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Published diagnostic criteria for chronic nonbacterial osteomyelitis (CNO)/chronic recurrent multifocal osteomyelitis (CRMO)

Published diagnostic criteria for chronic nonbacterial osteomyelitis (CNO)/chronic recurrent multifocal osteomyelitis (CRMO)
Jansson criteria[1] Bristol criteria[2]
Major criteria Required
  1. Radiologically proven osteolytic/sclerotic bone lesion
  2. Multifocal bone lesions
  3. PPP or psoriasis
  4. Sterile bone biopsy with signs of inflammation and/or fibrosis, sclerosis
  1. The presence of typical clinical findings (bone pain +/– localized swelling without significant local or systemic features of inflammation or infection)
  2. The presence of typical radiologic findings (preferably STIR MRI showing bone marrow edema +/– bone expansion, lytic areas and periosteal reaction or plain radiograph showing combination of lytic areas, sclerosis, and new bone formation)
Minor criteria Plus one of the following
  1. Normal blood count and good general state of health
  2. CRP and ESR mildly to moderately elevated*
  3. Observation time longer than 6 months
  4. Hyperostosis
  5. Associated with other autoimmune diseases apart from PPP or psoriasis
  6. Grade I or II relatives with autoimmune or autoinflammatory disease or with nonbacterial osteomyelitis
  1. More than 1 bone (or clavicle alone) involved without significantly raised CRP (CRP <30 g/L)
  2. Unifocal disease other than clavicle, or CRP >30 g/L, with bone biopsy showing inflammatory changes (plasma cells, osteoclasts, fibrosis, or sclerosis) with no bacterial growth whilst not on antibiotic therapy
Threshold of diagnosis: ≥2 major criteria or 1 major plus 3 minor criteria Threshold of diagnosis: Both 1 and 2, plus A or B

The Jansson criteria do not include other associated conditions in major criteria #3, such as inflammatory bowel disease. Another limitation of these criteria is that one would not make the diagnosis on the basis of major criteria #3 and minor criteria A, B, and C alone.

Caution is urged when making the diagnosis based upon clavicular involvement alone rather than involvement of more than one bone (see Bristol criteria A). Even though the clavicle is a typical site of involvement, the findings can also be due to malignancy.

CRP: C-reactive protein; ERS: erythrocyte sedimentation rate; PPP: palmoplantar pustulosis; STIR MRI: short tau inversion recovery magnetic resonance imaging.

* Defined as less than 2 times the upper limit of normal.
Reproduced from:
  1. Jansson A, Renner ED, Ramser J, et al. Classification of non-bacterial osteitis: Retrospective study of clinical, immunological and genetic aspects in 89 patients. Rheumatology (Oxford) 2007; 46(1):154-60. By permission of Oxford University Press. Copyright © 2008.
  2. Roderick MR, Shah R, Rogers V, et al. Chronic recurrent multifocal osteomyelitis (CRMO) – Advancing the diagnosis. Pediatr Rheumatol 2016; 14:47. Available at: https://ped-rheum.biomedcentral.com/articles/10.1186/s12969-016-0109-1. Copyright © 2016 Roderick MR, Shah R, Rogers V, et al. Reproduced under the terms of the Creative Commons Attribution License 4.0.
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