Background/Purpose: Musculoskeletal (MS) corticosteroid (CS) injections are commonly used for joint inflammation with a perceived low risk of systemic toxicity, including hyperglycemia and adrenal suppression. However, rare neuropsychiatric complications, such as acute psychosis, have been reported after MS-CS injection. The exact mechanism is unclear, but systemic absorption and individual vulnerability may play roles. This study examines the incidence and predisposing factors of neuropsychiatric complications following MS-CS injections in rheumatology patients.

Methods: A retrospective analysis was performed on 5487 MS-CS injections at the University of New Mexico Hospital, supervised by one attending. Electronic medical records were reviewed to identify patients with new-onset psychiatric symptoms within seven days post-injection. Psychiatric complaints were confirmed based on provider documentation and mental health evaluations, when applicable. Data collected included the type and dose of corticosteroid, number of injection sessions, psychiatric symptom patterns, symptom duration, and whether proactive treatment was implemented during subsequent injections. A comparison was made between patients with and without psychiatric symptoms, focusing on baseline psychiatric history, particularly anxiety disorders.

Results: Of 5487 individual MS-CS injections in 596 individuals, 221 injections (4.02%) resulted in psychiatric complaints that were relayed to a medical provider. These complaints were concentrated in 24 patients, who had recurrent symptoms on reinjection. The mean dose of TA was 73.3±43.7 mg per injection session. The psychiatric symptoms post MS-CS injection in affected patients were vasomotor symptoms (100%), anxiety (100%), paranoia (37.5%), and hallucination (25%), and in certain cases acute medical consultation and/or treatment (29.2%) was required. Preexisting clinical depression (68.4%-83.3%) and anxiety syndromes (47.4%-87.5%) were very common in all rheumatology patients undergoing MS-CS injections (Table I). When comparing patients with neuropsychiatric symptoms after MS-CS injection to representative group who did not develop symptoms, a pre-existing anxiety syndrome was markedly increased in the neuropsychiatric group (Table 1). All symptoms typically resolved within 3 days. Because of the recurrent nature of these symptoms in individual patients on reinjection, 11/24 (45.3%) of affected patients requested proactive treatment after an injection, and lorazepam 1 mg every 8 hours after the injection for 2-3 days was prescribed with complete prevention the symptoms.

Conclusion: Preexisting neuropsychiatric disease – especially depression and anxiety syndromes – is present in majority of rheumatology patients undergoing MS-CS injections. MS-CS injections can cause significant psychiatric symptoms in about 4% of cases and typically follows a stereotypic pattern with anxiety most common though psychotic symptoms can also occur. The major predisposing factor appears to be a pre-existing anxiety disorder. For affected patients, short-term benzodiazepine treatment may provide symptomatic relief and prevention.

Table 1. Neuropsychiatric Symptoms after Musculoskeletal Corticosteroid Injection

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/steroid-psychosis-and-neuropsychiatric-symptoms-induced-by-corticosteroid-injection-in-rheumatology-patients/