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Corticosteroids, commonly called steroids, have been widely used in treating COVID-19 severe cases. It has both benefits and side effects. According to recent news, three under forty COVID-19 patients in Hinduja Hospital in Mumbai were reported with avascular necrosis or 'bone death' due to the use of steroids two months after the treatment.
This post-COVID complication due to the use of steroids is not new in the list as earlier, several cases of mucormycosis or black fungus have been reported during the first wave, which is said to be the first life-threatening side effect of COVID-19 due to the usage of the steroid.
Steroids are artificial forms of steroid hormones that are naturally built in our bodies. It is administered to patients depending on their disorder and the severity. Steroid, however, is not given to cure the condition, but to reduce the symptoms such as inflammation.
According to the WHO, steroids are beneficial for COVID-19 patients who fall under moderate to severe categories. For patients with mild symptoms, steroids may suppress immunity and worsen symptoms.
So, what exactly is avascular necrosis and why steroids are considered to be its main cause. Take a look.
About The Report
Dr Sanjay R Agarwala of Hinduja Hospital, along with doctors Mayank Vijayvargiya and Prashant Pandey, published a paper on the case report of three COVID-19 recovered patients who were diagnosed with avascular necrosis. The paper was named 'Avascular necrosis as part of Covid-19' and is published in the medical journal 'BMJ Case Studies'. 
Case 1: The patient was a 36-year-old male patient. The total steroid he has received during the treatment was 1250 mg of prednisolone. He was diagnosed with bilateral hip avascular necrosis sixty-seven days after the COVID-19 diagnosis.
Case 2: The patient was a 39-year-old male patient. The total dose of steroids he has received was 60 mg of oral dexamethasone and 400 mg of prednisolone along with 200 mg of favipiravir. He was diagnosed with left hip avascular necrosis fifty-seven days after the COVID-19 diagnosis.
Case 3: The patient was a 37-year-old male patient. The total dose of steroids he had received was 500 mg of intravenous methylprednisolone. He was diagnosed with bilateral avascular necrosis 55 days after COVID-19 diagnosis
"At present, avascular necrosis (AVN), as sequelae of ‘long COVID-19' has yet not been documented. By large-scale use of life-saving corticosteroids in COVID-19 cases, we anticipate that there will be a resurgence of AVN cases", as mentioned in the paper by Dr Agarwala stated.
What Is Avascular Necrosis?
Avascular necrosis, also called osteonecrosis, is a temporary or permanent bone condition in which the bone cells die due to insufficient supply of blood. The condition typically affects long bones or weight-bearing joints like the hip, knee and thigh bones, and less commonly affects carpus and jaw. Overall, AVT can affect one bone or several bones at a time, or different bones at different times.
What Are The Causes Of Avascular Necrosis?
Avascular necrosis mainly occurs when the blood supply gets interrupted in the bones. This could be due to some of the primary causes like: 
- Bone trauma/ injury/fracture.
- Prolonged use of medications like corticosteroids.
- Deposition of fats in the blood vessels.
- Damage to blood vessels.
- Excessive use of alcohol.
- Certain medical conditions like Gaucher's disease, diabetes, sickle cell anaemia, HIV, lupus and pancreatitis.
- Certain medical treatments like radiation therapy, chemotherapy or organ transplant.
Some of the less common causes include:
What Are The Symptoms Of Avascular Necrosis?
Symptoms of avascular necrosis are unnoticeable at early stages and start occurring when the condition worsens. Some of the symptoms include: 
- Joint pain when weight is put on it.
- Aggravation of pain due to activities like walking or climbing.
- Pain even in the absence of movement or while lying down.
- Pain and tenderness in the commonly affected sites such as hips and knees.
- Limited internal rotations of the joints.
- Groin pain that may spread down the knee.
What Are The Complications Of Avascular Necrosis?
If left untreated, avascular necrosis can cause severe pain in the joints and surrounding areas.
Pain in the joints mainly occurs when tiny breaks occur in the bone that may cause them to collapse, potentially leading to arthritis. The pain may vary depending on which side of the bone is affected, one side (unilateral) or both the sides (bilateral). 
Avascular Necrosis And COVID-19
Corticosteroids are effective to reduce mortality in patients with COVID-19, only if given as per the guidelines.
The main effects of steroids are anti-inflammatory and immunosuppressive and not direct inhibition of the viral replication. At first, steroids inhibit the inflammatory cytokines which are causing the symptoms by directing white blood cells to the site of inflammation.
Sometimes, these steroids affect the lipid metabolism by combining with lipoprotein and forming fat emboli (unattached solid, liquid or gaseous mass) that may result in blockage of the blood vessels and thus, necrosis of bone tissues in the vascular area.
Likewise, steroids can affect the blood flow in many other body parts, resulting in the death of bone tissues due to the lack of blood. 
However, if we look into the positive side of corticosteroids, it can help reduce inflammation and improve lung functions in patients with severe COVID-19 and thus, improve their chances of survival.
According to the RECOVERY clinical trial (one of the biggest studies carried out on COVID-19 treatments), steroids can help decrease the risk of death by 20 per cent in hospitalised COVID-19 patients who are on ventilation or receiving oxygen. 
Some of the allowed corticosteroids in India include dexamethasone, methylprednisolone, hydrocortisone or prednisone.
Remember: Steroids should not be self-medicated and should only be taken if recommended by a medical expert. Also, one must avoid putting pressure on doctors to prescribe steroids.
Diagnosis Of Avascular Necrosis
Some of the methods to diagnose AVN include: 
- X-ray: To look for signs of damage to internal tissues, bones and organs.
- CT scan: To get detailed images of bones, fats, muscles and organs.
- Scintigraphy: To get an image of affected organs and also record their functioning.
- Osteoporosis drugs: To slow the progression of avascular necrosis and prevent the risk of arthritis.
- Blood thinners: To prevent clotting of arteries due to fat deposition.
- Cholesterol-lowering drugs: To lower cholesterol in the body that may lead to blockage in the blood vessels.
- Anti-inflammatory drugs: To ease the pain caused due to breakage in the bones.
- Surgical methods: This includes bone transplant, bone reshaping and joint replacement in patients with advanced avascular necrosis.
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Treatments Of Avascular Necrosis
The main focus of treating AVT is to reduce further bone loss in patients. The methods include:
Currently, there are not many studies on steroid-induced avascular necrosis in recovered COVID-19 patients. As more studies will be carried out on the same, easy and effective treatment methods can be evaluated. For now, early diagnosis of the condition is important to prevent the consequent bone collapse. Therefore, if you notice joint pain post-COVID recovery, immediately consult a medical expert for early treatment.
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