Multiple site osteonecrosis in HIV infection

R. H. Mullan and P. F. J. Ryan

Alfred Hospital, Commercial Road, Prahran, Victoria 3181, Australia

SIR, Osteonecrosis [alternatively known as avascular necrosis (AVN)] involving up to three joints has been reported infrequently as a complication of HIV infection. Potential risk factors cited in sporadic case reports include the presence of HIV infection itself, the associated incidence of acquired antiphospholipid syndrome and other autoimmune phenomena, the hyperlipidaemic effect of protease inhibitors, and the prior use of corticosteroid therapy [17]. We present a case of avascular necrosis at eight separate sites in a HIV-positive patient.

Our patient, a 42-yr-old Caucasian homosexual male, presented 2 yr after a positive diagnosis of HIV infection, with an 18-month history of joint pain affecting his ankles, knees and hips, made worse by weight-bearing and walking. No joint swelling or evidence of synovitis was seen on musculoskeletal examination and there was no other evidence of connective tissue disease. A whole-body 99mTc methylene-diphosphate bone scan performed to look for inflammatory arthritis showed changes consistent with avascular necrosis bilaterally in the femoral heads, the talar domes, both lateral femoral condyles of the knees, and both glenohumeral joints. MRI scanning of the lower limb joints confirmed AVN at the six corresponding lower-limb joints affected on the bone scan. Anticardiolipin antibodies, lupus inhibitor screen and cryoglobulins were negative.Go



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FIG. 1. T1-weighted MRIs with coronal views of the hip, knee and ankle joints. (a) Bilateral osteonecrosis of the femoral heads. (b) Extensive osteonecrosis of both medial and lateral condyles of the femur, the medial and lateral condyles of the tibia on the left, and the medial condyle of the tibia on the right. (c) Bilateral osteonecrosis of the talar domes (arrows).

 
Possible risk factors for AVN identified from the patient's history were continuous treatment with protease inhibitors since diagnosis of HIV, hypertriglyceridaemia of 6.7 mmol/l (normal range 0.0–2.0 mmol/l) prior to the first onset of joint pain, and a 3-month course of corticosteroids (dexamethasone, 4 mg q.i.d. initially, as a reducing dose) for cerebral toxoplasmosis. Within 6 months of stopping corticosteroid therapy, the patient began complaining of ankle and knee pain severe enough to require the aid of a walking stick. At that time, he was treated with an NSAID without further investigation. Since his diagnosis of AVN he has suffered from chronic immobility and pain requiring 20 mg of MS Contin (morphine) twice daily.

To our knowledge, such extensive AVN in the setting of HIV has not been reported in the literature before. Although the diagnosis is made infrequently, its true prevalence is likely to be higher due to underdiagnosis on the part of treating physicians. A recent case–control trial reported a mean delay in diagnosis from onset of symptoms of 125 days [8]. Furthermore, a high prevalence of asymptomatic AVN of the hip has been demonstrated with MRI scanning in a large group of patients with HIV [9]. Given the increased longevity of AIDS patients receiving highly active antiretroviral therapy, many of these patients could go on to develop symptomatic disease unless potential risk factors are recognized and minimized.

Corticosteroid therapy in the treatment of other diseases is associated with a high rate of developing the radiological features of AVN on MRI, which can reverse after discontinuation of therapy [10, 11]. Of the risk factors for AVN proposed in HIV infection, only prior use of corticosteroids has been shown to be an independent risk factor in a recent controlled trial [12]. The onset of joint pain 6 months after high-dose dexamethasone treatment would be consistent with steroid-induced AVN and is the most likely precipitant in our patient.

Our case highlights the need for increased awareness of AVN in HIV-positive patients with joint pain. Clinicians need to be aware of the risks associated with corticosteroid therapy in this subgroup of patients, minimize its use when possible and investigate joint pain specifically for AVN so that disease-limiting interventions can be undertaken early.

Notes

Correspondence to: 20 Donnybrook Court, Beech Hill Road, Donnybrook, Dublin 4, Republic of Ireland. Back

References

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  9. Miller KD, Masur H, Jones EC et al. High prevalence of osteonecrosis of the femoral head in HIV-infected adults. Ann Intern Med 2002;137:17–25.[Abstract/Free Full Text]
  10. Oinuma K, Harada Y, Nawata K et al. Osteonecrosis in patients with systemic lupus erythematosus develops very early after starting high dose corticosteroid treatment. Ann Rheum Dis 2001;60:1145–8.[Abstract/Free Full Text]
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Accepted 25 March 2002





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