Thanks Kaleb for a great case! This is a case of a young man with a history of Hodgkin Lymphoma (sp ABVD and autoSCT) presenting to an outpatient clinic with hip pain found to have avascular necrosis likely from high dose steroids used to treat bleomycin-induced pneumonitis.
- ) Hodgkin lymphoma is generally treated with combination chemotherapy and radiation with a high cure rate. Some complications to consider include chemo and XRT related including heart failure (doxorubicin), ILD (bleomycin), neuropathy (vinblastine), early onset CAD, constrictive pericarditis (XRT) and secondary malignancies.
- ) Localization is helpful for the diagnosis of hip pain. Posterior pain can be referred lumbrosacral disease, sacroiliac pain or bursitis. Lateral hip pain should make someone consider trochanteric bursitis or meralgia paresthetica. Anterior hip pain is more consistent with hip joint pathology. The differential should also include pathology outside of the MSK hip region including a retroperitoneal and intraabominal process especially if the patient has a normal gait or symptoms that point against an MSK etiology.
- ) A dedicated hip exam should include inspection, palpation, range of motion, strength, specific maneuvers to help logalize the pathology, and gait. See this great Stanford 25 page that illustrates various aspects of the hip exam to localize pathology.
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Hip pain differential
One way to formulate a differential is based on where the pain is located.
- referred lumbrosacral – if suspected, perform back exam
- piriformis syndrome – specific maneuvers to isolate the piriformis
- sacroiliac – suspected with positive FABER test (Flexion, ABduction, External Rotation)
- bursitis – usually pain with palpation of iliopsoas or ischiogluteal bursae
- meralgia paresthetica – usually presents with neuropathy symptoms in the thigh
- IT band syndrome
- trochanteric bursitis – pain with palpation of the greater trochanter
- hip joint pathology – suspect in pain with passive ROM maneuvers
- meralgia paresthetica
- retroperitoneal/ intraabdominal pathology
Autologous Hematopoietic Stem Cell Transplant (Auto HSCT)
Autologous hematopoietic stem cell transplant is indicated for multiple malignancies (eg some lymphomas, myeloma, testicular cancer) and involves harvesting the patient’s own stem cells to be returned to reconstitute the bone marrow after intensive chemotherapy +/- radiation to treat the malignancy. Advantages include fewer side effects than allogeneic (donor derived stem cells) due to lack of GVHD and being in an immunosuppressed state only peri-transplant. However, patients do not get the benefit of graft versus tumor that allogeneic transplants confer. Here is a chart on complications to watch out for after an autoSCT from a great overview review article on autologous stem cell transplant.