Avascular necrosis as a part of ‘long COVID-19’

Abstract

‘Long COVID-19’ can affect different body systems. At present, avascular necrosis (AVN) as a sequalae of ‘long COVID-19’ has yet not been documented. By large-scale use of life-saving corticosteroids in COVID-19 cases, we anticipate that there will be a resurgence of AVN cases. We report a series of three cases in which patients developed AVN of the femoral head after being treated for COVID-19 infection. The mean dose of prednisolone used in these cases was 758 mg (400–1250 mg), which is less than the mean cumulative dose of around 2000 mg steroid, documented in the literature as causative for AVN. Patients were symptomatic and developed early AVN presentation at a mean of 58 days after COVID-19 diagnosis as compared with the literature which shows that it generally takes 6 months to 1 year to develop AVN post steroid exposure.

Corticosteroid induced avascular necrosis and COVID-19: The drug dilemma

“…Superadded to this; it was noted that the patients presented with the features of AVN at a mean of 58 days after their initial COVID-19 diagnosis and treatment. This is in contrast to the current literature which states that AVN takes 6 months to 1 year to develop post corticosteroid therapy [15,17]. It has been long established that steroids induced AVN, however reports of AVN developing rapidly in COVID-19 patients post treatment where specific treatment guidelines to avoid steroid induced AVN have been adhered to suggest that the COVID-19 infection itself may also be instrumental in the development of AVN and that steroid use is not the sole benefactor to inducing AVN post steroid therapy [15,16].…”

“…This is in contrast to the current literature which states that AVN takes 6 months to 1 year to develop post corticosteroid therapy [15,17]. It has been long established that steroids induced AVN, however reports of AVN developing rapidly in COVID-19 patients post treatment where specific treatment guidelines to avoid steroid induced AVN have been adhered to suggest that the COVID-19 infection itself may also be instrumental in the development of AVN and that steroid use is not the sole benefactor to inducing AVN post steroid therapy [15,16]. Prevention Current guidelines suggest that a cumulative ceiling dose of 2000mg of prednisolone or its equivalent should not be breached in order to prevent the development of AVN, however as seen in the research conducted by Agarwal et al it is evident that AVN is being induced in patients treated far below the 2000mg ceiling.…”

Risk factors and pathogenesis of steroid-induced osteonecrosis of femoral head - A scoping review

“…30,32e34 Liu et al suggested that genetic variants could be related to geographical and demographic distributions, and cases with a family history are at higher risk. 22 Chang et al also supported that some genes play an important role in predisposing an individual on steroids to develop SONFH. They found that the mutations in genes like eNOS, PAI-1, VEGF, and ApoA increase the risk for SONFH.…”

“…9 Liu et al suggested a daily dose of 40 mg steroids increases the risk for SONFH and above this level, every 10 mg increase in dose causes 3.6% increase in incidence. 22 Chang et al also found an increase in incidence with increase in dose and duration of steroids, but they were not able to calculate the average safe level of steroids. 10 ARCO task force has stated that the assignment of corticosteroids as the cause of a patient's ON, can only be made if the history of steroid Intra-medullary fatty infiltration Xudong et al 42 Cui et al 43 Cui et al 44 Yin et al 45 Miyanishi et al 46 Zhou et al 47 Increased intramedullary adipogenesis Decreased osteogenesis Tamponade effect due to fat accumulation.…”

“…21 During COVID-19 pandemic, an increased and early onset ONFH was reported and was correlated with the use of high doses of steroids and to the coagulopathy associated with this disease. 12,22 Osteonecrosis in a steroid-treated case does not mean that mere steroids might have caused it. All the possible risk factors should be considered as in most cases it's a cumulative effect leading to ON.…”