Fig. 1

Radiographic and clinical imaging of both patients. A-B X-rays of Patient 1 showed ‘onion skin-like’ cortical thickening of the tibiae and fibulae, particularly on the medial side, along with narrowing of the medullary cavity. C-D After 2 years of etoricoxib treatment, Patient 1 displays a significant reduction in the cortical thickening of the tibiae, with less pronounced ‘onion skin-like’ features compared to earlier images. E–H The diaphyses of the ulnae, radii, femurs, and tibiae/fibulae are thickened in Patient 2, accompanied by bilateral bowing deformities in the ulnae and radii. Layered periosteal reactions are also visible around these bones. I The Pedigree for Patient 2. J-L Patient 2 exhibits clubbing of the distal extremities and noticeable skin swelling in the lower limbs