8.1 Aseptic femoral necrosis in a patient with systemic JIA

A 15 year old girl with a systemic onset of JIA and a persistent systemic course, who had been followed up for 14 months in our clinic, presented with a continuous pain, unresponsive to analgesics, located in the soft tissues of the lower part of her right thigh. Up to that time the patient had received prednisone (PS) 0.8→0.3 mg/kg/d for 4 months and then on alternate days, methotrexate 15 mg/m² and indometacin 2 mg/kg/d. At the time the pain occurred she was receiving indometacin, PS (20 mg/kg/d), and cyclosporin A (3 mg/kg/d). There was no previous history of trauma in the affected limb. Her imaging work up showed the following:x rays of knees and femur—skip lesions in the right femur, one sclerotic in the middle shaft with heavy periosteal reaction and another one mainly lytic with destruction of the cortical bone and periosteal reaction. Magnetic resonance imaging showed skip lesions localised in the middle third of diaphysis and in the distal metaphysis of the femur. The lesions destroyed the cortical bone, infiltrated the bone marrow, and produced a periosteal reaction without extension to the soft tissues or in the epiphysis. These lesions were indicative of a possible bone solid tumour—that is, osteosarcoma or …