AVN of All Four Heads in a Case of T Cell Acute Lymphocytic Leukemia: A Rare Case Report
Journal Title: Journal of Bone and Joint Diseases - Year 2017, Vol 0, Issue 0
Abstract
Introduction: Avascular necrosis (AVN) of bone is a significant long-term complication of treatment of hematological malignancies that can result in significant morbidity and alteration of quality of life. There are a few reports of AVN in patients with lymphoma or leukemia describing the incidence, risk factors, and diagnostic studies. Incidence rate vary widely depending on the time the study was conducted and the methods used for diagnosis. In patients with ALL multiple factors can contribute to the pathogenesis of AVN, such as the malignancy itself, procoagulant states and cytotoxic drugs. However, corticosteroids are considered to be the most important etiological factor. We hereby present a unique case where all the four heads, both femoral and humeral are simultaneously involved in a case of ALL at the time of presentation. Case Report: A 28 year old female, diagnosed as a case of T cell ALL under treatment presented to our OPD with complaints of pain in both shoulders and hip joints. High dose of prednisone and methotrexate was administered. She finally underwent allogenic stem cell transplantation 1 year after the diagnosis was made. On clinico-radiological examination both humeral and femoral head AVN was diagnosed. AVN of femoral head was managed operatively by core decompression and non weight bearing for 3 months. AVN of humeral head was managed non operatively by physiotherapy. Zolendronic Acid was given yearly 6 months post op and supplemental calcium, vitamin D for 2 years. At the end of 1 year patient was revaluated clinico-radiologically which showed marked improvement in hip ROM with Harris Hip Score improved from 54 to 72 on the right side and from 51 to 69 on the left side. For shoulder there was improvement too with Constant- Murley score improved from 50.3 to 92.0 on the right side and from 60.9 to 96.0 on the left side. Discussion: Bone pain is a complaint in as many as 50% of patients with acute leukemia, especially those with ALL. Joint pain occurs much more commonly than other bone pain in patients with leukemia and may be due to hyperuricemia, leukemic joint infiltration and, rarely, AVN. Management of AVN of femoral head involves non operative and operative management. With the current evidence, bisphosphonates are the mainstay in non operative management of AVN and can be used for 3 years in Stage-I, II and III (Stienberg Classification). Core decompression is the most routinely performed surgical procedure for treatment of early AVN. This is a novel case reported in which there is a simultaneous involvement of bilateral shoulder joints along with the hip joints. Conclusion: This is a novel case reported in which there is a simultaneous involvement of bilateral shoulder joints along with the hip joints. A high level of suspicion is required while treating AVN especially in cases of known long term steroid intake. Institution of early treatment is the key in the management of AVN for a favourable outcome.
Authors and Affiliations
Pramod Bhilare, Md Sehal Khan Abid, Md Talha Khan Abid, Neeraj Mishra, Sarang Patki, Pravin Bande
Keywords
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