Fat Embolization Syndrome Secondary to Steroid Treatment for Intractable Migraine

Abstract

Sickle vaso-occlusive crises secondary to steroid therapy are well reported in the medical literature. Fat embolization syndrome (FES) is an uncommon yet serious complication that occurs due to bone marrow necrosis and is usually associated with increased mortality or damaging neurologic sequelae to the surviving patient. We report a case of FES secondary to steroid therapy administered for an unrelated condition. Our patient was initially admitted for intractable migraine. The initial work up for other intracranial emergencies was negative and she was administered steroids for intractable migraine. Within 24 hours of initiating steroid therapy, she developed pain in her neck and shoulders progressing to her chest and lower extremities. The initial signs of FES following steroid therapy in this patient included altered mental status and hypoxic respiratory failure. Cerebral imaging showed diffuse bilateral cerebral/cerebellar and brainstem micro-hemorrhages. Lung imaging showed bilateral diffuse lung infiltrates confirming acute chest syndrome. The patient was transferred to the intensive care unit for further management of her hypoxic respiratory failure secondary to acute chest syndrome (ACS). In addition to ACS, she had acute kidney and hepatocellular injury in keeping with multi-organ failure. Steroid therapy was discontinued and she was treated with red cell exchange transfusion for multi-organ failure. The patient had an almost complete resolution of multiple organ damage except for hypoesthesia of her lower jaw and lower lip- the "numb chin syndrome". This case report highlights the importance of recognizing potentially fatal multi-organ failure secondary to steroid therapy and for hematologists to consider concurrent red cell transfusions to attenuate the risk of such complications from steroid therapy.