556 - Bilateral avascular necrosis of the hip following steroid treatment for COVID 19: A Case Report and Review of Literature

Case Diagnosis: Bilateral avascular necrosis (AVN) of the femoral heads

Case Description: A 40-year-old female presented with a one-year history of right hip pain without known injury. The patient had a history significant for chronic pelvic pain secondary to endometriosis. She underwent excision of her endometriosis by gynecology with resolution of her pelvic and abdominal pain. However, her hip pain persisted. It failed to respond to physical therapy, NSAIDs, and baclofen.

She was subsequently referred to PM&R. Physical examination suggested intra-articular hip pathology. Plain right hip radiographs and MRI were consistent with AVN of the femoral head with collapse and labral tear. Interestingly, there was also osteonecrosis of the left femoral head without collapse. She was referred to orthopedic surgery for continued management. Further investigation of her medical history revealed she was hospitalized in December 2021 for COVID-19 and was treated with dexamethasone, which may have precipitated the development of her osteonecrosis.

Discussions: AVN of the hip is a rare condition with multiple risk factors, including prolonged glucocorticoid use. This case presents an instance of AVN in the setting of recent COVID-19 infection and short-term steroid use. Previous reports have documented AVN following COVID involving steroid treatment, and the literature is not yet clear on whether steroids, SARS-CoV-2, or a combination of both are responsible for an increased risk of AVN. In addition, this patient’s longstanding endometriosis obscured the underlying etiology of her hip pain. This highlights the importance of considering avascular necrosis in the differential for patients following COVID-19 infection.

Conclusions: Avascular necrosis should be considered in the differential diagnosis for patients with musculoskeletal symptoms following COVID-19. In cases such as the one presented where multiple explanations may exist for a patient’s pain, we recommend clinicians rule out avascular necrosis through standard imaging modalities, including plain radiograph and MRI without contrast of the involved joint.