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Chronic Recurrent Multifocal Osteomyelitis of The Mandible: Report of Three Cases
Chronic Recurrent Multifocal Osteomyelitis of The Mandible: Report of Three Cases
Jornal de Pediatria
Copyright © 2003 by Sociedade Brasileira de Pediatria
CASE REPORT
Chronic recurrent multifocal osteomyelitis of the
mandible: report of three cases
Bernadete Lourdes Liphaus,
2
3
Luciana B. Paim,
André C. Rocha,
4 5
Aura Ligia Z. Castellanos, Clovis Artur A. Silva
Abstract
Objective: To report three cases of chronic recurrent multifocal osteomyelitis of the mandible, an inflammatory
disease affecting one or more bones with absence of isolated microorganisms in affected areas.
Description: The first case is a 13 yearold female presenting with pain and fever after dental treatment. The
patient received antibiotic treatment for osteomyelitis, but developed progressive enlargement of the mandible and
palmoplantar pustulosis. Bone scintigraphy showed intense and diffuse uptake in the mandible. The swelling
decreased after indomethacin and hyperbaric oxygen therapy. Case 2 is a 9 yearold female patient with recurrent
pain and edema of the right mandible for three years. The diagnosis of osteomyelitis was established and
amoxacillin introduced. After three months, tomography showed diffuse mandible osteolysis. Indomethacin and
hyperbaric oxygen therapy were introduced, however the patient presented a relapse and was treated with
prednisone, rofecoxib and methotrexate. Patient 3, a 10 yearold male, had palmoplantar pustulosis and recurrent
enlargement of the mandible. Tomography showed diffuse mandible osteolysis and scintigraphy revealed intense
and diffuse uptake in the mandible. The patient was treated with prednisone. Rofecoxib was replaced after two
relapses.
Comments: Chronic recurrent multifocal osteomyelitis of the mandible is often associated with prolonged pain
periods and periods of activity and remission of the inflammatory process. Its recognition is important to prevent
the patient from being submitted to prolonged antibiotic therapy and unnecessary invasive procedures.
J Pediatr (Rio J) 2003;79(5):46770: Chronic osteomyelitis, mandible.
467
468 Jornal de Pediatria Vol. 79, Nº5, 2003 Chronic recurrent multifocal osteomyelitis of the mandible – Paim LB
et alii
osteitis (groundglass appearance), with no collections
present; mandibular biopsy revealed giant cells with
Radiographic findings are similar to with septic fusiform cell stroma and inflammatory neutrophil infiltration
osteomyelitis, with osteolytic lesions and circumscribed and a culture from the biopsy isolated Propionibacterium sp.
sclerosis. Bone scintigraphy is of help in locating Bone scintigraphy found accentuated and heterogeneous
1,2 diffuse hyperdeposition of the radiolabeled drug along the
asymptomatic lesions. Biopsies do not generally find
entire extent of the mandible, to a lesser degree in the
evidence of infectious agents. Prognosis is uncertain and
mandibular rami. Erythrocyte sedimentation velocity (ESV)
13
clinical course can be painful and prolonged. was 55 mm in the first hour and Creactive protein (CRP)
Treatment is habitually given with non hormonal anti was 80 mg/dl. Complete hemogram, urea, creatinine,
coagulation test, urine I and radiography of the entire spine
inflammatories, corticosteroids, sulfasalazine and/or
and long bones were all normal. The HLAB27 antigen, anti
1,8,9
methotrexate. nuclear factor (ANF), rheumatoid factor (RF) assays were
negative. Blood and urine cultures were also negative. The
patient was treated with roxithromycin for three months.
Despite the antibiotic therapy the patient evolved with
The objective of the present study is to describe three
continuing pain and indomethacin was introduced based on a
cases of CRMO of the mandible monitored at the
diagnostic hypothesis of CRMO associated with pustulosis
Pediatric Rheumatology Unit at the Children’s Institute at
palmoplantaris and sessions were initiated (three sessions
the Hospital das Clínicas of the Medical faculty of the weekly to a total of 96 sessions). There was progressive
Universidade de São Paulo during the period between improvement and regression of the mandibular tumorization.
1998 and 2003. In July 2000 indomethacin was suspended as the patient had
been asymptomatic for more than a year and inflammatory
tests were negative. In May 2001 the patient presented
relapse, with pain and localized edema, requiring the
Case descriptions
reintroduction of indomethacin. She is currently
asymptomatic, using indomethacin, has an ESV of 16
Case 1 mm for the first hour and CRP is negative.
Female patient, white, 13 years and 3 months old, in March Case 2
1995 developed diffuse mandibular pain after dental
treatment with local hyperemia and fever. Was given a
number of antibiotics (crystalline penicillin, amoxycillin,
White female patient, nine years and five months, presented
clindamycin and metronidazole) diagnosed with
high intensity pain and recurrent mandibular edema for three
osteomyelitis, progressing with periods of improvement and
years. No fever, purulent secretion or local traumas.
periods of exacerbation of the mandibular tumorization. In
Odontological investigation did not uncover evidence of any
November 1998 she was interned at our unit for
oral abnormalities. In November of 2000, the patient was
investigation of diffuse mandible tumors, associated with a
referred to the Mouth and Jaw Service. The initial physical
restricted ability to open the mouth and pustulosis
examination found evidence of painful right side
palmoplantaris. Complementary examinations revealed:
submandibular tumorization, without erythema and with no
computerized tomography (CT) with diffuse mandibular
local heat; restricted ability to open the mouth and light
edema on gums. The initial diagnostic hypothesis was tumefaction of soft areas adjacent to bone cysts. The patient
osteomyelitis and aspiration puncture was performed and received prednisone for a month with improvement and once
amoxacillin instigated. After three months of treatment, more presented relapse when it was suspended, with the use
without clinical or laboratory improvement she was referred of rofecoxib 25 mg/day and methrotrexate 20 mg/ week
to the Children’s Institute and naproxen and amoxycillin becoming necessary. After two months the patient presented
were introduced. The latter was used for eight months, until clinical improvement and currently ESV is at 32 mm for the
ESV normalized. The patient evolved with bilateral first hour.
enlargement of the mandible, painful to the touch and with
restricted opening. Complementary examinations revealed
ESV at 26 mm for the first hour, CRP 7.0 mg/dl. Complete
hemogram, urea, creatinine, coagulation test, urine I and
radiography of the thorax and long bones were all normal. Case 3
Tests for HLAB27 antigen, ANF and RF were negative as
were blood and urine cultures. Computerized tomography of
the mandible found thickening, sclerosis of the mandibular
White male patient, 10 years old, presented pustulosis
rami and a body with osteolytic, rounded area (groundglass
palmoplantaris and diffuse bilateral mandibular
pattern), compatible with bone dysplasia. A diagnosis of
enlargement from August 2000 onwards with pain, heat,
CRMO was established and indomethacin and hyperbaric
fever and restricted mouth opening which improved after
chamber (a total of 80 sessions) were introduced. In
a nonhormonal antiinflammatory was used (diclofenac).
November of 2001 the patient presented with relapse
(significant pain and increased mandibular volume). He was referred to the Mouth and Jaw Service and
Examination by CT found bilateral volumetric enlargement Pediatric Rheumatology Unit in November 2001 because
of the mandible with an osteodysplasic aspect with light of recurrent pain. Complementary examinations revealed:
CT with thickening, sclerosis of diffuse mandibular
Chronic recurrent multifocal osteomyelitis of the mandible – Paim LB et alii Jornal de Pediatria Vol. 79, Nº5,
2003 469
osteitis areas (groundglass appearance), compatible with Rarely the disease can affect the mandible in isolation,
bone dysplasia; mandible biopsy found evidence of 7
and multiple lesions can occur, as were observed with
chronic inflammatory processes and fibrosis. Bone
9
scintigraphy found diffuse hyper deposition. Initial ESV our patients. Benedetta et al. described 260 pediatric
was 50 mm for the first hour and CRP was 6.0 mg/dl. patients with CRMO, and mandibles were involved in
Panoramic radiography of the mandible found osteolytic just 13 cases 5%.
lesions and cortical thickening. Complete hemogram and
radiography of the whole spine and the long bones were
normal. Assays for the HLAB27 antigen, ANF and RF
Chronic recurrent multifocal osteomyelitis within the
were negative. Blood and urine cultures were also
pediatric age group can be associated with a number of
negative. A diagnosis of CRMO was established and the
13
patient was initially treated with prednisone for one cutaneous manifestations: pustulosis palmoplantaris
month. The patient presented two relapses (January and (considered by some dermatologists to be a variant of
February of 2002), and was maintained on 25 mg/day of 5
psoriasis vulgaris), diffuse pustulosis; psoriasis vulgaris;
rofecoxib. There is currently total regression of the
911 9
tumorization. Panoramic mandible radiography shows acne; Sweet’s syndrome and pyoderma gangrenosum.
improvement to the cortical thickening. Two of our patients presented pustulosis palmoplantaris.
Test results ESV and CRP are elevated during the acute
4
phase and normalize during remissions. Cultures are
habitually negative for bacteria, fungi and mycobacteria,
Discussion
however, Propionibacterium acnes in bone aspirate may be
1,9,11
Patients with chronic recurrent multifocal osteomyelitis associated with OCMR. Radiography shows osteolytic
CRMO present with an insidious onset involving heat and
1,3
edema of soft tissues, restricted to one or more bones.
destruction in the metaphysial regions of long bones,
Systemic manifestations including fever and weight loss
followed by progressive sclerosis. Bone scintigraphy is
1.2
habitually occur during the acute phase of the disease, as useful for detecting silent lesions, showing an increase in
was the case with two of our patients. 1,2
depositing in the affected areas. Nuclear magnetic
resonance or computerized tomography, while not essential
to diagnosis, are useful to show the extent of lesions and the
Effects are usually symmetrical and multifocal (there may 1
only be one bone affected). Clinical course is intermittent involvement of joints and adjacent soft tissues.
2,3
with periods of remission and exacerbation. Lower limb
bones are the most often affected 55% , followed by the
axial skeleton pelvis in 55%, spine in 15%, thoracic wall in Biopsies show that lesions are not septic and that this
1 agent functions as a trigger for the immunological and
13% and clavicle (8%).
16
inflammatory reactions; as was observed in case 1.
Histopathological investigation of the bone lesions syndrome the hypothesis that DSOM may be a localized
returns variable results. The initial lesion is characterized 12
manifestation of the same entity has been suggested.
by the presence of neutrophils, and is classed as a pseudo
abscess. The chronic lesion has a predominance of
lymphocytes with the occasional presence of
1,9 The use of antimicrobial therapy with CRMO does not
plasmacytes, histiocytes and fibrosis.
4
alter the course of the disease. Nonsteroidal anti
inflammatories (naproxen, indomethacin or aspirin)
constitute initial treatment and a rapid course of
Recent studies suggest the following criteria for a
corticosteroids is recommended in refractory cases.
diagnosis of CRMO: a duration of more than three
Nonsteroidal antiinflammatories which inhibit the cyclo
months; histological evidence of chronic bone
oxygenase2, such as meloxicam, have been used with
inflammation, excluding other diseases and an absence of
16
9 CRMO cases which do not respond to naproxen. Two
bacterial growth in cultures.
of our patients received rofecoxib at a dosage of 0.6
mg/kg/ day, following the dosage previously used for
15
Some authors consider CRMO to be part of the spectrum of juvenile rheumatoid arthritis. Other treatments such as
the SAPHO syndrome (synovitis, acne, pustulosis 1 8
sulfasalazine, methotrexate and a hyperbaric
palmoplantaris, hyperostosis and osteitis). This acronym
12
emphasizes the association between bone inflammation and chamber, are indicated in painful and refractory cases,
911 as was the case with two of our patients.
cutaneous manifestations. An association is described
between the SAPHO syndrome and spondyloarthropathies
and the HLAB27 antigen. The prevalence of the HLAB27
antigen is 9% among European pediatric patients with The hyperbaric chamber or hyperbaric oxygenation is a safe
9 and efficient procedure for cases of acute and chronic
OCMR, particularly among pediatric patients with
osteomyelitis and can be used with patients suffering intense
1
osteolytic lesions and cutaneous involvement. Our three 12,16
pain and be maintained. Hyperbaric oxygen aids
patients did not present the HLAB27 antigen.
healing stimulating fibroblasts, and increasing the
16
production of collagen and angiogenesis.
Other authors define CRMO located exclusively in the
mandible as diffuse sclerosing osteomyelitis of the mandible
1214 Prognosis is doubtful with CRMO which can present a
(DSOM). Due to the clinical, radiological,
prolonged and painful clinical course with intervals of
scintigraphic and histological similarities with the SAPHO
13
inflammatory process activity and remission.
470 Jornal de Pediatria Vol. 79, Nº5, 2003 Chronic recurrent multifocal osteomyelitis of the mandible – Paim LB
et alii
It is important that pediatricians recognize CRMO, and Ravelli A, Marseglia GL, Viola S, Ruperto N, Martini A. Chronic
differentiate between it and acute osteomyelitis avoiding recurrent multifocal osteomyelitis: with usual features. Acta
Paediatr 1995;84:2225.
prolonged, unnecessary antibiotic therapy. The presence
of recurrent or chronic (more than three months) painful
mandibular tumorization alert us to the diagnosis.
Girschick HJ, Raab P, Kirschner S, Suerbaum S, Wurzburg T.
Scintigraphy, tomography or resonance are useful to
Chronic recurrent multifocal osteomyelitis in children: long term
identify osteolytic lesions. Biopsy is necessary in order to
followup and treatment of relapses. Arthritis Rheum 2001;44
rule out bone tumors and infectious osteomyelitis. Initial Suppl 9:272.
treatment includes non hormonal anti inflammatories
and/or corticosteroids. A hyperbaric chamber or
methrotrexate can be used in refractory cases with
Lavis JF, Gigon S, Gueit I, Michot C, Tardif A, Mallet E, et al.
significant or prolonged pain. Chronic recurrent multifocal osteomyelitis of the mandible. A case
report. Arch Pediatr 2002;9:12525.
Akikusa JD, Zacharin M, Shugg AW, Melbourne RCA, Tasmania VC.
Bisphosphonates in the treatment of chronic recurrent multifocal
osteomyelitis. Arthritis Rheum 2001;44 Suppl 9:171.
References
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Kressebuch H, Bianchetti MG. Synovitis, acne, pustulosis,
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JobDeslandre C, Krebs S, Kahan A. Chronic recurrent multifocal ten cases and review of the literature. Eur J Pediatr 2000;159:594
osteomyelitis: fiveyears outcomes in 14 patients cases. J Bone Spin 601.
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Hamanova J, Kabicek P. The SAPHO syndrome in a 16yearold
Schultz C, Holterhus PM, Seidel A, Jonas S, Barthel M, Kruse K, et boy: coincidence of acne conglobata and osteoarthritis. J Adolesc
al. Chronic recurrent multifocal osteomyelitis in children. Pediatr Health 1993;14:1203.
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Kotilainen P, MerilahtiPalo R, Lehtonen OP, Manner I, Helander I,
Bjorkstén B, Gustavson KH, Eriksson B, Lindholm A, Nordstrom S. Möttönen T, et al. Propionibacterium acnes isolated from sternal
Chronic recurrent multifocal osteomyelitis and pustulosis osteitis in a patient with SAPHO syndrome. J Rheum
palmoplantaris. J Pediatr 1978;93:22731. 1996;23:13024.
King SM, Laxer RM, Manson D, Gold R. Chronic recurrent van Merkesteyn JPR, Groot RH, Bras J, McCarroll RS, Bakker DJ.
multifocal osteomyelitis: a noninfectious inflammatory process. Diffuse sclerosing osteomyelitis of the mandible: A new concept of
Pediatr Infect Dis J 1987;6:90711. its etiology. Oral Surg Oral Med Oral Pathol 1990;70(4):4149.
Clovis Artur Almeida da Silva Rua Raul Pompéia, 303/43
Suei Y, Taguchi A, Tanimoto K. Diffuse sclerosing osteomyelitis of the CEP 05025010 – São Paulo, SP, Brazil
mandible: its characteristics and possible relationship to synovitis, acne,
pustulosis, hyperostosis, osteitis (SAPHO) syndrome. J Oral Maxillofac
Surg 1996;54:11941200.
Tel.: +55 (11) 3865.1901 – Fax: +55 (11) 3069.8503 E
mail: clovisaas@icr.hcnet.usp.brX
Kahn MF, Hayem F, Hayem G, Grossin M. Is diffuse sclerosing
osteomyelitis of the mandible part of the synovitis, acne, pustulosis,
hyperostosis, osteitis (SAPHO) syndrome? Analysis of seven cases. Oral
Surg Oral Med Oral Pathol 1994;78:5948.
Rose ES, Ferrandiz M, Kiss M, Forre O, Vehe R, Higgins G, et al.
Steadystate plasma concentrations of rofecoxib in children (ages 2
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Suppl:291.
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Corresponding author:
Case report
Pasien wanita, putih, 13 tahun dan 3 bulan, pada bulan Maret 1995 mengembangkan nyeri mandibula
yang menyebar setelah perawatan gigi dengan hiperemia dan demam lokal. Diberikan sejumlah
antibiotik (penisilin kristal, amoksisilin, klindamisin dan metronidazol) yang didiagnosis dengan
osteomielitis, berlanjut dengan periode perbaikan dan periode eksaserbasi tumorisasi mandibula. Pada
bulan November 1998 dia diasingkan di unit kami untuk penyelidikan tumor mandibula difus, terkait
dengan kemampuan terbatas untuk membuka mulut dan pustulosis palmoplantaris. Pemeriksaan
komplementer terungkap: tomografi terkomputerisasi (CT) dengan osteitis mandibula yang menyebar
(penampilan di permukaan kaca), tanpa koleksi hadir; Biopsi mandibula menunjukkan sel raksasa
dengan stroma sel fusiform dan infiltrasi neutrofil inflamasi dan biakan dari biopsi yang diisolasi
Propionibacterium sp. Scintigrafi tulang ditemukan hiper-deposisi berdifusi dan beragam heterogen
dari obat radiolabeled sepanjang batas mandibula, pada tingkat yang lebih rendah pada rami
mandibula. Kecepatan sedimentasi eritrosit (ESV) adalah 55 mm pada jam pertama dan protein C-
reaktif (CRP) adalah 80 mg / dl. Hemogram lengkap, urea, kreatinin, tes koagulasi, urin I dan
radiografi seluruh tulang belakang dan tulang panjang semuanya normal. Faktor antigen HLA-B27,
faktor anti-nuklir (ANF), faktor rheumatoid (RF) negatif. Kultur darah dan urine juga negatif. Pasien
diobati dengan roxithromycin selama tiga bulan. Meskipun terapi antibiotik pasien berkembang
dengan rasa sakit dan indometasin yang berlanjut diperkenalkan berdasarkan hipotesis diagnostik
CRMO yang terkait dengan pustulosis palmoplantaris dan sesi dimulai (tiga sesi setiap minggu sampai
total 96 sesi). Terjadi peningkatan progresif dan regresi tumorisasi mandibula. Pada bulan Juli 2000
indometasin dipalsukan karena pasien telah mengalami asimtomatik lebih dari satu tahun dan tes
peradangan negatif. Pada bulan Mei 2001 pasien menunjukkan kambuh, dengan nyeri dan edema
lokal, yang memerlukan
Reintroduksi indometasin. Dia saat ini asimtomatik, menggunakan indometasin, memiliki ESV 16 mm
untuk jam pertama dan CRP negatif
Diskusi
Pasien dengan osteomyelitis multifokal kronik berulang CRMO hadir dengan onset berbahaya yang
melibatkan panas dan edema jaringan lunak, terbatas pada satu atau lebih tulang.1,3 Manifestasi
sistemik termasuk demam dan penurunan berat badan biasanya terjadi selama fase akut penyakit ini,
1,2 seperti pada Kasus dengan dua pasien kami.
Efeknya biasanya simetris dan multifokal (mungkin hanya ada satu tulang yang terpengaruh). Kursus
klinis terputus-putus dengan periode remisi dan eksaserbasi.2,3 Tulang ekstremitas bawah adalah yang
paling sering terkena dampak 55%, diikuti oleh tulang panggul aksial di 55%, tulang belakang 15%,
dinding toraks 13% dan klavikula (8% ) .1
Jarang penyakit ini dapat mempengaruhi mandibula dalam isolasi, dan banyak lesi dapat terjadi, 7
seperti yang diamati pada pasien kami. Benedetta dkk.9 menjelaskan 260 pasien anak dengan CRMO,
dan mandibula hanya terlibat dalam 13 kasus 5%.
Ostomyelitis multifokal kronis berulang dalam kelompok usia anak dapat dikaitkan dengan sejumlah
manifestasi kutaneous: pustulosis palmoplantaris1-3 (dipertimbangkan oleh beberapa ahli kulit
sebagai varian vulgaris psoriasis), 5 pustulosis difus; Psoriasis vulgaris; Jerawat; 9-11 Sindrom manis
dan pyoderma gangrenosum. 9 Dua pasien kami mempresentasikan pustulosis palmoplantaris. Hasil
uji ESV dan CRP meningkat selama fase akut dan menormalkan selama remisi.4 Kultur biasanya
bersifat negatif untuk bakteri, jamur dan mikobakteri,
Namun, Propionibacterium acnes pada aspirat tulang dapat dikaitkan dengan OCMR.1,9,11
Radiografi menunjukkan osteolitik.
Penghancuran di daerah metafisi tulang panjang, diikuti oleh sklerosis progresif. Scintigrafi tulang
berguna untuk mendeteksi lesi diam, menunjukkan adanya peningkatan penyetoran di daerah yang
terkena dampak.1,2 Resonansi magnetik nuklir atau tomografi komputer, walaupun tidak penting
untuk diagnosis, berguna untuk menunjukkan tingkat lesi dan keterlibatan sendi dan sekitarnya.
Jaringan lunak
Biopsi menunjukkan bahwa lesi tidak septik dan agen ini berfungsi sebagai pemicu reaksi imunologis
dan inflamasi; 16 seperti yang diamati pada kasus 1. Investigasi histopatologis pada lesi tulang
menghasilkan hasil yang bervariasi. Lesi awal ditandai oleh adanya neutrofil, dan digolongkan sebagai
abses pseudo. Lesi kronis memiliki dominasi limfosit dengan adanya plasmacytes, histiosit dan
fibrosis sesekali.1,9
Studi terbaru menunjukkan kriteria berikut untuk diagnosis CRMO: durasi lebih dari tiga bulan; Bukti
histologis peradangan tulang kronis, tidak termasuk penyakit lain dan tidak adanya pertumbuhan
bakteri dalam budaya.9
Beberapa penulis menganggap CRMO sebagai bagian dari spektrum sindrom SAPHO (sinovitis,
jerawat, pustulosis palmoplantaris, hyperostosis dan osteitis). Akronim ini menekankan hubungan
antara peradangan tulang dan manifestasi kutaneous.9-11 Suatu asosiasi digambarkan antara sindrom
SAPHO dan spondylo-arthropathies dan antigen HLA-B27. Prevalensi antigen HLA-B27 adalah 9%
di antara pasien anak-anak Eropa dengan OCMR, 9 terutama di antara pasien anak-anak dengan lesi
osteolitik dan keterlibatan kulit.1 Tiga pasien kami tidak menunjukkan antigen HLA-B27.
Penulis lain mendefinisikan CRMO yang terletak secara eksklusif di mandibula sebagai osteomielitis
sklerosing difus dari mandibula (DSOM) .12-14 Karena kesamaan klinis, radiologis, skintigrafi dan
histologis dengan sindrom SAPHO, hipotesis bahwa DSOM adalah manifestasi lokal dari yang sama.
Entitas telah disarankan.12
Penggunaan terapi antimikroba dengan CRMO tidak mengubah jalannya penyakit.4 Antibiotik
nonsteroid (naproxen, indomethacin atau aspirin) merupakan pengobatan awal dan penanganan
kortikosteroid yang cepat dianjurkan dalam kasus refrakter. Antiinflamasi nonsteroid yang
menghambat siklooksigenase2, seperti meloxicam, telah digunakan dengan kasus CRMO yang tidak
merespons naproksen.16 Dua pasien kami menerima rofecoxib pada dosis 0,6 mg / kg / hari,
mengikuti dosis yang sebelumnya Digunakan untuk rheumatoid arthritis remaja.15 Pengobatan lain
seperti sulfasalazine, 1 methotrexate8 dan ruang hiperbarik, 12 diindikasikan pada kasus yang
menyakitkan dan refrakter, seperti yang terjadi pada dua pasien kami.
Ruang hiperbarik atau oksigenasi hiperbarik adalah prosedur yang aman dan efisien untuk kasus
osteomielitis akut dan kronis dan dapat digunakan dengan pasien yang menderita nyeri hebat dan
dijaga.12,16 Hiperbarik oksigen membantu penyembuhan yang merangsang fibroblas, dan
meningkatkan produksi kolagen dan angiogenesis. .16
Prognosis diragukan dengan CRMO yang dapat menyajikan kursus klinis yang berkepanjangan dan
menyakitkan dengan interval aktivitas proses inflamasi dan remisi.1-3
Adalah penting bahwa dokter anak mengenali CRMO, dan membedakannya dengan osteomielitis akut
dan menghindari terapi antibiotik yang berkepanjangan dan tidak perlu. Adanya tumor nasal
mandibular berulang atau kronis (lebih dari tiga bulan) mengingatkan kita pada diagnosis. Scintigrafi,
tomografi atau resonansi berguna untuk mengidentifikasi lesi osteolitik. Biopsi diperlukan untuk
menyingkirkan tumor tulang dan osteomielitis menular. Pengobatan awal mencakup anti-peradangan
dan / atau kortikosteroid non-hormonal. Ruang hiperbarik atau methrotrexate dapat digunakan pada
kasus refrakter dengan nyeri yang signifikan atau berkepanjangan.