Clinical records of 877 patients with Crohn’s disease were retrospectively reviewed by the authors. Four patients with osteonecrosis were found, including two who were previously reported elsewhere. Follow-up data were available, with a mean for the entire patient group of 7.8 years. Osteonecrosis was diagnosed on the basis of routine radio- graphic studies and nuclear scanning, as well as modern imaging methods, including MRI, which has been available at the University of British Columbia Hospital, Vancouver, British Columbia since 1981. Statistical evaluation of the steroid and nonsteroid population included the Fisher’s exact test.
Case 1: A 28-year-old man was admitted to a community hospital in January 1987 because of abdominal pain and chronic diarrhea for three months with an associated weight loss of 10 kg. Barium radiographic and colonoscopic examinations revealed ulcerative and stenotic changes of Crohn’s disease involving the ileum, descending colon and sigmoid colon. Biopsies showed giant cell granulomas. Fecal cultures and examinations for parasites were negative. Treatment initially comprised intravenous hydrocortisone 480 mg daily and parenteral nutrition (including lipid emulsion). His diarrhea resolved completely, and his treatment was changed after three weeks of intravenous corticosteroids to predni- sone 60 mg orally daily. Arthralgias developed in both knees, but radiological studies were normal so he was discharged on 5-aminosalicylic acid (Asacol, Proctor & Gamble Pharmaceuticals Canada, Inc, Toronto, Ontario) and prednisone 45 mg daily. This dose was gradually reduced over the next two months and then discontinued. A colonoscopy showed ileal and cecal aphthous ulcers. He was asymptomatic for two weeks, but diarrhea recurred up to 10 times/day. There were no joint symptoms. The patient self-directed his prednisone treatment beginning at a dose of 50 mg daily with dosage changes depending on the presence or absence of knee arthralgias. He was seen in another hospital by a different gastroenterologist. Results of a sigmoidoscopy were normal. He was advised to reduce his corticosteroid dosage but used 10 mg to 20 mg daily over the next year. In August 1988, he ceased using prednisone, but right shoulder pain developed after a fall at his workplace and radiographs showed features of right humeral head osteonecrosis.
In August 1988, he was first seen at the University of British Columbia Hospital. His only symptom was right knee pain. Radiographs, bone scan and MRI showed osteonecrosis in the right humeral head and changes of osteonecrosis in both femoral condyles. In addition, MRI revealed early changes in both femoral heads. In November 1988, arthroscopy and decompression drilling of the left lateral femoral condyle were done to reduce pain and improve vascularization. Clinical evaluation in July 1989 revealed resolution of knee pain. No further follow-up data were available.
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