Voriconazole-Induced Periostitis
A 65-year-old woman who had undergone lung transplantation 8 years earlier was evaluated by the rheumatology service for progressive swelling in both hands and diffuse body pain. Since transplantation, the patient had received antifungal prophylaxis with daily voriconazole. On examination, there was prominent joint and soft-tissue swelling and pain in both hands (Panel A), restricted range of motion in both shoulders, and tenderness on palpation of the bony prominences of the shoulders, elbows, neck, lower back, and knees. The alkaline phosphatase level was 742 U per liter (reference range, 34 to 123). Radiographs of the hands (Panel B) showed dense, irregular, nodular periostitis of the bones in her hands and wrists, a finding consistent with voriconazole-induced periostitis. Voriconazole is a trifluorinated antifungal medication; the mechanism of the periostitis is thought to be related to the effects of fluoride on bone. Voriconazole was discontinued in the patient. After consultation with the transplantation team, no further antifungal prophylaxis was initiated. At a 7-month follow-up visit, the pain had decreased, although limitations in range of motion and bony swelling of the hands persisted.