Bilateral femoral head avascular necrosis with physiological
Avascular necrosis (AVN) of the femoral head is a dreaded complication of corticosteroid therapy. Seldom is this complication seen in endocrinology practice because the usual doses used in endocrinology are physiological doses given as replacement for steroid deficiency.

Published in the Indian Journal of Endocrinology, the authors report a case of bilateral femoral head AVN with replacement doses of oral prednisolone therapy. This patient was a 38-year-old male with non-secreting pituitary macroadenoma who was operated and eventually developed pan-hypopituitarism for which he was treated with thyroxine, testosterone injections and replacement doses of corticosteroids.

He had also received dexamethasone tablets 2 mg per day for 1 month prior to surgery. He presented 2 months after surgery with adrenal insufficiency when he was initiated on prednisolone 7.5 mg which was later reduced to a daily dose of 5 mg. After about 2 years of prednisolone therapy (daily dose 5 mg), he started having pain in bilateral hip associated with limping. He was diagnosed as bilateral femoral head AVN.

The 2nd case, the authors came across was a 60-year-old female patient who was diagnosed as Sheehan's syndrome at the age of 45 years. She had been on thyroxine and 5 mg of prednisolone for past 16 years (during which period she maintained a weight of 49–50 kg). Increase of prednisolone dose to 7.5 mg for 1 month during illness resulted in puffiness, fullness and redness of cheeks.

She was subsequently shifted to hydrocortisone 20 mg daily, which she took for one-and-half years, after which she started experiencing pain in both hips in succession associated with progressing limping.

She was evaluated for hip pain and found to be having AVN of both the femoral heads. Her cortisol remained persistently low at 7.69 nmol/L, 12.6 nmol/L and 13.8 nmol/L during follow up. She could not tolerate further lowering of hydrocortisone doses.

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