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Steroid Induced Bilateral Avascular Necrosis of Head of Femur in an Adult Male Patient - A Case Report Dharamvirsinh Jadeja*,1, Vipul Solanki2, Bhavesh Chavada1 and Chandrabhanu Tripathi1

1Department of Pharmacology, Govt. Medical College, Bhavnagar, Gujarat, India 2Department of Radiodiagnosis, Govt. Medical College, Bhavnagar, Gujarat, India

Abstract: A 28 year old male patient, known case of pemphigus vulgaris was on dexamethasone pulse therapy. Total 7 pulses were given after that he developed avascular necrosis of head of femur on both sides, which was confirmed by digital X- ray and MRI. Avascular necrosis is a disabling and progressive condition in young patients gradually leads to femoral head collapse and eventual total hip arthroplasty. As per WHO-UMC causality assessment criteria, the association between reaction and drug was possible, Naranjo’s score was 7. According to Modified Schumock and Thornton’s criteria, this reaction was not preventable. The Modified Hartwig and Siegel’s scale showed that the reaction was severe (level 6). Here we present a case where the use of steroid for pemphigus vulgaris resulting in the development of bilateral avascular necrosis of head of femur.

Keywords: Corticosteroids, avascular necrosis, osteonecrosis, dexamethasone.

INTRODUCTION

Avascular Necrosis of the Femoral Head (ANFH) is a disabling and progressive condition in young patients gradually leads to femoral head collapse and eventual total hip arthroplasty [1, 2]. Corticosteroids (CSs) affect every system of the body and long-term use is associated with a myriad of well-established side effects, such as Avascular Necrosis (AVN). Ischemia is the underlying cause that leads to necrosis [3]. The common sites of involvement are the hip, the epiphysis of long bones like the femur and humerus, carpal bones, talus, metatarsals, and the mandible. More than 90% of cases involve the head of the femur, and 40% to 80% of cases are bilateral [3]. Here we present a case where the use of steroid for pemphigus vulgaris result in the development of bilateral avascular necrosis of head of femur in young men.

CASE REPORT

A 28 years old male patient, weight 45 kg, presented to the outpatient department of dermatology of Sir Takhtsinhaji General Hospital Bhavnagar, with a chief complain of multiple lesions on the body and pain in the leg for 3 months. He was a known case of pemphigus vulgaris and was taking dexamethasone pulses (200 mg per pulse) for it, total 7 pulses were given. No history of any allergy. After 3 days patient again come to the OPD of dermatology with same complain as described above. At that time patient was admitted in the dermatology ward and treatment was started. On admission, the patient was

*Address correspondence to this author at the Department of Pharmacology, Govt. Medical College, Bhavnagar, Gujarat, India; Tel: ?????????????????????; Fax: ???????????????????????; E-mail: dharamvir.jadeja@yahoo.com

conscious and stable with a pulse rate of 80/minute, blood pressure of 110/80 mmHg, temperature (99 ºF) and normal respiration. On examination multiple healed scar present on the body. Diffuse post inflammatory hyperpigmentation seen on the trunk and upper extremity. The patient was continuously complaining of pain in the joints and of muscle weakness, for that reason he was referred to an orthopedic doctor for expert opinion. The orthopedic doctor advised him for X-ray and MRI of the pelvis with both hip joints. Digital X-ray of pelvis with both hip joint shows subchondral lucency in the right femur head, marginal sclerosis in both acetabulum, irregular cortical outline of both femur head, loss of compression type of trabeculla (least), normal joint space of both hip joint suggestive of avascular necrosis of head of femur on both sides (right > left), Steinberg’s grade III (Fig. 1). An MRI was done under sedation as the patient has constant shaking movements of both legs during the procedure. Findings of MRI report show a geographic area of altered signal intensity involving bilateral femoral heads with irregular contours of both femoral heads. Bilateral hip joint spaces are reduced. Marrow edema is seen involving the neck and the rest of the head of the femur bilateral. Mild bilateral joint effusion. Mild marrow edema in the bilateral anterior column of the acetabulum, which was suggestive of avascular necrosis of head of femur on both sides. Laboratory investigation shows serum urea, serum creatinine, S.G.P.T., S.G.O.T., serum alkaline phosphatase, total bilirubin, direct bilirubin, indirect bilirubin, total protein, albumin, globulin, A.G. Ratio, plasma glucose was within normal range. Hematological parameters like hemoglobin, total white blood cells count, differential count, red blood cell count, packed cell volume, red blood cell indices, platelet count, erythrocyte sedimentation rate, were within normal range.

Dharamvirsinh Jadeja

2 Current Drug Safety, 2016, Vol. 11, No. 3 Jadeja et al.

Fig. (1).

Treatment was started with tablet azathioprine 50 mg two times a day, tablet chlorpheniramine two times a day, tablet aspirin 150 mg once a day, tablet dicofenac sodium 50 mg two times a day, capsule omeprazole 20 mg two times a day, tablet atorvastatin 10 mg two times a day, tablet multivitamin and tablet calcium. After confirmation of grade III bilateral avascular necrosis of head of femur by digital X-ray and MRI, dexamethasone pulse therapy was stopped, re-challenge was not performed. The patient was advised leg exercise for leg pain and muscle pain. The orthopedic doctor advised him for an operation, but the patient was refused to do so and continue with the same treatment, after 3 to 4 days of treatment patient was discharged from the hospital on request. Causality assessment was done by using Naranjo’s scale and WHO-UMC causality assessment criteria. Naranjo’s score was 7 [4]. As per WHO-UMC causality assessment criteria, the association between reaction and drug was possible [5]. According to Modified Schumock and Thornton’s criteria, this reaction was not preventable [6]. The Modified Hartwig and Siegel’s scale showed that the reaction was severe (level 6) [7].

DISCUSSION

Avascular Necrosis (AVN) occur due to the temporary or permanent loss of the blood supply to an area of bone, because of this the bone tissue dies and the bone became collapses [8]. Several risk factors have been identified in the etiology of avascular necrosis including, corticosteroid use, alcohol, trauma, infection, sickle cell disease, connective tissue disease, vasculitis, myeloproliferative disease, Gaucher’s disease, caisson’s ‘disease’, coagulopathies, pancreatitis, pregnancy and radiation [9]. Studies show that long term use of oral or intravenous corticosteroids is associated with non-traumatic osteonecrosis [10]. There are several pathogenic mechanisms for the avascular necrosis. Currently the vascular hypothesis, in which local microvascular thrombosis leads to a decrease in blood flow in the femoral head is accepted [11]. Steroid-induced avascular necrosis may develop in patients who

receive steroids in very high short-term doses, in lower long term doses, or even by intra-articular injection [12]. Radiographs, computed tomography scans, magnetic resonance imaging, and bone scans play an important role in the diagnosis of the disease at an early stage and thereby reducing the number and/or severity of complications and morbidity associated with the disease [1].   MRI is more sensitive than other diagnostic tools in the early stages of Avascular Necrosis of Femoral Head (ANFH). In this case avascular necrosis was diagnosed by history, physical examination, digital X - ray and MRI. Patient with pemphigus vulgaris has high risk of developing avascular necrosis due to long term use of high dose corticosteroid therapy [13]. Corticosteroid induced osteoporosis should also be monitored and timely management of the same is required to prevent avascular necrosis [13]. In conclusion, this case shows that avascular necrosis, which is an orthopedic emergency, are commonly caused by the use of long term corticosteroid therapy. Increase awareness of prescribers of high-risk drugs, close monitoring of systemic symptoms, with the withdrawal of the culprit drug may be the most cost-effective method to prevent such type of serious adverse drug reaction. Proper diagnosis by digital X-ray, MRI and other imaging techniques will help the clinicians to detect the condition at the earliest stage and obviating the need of hip replacement.

CONFLICT OF INTEREST

The authors confirm that this article content has no conflict of interest.

ACKNOWLEDGEMENTS

Declared none.

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Received: February 3, 2016 Revised: March 24, 2016 Accepted: April 3, 2016