MOFFITT HOLIDAY PEARLS 12/22/16: MRONJ and Adult Still’s!

Thanks to Dave Anderson for putting these pearls together as our guest chief for the day and future Moffitt chief extraordinaire!!

Thank you to Kresh and Vaibhav for presenting two great cases in today’s afternoon report. We learned about the approach to jaw pain and more specifically osteonecrosis of the jaw 2/2 IV bisphosphonates. In addition, we talked through the classic rheum, infectious and malignancy (thank you Tejaswi) differential of a 36M presenting w/ chronic fevers, arthritis and rash found to have Still’s Disease! See below for some pearls.

Medication-related osteonecrosis of the jaw (MRONJ)

  • Relatively uncommon, but potentially serious side effect of treatment w/ either IV high-potency bisphosphonates (zoledronic acid in our case) or denosumab.
  • Consider in patients with the following characteristics:
    1. Current or previous treatment with antiresorptive or antiangiogenic agents
    2. Exposed bone
    3. No hx of radiation or metastatic disease to jaw
  • Overall risk increases with years of therapy as follows: < 2 % in first year, 3 percent in second year and 7 percent thereafter

Adult Still’s Disease (ASD)

    • A very uncommon inflammatory disorder (0.16 per 100,000) w/ equal distribution between the sexes and bimodal age distribution 15-25 and 36-46.
  • ASD is a diagnosis of exclusion w/ Yamaguchi criteria most sensitive and widely used


  • The four major Yamaguchi criteria are:
    1. Fever of at least 39ºC (102.2ºF) lasting at least one week
    2. Arthralgias or arthritis lasting two weeks or longer
    3. A nonpruritic macular or maculopapular skin rash that is salmon-colored in appearance and usually found over the trunk or extremities during febrile episodes
    4. Leukocytosis (10,000/microL or greater), with at least 80 percent granulocytes



Sammy (and Dave!)



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