Unusual reaction to a local corticosteroid injection to the heel: Tachon’s syndrome?

Key message

Transient excruciating back or chest pain has rarely been reported after a local corticosteroid injection.

Dear Editor, A 42-year-old man presented to the rheumatology clinic with a 6-month history of severe inferior left heel pain, which was worse on starting to walk and easing after a few minutes. The onset was gradual, with no preceding trauma. His BMI was 29. The tenderness was maximal at the centre of the heel. He had no significant past medical history and took no regular medications. A clinical diagnosis of plantar fasciitis of the left foot was made. He was treated with conservative measures including a heel pad, taking naproxen, stretching exercises and wearing supportive footwear, but there was no significant improvement. It was decided to try an unguided local corticosteroid injection.

He received a local injection of 2 ml of 2% lidocaine followed by 40 mg of methylprednisolone into the medial side of the left heel. The patient was anxious. There were no immediate complications, however, within 2–3 min he developed excruciating pain in the dorso-lumbar spine and ribcage posterolaterally. He looked very unwell and appeared flushed and short of breath. His pulse was elevated at 110 bpm, blood pressure 130/80 mmHg, respiratory rate 16/min and normal temperature. He was in sinus rhythm with a clear chest and normal heart sounds. Within less than 5 min his symptoms spontaneously resolved, to the extent that he was profoundly apologetic for his presentation. Cardiac enzymes and an ECG were normal. Although there was no family history of ischaemic heart disease and no other risk factors, but in view of a small but possible risk of acute coronary syndrome within a week of a local corticosteroid injection, we arranged subsequent exercise ECG, echocardiogram and 24-h tape; all were normal [1].

Similar presentations of excruciating lumbar, dorsal or chest pain have rarely been reported after a local injection of corticosteroids into the lumbar epidural space, upper limb, lower limb (mostly heel) or paravertebral areas [2–4]. This is referred to as Tachon’s syndrome, first described by Gerard Andre Joseph Tachon (1936–1996). Only 3% of the cases reported included lidocaine, so the reaction is thought to be due to injected corticosteroids, such as cortivazol, hydrocortisone, betamethasone and paramethasone. Almost all the reported cases are from France, with an incidence of roughly 1 in 8000 injections. These preparations are not used in the UK. The syndrome is characterized by rapid onset (<5 min) and rapid resolution of symptoms. Symptoms include anxiety (87%), shortness of breath (64%), diffuse sweating (41%), chest pain (36%) and/or uneasiness (29%). Less frequently, Tachon’s syndrome includes transient symptoms such as cough (23%), abdominal pain (20%), hypertension (15%), hypotension (8%), pallor (10%), diarrhoea (3%), headache (3%), nausea or intense asthenia [1].

The pathogenesis of Tachon’s syndrome remains unclear. It is thought not to be an allergic reaction, as <2% of cases developed urticaria. There is a suggestion that this reaction could be secondary to leakage of corticosteroid into a vein, in contrast to Nicolau’s syndrome, where the leak is into an artery, and as this would pass through the lungs prior to being filtered by the kidney, this could explain the acute dyspnoea that preceded the axial pain. However, the time lag between injection and symptoms suggests there may be an additional mechanism of the clinical manifestation of Tachon’s syndrome [3].

The outcome for patients is very good. It spontaneously resolves and does not lead to any lasting damage. There were only four hospitalizations resulting from Tachon’s syndrome in the literature [3]. Although the presentation may seem alarming, the initial approach is to stabilize the patient and rule out any medical emergency.

We have presented this case in several regional meetings. The verbal response from 52 rheumatologists working in the London area and South East England was that they have not seen a similar reaction.

Although our case report fits with Tachon’s syndrome, we believe the symptoms and signs may be a reflection of anxiety and apprehension following a painful procedure. The patient can be reassured that this a well-documented, albeit rare side effect of injected corticosteroids.