Corticosteroids have been used in many inflammatory conditions across different specialities since their invention by Philip Hench in 1950. However, the irrational use of steroids can cause side effects, which can be in multiple systems causing high morbidity and mortality. Long term steroids cause Cushing's syndrome, obesity and diabetes.1 Osteoporosis and fragility fractures are common in patients taking steroids.2 This case is presented to highlight the complexity of diagnosis and management of steroid-related osteoporotic vertebral collapse3 and the need other speciality inputs, especially during the Covid Pandemic.
We report a 68-year-old lady with a long history of rheumatoid arthritis and had been on prednisolone 5mg for the last 2 years, and anti-inflammatory drugs presenting with vomiting and unable to tolerate any medicines or food. She didn’t have any fever or cough.
She was advised to stop steroids because of gastritis and oral candidiasis before this presentation. During the evaluation, she had features of hypoadrenalism with low sodium (Serum sodium: 128 mEq/L, Blood Pressure: 90/40 mmHg,) hypotension and fatigue, which improved with hydrocortisone injection. She also had recent onset of diabetes for 6 months and developed an abdominal wall wound, which was more like ulceration with clear margins.
After 3 days she complained of back pain and unable to weight bear. Examination showed paraparesis, with power 2/5 in legs, sensation reduced below L1 and normal bladder and bowel functions. She urgently had MRI of spine (Figure 1) that showed collapsed osteoporotic vertebra and impingement of the cord resulting in leg weakness. She was screened for Covid 19 as per institutional protocol and was found to have an RTPCR test negative. Her CT chest Showed fibrotic strands and no ground glass changes or nodes.
She was evaluated for myeloma and metastasis from unknown primary and results were normal. She didn’t remember any fall and she came in with features of Addisonian crisis due to sudden withdrawal of long term corticosteroids. While she was being prepared for surgery she had Zoledronic acid infusion. DEXA scan couldn’t be done due to urgency. Abdominal wall wound was swabbed for culture.
She underwent urgent spinal decompression and fixation/stabilisation using D12, L1 screws, D11 laminectomy and D10 to L1 stabilisationFigure 2 and she was making slow recovery. Her neurological recovery was fast with passive and active movements of her legs.
Corticosteroids are the main drugs in the therapeutic armamentarium of various inflammatory diseases across various specialities. Steroids causing complications have been proven for years and can have devastating consequences to the patients like fracture femur or spine, diabetes and risk of cardiovascular disease 4 Over the counter remedies also do have steroids. Non Allopathic doctors too prescribe allopathic medications. Systemic steroids have to be used only for the short term. Our patient had steroids for 2 years and now had a total collapse of a vertebra with neurological consequences which was managed at the right time. 5
Early and appropriate diagnosis with other specialist involvement helped to solve this patient’s back pain. It is advised to review all medicines whenever patients come for consultation and flag up those Medicines for the patients to reconsider if the risk outweighs the benefit.
Any consultation will be incomplete unless the doctor reviews all medications for the patient
Osteoporosis and fractures need acute intervention and long term treatment as National Osteoporosis Framework guidance.4
I would like to thank the patient and family, the specialists involved in this patients care and the neurosurgeon for a swift response during covid too.