Lesson of the week: Depot corticosteroid treatment for hay fever causing avascular necrosis of both hips

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Abstract
Case report A 42 year old man of Sri Lankan origin developed hay fever at 21 years of age, but his symptoms became severe and disabling only at the age of 27. Every year in mid-April he developed uvular swelling, palatal irritation, profuse rhinorrhoea, incessant sneezing, nasal obstruction, and conjunctivitis. Symptoms continued until the end of July, peaking in June, consistent with tree and grass pollen allergy. His symptoms were so severe that he was unable to work, and he had to sleep with a towel over his pillow. For the past eight years he had also developed seasonal asthma that started in early July and lasted for 2–3 weeks. He had used antihistamines and a number of topical nasal corticosteroids, including beclometasone, fluticasone, and budesonide, but without relief of symptoms; therefore his general practitioner resorted to depot corticosteroids. From 1987 to 1997 he was given 16 injections of depot corticosteroid: nine of Kenalog (triamcinolone; Bristol-Myers Squibb, Hounslow) 40 mg and seven of Depo-Medrone (methylprednisolone; Pharmacia & Upjohn, Milton Keynes) 80 mg. After each injection his symptoms were substantially relieved for up to six weeks. He had no history of atopy or asthma outside the grass pollen season. He was a non-smoker, did not drink alcohol, and had no history of substance abuse or previous musculoskeletal problems. View larger version: In this window In a new window Fig 1 Plain radiograph of the hip joints, showing severe avascular necrosis on the right, with collapse of the femoral head associated with underlying lysis and sclerosis. The acetabular joint surface is normal, confirming that this is not a degenerative (osteoarthritic) process. Mild avascular necrosis is seen on the left, with an area of lysis surrounded by a diffuse area of sclerosis In August 1997 he developed a limp, with pain in his right hip, and a few months later developed similar symptoms in his left hip. Plain radiographs showed abnormalities in both hip joints (figure 1). A magnetic resonance scan arranged by an orthopaedic surgeon showed avascular necrosis of the superior segment of the right femoral head, with early avascular necrosis of the left femoral head (figure 2). It was thought that he would require bilateral total hip replacement at some stage in the future. View larger version: In this window In a new window Fig 2 Magnetic resonance image (T1 weighted) of the hips. The entire femoral head is reduced in signal on the right, indicating diffuse oedema around the necrotic segment. On the left, a line of low signal surrounds an area of normal signal, indicating a previous avascular insult. The normal signal within the lesion corresponds to normal fat and indicates that the marrow at this site is still viable