Case Author(s): Christian T. Schmitt, M.D. and Keith C. Fischer, M.D. , 10/14/02 . Rating: #D3, #Q4

Diagnosis: Chronic Recurrent Multifocal Osteomyelitis

Brief history:

9 year old girl with chronic right ankle problems


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Full history/Diagnosis is available below

Diagnosis: Chronic Recurrent Multifocal Osteomyelitis

Full history:

9 year old girl initially presented with a right ankle effusion and was found to have a lytic lesion. This was treated with prolonged courses of antibiotics for presumed osteomyelitis. Cultures were negative. After almost 2 years, the patient developed bilateral ankle swelling. Cultures and surgical pathology were still negative for an infectious etiology.


9 mCi Tc-99m MDP, i.v.


Bone Scan: Abnormal increased uptake in distal tibiae, more prominent on the right. Additional focus of increased uptake in the distal left femoral metaphysis.

Radiographs: Lytic lesions involving the distal left femur and bilateral tibiae.


The patient was diagnosed with chronic recurrent multifocal osteomyelitis and is being treated with non-steroidal anti-inflammatory medications. All cultures have remained negative.

Major teaching point(s):

The etiology of chronic recurrent multifocal osteomyelitis is not clearly understood. It may be immune related. It occurs more often in girls, usually between the ages of 7 and 12 years old.

Patients present with pain and swelling of the affected areas. The lesions are commonly multiple and often symmetrical. The distal tibia is the most commonly affected site, but lesions may involve the distal femur, proximal tibia and clavicles. Lesions can develop in multiple sites over time.

Clinically, in the absence of an infectious etiology, lack of response over about 3 months results in the presumed diagnosis of chronic recurrent multifocal osteomyelitis. Therapies have included steriods, antibiotics, non-steroidal anti-inflammatory drugs and curretage. None are consistently effective. This is usually self limited.

Reference: ACR syllabus: Pediatric Disease (fifth series) test and syllabus, pgs. 214-215.

ACR Codes and Keywords:

References and General Discussion of Bone Scintigraphy (Anatomic field:Skeletal System, Category:Inflammation,Infection)

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Case number: bs132

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