We report the unique occurrence and treatment of spontaneous multiple
insufficiency fractures after
sepsis in a patient with
rheumatoid arthritis (RA). The patient was a 53-year-old woman with a 13-year history of RA.
Her disease activity was not influenced by a
disease-modifying antirheumatic drug (
DMARD) regimen that included
bucillamine,
D-penicillamine,
gold,
sulfasalazine, and
methotrexate. Due to an increased disease activity, her
DMARD treatment regimen was changed to
leflunomide. She had also undergone
corticosteroid therapy with
prednisolone ranging from 10 to 15 mg daily over the previous 8 years. She first presented with a
wound infection at the surgical site of resection
arthroplasty on her left foot, which had caused hematogenous dissemination that led to pelvic
abscess and
sepsis. For the next 2 years, she experienced multiple
insufficiency fractures in parts of the ilium, sacral body, sacral ala, three thoraco-lumbar vertebral bodies (T12, L1, and L2), and subcapital femoral neck without low energy
trauma.
Postmenopausal osteoporosis, pelvic
abscess,
sepsis, decreasing daily activity, high RA disease activity, and high-load
corticosteroid therapy were considered to be the causes of these fractures. Nonspecific symptoms such as
low back pain and
fever delayed diagnosis, which may have led to secondary fractures. Although her course
after treatment was satisfactory during the study period, we recommend taking repetitive radiographs to detect
insufficiency fracture for RA patients with continuing
pain and reducing the
corticosteroid dose to prevent
infection and fracture.