P27 A challenging case of multi-site avascular necrosis

Abstract

Background: A 32 year old gentleman was assessed in the rheumatology department in August 2018 having been referred for investigation into the cause of multi-site avascular necrosis (AVN). Method(s): He had mild Raynaud's symptoms in his hands and recurrent oral ulceration. He was previously fit and well without any history of thrombotic events or family history. He smoked 2 cigarettes a day and denied any alcohol intake. Result(s): In February 2011 he was diagnosed with T-cell lymphoma while in the Navy. He underwent chemotherapy in a medical oncology department at a tertiary care centre. His chemotherapy regime involved 2 cycles of cyclophosphamide, doxorubicin, vincristine and prednisolone (CHOP) and 4 cycles of cyclophosphamide, cytarabine, vincristine, doxorubicin, methotrexate, ifosfamide, etoposide, cytarabine (CODOX-M IVAC) which finished in September 2011. He developed severe bilateral hip pain 6 months after completing his chemotherapy. X-rays revealed bilateral avascular necrosis (AVN). He was discharged from the Navy on medical grounds and underwent bilateral total hip replacements in 2013. In March 2014 he developed pain involving both shoulders. An MRI scan revealed extensive bilateral humeral head AVN. He was seen by an orthopaedic surgeon at a tertiary centre and underwent re-surfacing surgery on both shoulders. Meanwhile he was reviewed by the pain team and a palliative care consultant in June- July 2014 for ongoing widespread pain in his elbows, wrists, knees and ankles. He also suffered from depression, poor sleep and expressed frustration regarding his general health and inability to work. Multiple analgesic agents used included amitriptyline, dothiepin, pregabalin, oxycodone, oxynorm and clonazepam. He also tried cognitive behavioural therapy (CBT). He developed a headache and saw a neurologist who investigated this and concluded the patient had an analgesia overuse headache. In December 2017 he developed more pain in his knees and ankles and X-rays revealed AVN of both knees. He underwent a right total knee replacement in June 2018. An MRI scan of his ankles revealed signs of bilateral AVN with bone infarction of the distal tibia and a small area of the talus bilaterally. When he was assessed in the rheumatology clinic in August 2018, he had a number of investigations which revealed normal blood counts, haemoglobin electrophoresis and clotting screen. An autoimmune screen was negative including ANA, ENA and antiphospholipid antibodies. An infection screen including HIV was also negative. A lipid screen revealed a triglyceride level of 10.9, cholesterol 8.1 and HDL ratio of 9.3. Conclusion(s): This challenging case involves a young patient with AVN in 8 sites which is rare. The AVN is likely related to chemotherapy, steroids and untreated hyperlipidaemia. There have been devastating painful and psychological consequences to his daily functioning. Ongoing issues include widespread pain and further sites of AVN.