Juvenile-onset multifocal osteonecrosis in systemic lupus erythematosus

Abstract

Rationale: Osteonecrosis (ON) is a devastating illness that leads to bone ischemia and potential joint destruction. Systemic lupus erythematosus (SLE) is a chronic, autoimmune disease, with multi-system involvement which is closely associated with occurrence of ON. Multifocal ON, with an estimated morbidity of 3% in SLE patients, is extremely rare in juvenile subjects. Patient concerns: A 13.3-year-old female SLE patient was admitted to hospital 20 months following the SLE diagnosis because of a sudden aggravation of sore knees. She suffered from double knee joint pain and her left knee joint showed typical signs of inflammation including redness, swelling, heat, and pain. Diagnoses: The SLE patient was diagnosed with multifocal ON of her knee joint based on magnetic resonance imaging findings of bone destruction and osteoproliferation at the bilateral distal femur and proximal tibia. Interventions: The patient received high-dose methylprednisolone and intravenous cyclophosphamide pulse therapies for controlling active lupus and nephritis. Oral calcitriol and dipyridamole were administered to alleviate knee pain and inhibit thrombi formation, thereby suppressing ON progress. Outcomes: Three weeks following the treatment, the swelling in patient's left knee subsided. Her self-reporting pain score decreased from 9 to 4 and walking time increased from 45minutes to 90minutes per day. Nearly 5 weeks later, the pain in bilateral knee joints disappeared and the patient could walk without difficulties. Lessons: This patient is the youngest SLE patient who developed multifocal ON based on the reported literature. It suggests that ON can occur in young SLE patients. A combination of internal and external risk factors can promote the development of ON. The balanced approach to the application of corticosteroids and immunosuppressors in the treatment of SLE and prevention of ON is a challenging problem that deserves further exploration.

Clinical Study on Systemic Lupus Erythematosus Complicated with Knee Bone Infarction

“…In addition to nondestructive arthritis, SLE can also lead to bone infarction, which is a serious complication of the disease [7][8][9][10]. In the bone marrow lumen of the long tubular bones located in the extremities, the thin and small nutrient vessels with few branches can easily lead to bone marrow ischemia necrosis and bone infarction.…”

Musculoskeletal symptoms in juvenile onset systemic lupus erythematosus

“…Дебют СКВ в детском и подростковом возрасте является фактором риска развития АВН, который при локализации в области коленных суставов может проявляться в первую очередь синовитом, в области тазобедренных суставовболью и ограничением функции, что нередко ошибочно трактуется как обострение артрита вследствие активности заболевания [50][51][52]. Впервые ассоциация этого осложнения с СКВ описана E.L. Dubois и L. Cozen в 1960 г.…”