Case presentation
A 53-year-old man with a history of diabetes and hypertension, was
followed since 2020 for a severe spontaneous pain on the left leg
without triggering factor, mild at first, then getting worse gradually.
Pain was prolonged, chronic and recurrent and was worsened by physical
activity. He did not report any illness of the right leg. Nonsteroidal
anti-inflammatory drugs (NSAID) were ineffective. The patient did not
report any notable trauma or infection or familial bone disease history.
At examination, we did not notice local heat, swelling, or redness.
Laboratory data were within normal limits: erythrocyte sedimentation
rate (ESR) :20 mm, C-reactive protein (CRP) :5 mg/l, normal liver and
kidney function, calcemia : 2.3 mmol/l, phosphoremia : 1.18 mmo/l,
alkaline phosphatase: 58 UI/L.
Plain Radiographies showed bilateral massive sclerotic intramedullary
lesion of tibial shafts, cortical bone thickening, and narrowing of the
medullary cavity. No periosteal reaction or soft-tissue abnormality or
fracture lines were seen (Figure 1, Figure 2). The diagnosis of IMOS of
both tibia shafts was suspected. As etiological diagnosis of the
osteosclerosis, we discussed malignant tumors (osteosarcoma, lymphoma,
bone metastasis), benign tumors such as multifocal osteoid osteoma,
stress fractures, metabolic disorders and hereditary bone diseases.
Nevertheless, all these diagnosis were excluded as laboratory findings
were normal, no familial bone disease history was present, no extensive
periosteal new bone formation and soft-tissue abnormality were noted on
the radiography. Indeed, the bilateral characteristics of the process,
and the exclusion of other diagnosis were sufficient to retain the
diagnosis of IMOS and we did not perform any supplementary exploration.
Concerning therapeutic management, the patient received level 2
analgesic and NSAID with a good response. The last outpatient meeting
was held on February 2022 and he reported a good evolution.