Combination therapy with methotrexate and etanercept for refractory chronic recurrent multifocal osteomyelitis.

Chronic recurrent multifocal osteomyelitis (CRMO) is a form of chronic nonbacterial osteitis (CNO) characterized by one or more lytic bone lesions with no identifiable cause1. The metaphyses of long bones and the clavicle are most frequently affected, although any bone may be involved. Most cases begin in childhood, and follow an intermittent course. Pain is the most common presenting symptom. Affected individuals are sometimes febrile, and acute-phase reactants may be increased, pointing to the inflammatory expression of this condition. Lesions may resolve at or before the time of puberty, but in some cases skeletal deformity and/or disability may occur2. We describe 2 children with CRMO whose symptoms persisted after trials of nonsteroidal antiinflammatory medication, glucocorticoids, and methotrexate (MTX). Combination therapy with MTX and etanercept resulted in amelioration of pain, accompanied in one patient by radio graphic improvement in a lytic bone lesion.