Corticosteroids are an important treatment for many inflammatory, allergic, immunologic, malignant, and orthopedic conditions. Joint aspirations and injections have been described in the literature since the early 1930s (16). Early intraarticular injections included formalin, glycerin, lipidol, lactic acid, and petroleum jelly and were not effective at reducing pain (16). In 1951, the first joint injection with corticosteroid was documented (24). Since that time, intraarticular, peritendinous, and bursal corticosteroid injections have been used for a wide variety of musculoskeletal disorders by targeting their anti-inflammatory effects to specific areas of pathology. By reducing pain after a successful corticosteroid injection, patients are more likely to complete physical therapy, which promotes healing and ultimately a return to their chosen activity (46).
Mechanism of Action
Injectable corticosteroids are analogs of natural steroids produced by the adrenal cortex (1). These analogs have the same characteristics as their natural counterparts, which are hydrophobic macromolecules that bind to nuclear receptors and induce lasting effects on cellular physiology at the level of DNA transcription (37). Many of the adverse events that are manifested postinjection are a result of this change in physiology. Cellular physiology is complex; as such, the complete pathway of steroidogenesis and steroid interactions are beyond the scope of this review (21,34).
However, two major effects take place at the level of cellular transcription that explain many of the adverse events from steroid injections. The common pathway between these two effects is as follows. The amphipathic steroid transfuses across the cellular membrane and binds to a cytoplasmic receptor, the glucocorticoid receptor (GR). The steroid receptor complex then translocates to the nucleus and binds to a glucocorticoid response element (21). The end result impacts cellular transcription through two pathways. The first involves either the transcription of multiple anti-inflammatory genes or the suppression of inflammatory gene transcription (21). Second, interactions with GR and other transcription factors such as tumor necrosis factor alpha, nuclear factor kappa-light-chain-enhancer of activated B cells, and activation protein 1 also inhibit proinflammatory factors from activating their genes, thus suppressing inflammation (21,34). Through these mechanisms, one can begin to understand why systemic reactions occur, because many of the genes mentioned above influence other cellular pathways outside of inflammation.
Providers inform patients on the well-known risks that are associated with corticosteroid injections, but they should be aware that other less commonly reported adverse events are known to occur. The informed consent for most physicians include more common adverse events such as flare (increased pain), allergic reaction, facial erythema, hypopigmentation, fat pad necrosis, cutaneous atrophy, and a transient increase in blood glucose (especially in diabetic patients). Cartilage damage, tendon rupture, infection, and cataracts also are commonly included not because they are common adverse events, but rather because of common knowledge. The purpose of this case series and review is to help physicians recognize less commonly reported adverse reactions of steroid injections. A list of less commonly reported adverse events noted in the literature can be found in the Table (10,20,27,32,39).
A 49-year-old woman with bilateral osteoarthritis (OA) of the knee was treated with bilateral intraarticular triamcinolone (80 mg) injections. The patient had a medical history of obesity, hyperlipidemia, glucose intolerance, chronic kidney disease and accompanying sequelae, mild exophthalmos, urticaria, gastroesophageal reflux disease (GERD), major depressive disorder, chronic low back pain, endometriosis, irritable bowel syndrome, and uterine leiomyoma. The patient had a right knee arthroscopy performed 2 years previously with a lateral retinacular release and patellar chondroplasty. She also had a 6-year history of bilateral intraarticular corticosteroid injections of the knees every 6 months, excluding a 2-year period where she received hyaluronan (viscosupplementation) injections as treatment. Eleven days postinjection of triamcinolone (80 mg) with 1% lidocaine, she complained of vision disturbances including black spots bilaterally and difficulty seeing out of her left eye. Other general complaints at this time included excruciating headaches and shortness of breath with accompanying left shoulder and arm pain. Previous problems after corticosteroid injections of her knees included rapid onset hypertension, headaches, facial flushing, and lightheadedness. Ophthalmology was consulted and she was found to have fluid under her retina consistent with idiopathic central serous chorioretinopathy (ICSC). Initial treatment was observation, and the patient was informed that her vision would be monitored over the next few months to a year. After 5 wk, vision acuity of her right eye had improved, but the vision on her left eye remained blurry. An increase in fluid accumulation, in addition to the fluid present at diagnosis, in the subretinal space of the left eye was observed at that time. Observation with close monitoring was continued, and by 1 year postinjection, she did not complain of any vision disturbances and tolerated a unilateral intraarticular steroid injection into the knee without any disturbances in vision.
An active 33-year-old woman who was 7 months postpartum and breastfeeding presented with significant left wrist pain of the first dorsal compartment. She had no chronic medical conditions and took no medications other than a multivitamin. Obstetrical history also was unremarkable with vaginal delivery of a healthy full-term baby. After a thorough history and examination including a positive Finkelstein test, a diagnosis of de Quervain tenosynovitis was made. Conservative treatment including nonsteroidal anti-inflammatory drugs (NSAIDs) and a custom thumb spica splint provided minimal relief. The patient then opted for an ultrasound-guided triamcinolone (40 mg) injection into the first dorsal compartment of the wrist along with 2 mL of 1% lidocaine. No complications were observed during the procedure. The patient reported immediate pain relief, and a negative Finkelstein test was observed after the injection. Twenty-four hours postinjection, the patient reported a 90% decrease in lactation as measured by breast pumping before and after the injection. She was advised to continue breastfeeding and to breast pump to further stimulate lactation. She also began taking fenugreek, an herbal remedy known to stimulate lactation, to further enhance milk expression. One week later, she reported a 50% increase in milk production. One month postinjection lactation increased sufficiently to support her child’s needs, and the patient returned to her active lifestyle without further complications.
A 45-year-old white male previous division 1 football player presented to sports medicine clinic with a history of progressive bilateral knee pain. He had no chronic medical conditions and took no medications. He was diagnosed with moderate OA of his knees bilaterally. He did not improve with outpatient physical therapy, analgesics, and NSAIDs. Physical therapy consisted of quadriceps, hamstring, and hip muscle strengthening; knee range of motion; and balance/gait retraining. He desired treatment with a corticosteroid knee injection. His more symptomatic knee (right) was injected with intraarticular triamcinolone (80 mg) with 1% lidocaine. He tolerated the procedure well without complications. Seven days after the injection, he noted feelings of acute anxiety manifested by panic attacks (chest pain, diaphoresis, palpitations, nervousness, and tingling in his arms and legs). He was evaluated urgently in the emergency department with an unremarkable evaluation including a normal chest radiograph, ECG, cardiac telemetry, and laboratory tests (metabolic panel, urine drug screen, cardiac markers, blood counts, and thyroid testing). His symptoms were felt to be related to the corticosteroid injection by the emergency department providers, his primary care physician, and his orthopedic team. Reassurance was provided and his symptoms resolved 2 wk later. He was diagnosed with substance-induced anxiety.
Commonly Listed and Life-threatening Adverse Events
Most physicians counsel patients on the well-known adverse events that may occur after a steroid injection. Although this is an essential part of the process, informed consent is very much at the discretion of the physician. The list of adverse events is extensive, and this article specifically focuses on those that are less well known and rarely reported in the literature such as the three specific uncommon adverse events highlighted in this review.
Life-threatening adverse events related to corticosteroid injections include sepsis, necrotizing fasciitis, hypotension, air embolism, apnea, anaphylactic reaction, vasomotor collapse, adrenal insufficiency, and left ventricular rupture (4,39). The majority of these potentially life-threatening events are very rare, and because of heterogeneity of the data in the literature and the fact that most of the data on these events are based on case reports, quantification of the rates of occurrence for these events could not be pooled (6). Skin infections (cellulitis, abscess) and septic arthritis account for the majority of steroid-related adverse events and occur between 0.01% and 0.04% of cases (20,25,39), highlighting the importance of aseptic procedures (6,10,20,23,32). The probability of an adverse event can be decreased by employing sterile injection technique (22,40) and having a solid understanding of the physiological effects of adrenal-like hormones both at the local and systemic level (32,39,41). Therefore, it is advised that practitioners stay abreast of the current literature and maintain proper technique to avoid the infrequent but dangerous adverse events mentioned herein (41).
Rare Adverse Events
Overall, the rate of adverse events after steroid injection is very uncommon. The three cases presented previously are extremely rare and may cause concern when they occur.
A few weeks after injection with triamcinolone, the first patient presented with blurriness and black spots in her field of vision, which was diagnosed as ICSC. ICSC is characterized by serous retinal or retinal pigment epithelial detachment caused by a proposed build-up of fluid into the subretinal space (36). ICSC is the fourth most common vision-threatening retinopathy, behind only age-related macular degeneration, diabetic retinopathy, and branch retinal vein occlusion (48). The largest study evaluating the incidence of acute ICSC was a population-based, retrospective cohort, and case-control study based out of Olmsted County, MN, documenting all new cases of ICSC from 1980 to 2002 (29). Their study showed a mean age-adjusted incidence of 9.9 per 100,000 men, 1.7 per 100,000 women, with the incidence for men approximately six times greater than that for women.
The majority of individuals who develop ICSC regain their previous level of vision, but the risk of permanent damage and diffuse retinal pigment epitheliopathy, or chronic ICSC, is present. The mechanism by which ICSC occurs is incompletely understood, and the list of risk factors associated with ICSC continues to grow (35,36,40). One recurring theme in the literature is that corticosteroids are well-known risk factors (36,49). Other risk factors include obstructive sleep apnea, Cushing syndrome, pregnancy, type A personality, hypertension, GERD in the presence of Helicobacter pylori, use of phosphodiesterase type 5 inhibitor (PDE-5) inhibitors, sympathomimetic agents, and alcohol use (36). There also appears to be a genetic predisposition to developing ICSC that may help explain the mechanism behind this adverse event. One publication compared 400 ICSC cases with 1,400 matched controls and demonstrated a significant association between four common cadherin 5 single-nucleotide polymorphisms in ICSC male patients. Cadherin 5 plays a role in intercellular adhesion in the vascular endothelium, and its function is downregulated by corticosteroids. Corticosteroid treatment could lead to a decrease in intercellular adhesion via its effects on cadherin 5, resulting in increased permeability and weakness of the vascular endothelium within the retina (44). There is also speculation that cortisol inhibits vascular regulation and collagen synthesis while simultaneously increasing the permeability and pressure of the choriocapillaries (5,17,35,47,49). Another author has postulated that corticosteroids regulate ion and water channels within the eye through mineralocorticoid receptors, resulting in the edema-producing effects of steroids in ICSC (12).
Many patients who develop ICSC have a history of steroid use as a systemic regimen, a local treatment, or both. Vigilant care and observation should be given to those showing signs of ICSC, because these individuals are at risk for permanent vision loss (40). Typically, the visual acuity decrement after ICSC spontaneously resolves within 1 to 4 months after the injection (36). Should visual acuity fail to return within that period, several treatment modalities are available. These include antiglucocorticoid therapy such as ketoconazole, mifepristone, rifampin, antiadrenergics (poor evidence), carbonic anhydrase inhibitors (poor evidence), anti-vascular endothelial growth factor agents (poor evidence), laser photocoagulation (good evidence), and photodynamic therapy (good evidence) (36,49). The level of evidence presented above is based on current research and outcomes after treatment. The goal of therapy is reattachment of the neurosensory retina. The first line of defense is to remove the exacerbating factor, which in the case of ICSC after steroid injection is the steroid injection itself. As such, the practitioner should refrain from injecting steroid until the complication has resolved completely. Should this fail, the aforementioned treatment modalities should be considered. The frequency of this complication is underestimated, especially with transient blurred vision (4). The fact that patients rarely think of telling their eye specialist about recent corticosteroid injections also may play a role in missed diagnoses (4). Experiencing ICSC is not an absolute contraindication for future corticosteroid injections, although patients may decide to not risk a recurrence from a future corticosteroid injection because recurrence rates are poorly understood (12). One year of recurrence rates after a primary event may be as high as 50% and associated with diminished visual acuity, color vision, and stereopsis (48).
De Quervain tenosynovitis has an increased prevalence in breastfeeding and pregnant women compared with the general population (2,3). The higher propensity for de Quervain tenosynovitis in postpartum women is felt to be secondary to repetitive use of the extensor pollicis brevis and abductor pollicis longus tendons while lifting the infant (45). The efficacy of nonsurgical treatments in postpartum women has been investigated, and initial reports state that corticosteroid injections are highly effective (2,9). A nonsurgical approach was taken in the patient presented in case 2, and the corticosteroid injection alleviated her symptoms. Although her wrist pain was alleviated, the treatment did cause a drastic decrease in lactation. The prevalence of lactation cessation has been linked to the nonsurgical treatment of de Quervain tenosynovitis, specifically triamcinolone injections (33). Although this is a relatively new finding and the mechanism of action is incompletely understood, one author observed that a low-dose injection of betamethasone did not cause as severe of a decrease in lactation as did a high-dose triamcinolone injection (33).
In non-breastfeeding patients, tertiary adrenal insufficiency symptoms related to administration of corticosteroid may include weakness, fatigability, myalgia, arthralgia, and psychiatric symptoms. In tertiary adrenal insufficiency, symptoms and signs of primary adrenal insufficiency such as skin hyperpigmentation, hyperkalemia, and dehydration are absent because of the presence of mineralocorticoid (8). Higher doses and longer use of corticosteroid appear to be directly related to risk for adrenal insufficiency (7). The role of the hypothalamic-pituitary-adrenal axis in the production and release of prolactin, which leads to milk production, may be interconnected and could explain the lack of milk production after injection of corticosteroids. Evidence suggests that a single intraarticular injection with corticosteroid can result in tertiary adrenal insufficiency ranging from minor to major insufficiency (25% of patients between 2 and 4 wk postinjection) (18) and was observed in 60% of patients receiving bilateral knee injections 1 wk postinjection (13,19). The only case of a breastfeeding mother who had lactation suppression after initiation of breastfeeding as a result of an injection not related to de Quervain tenosynovitis reported in the literature occurred after an intervertebral injection of high-dose triamcinolone. Lactation was restored within a week after repeated milk expression and use of domperidone (33). Interestingly, breast milk production also has been shown to be decreased during lactogenesis in women who delivered preterm and were given betamethasone injections between 28 and 34 wk of gestation who then delivered 3 to 9 d later. Women who delivered prematurely were at increased risk of delayed lactogenesis with decreased milk production after receiving antenatal steroids (22). Current evidence suggests that women who are struggling to lactate should initially try conservative treatment options to increase milk expression, which include increased breast pumping and continued breastfeeding (26). Pharmacological intervention is available should conservative treatment efforts fail (15,26). These agents are classified as galactogogues and include domperidone, metoclopramide, fenugreek, chlorpromazine, and human growth hormone (15). These pharmacological agents work by decreasing the effects of dopamine and act to increase the amount of prolactin released. Although lactation returned for the patient in this case as well as others reported in the literature, providers should weigh the risks and benefits on an individual basis depending on the context, i.e., avoiding a corticosteroid injection for a new mother experiencing difficulties with lactation.
Psychiatric Complications of Corticosteroids
The third and final complication is a case of steroid-induced anxiety. Although psychiatric adverse events are rare after steroid injection, their results can be catastrophic. For instance, episodes of hallucination and psychosis could cause potential danger to the patient and/or the public at large. It should be emphasized that these events are very rare and include hypomania, mania, depression, anxiety, panic disorders, delirium, suicidal thinking and behavior, aggressive behavior including thoughts of murder, insomnia, agitation, depersonalization, and cognitive impairments (28). These events are more often seen in individuals who are treated with systemic corticosteroids but also are documented after a single articular injection of corticosteroid (38,43). It should be understood by those providing these injections that incidents of acute psychiatric adverse events are possible and tend to be associated with a few predisposing factors, although these factors are not always known upon presentation, such as hypoalbuminemia and use of cytochrome P450 (CYP) 3A4 inhibitors (11,28). Those with hypoalbuminemia have been reported to have an increased propensity for steroid-induced psychosis with an odds ratio of 2.2 (confidence interval, 1.9 to 2.5; P = 0.03) (28). Also, those who are taking concurrent medications that are CYP 3A4 inhibitors show a propensity for steroid-induced psychosis, because this enzyme is responsible for the degradation of prednisolone, the biologically active form of prednisone (28). CYP 3A4 inhibitors include but are not limited to grapefruit juice, clarithromycin, ketoconazole, itraconazole, and verapamil (14).
If an acute psychiatric adverse reaction occurs, it typically manifests within 1 wk of the injection (28,43). Treatment is observation and supportive in nature (hydration, benzodiazepines, education, etc.) because symptoms are relieved as the drug is metabolized over the following 3 to 5 d (42). Should symptoms continue unresolved, over a prolonged time frame (3 to 4 wk), antidepressants and antipsychotics have been efficacious in assisting in relief (28). It should be noted that tricyclic antidepressants are not recommended in this situation because patient’s symptoms are often exacerbated after administration of tricyclic antidepressants (30). It is also noted in the literature that those who manifest symptoms after the first injection are likely to continue to manifest with each subsequent injection (31,38). Prophylactic administration of antidepressants and antipsychotics, including lithium, has been effective in preventing steroid-induced psychoses (28). However, providers should consider the risks and benefits of repeating a corticosteroid injection if acute psychiatric adverse events have occurred in the past. The great majority of investigations and publications have been directed toward oral or intravenous administration of corticosteroids, and more research into corticosteroids administered via intraarticular, peritendinous, and bursal routes is needed with regard to steroid-induced anxiety and other psychiatric adverse events.
Corticosteroid injections are commonly used in the treatment of musculoskeletal disorders. Appropriate counseling on the potential risks and monitoring for adverse consequences of the therapy are essential components of informed consent and follow-up care. This article highlights three uncommon adverse effects — ICSC, decreased lactation, and acute anxiety — in an effort to assist others in recognizing and managing similar complications in their practices. Although all three uncommon adverse events are typically self-limited, providers should be aware that they can occur and consider whether or not future corticosteroid injections should be offered. In the case of ICSC, recurrence rates as high as 50% have been reported and future injections with corticosteroid may need to be avoided although successfully provided in the described case. Providers should consider including the risk of lactation cessation during the consent process for a patient presenting with de Quervain tenosynovitis desiring a corticosteroid injection if breastfeeding. Acute psychiatric adverse events typically present within 1 wk of injection and are self-limited, highlighting the importance of taking a complete history when evaluating any patient presenting with acute psychiatric concerns.
The authors declare no conflict of interest and do not have any financial disclosures.
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