{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,27]],"date-time":"2026-08-27T20:02:00Z","timestamp":1787860920345,"version":"build-2784847793"},"reference-count":16,"publisher":"BMJ","issue":"12","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Case Rep"],"accepted":{"date-parts":[[2025,11,30]]},"published-print":{"date-parts":[[2025,12]]},"abstract":"<jats:p>Chronic non-bacterial osteomyelitis (CNO) is a rare, autoinflammatory bone disorder that primarily affects children and adolescents. Bone pain is its hallmark, though other symptoms may occur. The gradual onset and variable presentation make CNO difficult to diagnose and can delay treatment. Notably, systemic signs such as fever or weight loss are recognised but less common manifestations of the disease and are rarely the initial complaint.<\/jats:p>\n                  <jats:p>We report an adolescent male with two weeks of daily fevers, rigours, night sweats, headaches and weight loss. Bone pain appeared later, intermittently affecting multiple joints. Ultimately, MRI and bone biopsy results supported an autoinflammatory process. Symptoms and inflammatory markers improved with non-steroidal anti-inflammatory drugs, supporting the diagnosis of CNO.<\/jats:p>\n                  <jats:p>This case emphasises the atypical presentation and highlights the need to consider CNO in children with prolonged fever of unclear origin, even when bone pain is not the presenting symptom.<\/jats:p>","DOI":"10.1136\/bcr-2025-269450","type":"journal-article","created":{"date-parts":[[2025,12,16]],"date-time":"2025-12-16T01:35:13Z","timestamp":1765848913000},"page":"e269450","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":2,"title":["When fever comes first: an unusual presentation of chronic non-bacterial osteomyelitis"],"prefix":"10.1136","volume":"18","author":[{"given":"Michaela","family":"Karam","sequence":"first","affiliation":[{"name":"SMHS, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-2037-519X","authenticated-orcid":false,"given":"Eman","family":"Bamashmous","sequence":"additional","affiliation":[{"name":"Pediatric Rheumatology, Children\u2019s National Hospital, Washington, District of Columbia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4344-7032","authenticated-orcid":false,"given":"Anand","family":"Gourishankar","sequence":"additional","affiliation":[{"name":"Children\u2019s National Hospital, Washington, District of Columbia, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-9150-1530","authenticated-orcid":false,"given":"Jamie Marie Weihe","family":"DuBose","sequence":"additional","affiliation":[{"name":"Pediatric Hospital Medicine, Children\u2019s National Hospital Division of Hospitalist Medicine, Washington, Florida, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2025,12,15]]},"reference":[{"key":"2025121517350874000_18.12.e269450.1","doi-asserted-by":"crossref","first-page":"681","DOI":"10.1007\/s13312-023-2972-4","article-title":"Chronic Recurrent Multifocal Osteomyelitis Presenting With Fever of Unknown Origin","volume":"60","author":"Kimura","year":"2023","journal-title":"Indian Pediatr"},{"key":"2025121517350874000_18.12.e269450.2","first-page":"196","article-title":"Chronic Recurrent Multifocal Osteomyelitis in a 9-year-old Boy","volume":"5","author":"Malek","year":"2017","journal-title":"Arch Bone Jt Surg"},{"key":"2025121517350874000_18.12.e269450.3","unstructured":"Petty RE , Laxer RM , Lindsley CB , et al . 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LPIN2-related majeed syndrome. In: GeneReviews. Seattle, WA: University of Washington, 2023."},{"key":"2025121517350874000_18.12.e269450.10","doi-asserted-by":"crossref","first-page":"2301","DOI":"10.1007\/s00296-023-05491-3","article-title":"SAPHO syndrome: current clinical, diagnostic and treatment approaches","volume":"44","author":"Demirci Yildirim","year":"2024","journal-title":"Rheumatol Int"},{"key":"2025121517350874000_18.12.e269450.11","unstructured":"Morice A , Kadlub N , Coudert A . Cherubism. In: GeneReviews. Seattle, WA: University of Washington, 2025."},{"key":"2025121517350874000_18.12.e269450.12","doi-asserted-by":"crossref","unstructured":"Sheikh Y , Glick Y , Kearns C , et al . Chronic recurrent multifocal osteomyelitis. 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