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Osteomyelitis and multiple avascular necrosis of bone (AVN) in a patient with systemic lupus erythematosus (SLE)

Introduction: Avascular necrosis of bone (AVN) is a rare musculoskeletal manifestation in patients with systemic lupus erythematosus (SLE). The poorly vascularized bone is a well recognized predisposing factor to osteomyelitis, but coincidental development of AVN and bone infection in SLE has rarely been described. We present a 17 year-old girl who was admitted to our Department in June 2006 with a 3-week history of polyarthralgia, fever, headache and facial rash. Diagnosis of SLE was made according to ACR criteria and treatment with methylprednisolone was started. She didn’ t respond well, and hydroxycloroquine and azathioprine were introduced. Three months later, she was readmitted because of right knee pain, weakness and myalgia with increased acute inflammatory parameters. SLE laboratory features were negative. Four days later she developed fever with painful and swollen right low extremity. She was diagnosed by MRI as having bilateral tibial AVN and distal femoral and proximal tibial osteomyelitis. Biopsy and drainage of right distal femur and knee were performed, and the culture revealed the presence of Staphylococcus aureus. Owing to severe sideffects to clindamycin and ciprofloxacin, therapy was modified to rifampicin and cloxacillin intravenously, which she is still receiving. Methylprednisolone was tapered to 0, 2 mg/kg and azathioprine was stopped. At present, SLE is in complete clinical and laboratory remission and there are no clinical signs of infection.

Osteomyelitis; avascular necrosis; bone; systemic lupus erythematosus; child

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