Aseptic femoral head necrosis in a patient receiving long term courses of inhaled and intranasal corticosteroids

Aseptic (avascular) necrosis of the femoral head in adults has been associated with a variety of disease entities. It is also recognized as a potential complication of systemic corticosteroid therapy. Inhaled corticosteroids are the first line anti-inflammatory agents for the long term treatment of asthma. However, long term treatment of asthma with inhaled corticosteroids has been accompanied by concern about both systemic and topical side effects. The most worrying potential systemic effects are adrenal insufficiency, growth suppression, glaucoma and osteoporosis. Fluticasone proprionate may be prescribed at higher doses to relieve respiratory symptoms in the belief that it generates fewer side effects than other inhaled steroids. Studies have shown that fluticasone is safer than beclomethasone or budesonide, with limited oral absorption and extensive hepatic first pass metabolism leading to a lower systemic bioavailability. However growth retardation and asymptomatic adrenal suppression in children receiving high-dose fluticasone have been reported. We report a rare case of avascular osteonecrosis of the femoral head associated with the use of long term inhaled fluticasone propionate along with the intranasal application of triamcinolone acetonide.