ABSTRACT
CASE: A 37-year-old Hispanic female was referred to a tertiary center nine months status-post lung transplant secondary to post-COVID ARDS for evaluation of constant, dull, aching, gradually progressive pain in her bilateral lower extremities that was insidious in onset. Lab work was notable for persistently elevated alkaline phosphatase. 12 months prior to this admission, the patient was admitted for COVID-19 pneumonia for a week of ongoing fever, shortness of breath, and chest discomfort. Her hospital course was complicated by PE, ARDS, pneumothorax, required chest tube placement, intubation and ECMO. She was treated with dexamethasone, remdesivir, ceftriaxone, azithromycin, and convalescent plasma. Unfortunately, the patient developed post-ARDS pulmonary fibrosis and she was unable to wean off ECMO. Three months later, she underwent lung transplantation for postCOVID ARDS. Post- operative course was significant for profound shock intraoperatively, acute blood loss with delayed chest closure, Grade 3 primary graft dysfunction (PGD), critical illness myopathy, AKI with a need for continuous renal replacement therapy (CRRT) / hemodialysis, and Aspergillus pneumonia. She received two doses of COVID-19 vaccination. The patient underwent a bone scan that showed asymmetrically increased uptake in the bilateral femoral metadiaphysis, metaphysis, and proximal tibial metaphysis. There was questionable increased uptake in the humeral heads. MRI of the tibia showed bilateral distal tibial metaphysis/epiphysis heterogeneous T1 and T2 signal intensity lesions compatible with intramedullary infarct. There was no evidence of acute fracture or dislocation. Overall, the findings were consistent with multifocal osteonecrosis secondary to corticosteroid treatment. She is currently managed with analgesics in view of a nonsurgical approach as advised by the orthopedic team. IMPACT/DISCUSSION: Coronavirus disease 2019 (COVID-19) pandemic continues to present critical challenges for public health and medical communities globally. Its manifestations are predominantly respiratory, with multiorgan dysfunction in severe cases. Skeletal involvement is uncommon. Systemic corticosteroids such as dexamethasone are frequently used as the standard of care for critically ill COVID-19 patients to alleviate the hyperinflammatory response and reduce the need for mechanical ventilation. However, long-term treatment with dexamethasone can increase the risk of the development of osteonecrosis. In this case report, to our knowledge, we describe the first case of multifocal bone infarction in a patient treated with corticosteroids status-post lung transplant secondary to COVID-19 pneumonia. CONCLUSION: Recognizing clinical features of multifocal bone infarct as a late effect of corticosteroid treatment may be challenging given a complicated history of transplant and COVID-19. However, it may be prudent to consider osteonecrosis when a patient with prior steroid treatment history presents with musculoskeletal complaints.