Abstract Text: The COVID-19 pandemic was associated with the use of steroids at an unprecedented scale all over the world, and many patients required the use of intravenous bolus of methylprednisolone. High doses of steroids can be associated with avascular necrosis of the hips (AVN). A 38-year-old female presented to our center with progressive pain in the large joints. Her history was unremarkable except for a history of severe COVID pneumonia treated in the “second wave” with IV boluses of methylprednisolone two years earlier. Over the next few months, she had difficulty ambulating and had severe morning stiffness in the ankles, shoulders, and knees; the diagnosis was revised to rheumatoid arthritis since her rheumatoid factor and the ACPA were positive. She was initiated on DMARDs (arthritis medicines) and yet needed low-dose steroids and NSAIDs for symptom control, which now included stiff and painful shoulders and stiff ankles. There was a suboptimal response to DMARDs, and the patient continued to be miserable. The patient presented for a second opinion at our center after minimal response to treatment. The evaluation revealed AVN of the hips, shoulders, and talar domes. Her RF and ACPA were negative, and she had negative inflammatory markers. Her diagnosis was revised to osteonecrosis of multiple joints (AVN), and she was treated with NSAIDs and Bisphosphonates. Multi-site osteonecrosis is a rare entity and can mimic rheumatoid arthritis and spondyloarthritis; we may well be at the cusp of an epidemic of multisite AVN that will mimic rheumatoid arthritis over the next decade.
