Avascular Bone Necrosis in Systemic Lupus Erythematosus: An European Review Uncovering Hidden Risks, Early Diagnostic Gaps and Clinical Case Insight

Aseptic bone necrosis (ABN), also known as avascular necrosis (AVN), is a serious and often overlooked complication of systemic lupus erythematosus (SLE), a chronic autoimmune disease with diverse symptoms. AVN in SLE is caused by multiple factors, including blood supply disruption due to clotting disorders, chronic inflammation, and especially prolonged use of moderate to high- dose corticosteroids. This review analyzes 17 out of 62 peer-reviewed European studies (2015–2024) from the PubMed database, focusing on osteonecrosis in lupus. ABN affects between 0.8% and 33% of SLE patients, with a mean symptomatic rate of 9%, while up to 29% may be asymptomatic. The femoral head is most commonly involved. Besides corticosteroid use, other risk factors include antiphospholipid antibodies (especially anticardiolipin IgM), endogenous hypercortisolemia, hypercoagulability, dyslipidemia, and active disease. In Romania, where no national registry exists, a representative case of a 27-year-old woman with undiagnosed SLE and bilateral femoral head necrosis without steroid exposure highlights the role of autoimmune coagulopathy. Misdiagnosis of her facial rash as rosacea delayed proper identification, emphasizing the importance of clinical awareness in atypical cases.