case_images: PMC6791280_01
case_images: Nuclear bone scan performed on 12/14/2018 of CRMO. Imaging reveals increased uptake of the left side of pelvis and ileum best seen on posterior views, and the proximal sternum and bilateral medial clavicles best seen on anterior views.
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case_images: PMC6791280_01_CRIRH2019-8206892.001.jpg
case_images: fig1
case_images: Additional workup included a mammogram on 12/27/2018 that revealed small asymmetry in the right breast and a bone scan on 12/14/2018 that revealed increased uptake and multifocal abnormal osseous activity in the left side of pelvis, ileum, proximal sternum, and bilateral medial clavicles (Figure 1).
case_images: PET scan whole body performed on 1/9/2019. (a) Anterior view and (b) posterior view with hypermetabolism of the left side of pelvis and ileum and bilateral medial clavicles.
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case_images: PMC6791280_01_CRIRH2019-8206892.002.jpg
case_images: fig2
case_images: A follow-up PET scan obtained on 1/9/2019 revealed hypermetabolism only in the bony sites previously identified by the bone scan without evidence of hypermetabolic visceral disease (Figure 2).
case_images: PA and lateral chest x-rays performed on 1/16/2019. (a) PA view with asymmetry at the left apex, which could relate to osseous structures, with questionable expansion of the proximal left first anterior rib, and (b) lateral view with questionable expansion of the inferior sternum.
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case_images: PMC6791280_01_CRIRH2019-8206892.003.jpg
case_images: fig3
case_images: PA and lateral chest x-rays performed on 1/16/19 (Figure 3) demonstrated asymmetry at the apices with questionable osseous lesions, questionable expansion of the proximal left first anterior rib, and questionable expansion of the inferior sternum on the lateral view with resultant recommendation for chest CT for further characterization.
case_images: CT biopsy imaging axial body view with a slice thickness of 2.00 demonstrating lytic (example inside circle) and sclerotic lesions (examples of thickened bone pointed to with arrows) of the left medial clavicle and left first rib.
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case_images: PMC6791280_01_CRIRH2019-8206892.004.jpg
case_images: fig4
case_images: CT-guided biopsies on 1/21/19 of her left clavicle, first rib, sacrum, and ileum. CT imaging performed during the biopsies also commented on the lytic and sclerotic appearance of the lesions that were to be biopsied of the left medial clavicle and the left first rib (Figure 4), left sacrum, and left ileum (Figure 5).
case_images: CT biopsy imaging axial body view with slice thickness 5.00 demonstrating lytic (example inside circle) and sclerotic lesions (examples of thickened bone pointed to with arrows) of the left sacrum and left ileum. Also, notice fusion of the left sacro-iliac joint. For reference, the patient is prone in this image as it was taken during the time of biopsy; therefore, the left ileum/sacrum is on the left of the image.
case_images: CRIRH2019-8206892.005.jpg
case_images: PMC6791280_01_CRIRH2019-8206892.005.jpg
case_images: fig5
case_images: CT-guided biopsies on 1/21/19 of her left clavicle, first rib, sacrum, and ileum. CT imaging performed during the biopsies also commented on the lytic and sclerotic appearance of the lesions that were to be biopsied of the left medial clavicle and the left first rib (Figure 4), left sacrum, and left ileum (Figure 5).
case_images: Bone biopsy of the left medial clavicle performed on 1/21/2019. (a) H&E 200x marrow fibrosis with plasma cell infiltrate. (b) H&E 400x marrow fibrosis (lighter purple color throughout indicated by black arrow) in place of a fatty marrow background with plasma cell infiltrate that contains eccentric nuclei (area indicated by white arrow) representing changes indicative of chronic inflammation.
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case_images: PMC6791280_01_CRIRH2019-8206892.006.jpg
case_images: fig6
case_images: Pathology revealed dense bone with reactive changes and mild marrow fibrosis; changes noted to be consistent with a chronic inflammatory process such as chronic recurrent multifocal osteomyelitis (CRMO) (Figures 6 and 7); and no evidence of Paget's disease or neoplasm.
case_images: Bone biopsy of the left medial clavicle performed on 1/21/2019. (a) H&E 200x marrow fibrosis with plasma cell infiltrate. (b) H&E 400x marrow fibrosis (lighter purple color throughout indicated by black arrow) in place of a fatty marrow background with plasma cell infiltrate that contains eccentric nuclei (area indicated by white arrow) representing changes indicative of chronic inflammation.
case_images: CRIRH2019-8206892.007.jpg
case_images: PMC6791280_01_CRIRH2019-8206892.007.jpg
case_images: fig7
case_images: Pathology revealed dense bone with reactive changes and mild marrow fibrosis; changes noted to be consistent with a chronic inflammatory process such as chronic recurrent multifocal osteomyelitis (CRMO) (Figures 6 and 7); and no evidence of Paget's disease or neoplasm.