. 2025 May 8.

doi: 10.1002/art.43137. Online ahead of print.

EULAR/American College of Rheumatology Classification Criteria for Pediatric Chronic Nonbacterial Osteomyelitis

Yongdong Zhao¹, Melissa S Oliver², Anja Schnabel³, Eveline Y Wu⁴, Zhaoyi Wang¹, Achille Marino⁵, Cassyanne L Aguiar⁶, Jonathan D Akikusa⁷, Ummusen Kaya Akca⁸, Beverley Almeida⁹, Simone Appenzeller¹⁰, Erin Balay-Dustrude¹, Ozge Basaran¹¹, Matthew L Basiaga¹², Yelda Bilginer⁸, David A Cabral¹³, Martina Capponi¹⁴, Nathan Donaldson¹⁵, Bugra Han Egeli¹⁶, Emily J Fox¹⁷, Antonella Insalaco¹⁸, Ramesh S Iyer¹⁹, Annette F Jansson²⁰, Inna Kostik²¹, Mikhail Kostik²², Leonard K Kovalick⁴, Katia Tomie Kozu²³, Sivia K Lapidus²⁴, Tzielan C Lee²⁵, Aleksander Lenert²⁶, Kamran Mahmood⁹, Edoardo Marrani²⁷, Doaa Mosad Mosa²⁸, Ian Muse¹, Alexander Mushkin²⁹, Katherine D Nowicki¹⁵, Farzana Nuruzzaman³⁰, Karen Onel³¹, Manuela Pardeo¹⁸, Trang Sophia Pham¹, Lauren Potts³², Athimalaipet V Ramanan³³, Angelo Ravelli³⁴, Nathan D Rogers¹⁵, Andrew W Grim³⁵, Micol Romano³⁶, Natalie Rosenwasser¹, Takashi Shawn Sato³⁷, Gabriele Simonini²⁷, Jennifer B Soep¹⁵, Sara M Stern³⁸, Timmy Strauss³, Angela Taneja Kohli³⁹, Alexander C Theos⁴⁰, Lori B Tucker¹³, Leslie F Vogel⁴¹, Shima Yasin⁴², Stephen C Wong¹, Katerina Bouchalova⁴³, Alison M Hendry⁴⁴, Kevin C Cain⁴⁵, Hermann J Girschick⁴⁶, Fatma Dedeoglu¹⁶, Christian M Hedrich⁴⁷, Ronald M Laxer⁴⁸, Polly J Ferguson⁴², Raymond Naden, Seza Ozen⁸

Affiliations

¹ Pediatric Rheumatology, Department of Pediatrics, University of Washington School of Medicine, Seattle.
² Division of Pediatric Rheumatology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis.
³ Department of Pediatrics, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
⁴ Division of Pediatric Rheumatology, Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill.
⁵ Pediatric Rheumatology, ASST Gaetano Pini-CTO, Milan, Italy.
⁶ Division of Pediatric Rheumatology, Department of Pediatrics, Children's Hospital of The King's Daughters, Eastern Virginia Medical School, Norfolk.
⁷ Rheumatology service, Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.
⁸ Hacettepe University Faculty of Medicine, Department of Pediatric Rheumatology, Ankara, Turkey.
⁹ Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, UK.
¹⁰ Department of Orthopedics, Rheumatology and Traumatology, School of Medical Science, University of Campinas, Brazil.
¹¹ Hacettepe University Faculty of Medicine, Department of Pediatric Rheumatology, Ankara, Turkey, and Division of Pediatric Rheumatology, Hospital for Special Surgery, New York, New York.
¹² Division of Pediatric Rheumatology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota.
¹³ BC Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada.
¹⁴ Department of Maternal Sciences and Urological Sciences, Sapienza University of Rome, Rome, Italy.
¹⁵ University of Colorado School of Medicine, Aurora.
¹⁶ Division of Immunology, Rheumatology Program, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
¹⁷ Division of Pediatric Rheumatology, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri.
¹⁸ Division of Rheumatology, ERN RITA Center, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy.
¹⁹ Pediatric Radiology, Department of Radiology, University of Washington School of Medicine, Seattle.
²⁰ Division of Pediatric Rheumatology and Immunology, Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany.
²¹ Sanatorium for Children 'Detskie Duny', Saint-Petersburg, Russia.
²² Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russia.
²³ Pediatric Rheumatology Unit, Instituto da Criança e do Adolescente, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil.
²⁴ Pediatric Rheumatology Division, Joseph M. Sanzari Children's Hospital, Hackensack University Medical Center and Hackensack Meridian School of Medicine, Hackensack, New Jersey.
²⁵ Division of Pediatric Rheumatology, Stanford University School of Medicine, Stanford, California.
²⁶ Division of Immunology, Department of Internal Medicine, Carver College of Medicine, University of Iowa Hospitals & Clinics, Iowa City.
²⁷ Rheumatology Unit, ERN ReCONNET Center, Meyer Children's Hospital IRCCS, Florence, Italy.
²⁸ Rheumatology Department, Mansoura University Hospitals, Mansoura University Faculty of Medicine, Mansoura, Egypt.
²⁹ Science-Research Institute of Phthisiopulmonology, Saint-Petersburg, Russia.
³⁰ Renaissance School of Medicine at Stony Brook University, Stony Brook, New York.
³¹ Division of Pediatric Rheumatology, Hospital for Special Surgery, New York, New York.
³² Patient Research Partner, California.
³³ Bristol Royal Hospital for Children & Translational Health Sciences, University of Bristol, Bristol, UK.
³⁴ IRCCS Istituto Giannina Gaslini and Università degli Studi di Genova, Genoa, Italy.
³⁵ Division of Pediatric Rheumatology, Department of Pediatrics, Michigan Medicine, Ann Arbor.
³⁶ Pediatric Rheumatology, ASST Gaetano Pini-CTO, Milan, Italy, and Department of Pediatrics, Division of Pediatric Rheumatology, Behcet and Autoinflammatory Disease Center, Western University, London, Ontario, Canada.
³⁷ Stead Family Children's Hospital, University of Iowa Hospitals and Clinics, Iowa City.
³⁸ University of Utah, Salt Lake City.
³⁹ Emory University School of Medicine/Children's Healthcare of Atlanta, Georgia.
⁴⁰ Patient/Parent Partner, Georgetown University, Washington, DC.
⁴¹ Department of Rehabilitation Seattle Children's Hospital, Seattle, Washington.
⁴² Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City.
⁴³ Department of Pediatrics, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital, Olomouc, Czech Republic.
⁴⁴ General Medicine and Rheumatology Service, Division of Medicine, Middlemore Hospital Counties Manukau District Health, Auckland, New Zealand.
⁴⁵ Department of Biostatistics, University of Washington, Seattle.
⁴⁶ Department of Pediatrics, Vivantes Clinic Friedrichshain, Berlin, Germany.
⁴⁷ Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Eaton Road, and Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
⁴⁸ The Hospital for Sick Children, St. Michael's Hospital and the University of Toronto, Ontario, Canada.

PMID: 40342207
DOI: 10.1002/art.43137

EULAR/American College of Rheumatology Classification Criteria for Pediatric Chronic Nonbacterial Osteomyelitis

Yongdong Zhao et al. Arthritis Rheumatol. 2025.

. 2025 May 8.

doi: 10.1002/art.43137. Online ahead of print.

Authors

Affiliations

¹ Pediatric Rheumatology, Department of Pediatrics, University of Washington School of Medicine, Seattle.
² Division of Pediatric Rheumatology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis.
³ Department of Pediatrics, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
⁴ Division of Pediatric Rheumatology, Department of Pediatrics, The University of North Carolina at Chapel Hill, Chapel Hill.
⁵ Pediatric Rheumatology, ASST Gaetano Pini-CTO, Milan, Italy.
⁶ Division of Pediatric Rheumatology, Department of Pediatrics, Children's Hospital of The King's Daughters, Eastern Virginia Medical School, Norfolk.
⁷ Rheumatology service, Department of General Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia.
⁸ Hacettepe University Faculty of Medicine, Department of Pediatric Rheumatology, Ankara, Turkey.
⁹ Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, UK.
¹⁰ Department of Orthopedics, Rheumatology and Traumatology, School of Medical Science, University of Campinas, Brazil.
¹¹ Hacettepe University Faculty of Medicine, Department of Pediatric Rheumatology, Ankara, Turkey, and Division of Pediatric Rheumatology, Hospital for Special Surgery, New York, New York.
¹² Division of Pediatric Rheumatology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota.
¹³ BC Children's Hospital and University of British Columbia, Vancouver, British Columbia, Canada.
¹⁴ Department of Maternal Sciences and Urological Sciences, Sapienza University of Rome, Rome, Italy.
¹⁵ University of Colorado School of Medicine, Aurora.
¹⁶ Division of Immunology, Rheumatology Program, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts.
¹⁷ Division of Pediatric Rheumatology, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri.
¹⁸ Division of Rheumatology, ERN RITA Center, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy.
¹⁹ Pediatric Radiology, Department of Radiology, University of Washington School of Medicine, Seattle.
²⁰ Division of Pediatric Rheumatology and Immunology, Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany.
²¹ Sanatorium for Children 'Detskie Duny', Saint-Petersburg, Russia.
²² Saint-Petersburg State Pediatric Medical University, Saint-Petersburg, Russia.
²³ Pediatric Rheumatology Unit, Instituto da Criança e do Adolescente, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil.
²⁴ Pediatric Rheumatology Division, Joseph M. Sanzari Children's Hospital, Hackensack University Medical Center and Hackensack Meridian School of Medicine, Hackensack, New Jersey.
²⁵ Division of Pediatric Rheumatology, Stanford University School of Medicine, Stanford, California.
²⁶ Division of Immunology, Department of Internal Medicine, Carver College of Medicine, University of Iowa Hospitals & Clinics, Iowa City.
²⁷ Rheumatology Unit, ERN ReCONNET Center, Meyer Children's Hospital IRCCS, Florence, Italy.
²⁸ Rheumatology Department, Mansoura University Hospitals, Mansoura University Faculty of Medicine, Mansoura, Egypt.
²⁹ Science-Research Institute of Phthisiopulmonology, Saint-Petersburg, Russia.
³⁰ Renaissance School of Medicine at Stony Brook University, Stony Brook, New York.
³¹ Division of Pediatric Rheumatology, Hospital for Special Surgery, New York, New York.
³² Patient Research Partner, California.
³³ Bristol Royal Hospital for Children & Translational Health Sciences, University of Bristol, Bristol, UK.
³⁴ IRCCS Istituto Giannina Gaslini and Università degli Studi di Genova, Genoa, Italy.
³⁵ Division of Pediatric Rheumatology, Department of Pediatrics, Michigan Medicine, Ann Arbor.
³⁶ Pediatric Rheumatology, ASST Gaetano Pini-CTO, Milan, Italy, and Department of Pediatrics, Division of Pediatric Rheumatology, Behcet and Autoinflammatory Disease Center, Western University, London, Ontario, Canada.
³⁷ Stead Family Children's Hospital, University of Iowa Hospitals and Clinics, Iowa City.
³⁸ University of Utah, Salt Lake City.
³⁹ Emory University School of Medicine/Children's Healthcare of Atlanta, Georgia.
⁴⁰ Patient/Parent Partner, Georgetown University, Washington, DC.
⁴¹ Department of Rehabilitation Seattle Children's Hospital, Seattle, Washington.
⁴² Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City.
⁴³ Department of Pediatrics, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital, Olomouc, Czech Republic.
⁴⁴ General Medicine and Rheumatology Service, Division of Medicine, Middlemore Hospital Counties Manukau District Health, Auckland, New Zealand.
⁴⁵ Department of Biostatistics, University of Washington, Seattle.
⁴⁶ Department of Pediatrics, Vivantes Clinic Friedrichshain, Berlin, Germany.
⁴⁷ Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Eaton Road, and Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
⁴⁸ The Hospital for Sick Children, St. Michael's Hospital and the University of Toronto, Ontario, Canada.

PMID: 40342207
DOI: 10.1002/art.43137

Abstract

Objective: To develop and validate classification criteria for pediatric chronic nonbacterial osteomyelitis (CNO) jointly supported by EULAR and the American College of Rheumatology (ACR).

Methods: This international initiative had 4 phases: (1) candidate items were proposed in a survey of pediatric rheumatologists, (2) criteria definition and reduction by Delphi and nominal group technique exercises, (3) criteria weighting using multicriteria decision analysis, and (4) refinement of weights and threshold score in a development cohort of 441 patients and validation in another cohort of 514 patients.

Results: The new EULAR/ACR classification criteria for CNO require typical radiographic or magnetic resonance imaging findings and bone pain as an obligatory entry criterion and exclusion criteria of malignancy, infection, vitamin C deficiency, and hypophosphatasia, followed by additive weighted criteria in 5 clinical (site of bone lesions, pattern of bone lesions, age at onset, coexisting conditions, fever) and 4 pathology/laboratory domains (bone biopsy findings if done, anemia, C-reactive protein level, and erythrocyte sedimentation rate). A total score ≥55 is required for classification as CNO. The new criteria had a sensitivity of 82% and specificity of 98% in the validation cohort.

Conclusion: These new classification criteria for pediatric CNO developed with international input reflect current views about CNO, have high specificity and good sensitivity, and provide a key foundation for future CNO research.

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Cited by

Diagnostic and therapeutic insights from a cohort of chronic recurrent multifocal osteomyelitis (CRMO) patients.
Ashari KA, Mousavi M, Sharabian FT, Assari R, Raeeskarami SR, Ziaee V. Ashari KA, et al. BMC Rheumatol. 2025 Jul 1;9(1):70. doi: 10.1186/s41927-025-00537-4. BMC Rheumatol. 2025. PMID: 40598636 Free PMC article.

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EULAR/American College of Rheumatology Classification Criteria for Pediatric Chronic Nonbacterial Osteomyelitis

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EULAR/American College of Rheumatology Classification Criteria for Pediatric Chronic Nonbacterial Osteomyelitis

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