title: Periostitis secondary to prolonged voriconazole therapy in a lung transplant recipient.
abstract: This article reports a case of perostitis deformans in a lung transplantation patient taking the fluoride-containing medication voriconazole, a relatively new and potent anti-fungal. The patient had a normal range of motion in all joints and a normal gait. On radiographs at presentation, multifocal areas of periostitis were visualized involving the left-hand first, second, and third proximal phalanx shafts. Similar periostitis was present on the left-hand third, fourth, and fifth middle phalanx shafts. Plain radiographs of the right hand also demonstrated multifocal periostitis of the third and fourth proximal and middle phalanges. Aggressive periostitis at the level of the right fourth proximal and middle phalanges was also present. Given her long-term treatment with voriconazole and a presentation consistent with periostitis deformans, voriconazole was presumed to be the offending agent and was replaced with itraconazole. The patient's symptoms resolved shortly after withdrawal of voriconazole.Voriconazole-associated periostitis has only recently been reported in the literature. Food and Drug Administration-approved in 2002, voriconazole is efficacious in treating serious, invasive fungal infections that are generally seen in immunocompromised patients. Due to the novel nature of voriconazole and the uncommon indications for its long-term use, the periostitis deformans described in this article may be unfamiliar to the orthopedic surgeon. Consequently, a patient presenting with bone pain and periosteal involvement on plain radiographs may provoke a broad, expensive, and ultimately unnecessary diagnostic evaluation. The clinical case and imaging findings presented here can help to promote understanding of this benign condition and its simple cure: voriconazole discontinuation.
authors: Department of Orthopaedics, The Ohio State University, Columbus, Ohio, USA.
authors: David P
authors: DP
authors: Lustenberger
authors: Jaymes D
authors: JD
authors: Granata
authors: Thomas J
authors: TJ
authors: Scharschmidt
mesh_terms: D000328:Adult; D019072:Antibiotic Prophylaxis / Q000009:adverse effects; D000935:Antifungal Agents / Q000009:adverse effects*; D057915:Drug Substitution; D005260:Female; D006801:Humans; D016867:Immunocompromised Host; D017964:Itraconazole / Q000627:therapeutic use; D008172:Lung Diseases, Fungal / Q000209:etiology / Q000517:prevention & control; D016040:Lung Transplantation / Q000009:adverse effects* / Q000000981:diagnostic imaging; D010522:Periostitis / Q000139:chemically induced* / Q000175:diagnosis; D011183:Postoperative Complications; D011743:Pyrimidines / Q000009:adverse effects*; D011859:Radiography; D016896:Treatment Outcome; D014230:Triazoles / Q000009:adverse effects*; D065819:Voriconazole
chemical_list: D000935:Antifungal Agents; D011743:Pyrimidines; D014230:Triazoles; D017964:Itraconazole; D065819:Voriconazole