A previously healthy15-year-oldfemale presented to the emergency department (ED) in June 2013 with
a two month history of fever and pain in her right thigh and buttock. On
examination, she was febrile at 39°C. She had tenderness at the right
sacroiliac joint but full range of hip and knee joint movements. The remainder
of her examination was unremarkable, in particular, no evidence of
hepatosplenomegaly, petechiae or lymphadenopathy.
Her initial
blood tests showed mild hypochromic, microcytic anaemia with a haemoglobin of
105 g/L (normal range: 110-145 g/L), normal white cell count 6.8 X 109/L
(normal range: 5-17 X 109/L) and platelets 224 X 109/L (normal range: 150-400 X
109/L). Her inflammatory markers were markedly elevated, erythrocyte
sedimentation rate (ESR) 82 mm/hr (normal <15 mm/hr) and C-reactive protein
(CRP) 68 mg/L (normal <10 mg/L). Her liver function tests and lactate
dehydrogenase (LDH) were normal. She also had a pelvic X- ray which did not
reveal any abnormalities.
She was
admitted under the orthopaedic team with a presumed chronic skeletal infection.
Her bone scan showed irregular increased uptake at multiple sites including the
right sacroiliac joint, right femur, multiple ribs and multiple areas within
the thoracic spine. Chronic recurrent multifocal osteomyelitis (CRMO) was added
to the differential diagnosis. Magnetic Resonance Imaging (MRI) showed
multifocal areas of T2 hyperintensity in the right ilium, right ischial
tuberosity, right intertrochanteric region, right and left sacral alae and left
posterior acetabulum suggestive of osteonecrosis or infection. Diffuse abnormal
marrow signal with symmetric areas of sparing in the proximal femoral regions
were in keeping with extensive red marrow conversion on the MRI.
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