Caffey Disease Imaging
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Caffey disease, or infantile cortical hyperostosis, is a benign, rare, proliferating bone disease affecting infants. Caffey and Silverman first reported this disease as a distinct entity in 1945. [1]
Classically, Caffey disease occurs in the early part of the first year of life (< 5 mo). It is characterized by a clinical triad (fever, soft-tissue swelling, hyperirritability) and a clinching radiographic picture of underlying cortical hyperostosis (thickening or bony expansion). In addition to the skeleton, the adjacent fascia, muscles, and connective tissues are also involved. [2, 3]
Some have suggested that Caffey disease has a predilection for patients with immunodeficiency disorders. [4, 5, 6] The skeletal effects of Caffey disease are demonstrated in the images below.
Two forms of Caffey disease have been described: prenatal and infantile. The prenatal form is rare and has a poor prognosis.
The prenatal form has been described as a more severe, congenital form of Caffey disease that is probably inherited as an autosomal recessive trait. Patients present with major angulation of the long bones, generalized symmetrical involvement of the skeleton, and polyhydramnios. Because the prenatal form is a rare presentation of Caffey disease, the remaining discussion in this article, except in the differential diagnostic section, pertains to the more common, infantile form. [7, 8]
Hyperostosis has also been reported in patients receiving therapeutic doses of prostaglandin E. Prostaglandins E1 and E2 maintain patency of the ductus arteriosus in infants born with ductus-dependent cyanotic congenital heart disease. This treatment helps to provide adequate time for the infant to mature in preparation of surgical intervention. However, cortical hyperostosis can occur as a complication of long-term treatment (4-6 wk). The bony changes appear to be dose and duration dependent. Regression of the bony changes occurs on the discontinuation of treatment. [9, 10]
Overall, the age of onset, clinical signs, laboratory results, and typical radiographic features are the clues leading to the correct diagnosis of Caffey disease. [1, 11]
Three pathologic phases of the skeletal and soft-tissue manifestations of Caffey disease have been described: early, subacute, and late.
The early phase is characterized by an acute intraperiosteal inflammatory reaction consisting of edema and cellular infiltration, with subsequent thickening of the periosteum. The inflammatory process can extend into the neighboring soft tissues, and cortical resorption may be present.
In the subacute phase, inflammation diminishes, the periosteum thickens, and ossifying periostitis subsequently develops. Beneath the periosteum, layers of immature lamellar bone are produced; these can be exuberant in nature. Bony deposition may occur in the neighboring soft tissues.
The late phase involves the removal of peripheral bone, beginning along the inner surface and extending outwardly. Cortical remodeling may also be observed.
The general radiographic findings of Caffey disease reflect the features described below.
The bones most commonly affected are flat bones: mandible (75% involvement), clavicle, rib (especially the lateral arches), scapula, skull, and ilium.
The tubular bones most commonly affected are the ulna bones, which usually show asymmetrical involvement.
Bones rarely affected are the vertebrae, carpus, tarsus, and phalanges. Symmetrical or asymmetrical distributions may be observed, and involvement can be monostotic and polyostotic. Tubular-bone involvement affects the diaphysis and spares the metaphysis and epiphysis.
The scapula is altered in 10% of cases, and any associated with exuberant hyperostosis may resemble neoplasm. Scapular involvement is also associated with neurologic deficit and diaphragmatic elevation.
When the ribs are affected, costal hyperostosis can be associated with an ipsilateral exudative pleural effusion. Bony rib fusion may occur and lead to scoliosis. In the forearm, when both the radius and ulna are affected, bony fusion is a particular risk, and the resulting synostosis may persist after the disease resolves.
Plain radiographs may show soft-tissue swelling and/or cortical hyperostosis (with doubling or tripling of the normal width of the bone). The periosteal reaction progresses to subperiosteal new bone formation.
Radiographic findings can range from a subtle indistinctness of the cortical margin (mild periosteal reaction) associated with soft-tissue swelling to a thick bony cloaking of the diaphysis of long bones. [12, 13]
Although Caffey disease is an abnormality of bone formation, destructive lesions of the skull or tubular bones have been identified.
The radiographic features of Caffey disease are demonstrated in the images below.
T1- and T2-weighted magnetic resonance imaging (MRI) scans reveal the periosteal reaction in Caffey disease, which appears prior to the characteristic radiographic findings of hyperostosis.
MRI provides excellent differentiation between bone and soft tissues. The modality also allows an evaluation of the extent of soft-tissue involvement, which includes edema. Soft-tissue edema has decreased signal intensity on T1-weighted images and increased signal intensity on T2-weighted images. Marrow edema has increased signal intensity on T2-weighted MRI.
Compared with plain radiography overall, MRI adds little important additional information for the clinical evaluation of Caffey disease, but it is useful when infection or neoplasia are considered more likely diagnoses.
MRI may be used to exclude subperiosteal hemorrhage; however, it is rarely used in this way. MRIs depict hemorrhage with subsequent new bone formation, as seen with differential diagnoses (eg, trauma, scurvy).
Soft tissue may be easily identified with ultrasonography, which is easy to perform on infants. Early periosteal new bone formation is also easily visualized with high frequency (10-14 MHz) transducers.
A soft-tissue mass would have nonspecific appearances and could not reliably exclude infection or neoplasia.
The distribution of radiotracer accumulation is similar with bone and gallium scans. Accumulation of the radiopharmaceutical in the involved bones is markedly increased during the active phase of the disease.
The characteristic “bearded-child” appearance is due to the intense and diffuse abnormal accumulation of radiotracer in the mandible.
Nuclear medicine scans are positive before radiographic signs develop. In addition, nuclear medicine studies may be useful for documenting the extent of skeletal involvement.
CT scanning findings in Caffey disease include the following: soft-tissue swelling; periosteal reaction (ossifying periostitis), which can progress to abundant subperiosteal new bone formation; and cortical thickening (cortical sclerosis due to the deposition of new bone). CT scanning is seldom necessary and is generally avoided because of its high radiation burden. [14]
Caffey J, Silverman WA. Infantile Cortical Hyperostosis. Preliminary report on a new syndrome. Am J Roentgenol. 1945. 54:1-16.
Mishra P, Panda SS, Tripathy M, Panda M, Das RR. Infantile cortical hyperostosis: two cases with varied presentations. J Clin Diagn Res. 2014 Oct. 8 (10):PJ01-2. [Medline].
Nistala H, Makitie O, Jüppner H. Caffey disease: new perspectives on old questions. Bone. 2014 Mar. 60:246-51. [Medline].
Kamoun-Goldrat A, le Merrer M. Infantile cortical hyperostosis (Caffey disease): a review. J Oral Maxillofac Surg. 2008 Oct. 66(10):2145-50. [Medline].
Wong YK, Cheng JC. Infantile cortical hyperostosis of the mandible. Br J Oral Maxillofac Surg. 2008 Sep. 46(6):497-8. [Medline].
Skiker I, Dafiri R. [Unusual lytic bone lesions in Caffey’s disease]. J Radiol. 2008 Nov. 89(11 Pt 1):1767-9. [Medline].
Kroon ND, Smith F, Sanghavi R, Sarkar P. Prenatal cortical hyperostosis (Caffey disease) with Down syndrome. J Obstet Gynaecol. 2009 Jan. 29(1):57-8. [Medline].
Kamoun-Goldrat A, Martinovic J, Saada J, Sonigo-Cohen P, Razavi F, Munnich A, et al. Prenatal cortical hyperostosis with COL1A1 gene mutation. Am J Med Genet A. 2008 Jul 15. 146A(14):1820-4. [Medline].
Estes K, Nowicki M, Bishop P. Cortical hyperostosis secondary to prostaglandin E1 therapy. J Pediatr. 2007 Oct. 151(4):441, 441.e1. [Medline].
de Almeida JF, Kimura H, Hercowitz LH, Korkes H, Troster EJ. Cortical hyperostosis secondary to prolonged use of prostaglandin E1. Clinics. 2007 Jun. 62(3):363-6. [Medline].
Kamoun-Goldrat A, le Merrer M. Infantile cortical hyperostosis (Caffey disease): a review. J Oral Maxillofac Surg. 2008 Oct. 66(10):2145-50. [Medline].
Szwed A, Kolban M, Romanowska H, Baryla-Pankiewicz E. Familial occurrence of Caffey-Silverman syndrome. Ortop Traumatol Rehabil. 2012 Jan-Feb. 14(1):75-83. [Medline].
Nemec SF, Rimoin DL, Lachman RS. Radiological aspects of prenatal-onset cortical hyperostosis [Caffey Dysplasia]. Eur J Radiol. 2012 Apr. 81(4):e565-72. [Medline].
Darmency V, Thauvin-Robinet C, Rousseau T, Mejean N, Charra S, Coron F, et al. Contribution of three-dimensional computed tomography in prenatal diagnosis of lethal infantile cortical hyperostosis (Caffey disease). Prenat Diagn. 2009 Sep. 29(9):892-4. [Medline].
Bonnie C Davis, MD Assistant Professor, Department of Radiology, Howard University College of Medicine
Bonnie C Davis, MD is a member of the following medical societies: American Roentgen Ray Society, National Medical Association, Radiological Society of North America
Disclosure: Nothing to disclose.
Welansa Asrat, MD Staff Physician, Departments of Medicine and Pediatrics, Saint Vincent’s Medical Center
Disclosure: Nothing to disclose.
Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.
Kieran McHugh, MB, BCh Honorary Lecturer, The Institute of Child Health; Consultant Pediatric Radiologist, Department of Radiology, Great Ormond Street Hospital for Children, London, UK
Kieran McHugh, MB, BCh is a member of the following medical societies: American Roentgen Ray Society, Royal College of Radiologists
Disclosure: Nothing to disclose.
Eugene C Lin, MD Attending Radiologist, Teaching Coordinator for Cardiac Imaging, Radiology Residency Program, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine
Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, Society of Nuclear Medicine and Molecular Imaging
Disclosure: Nothing to disclose.
The authors wish to thank Middleton Funches and Shauna Fields for their tremendous technical assistance. We are greatly indebted to Dr Clifton Leftridge, Jr, for providing invaluable images. Special thanks to Alice Davis for her unwavering support.
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