BMJ Case Reports 2018; doi:10.1136/bcr-2018-225532
  • Rare disease

Multifocal avascular osteonecrosis despite appropriate anticoagulation therapy in a patient with systemic lupus erythematosus and antiphospholipid syndrome

  1. Dario Roccatello1
  1. 1Department of Clinical and Biological Sciences, Center of Research of Immunopathology and Rare Diseases- Coordinating Center of Piemonte and Valle d’Aosta Network for Rare Diseases, University of Turin and S. Giovanni Bosco Hospital, Turin, Italy
  2. 2School of Specialization of Clinical Pathology, Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
  3. 3UGC Reumatologia, Hospital Universitario Reina Sofía de Córdoba, Córdoba, Andalucía, Spain
  1. Correspondence to Dr Savino Sciascia, savino.sciascia{at}
  • Accepted 3 October 2018
  • Published 1 November 2018


Multifocal avascular osteonecrosis (AON) is a serious manifestation of systemic lupus erythematosus (SLE). Prothrombotic factors, especially antiphospholipid antibodies (aPL), have been associated with the development of AON; therefore, attenuating the procoagulant state while balancing the haemorrhagic risks might have a rationale when managing this condition. We report a case of a 37-year-old patient with SLE, treated with low doses of corticosteroids and immunosuppressive therapy, who was started on vitamin K antagonist following an episode of deep vein thrombosis while having persistent positivity for aPL. After 2 years, he presented with multifocal AON, involving both femurs and shoulders. The patient underwent a bilateral hip replacement, but despite appropriate anticoagulation therapy after 2 years, he developed another episode of AON at both distal epiphyses of the femurs and proximal epiphyses of the tibias. Multifocal AON should be suspected, especially in the presence of aPL positivity. Its aetiology is still unknown and is most likely multifactorial. Its management is challenging and requires combined approaches.


  • Contributors IC and DR designed the study, performed data analysis and drafted the manuscript. IC, LP-S, SS and DR gave a substantial contribution to concept and study design and participated in the interpretation of data. All the Authors gave the final approval of the version to be published.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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