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An unusual complication of intra-articular injections of corticosteroids. Tachon syndrome
Annales de réadaptation et de médecine physique 50 (2007) 721–723 http://france.elsevier.com/direct/ANNRMP/
Clinical case
An unusual complication of intra-articular injections of corticosteroids. Tachon syndrome Two clinical case studies A. Hajjioui*, A. Nys, S. Poiraudeau, M. Revel Service de rééducation et de réadaptation de l’appareil locomoteur et des pathologies du rachis, APHP, université René-Descartes, groupe hospitalier Cochin, 27, rue du Faubourg–Saint-Jacques, Paris 75014, France Received 14 June 2007; accepted 21 June 2007
Abstract Local injections of corticosteroids can, in very rare cases, be complicated by Tachon syndrome–intense lumbar and/or dorsal and/or thoracic pain a few minutes after the injection, with rapid regression of the pain. Passing the drug into a vein through a nick made during the procedure could explain the pathophysiology of this disorder. We report two good cases illustrating the typical symptoms of this distressful syndrome. Diagnosis of Tachon syndrome is made by elimination of the usual medical and surgical causes, and physicians performing local injections should be aware of this phenomenon. The patient needs to be reassured of the temporal nature of the syndrome. © 2007 Elsevier Masson SAS. All rights reserved. Keywords: Corticosteroids; Intra-articular injections; Adverse reactions; Tachon’s syndrome; Low back pain
1. Introduction Intra-articular injections of corticosteroids are among the most frequently used treatments in rheumatology. Even though this local treatment can give rise to systemic effects [6–8], likely to cause generalized adverse reactions [8], it is most often well tolerated. In very rare cases, intra-articular injection of corticosteroids can lead to severe lumbar and/or dorsal and/ or thoracic pain consistent with Tachon syndrome [3–5]. We report two cases of Tachon syndrome after injection of a corticosteroid suspension. 2. Case one A 47-year-old male consulted for the third episode of right medial humeral epicondylitis. After failure of local physiotherapy and rehabilitation, he first received an intra-articular injection of prednisolone, 75 mg, at the site of the pain, with an * Corresponding
author. E-mail address: [email protected] (A. Hajjioui).
0168-6054/$ - see front matter © 2007 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.annrmp.2007.06.002
excellent initial result for 5 months. Recurrence of the disorder after 5 months, then a second recurrence 7 months later, were also treated with intra-articular injection of prednisolone, 75 mg, at the site of the pain. No adverse effects or allergic reactions occurred immediately following the injections. As in the previous episodes, physical examination, revealed pain at the medial humeral epicondyle, which was worsened by stretching and resisted isometric contraction of the flexor–pronator muscles. Elbow mobility was not limited, and no intraarticular effusion occurred. Neurological examination of the upper limbs was unremarkable. The patient had no limitation of mobility or pain in the cervical spine. Radiography of the elbow revealed no abnormalities, in particular, no calcifications. The previous injections had provided good pain relief; a new intra-articular injection with the same method was decided. After skin disinfection with pividone iodine, without lidocaine, the patient received an injection of prednisolone, 75 mg, in the painful medial humeral epicondyle; we noted no aspiration of blood before injection and no resistance during injection. Two minutes after the injection, the patient com-
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A. Hajjioui et al. / Annales de réadaptation et de médecine physique 50 (2007) 721–723
plained of cramping lumbar pain, with a feeling of chest oppression, accompanied by facial flushing. He was quickly placed in supine position with his legs elevated. Blood pressure was 160/100 mmHg. The intensive care unit was contacted. No modifications were seen on electrocardiography. No specific action was taken because of spontaneous improvement in symptoms by 20 min, with complete disappearance of the dorsal, lumbar and thoracic pain, regression of the facial flushing, and normalization of blood pressure. The patient remained under observation for approximately 1 h because he still felt tired, then he felt recovered and returned home. 3. Case two A 57-year-old man consulted for disabling low back pain and right L5 sciatica resistant to treatment for ambulation. Physical examination showed scoliosis with spinal pain syndrome. Neurological examination revealed hypoesthesia of the right foot in the L5 dermatome. Computed tomography of the lumbar region revealed right posterolateral disk herniation at L3L4 and degenerative disk disease at L4-L5. A first corticosteroid injection 6 months previously had provided excellent but transient improvement. A second caudal epidural injection was thus decided. The procedure was performed after premedication with a vial of nefopam hydrochloride. The patient’s skin was disinfected, observing the usual precautions considering the patient’s history of iodine allergy. We first injected 20 cc normal saline solution, then 125 mg prenisolone, then another 20 cc normal saline. On getting up from the treatment table, the patient felt unwell, began to sweat, and had thoracic then lumbar pain, facial and conjunctival erythema. He was placed in supine position with legs elevated. Systolic blood pressure was 95 mmHg and pulse 45 per min. A normal saline intravenous infusion was started. Electrocardiography results were normal, as were myoglobin and troponin assay findings. The patient’s condition improved spontaneously 1 h later, with disappearance of symptoms and normalization of pulse and blood pressure; the patient was discharged 4 h later after repeat electrocardiography gave normal findings. The troponin level was < 5 pg/l. 4. Discussion Tachon syndrome was first described a few years ago by the French rheumatologist Gérard Tachon concerning several cases he had personally encountered [1]. Scientific publications on this subject are rare. In fact, a literature search of indexed medical journals, in both French and English language, found only one other publication. In 2004, Berthelot et al., published the results of a retrospective study involving questionnaires mailed to 500 French rheumatologists to study adverse reactions known as Tachon syndrome. A total of 92 rheumatologists reported 318 cases. The estimated mean frequency was one case per 8000 injections or 6.5 years of practice. Onset of hyperacute pain was usually
(78%) within 1–5 min after the injection and persisted for 5– 15 min (51%). The signs and symptoms are in Table 1 and injection sites and products used are in Figs. 1 and 2, respectively. The outcome was always favorable, and the duration of symptoms was approximately 30 min. Tachon syndrome does not seem to be related to an allergic reaction absence of (asthma, rare urticaria (2%) and recurrence (13%)). The frequent onset of chest oppression before the appearance of dorsal and/or lumbar pain could be consistent with migration of corticosteroid microcrystal suspension in the lung, then kidney filters [1]. The frequent coexistence of other signs such as pallor, sweating, diarrhea and transient episodes of hyper- or hypo-tension could be linked to sympathetic and parasympathetic system reactions. Because the time to onset of the first clinical signs after injection can be several minutes, the corticosteroid might be not injected directly into the venous circulation but, rather, diffuses little by little through a nick created during the proTable 1 Clinical signs of Tachon’s syndrome
Fig. 1. Corticosteroid injection sites.
Fig. 2. Corticosteroids injected.
A. Hajjioui et al. / Annales de réadaptation et de médecine physique 50 (2007) 721–723
cedure (which can happen even in absence of blood on aspiration just before the injection). This situation is even more likely because this phenomenon occurs more often after injections in sites rich in vein plexuses (such as the heel and the peridural space) or where the subcutaneous cellular tissue is stretched (such as the epicondyle), which can further force passage of the suspension through the nick in the vein caused by the needle [2]. The two cases presented here illustrate Tachon syndrome, with onset of severe thoracic and lumbar pain minutes after injection of corticosteroid, followed by facial flushing, sweating and blood pressure disturbance, with spontaneous, rapid regression of pain and no other explanation for the occurrence. 5. Conclusion Though rare and rapidly reversible, Tachon syndrome is an immediate adverse reaction to local corticosteroid injection, with most often a favorable outcome. Physicians performing such injections should be aware of the phenomenon. The severe and sudden symptoms are distressful for the patient, so reassuring the patient is essential. Tachon syndrome, however,
723
remains a diagnosis by elimination, confirmed only after ruling out the usual medical and surgical emergencies. References [1] Berthelot JM, Tortellier L, Guillot P, Prost A, Caumon JP, Glemarec J, et al. Tachon’s syndrome (suracute back and/or thoracic pain following local injections of corticosteroids). A report of 318 French cases. Joint Bone Spine 2005;72(1):66–8. [2] Cherasse A, Kahn MF, Mistrih R, Maillard H, Strauss J, Tavernier C. Nicolau’s syndrome after local glucocorticoid injection. Joint Bone Spine 2003;70(5):390–2. [3] Grillet B, Dequeker J. Intra-articular steroid injection. A risk-benefit assessment. Drug Saf 1990;5(3):205–11. [4] Hunter JA, Blyth TH. A risk-benefit assessment of intra-articular corticosteroids in rheumatic disorders. Drug Saf 1999;21(5):353–65. [5] Kumar N, Newman RJ. Complications of intra- and periarticular steroid injections. Br J Gen Pract 1999;49(443):465–6. [6] Lazarevic MB, Skosey JL, Djordjevic-Denic G, Swedler WI, Zgradic I, Myones BL. Reduction of cortisol levels after single intra-articular and intramuscular steroid injection. Am J Med 1995;99:370–3. [7] Maillefert JF, Aho S, Huguenin MC, Chatard C, Peere T, Marquignon MF, et al. Effets systémiques des infiltrations épidurales de dexaméthasone. Rev Rhum 1995;62:453–6. [8] Ward A, Watson J, Wood P, Dunne C, Kerr D. Glucocorticoid epidural for sciatica: metabolic and endocrine sequelae. Rheumatol 2002;41:68–71.
Clinical case
An unusual complication of intra-articular injections of corticosteroids. Tachon syndrome Two clinical case studies A. Hajjioui*, A. Nys, S. Poiraudeau, M. Revel Service de rééducation et de réadaptation de l’appareil locomoteur et des pathologies du rachis, APHP, université René-Descartes, groupe hospitalier Cochin, 27, rue du Faubourg–Saint-Jacques, Paris 75014, France Received 14 June 2007; accepted 21 June 2007
Abstract Local injections of corticosteroids can, in very rare cases, be complicated by Tachon syndrome–intense lumbar and/or dorsal and/or thoracic pain a few minutes after the injection, with rapid regression of the pain. Passing the drug into a vein through a nick made during the procedure could explain the pathophysiology of this disorder. We report two good cases illustrating the typical symptoms of this distressful syndrome. Diagnosis of Tachon syndrome is made by elimination of the usual medical and surgical causes, and physicians performing local injections should be aware of this phenomenon. The patient needs to be reassured of the temporal nature of the syndrome. © 2007 Elsevier Masson SAS. All rights reserved. Keywords: Corticosteroids; Intra-articular injections; Adverse reactions; Tachon’s syndrome; Low back pain
1. Introduction Intra-articular injections of corticosteroids are among the most frequently used treatments in rheumatology. Even though this local treatment can give rise to systemic effects [6–8], likely to cause generalized adverse reactions [8], it is most often well tolerated. In very rare cases, intra-articular injection of corticosteroids can lead to severe lumbar and/or dorsal and/ or thoracic pain consistent with Tachon syndrome [3–5]. We report two cases of Tachon syndrome after injection of a corticosteroid suspension. 2. Case one A 47-year-old male consulted for the third episode of right medial humeral epicondylitis. After failure of local physiotherapy and rehabilitation, he first received an intra-articular injection of prednisolone, 75 mg, at the site of the pain, with an * Corresponding
author. E-mail address: [email protected] (A. Hajjioui).
0168-6054/$ - see front matter © 2007 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.annrmp.2007.06.002
excellent initial result for 5 months. Recurrence of the disorder after 5 months, then a second recurrence 7 months later, were also treated with intra-articular injection of prednisolone, 75 mg, at the site of the pain. No adverse effects or allergic reactions occurred immediately following the injections. As in the previous episodes, physical examination, revealed pain at the medial humeral epicondyle, which was worsened by stretching and resisted isometric contraction of the flexor–pronator muscles. Elbow mobility was not limited, and no intraarticular effusion occurred. Neurological examination of the upper limbs was unremarkable. The patient had no limitation of mobility or pain in the cervical spine. Radiography of the elbow revealed no abnormalities, in particular, no calcifications. The previous injections had provided good pain relief; a new intra-articular injection with the same method was decided. After skin disinfection with pividone iodine, without lidocaine, the patient received an injection of prednisolone, 75 mg, in the painful medial humeral epicondyle; we noted no aspiration of blood before injection and no resistance during injection. Two minutes after the injection, the patient com-
722
A. Hajjioui et al. / Annales de réadaptation et de médecine physique 50 (2007) 721–723
plained of cramping lumbar pain, with a feeling of chest oppression, accompanied by facial flushing. He was quickly placed in supine position with his legs elevated. Blood pressure was 160/100 mmHg. The intensive care unit was contacted. No modifications were seen on electrocardiography. No specific action was taken because of spontaneous improvement in symptoms by 20 min, with complete disappearance of the dorsal, lumbar and thoracic pain, regression of the facial flushing, and normalization of blood pressure. The patient remained under observation for approximately 1 h because he still felt tired, then he felt recovered and returned home. 3. Case two A 57-year-old man consulted for disabling low back pain and right L5 sciatica resistant to treatment for ambulation. Physical examination showed scoliosis with spinal pain syndrome. Neurological examination revealed hypoesthesia of the right foot in the L5 dermatome. Computed tomography of the lumbar region revealed right posterolateral disk herniation at L3L4 and degenerative disk disease at L4-L5. A first corticosteroid injection 6 months previously had provided excellent but transient improvement. A second caudal epidural injection was thus decided. The procedure was performed after premedication with a vial of nefopam hydrochloride. The patient’s skin was disinfected, observing the usual precautions considering the patient’s history of iodine allergy. We first injected 20 cc normal saline solution, then 125 mg prenisolone, then another 20 cc normal saline. On getting up from the treatment table, the patient felt unwell, began to sweat, and had thoracic then lumbar pain, facial and conjunctival erythema. He was placed in supine position with legs elevated. Systolic blood pressure was 95 mmHg and pulse 45 per min. A normal saline intravenous infusion was started. Electrocardiography results were normal, as were myoglobin and troponin assay findings. The patient’s condition improved spontaneously 1 h later, with disappearance of symptoms and normalization of pulse and blood pressure; the patient was discharged 4 h later after repeat electrocardiography gave normal findings. The troponin level was < 5 pg/l. 4. Discussion Tachon syndrome was first described a few years ago by the French rheumatologist Gérard Tachon concerning several cases he had personally encountered [1]. Scientific publications on this subject are rare. In fact, a literature search of indexed medical journals, in both French and English language, found only one other publication. In 2004, Berthelot et al., published the results of a retrospective study involving questionnaires mailed to 500 French rheumatologists to study adverse reactions known as Tachon syndrome. A total of 92 rheumatologists reported 318 cases. The estimated mean frequency was one case per 8000 injections or 6.5 years of practice. Onset of hyperacute pain was usually
(78%) within 1–5 min after the injection and persisted for 5– 15 min (51%). The signs and symptoms are in Table 1 and injection sites and products used are in Figs. 1 and 2, respectively. The outcome was always favorable, and the duration of symptoms was approximately 30 min. Tachon syndrome does not seem to be related to an allergic reaction absence of (asthma, rare urticaria (2%) and recurrence (13%)). The frequent onset of chest oppression before the appearance of dorsal and/or lumbar pain could be consistent with migration of corticosteroid microcrystal suspension in the lung, then kidney filters [1]. The frequent coexistence of other signs such as pallor, sweating, diarrhea and transient episodes of hyper- or hypo-tension could be linked to sympathetic and parasympathetic system reactions. Because the time to onset of the first clinical signs after injection can be several minutes, the corticosteroid might be not injected directly into the venous circulation but, rather, diffuses little by little through a nick created during the proTable 1 Clinical signs of Tachon’s syndrome
Fig. 1. Corticosteroid injection sites.
Fig. 2. Corticosteroids injected.
A. Hajjioui et al. / Annales de réadaptation et de médecine physique 50 (2007) 721–723
cedure (which can happen even in absence of blood on aspiration just before the injection). This situation is even more likely because this phenomenon occurs more often after injections in sites rich in vein plexuses (such as the heel and the peridural space) or where the subcutaneous cellular tissue is stretched (such as the epicondyle), which can further force passage of the suspension through the nick in the vein caused by the needle [2]. The two cases presented here illustrate Tachon syndrome, with onset of severe thoracic and lumbar pain minutes after injection of corticosteroid, followed by facial flushing, sweating and blood pressure disturbance, with spontaneous, rapid regression of pain and no other explanation for the occurrence. 5. Conclusion Though rare and rapidly reversible, Tachon syndrome is an immediate adverse reaction to local corticosteroid injection, with most often a favorable outcome. Physicians performing such injections should be aware of the phenomenon. The severe and sudden symptoms are distressful for the patient, so reassuring the patient is essential. Tachon syndrome, however,
723
remains a diagnosis by elimination, confirmed only after ruling out the usual medical and surgical emergencies. References [1] Berthelot JM, Tortellier L, Guillot P, Prost A, Caumon JP, Glemarec J, et al. Tachon’s syndrome (suracute back and/or thoracic pain following local injections of corticosteroids). A report of 318 French cases. Joint Bone Spine 2005;72(1):66–8. [2] Cherasse A, Kahn MF, Mistrih R, Maillard H, Strauss J, Tavernier C. Nicolau’s syndrome after local glucocorticoid injection. Joint Bone Spine 2003;70(5):390–2. [3] Grillet B, Dequeker J. Intra-articular steroid injection. A risk-benefit assessment. Drug Saf 1990;5(3):205–11. [4] Hunter JA, Blyth TH. A risk-benefit assessment of intra-articular corticosteroids in rheumatic disorders. Drug Saf 1999;21(5):353–65. [5] Kumar N, Newman RJ. Complications of intra- and periarticular steroid injections. Br J Gen Pract 1999;49(443):465–6. [6] Lazarevic MB, Skosey JL, Djordjevic-Denic G, Swedler WI, Zgradic I, Myones BL. Reduction of cortisol levels after single intra-articular and intramuscular steroid injection. Am J Med 1995;99:370–3. [7] Maillefert JF, Aho S, Huguenin MC, Chatard C, Peere T, Marquignon MF, et al. Effets systémiques des infiltrations épidurales de dexaméthasone. Rev Rhum 1995;62:453–6. [8] Ward A, Watson J, Wood P, Dunne C, Kerr D. Glucocorticoid epidural for sciatica: metabolic and endocrine sequelae. Rheumatol 2002;41:68–71.