Glucocorticoid-induced Multifocal Osteonecrosis: a Case Report

The development of osteonecrosis (ON) is a relatively rare but irreversible complication of glucocorticoid therapy. The pathological process usually occurs in the epiphyses of long bones: the femoral head, the distal part of the femur, and the proximal humerus. However, multifocal involvement affecting three or more anatomical zones simultaneously is also possible. The objective: to demonstrate a clinical case of multifocal ON (MFON) associated with glucocorticoid pulse therapy to raise clinicians’ awareness of this rare pathological condition. Materials and methods. To interpret a clinical case of MFON in accordance with current recommendations for the diagnosis and treatment of this disease, we conducted a search for scientific sources on ON in the PubMed, Web of Science, and Scopus databases, including articles published in English in peer-reviewed journals up to November 2024. The search terms included “osteonecrosis,” “multifocal osteonecrosis” and “glucocorticoids.” An interpretation of our own clinical case was performed in the context of current scientific data. Results. The described clinical case demonstrates the development of MFON in 26-year-old military personnel who received high-dose, long-term pulse therapy with methylprednisolone due to an eye injury. The patient’s primary symptom upon consultation was bone pain in multiple locations. Systemic connective tissue diseases, thrombophilias, and antiphospholipid syndrome were excluded during diagnostic evaluation. Magnetic resonance imaging scanning revealed signs of multiple avascular necrosis affecting 10 anatomical areas. The patient underwent surgery (arthroscopic debridement of the knee joints, tunneling of the femoral neck), intra-articular administration of bone marrow aspirate suspension into the hip and knee joints, as well as treatment with bisphosphonates, atorvastatin, сalcium supplements, and vitamin D. However, despite the treatment, the patient continued to experience persistent pain two years after initiating therapy. Conclusions. The onset of new joint pain during glucocorticoid therapy should raise suspicion of ON. Raising awareness of this pathological condition and its associated risk factors should help clinicians to identify patients at high risk of developing ON and choose the optimal dose and duration of glucocorticoid therapy.