Pain in NMOSD is not always neuropathic: multifocal avascular osteonecrosis mimicking neuropathic pain

Neuropathic pain is a common, well-known and often difficult-to-treat symptom in neuromyelitis optica spectrum disorder (NMOSD) and is usually related to spinal cord lesions. However, non-neurological pain can coexist, posing diagnostic difficulties and delaying treatments. We describe the clinical course and diagnostic workup of a young woman with relapsing myelitis related to Aquaporin-4 (AQP4) IgG positive NMOSD who presented repeatedly to the neurology clinic with persistent pain affecting initially lower limbs and then upper limbs despite apparently stable neurological disease. Joint MRI demonstrated multifocal avascular osteonecrosis involving both femoral and humeral heads, distal humerus and knees. She underwent bilateral total hip replacement; other joints were managed conservatively. Avascular necrosis due to corticosteroid use can cause unexplained persistent pain and should be considered as a differential diagnosis not only in NMOSD but any condition requiring corticosteroids. Early diagnosis can ensure timely and appropriate management, relieving pain and minimising complications.