Multiple drugs
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Multi-site avascular necrosis and analgesia overuse headache: case report An approximately 25-year-old man developed multi-site avascular necrosis (AVN) during treatment with cyclophosphamide, doxorubicin, vincristine, prednisolone, cytarabine, methotrexate, ifosfamide and etoposide. Additionally, he developed analgesia overuse headache during treatment with amitriptyline, dosulepin, pregabalin, oxycodone and clonazepam [routes and doses not stated]. The man, who was working in Navy, presented to the rheumatology department in August 2018 at the age of 32 year for evaluation of an aetiology of multi-site AVN. Anamnesis revealed that he had a history of mild Raynaud’s symptoms in his hands and recurrent oral ulceration. In February 2011, he was diagnosed with T-cell lymphoma while in the Navy. He received chemotherapy comprising two cycles of cyclophosphamide, doxorubicin, vincristine and prednisolone (CHOP regimen), and four cycles of cyclophosphamide, vincristine, doxorubicin, methotrexate, ifosfamide, etoposide and cytarabine (CODOX-M IVAC), which was completed in September 2011. Six months after the completion of chemotherapy (at an approximate age of 25-year), he developed severe bilateral hip pain. X-ray showed bilateral AVN. On medical grounds, he was discharged from the Navy. In 2013, he underwent bilateral total hip replacements. In March 2014, he developed pain in both shoulders. MRI scan showed extensive bilateral humeral head AVN. He underwent re-surfacing surgery on both the shoulders. Between June–July 2014, he was reviewed by the pain team and a palliative care consultant for his ongoing widespread pain in his wrists, elbows, knees and ankles. He also had poor sleep, depression and expressed frustration about his general health and inability to work. He received multiple analgesic medications including amitriptyline, pregabalin, dosulepin [dothiepin], oxycodone, clonazepam and oxycodone [Oxynorm]. He also received cognitive behavioural therapy. However, he developed a headache. He saw a neurologist, who concluded the headache as an analgesia overuse headache. In December 2017, he developed more pain in his ankles and knees. X-rays showed AVN of both knees. In June 2018, he underwent a right total knee replacement. MRI of ankles revealed signs of bilateral AVN with bone infarction of the distal tibia and a small area of the talus bilaterally. On current presentation in the rheumatology clinic, investigations showed underlying hyperlipidaemia. Other investigations were found to be unremarkable. The multi-site AVN was considered to be likely related to chemotherapy, steroid and underlying untreated hyperlipidaemia. The AVN had devastating painful and psychological consequences to his daily functioning. The man’s ongoing issues included widespread pain along with further progression of AVN to different sites. Haque A, et al. A challenging case of multi-site avascular necrosis. Rheumatology 59 (Suppl. 2): ii29 abstr. P27, Apr 2020. Available from: URL: http://doi.org/10.1093/ 803507752 rheumatology/ke
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