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Value of whole-body magnetic resonance imaging on progressive axial fusion and chronic non-bacterial osteomyelitis in pediatric Crohn’s disease: A case report
George Triantafyllou, Spyridon Prountzos, Konstantina Bolou, Nikolaos-Achilleas Arkoudis, Konstantina Liontou, Maria Piagkou, Lampros Fotis, Olympia Papakonstantinou
George Triantafyllou, Maria Piagkou, Department of Anatomy, School of Medicine, Faculty of Health Sciences, National and Kapodistrian University of Athens, Athens 11527, Attikí, Greece
Spyridon Prountzos, Nikolaos-Achilleas Arkoudis, Olympia Papakonstantinou, Second Department of Radiology, General University Hospital “Attikon”, National and Kapodistrian University of Athens, Athens 12462, Attikí, Greece
Konstantina Bolou, School of Medicine, Faculty of Health Sciences, National and Kapodistrian University of Athens, Athens 11527, Attikí, Greece
Nikolaos-Achilleas Arkoudis, Research Unit of Radiology and Medical Imaging, National and Kapodistrian University of Athens, Athens 11528, Attikí, Greece
Konstantina Liontou, Lampros Fotis, Rheumatology Unit, Third Pediatric Clinic, General University Hospital “Attikon”, National and Kapodistrian University of Athens, Athens 11527, Attikí, Greece
Author contributions: Triantafyllou G, Fotis L, and Papakonstantinou O contributed to conceptualization; Prountzos S, Arkoudis NA, Liontou K, Fotis L, and Papakonstantinou O contributed to data collection; Triantafyllou G, and Bolou K, Piagkou M, and Papakonstantinou O contributed to data analysis; Triantafyllou G, Prountzos S, and Bolou K contributed to writing- original draft; Arkoudis NA, Liontou K, Piagkou M, Fotis L, and Papakonstantinou O contributed to writing- review; Piagkou M, Fotis L, and Papakonstantinou O contributed to supervision; All authors contributed to approval of the final version.
Informed consent statement: Written informed consent was obtained from the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Corresponding author: George Triantafyllou, Department of Anatomy, School of Medicine, Faculty of Health Sciences, National and Kapodistrian University of Athens, 75 Mikras Asias Street, Goudi, Athens 11527, Attikí, Greece.
georgerose406@gmail.com
Received: December 25, 2025
Revised: January 17, 2026
Accepted: February 12, 2026
Published online: March 16, 2026
Processing time: 81 Days and 22.5 Hours
BACKGROUND
Musculoskeletal manifestations are the most common extraintestinal manifestations of pediatric inflammatory bowel disease (IBD). However, the coexistence of Crohn’s disease (CD) with chronic non-bacterial osteomyelitis (CNO) and axial spondyloarthropathy creates a complex autoinflammatory phenotype that is challenging to manage and prone to severe structural damage.
CASE SUMMARY
We report the longitudinal course of a male patient with CD and progressive skeletal involvement. Despite sequential trials of adalimumab and infliximab (both discontinued due to anaphylaxis) and vedolizumab, the patient developed extensive cervical-occipital fusion and C6-C7 pseudoarthrosis. At age 15, whole-body magnetic resonance imaging (WB-MRI) was pivotal in identifying multifocal periphyseal bone marrow edema (BME) characteristic of concomitant CNO, which had been missed by targeted spinal imaging. Genetic testing identified a heterozygous nucleotide-binding oligomerization domain-containing protein 2 p.Leu762Phe variant. Following the diagnosis of this phenotype, treatment was intensified to tofacitinib and intravenous zoledronic acid. A follow-up WB-MRI at age 16 demonstrated a marked reduction in multifocal BME and resolution of active inflammatory lesions, though structural spinal fusion remained permanent.
CONCLUSION
This case suggests that in pediatric patients with IBD with refractory skeletal pain, clinicians might consider the possibility of overlapping autoinflammatory syndromes. While based on a single observation, the use of WB-MRI was instrumental in identifying subclinical lesions, assisting in the differentiation between active inflammation and permanent structural damage.
Core Tip: Pediatric Crohn’s disease can coexist with chronic non-bacterial osteomyelitis and spondyloarthropathy, creating a severe autoinflammatory phenotype linked to nucleotide-binding oligomerization domain-containing protein 2 variants. This case demonstrates that persistent skeletal pain in inflammatory bowel disease patients requires a high index of suspicion for multifocal bone involvement. Whole-body magnetic resonance imaging should be considered for mapping total inflammatory load and preventing irreversible structural damage, such as cervical fusion. Management often necessitates a multi-target approach, utilizing Janus kinase inhibitors and bisphosphonates to address refractory systemic inflammation and preserve skeletal integrity.
