44; HLA B27 usually undetectable<br>&#8226; No evidence of infectious agents&#46;<br>Histology&#58; nonspecific inflammation &#40;initially neutrophilic then lymphomonocytic&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Imaging Dx&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; X-ray&#58; initially osteolysis&#44; then sclerosis &#40;principally in the long bone metaphysis&#41;<br>&#8226; Gammagraphy&#58; clear focal increase in activity in the joints involved&#46;<br>&#8226; Magnetic resonance&#58; inflammatory activity-dependent changes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Treatment and outcome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Antibiotics had no effect<br>&#8226; Clinical improvement with NSAID<br>&#8226; Recurrent and chronic outcome<br>&#8226; Good prognosis&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Source&#58; Ramanan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">10</span></a></p>"
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; The presence of typical clinical<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a> and radiological findings of CRO<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">b</span></a> in more than one bone &#40;or clavicle alone&#41; without significantly raised inflammatory markers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">&#8226; Typical clinical and radiological findings of CRO in one bone plus inflammatory changes &#40;plasma cells&#44; osteoclass&#44; fibrosis or sclerosis on bone biopsy with no bacterial growth&#41;&nbsp;\t\t\t\t\t\t\n
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              "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Typical clinical findings include pain with or without localised swelling&#46; Absence of significant local or systemic features of inflammation or infection&#46;</p>"
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            1 => array:3 [
              "identificador" => "tblfn0020"
              "etiqueta" => "b"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Typical radiological findings of CRO constitute&#58; plain X-rays showing a combination of lytic areas&#44; sclerosis and new bone formation or preferably STIR MRI showing bone marrow oedema&#44; bone expansion&#44; lytic areas and periosteal reaction&#46;</p>"
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          "en" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Bristol criteria for the diagnosis of CRO&#46;</p>"
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        "etiqueta" => "Table 5"
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          "leyenda" => "<p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Source&#58; Roberts et al&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a></p>"
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type I &#40;metaphyseal&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Type IA&#58; central metaphyseal lesion<br>&#8226; Type IIB&#58; metaphyseal lesion with cortical erosion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type II &#40;diaphyseal&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; Type IIA&#58; lesion with cortical and periosteal reaction<br>&#8226; Type IIB&#58; medullary abscess with onion skin periosteal reaction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type III &#40;epiphyseal&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; IIIA&#58; lesion in the epiphysis alone<br>&#8226; IIIB&#58; metaphyseal-epiphyseal lesion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Type IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8226; IVA&#58; erosive lesion in vertebral bodies<br>&#8226; IVB&#58; lesion in pelvic bones<br>&#8226; IVC&#58; lesion in small bones&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                0 => "xTab1316744.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Robert&#39;s classification of subacute haematogenous osteomyelitis&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:14 [
            0 => array:3 [
              "identificador" => "bib0075"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Subacute and chronic symmetrical osteomyelitis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "A&#46; Giedion"
                            1 => "W&#46; Holthusen"
                            2 => "L&#46;F&#46; Masel"
                            3 => "D&#46; Vischer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Radiol"
                        "fecha" => "1972"
                        "volumen" => "15"
                        "paginaInicial" => "329"
                        "paginaFinal" => "342"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/4403064"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Current understanding of the pathogenesis and management of chronic recurrent multifocal osteomyelitis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "P&#46;J&#46; Ferguson"
                            1 => "M&#46; Sandhu"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s11926-012-0239-5"
                      "Revista" => array:6 [
                        "tituloSerie" => "Curr Rheumatol Rep"
                        "fecha" => "2012"
                        "volumen" => "14"
                        "paginaInicial" => "130"
                        "paginaFinal" => "141"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22359228"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0085"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "Available at&#58; <a class="elsevierStyleInterRef" id="intr0010" href="http://pubs.rsna.org/doi/10.1148/rg.294085244">http&#58;&#47;&#47;pubs&#46;rsna&#46;org&#47;doi&#47;10&#46;1148&#47;rg&#46;294085244</a> &#91;accessed 11&#46;05&#46;09&#93;"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Imaging of chronic recurrent multifocal osteomyelitis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "G&#46; Khanna"
                            1 => "T&#46;S&#46; Sato"
                            2 => "P&#46;J&#46; Ferguson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1148/rg.294085244"
                      "Revista" => array:6 [
                        "tituloSerie" => "RadioGraphics"
                        "fecha" => "2014"
                        "volumen" => "29"
                        "paginaInicial" => "1159"
                        "paginaFinal" => "1177"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19605663"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Caso cl&#237;nico osteomielitis cr&#243;nica multifocal recurrente &#40;OCMR&#41;&#46; Experiencia en nuestro Servicio"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "S&#46;L&#46; Regueras"
                            1 => "B&#46;I&#46; Ledezma"
                            2 => "J&#46; Ferrero de la Mano"
                            3 => "E&#46; del Ri¿o Gonz&#225;lez"
                            4 => "C&#46;M&#46; Fern&#225;ndez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Bol Pediatr"
                        "fecha" => "2007"
                        "volumen" => "47"
                        "paginaInicial" => "136"
                        "paginaFinal" => "141"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:3 [
                  "comentario" => "Available at&#58; <a class="elsevierStyleInterRef" id="intr0015" href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3881012">http&#58;&#47;&#47;www&#46;ncbi&#46;nlm&#46;nih&#46;gov&#47;pmc&#47;articles&#47;PMC3881012</a> &#91;accessed 11&#46;05&#46;13&#93;"
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Autoinflammatory bone disorders with special focus on chronic recurrent multifocal osteomyelitis &#40;CRMO&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "C&#46;M&#46; Hedrich"
                            1 => "S&#46;R&#46; Hofmann"
                            2 => "J&#46; Pablik"
                            3 => "H&#46; Morbach"
                            4 => "H&#46;J&#46; Girschick"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1186/1546-0096-11-11"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Rheumatol Online J"
                        "fecha" => "2014"
                        "volumen" => "11"
                        "paginaInicial" => "11"
                        "paginaFinal" => "47"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23497068"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Update cytokine dysregulation in chronic nonbacterial osteomyelitis &#40;CNO&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "S&#46;R&#46; Hofmann"
                            1 => "A&#46; Roesen-Wolff"
                            2 => "G&#46; Hanh"
                            3 => "C&#46;M&#46; Hedrich"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Int J Rheumatol"
                        "fecha" => "2012"
                        "volumen" => "2012"
                        "paginaInicial" => "1"
                        "paginaFinal" => "7"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Chronic non-bacterial osteomyelitis in children"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "H&#46;J&#46; Girschick"
                            1 => "P&#46; Raab"
                            2 => "S&#46; Surbaum"
                            3 => "A&#46; Trusen"
                            4 => "S&#46; Kirschner"
                            5 => "P&#46; Schneider"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/ard.2004.023838"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Rheum Dis"
                        "fecha" => "2005"
                        "volumen" => "64"
                        "paginaInicial" => "279"
                        "paginaFinal" => "285"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15647436"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Osteomilitis cr&#243;nica multifocal recurrente o s&#237;ndrome SAPHO"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "B&#46; Panero"
                            1 => "S&#46; Allodi de la Hoz"
                            2 => "T&#46; Garc&#237;a de la Oliva"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Rev Esp Cir Ortop Traumatol"
                        "fecha" => "1998"
                        "volumen" => "42"
                        "paginaInicial" => "29"
                        "paginaFinal" => "31"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Chronic recurrent multifocal osteomyelitis&#58; report of eight patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "W&#46; Handrick"
                            1 => "D&#46; H&#246;rmann"
                            2 => "A&#46; Voppmann"
                            3 => "R&#46; Schille"
                            4 => "P&#46; Reichardt"
                            5 => "R&#46;B&#46; Tr&#246;bs"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s003830050485"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Surg Int"
                        "fecha" => "1998"
                        "volumen" => "14"
                        "paginaInicial" => "195"
                        "paginaFinal" => "198"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9880747"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Proposal of the Bristol criteria for the diagnosis of chronic non-bacterial osteitis from a cohort of 41 patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "A&#46;V&#46; Ramanan"
                            1 => "M&#46; Roderick"
                            2 => "R&#46; Shah"
                            3 => "A&#46; Finn"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/art.38195"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arthritis Rheumatol"
                        "fecha" => "2014"
                        "volumen" => "66"
                        "numero" => "S3"
                        "paginaInicial" => "107"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24431282"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Subacute hematogenous osteomyelitis in children&#58; a retrospective study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46;M&#46; Roberts"
                            1 => "D&#46;S&#46; Drummond"
                            2 => "A&#46;L&#46; Breed"
                            3 => "J&#46;A&#46; Chesney"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Pediatr Orthop"
                        "fecha" => "1982"
                        "volumen" => "2"
                        "paginaInicial" => "249"
                        "paginaFinal" => "254"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7130381"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Chronic nonbacterial osteomyelitis in childhood&#58; prospective follow-up during the first year of anti-inflammatory treatment"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46; Beck"
                            1 => "H&#46; Morbach"
                            2 => "M&#46; Beer"
                            3 => "M&#46; Stenzel"
                            4 => "D&#46; Tappe"
                            5 => "S&#46; Gattenl&#246;hner"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Arthritis Res Ther"
                        "fecha" => "2010"
                        "volumen" => "12"
                        "paginaInicial" => "1"
                        "paginaFinal" => "11"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Osteomielitis no bacteriana&#58; experiencia en un hospital terciario"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "E&#46; Barral"
                            1 => "X&#46; Freire"
                            2 => "E&#46; Enr&#237;quez"
                            3 => "R&#46; Casado"
                            4 => "P&#46; Bello"
                            5 => "J&#46; Arocena"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "An Pediatr &#40;Barc&#41;"
                        "fecha" => "2016"
                        "volumen" => "85"
                        "paginaInicial" => "18"
                        "paginaFinal" => "25"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Successful treatment of chronic recurrent multifocal osteomielitis with indomethacin&#58; a preliminary report of five cases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "J&#46;C&#46; Abril"
                            1 => "A&#46; Ram&#237;rez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/BPO.0b013e318070cbd3"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Pediatr Orthop"
                        "fecha" => "2007"
                        "volumen" => "27"
                        "paginaInicial" => "587"
                        "paginaFinal" => "591"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17585272"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
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Article information

ISSN: 19888856
Original language: English

DOI:10.1016/j.recote.2016.11.003

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Year/Month	Html	Pdf	Total

2024 November	5	0	5
2024 October	49	4	53
2024 September	41	4	45
2024 August	41	4	45
2024 July	30	7	37
2024 June	45	7	52
2024 May	39	4	43
2024 April	60	8	68
2024 March	33	8	41
2024 February	63	10	73
2024 January	87	8	95
2023 December	33	11	44
2023 November	51	11	62
2023 October	69	9	78
2023 September	40	9	49
2023 August	45	10	55
2023 July	47	6	53
2023 June	62	11	73
2023 May	97	8	105
2023 April	78	2	80
2023 March	76	2	78
2023 February	69	4	73
2023 January	67	10	77
2022 December	57	8	65
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