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Shetty AN, Cummings KW, Gotway MB, Jensen EA, Jokerst CE, Panse PM, Rojas CA. Thoracic periosteal reaction secondary to voriconazole use in an adult transplant patient. Radiol Case Rep 2024; 19:346-348. [PMID: 38028313 PMCID: PMC10663634 DOI: 10.1016/j.radcr.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/04/2023] [Indexed: 12/01/2023] Open
Abstract
Periosteal reaction may result from multiple causes including infection, trauma, medications, and neoplasms. One important etiology that must be considered in the differential diagnosis of symmetric periosteal reaction, especially in immunocompromised patients, is voriconazole use. We present a case of a 65-year-old man who underwent liver transplantation complicated by acute hypoxic respiratory failure and Aspergillus infection. Long term voriconazole therapy was initiated with resultant development of thoracic periosteal reaction which improved following discontinuation of the medication. Given the preferential upper body distribution of periosteal reaction induced by voriconazole, chest radiologists might be the first ones to recognize this adverse effect.
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Affiliation(s)
- Anisha N. Shetty
- Department of Radiology, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054 USA
| | | | - Michael B. Gotway
- Department of Radiology, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054 USA
| | - Eric A. Jensen
- Department of Radiology, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054 USA
| | - Clinton E. Jokerst
- Department of Radiology, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054 USA
| | - Prasad M. Panse
- Department of Radiology, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054 USA
| | - Carlos A. Rojas
- Department of Radiology, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ, 85054 USA
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Li Z, Wu C, Wang C, Deng Z. Spectrum of voriconazole-associated periostitis in clinical characteristics, diagnosis and management. Infection 2022; 50:1217-1224. [PMID: 35288847 DOI: 10.1007/s15010-022-01795-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/25/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Previous knowledge about the relationship between voriconazole exposure and periostitis was mainly based on limited case reports and few retrospective studies. The purpose of this study was to assess the clinical characteristics, diagnosis and management of voriconazole-associated periostitis. METHODS Case reports and case series from 1998 to November 30, 2021 on periostitis induced by voriconazole were collected for retrospective analysis. RESULTS Forty four patients (18 male and 26 female) from 34 studies were included in total. The median age was 58 years (29-74). The majority of patients had undergone organ transplantation (50.0%) or suffered from hematologic malignancy (31.81%). The median onset time of symptoms was 6 months after the start of voriconazole. The most common initial symptom was diffuse skeletal pain (68.28%) which can be severe and even disabling (66.7%). Ribs (37.21%), femurs (32.56%), scapulae (25.58%), humerus (23.26%), and clavicle (23.26%) were the common involved locations. Most cases were accompanied by different degrees of elevated serum alkaline phosphatase and fluoride level, while some presented with elevated bone-specific alkaline phosphatase. The main radiological features included periosteal reaction and multifocal high radiotracer uptake on bone scintigraphy. The formation of new bone was characterized with bilateral, irregular, nodular, as well as high density. The resolution of symptoms was observed with discontinuation of voriconazole in all patients, of whom 18 patients (52.94%) were relieved within a week. Itraconazole, posaconazole or isavuconazole were safe alternatives to voriconazole in voriconazole-induced periostitis. CONCLUSION Voriconazole-induced periostitis is an infrequent complication characterized by bone inflammation involving one or multiple skeletal areas. Bony pain, elevated serum alkaline phosphatase as well as fluoride level are suspicious signs during voriconazole treatment.
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Affiliation(s)
- Zuojun Li
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Cuifang Wu
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Chunjiang Wang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Zhenzhen Deng
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China.
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Guarascio AJ, Bhanot N, Min Z. Voriconazole-associated periostitis: Pathophysiology, risk factors, clinical manifestations, diagnosis, and management. World J Transplant 2021; 11:356-371. [PMID: 34631468 PMCID: PMC8465512 DOI: 10.5500/wjt.v11.i9.356] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/19/2021] [Accepted: 08/27/2021] [Indexed: 02/06/2023] Open
Abstract
Voriconazole use has been associated with osteoarticular pain and periostitis, likely due to high fluoride content in the drug formulation. This phenomenon has been described primarily with high dosage or prolonged course of voriconazole therapy in immunocompromised and transplant patient populations. Patients typically present with diffuse bony pains associated with elevated serum alkaline phosphatase and plasma fluoride levels in conjunction with radiographic findings suggestive of periostitis. We provide a comprehensive review of the literature to highlight salient characteristics commonly associated with voriconazole-induced periostitis.
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Affiliation(s)
- Anthony J Guarascio
- Department of Pharmacy, Duquesne University School of Pharmacy, Pittsburgh, PA 15282, United States
| | - Nitin Bhanot
- Division of Infectious Disease, Medicine Institute, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA 15212, United States
| | - Zaw Min
- Division of Infectious Disease, Medicine Institute, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA 15212, United States
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Fernández Ávila DC, Diehl M, Degrave AM, Buttazzoni M, Pereira T, Aguirre MA, Basquiera AL, Scolnik M. Voriconazole-induced periostitis. Reumatismo 2021; 73:44-47. [PMID: 33874646 DOI: 10.4081/reumatismo.2021.1368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 01/23/2021] [Indexed: 11/23/2022] Open
Abstract
Voriconazole is a fluorinated drug from the triazole group that is widely used in the prophylaxis and treatment of fungal infections in immunosuppressed patients. Chronic use of this medication can generate, as an adverse effect, a multifocal, asymmetric, diffuse and nodular periosteal reaction, associated with severe and disabling skeletal pain and elevated alkaline phosphatase and serum fluoride. Radiography is the imaging technique of choice for periostitis diagnosis. In general, clinical manifestations and radiographic findings disappear, when the drug is discontinued. We report the clinical case of a 44 year-old woman diagnosed with acute myeloid leukemia, who developed an invasive fungal infection treated with voriconazole after a stem cell transplant. Nine months after starting antifungal treatment, she manifested symptoms and radiological signs compatible with periostitis. Due to clinical suspicion, we decided to suspend voriconazole, with consequent resolution of clinical manifestations and radiological findings.
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Affiliation(s)
- D C Fernández Ávila
- Rheumatology Section, Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires.
| | - M Diehl
- Metabolic bone disease Section, Endocrinology Department, Hospital Italiano de Buenos Aires, Buenos Aires.
| | - A M Degrave
- Metabolic bone disease Section, Endocrinology Department, Hospital Italiano de Buenos Aires, Buenos Aires.
| | - M Buttazzoni
- Metabolic bone disease Section, Endocrinology Department, Hospital Italiano de Buenos Aires, Buenos Aires.
| | - T Pereira
- Metabolic bone disease Section, Endocrinology Department, Hospital Italiano de Buenos Aires, Buenos Aires.
| | - M A Aguirre
- Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires.
| | - A L Basquiera
- Hematology Section, Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires.
| | - M Scolnik
- Rheumatology Section, Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires.
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Viel-Thériault I, Bittencourt H, Autmizguine J, Ovetchkine P. Skeletal fluorosis after prolonged voriconazole therapy. Paediatr Child Health 2019; 25:7-8. [PMID: 33390733 DOI: 10.1093/pch/pxz023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 11/22/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Isabelle Viel-Thériault
- Infectious Diseases Division, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario
| | - Henrique Bittencourt
- Hematology-Oncology Division, Department of Pediatrics, CHU Sainte-Justine - Université de Montréal, Montréal, Québec
| | - Julie Autmizguine
- Infectious Diseases Division, Department of Pediatrics, CHU Sainte-Justine - Université de Montréal, Montréal, Québec
| | - Philippe Ovetchkine
- Infectious Diseases Division, Department of Pediatrics, CHU Sainte-Justine - Université de Montréal, Montréal, Québec
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Spectrum of Voriconazole-Induced Periostitis With Review of the Differential Diagnosis. AJR Am J Roentgenol 2018; 212:157-165. [PMID: 30403528 DOI: 10.2214/ajr.18.19991] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Voriconazole is an antifungal medication used primarily for the treatment of Candida and Aspergillus infections. A fairly newly described side effect of long-term voriconazole use is periostitis. The purpose of this article is to describe the main differential consideration-hypertrophic osteoarthropathy-and other differential diagnoses, including venous stasis, thyroid acropachy, and hypervitaminosis A. CONCLUSION With knowledge of imaging appearance, clinical manifestations, and outcomes, radiologists can make an accurate diagnosis of voriconazole-induced periostitis, and clinical teams can initiate appropriate management.
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Sircar M, Kotton C, Wojciechowski D, Safa K, Gilligan H, Heher E, Williams W, Thadhani R, Tolkoff-Rubin N. Voriconazole-Induced Periostitis & Enthesopathy in Solid Organ Transplant Patients: Case Reports. ACTA ACUST UNITED AC 2016; 4:8-17. [PMID: 27990445 PMCID: PMC5158005 DOI: 10.4236/jbm.2016.411002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Voriconazole is frequently used to treat fungal infections in solid organ transplant patients. Recently, there have been reports suggesting that prolonged voriconazole therapy may lead to periostitis. Aim Here we present two cases of voriconazole-induced periostitis in solid organ transplant patients. Case Presentation Voriconazole was given to two transplant patients-one with a liver transplant and the second with a heart transplant, to treat their fungal infections. Both developed voriconazole-induced toxicity. While undergoing voriconazole therapy, they had incapacitating bone pain. The liver transplant patient had to be taken off voriconazole, and the heart transplant patient succumbed to non-voriconazole related causes. Conclusions Voriconazole therapy in two solid organ transplant patients resulted in periostitis. We provide potential etiologies underlying voriconazole-induced periostitis, including fluoride toxicity, abnormalities in the pulmonary vascular bed leading to the production of downstream inflammatory mediators, and abnormal pharmacokinetics of hepatic drug metabolism. In addition to monitoring blood voriconazole trough levels, we suggest careful assessment for musculoskeletal pain in patients undergoing voriconazole treatment for two months or more, particularly if their daily dosages of voriconazole exceed 500 mg per day. Appropriate workup should include measurement of alkaline phosphatase, voriconazole trough and fluoride levels as well as a bone scan. Overall, early recognition of voriconazole-induced musculoskeletal toxicity is important for better morbidity outcomes.
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Affiliation(s)
- Monica Sircar
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Camille Kotton
- Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - David Wojciechowski
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; MGH Transplant Center, Departments of Medicine and Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Kassem Safa
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; MGH Transplant Center, Departments of Medicine and Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Hannah Gilligan
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; MGH Transplant Center, Departments of Medicine and Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Eliot Heher
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; MGH Transplant Center, Departments of Medicine and Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Winfred Williams
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; MGH Transplant Center, Departments of Medicine and Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Ravi Thadhani
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Nina Tolkoff-Rubin
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; MGH Transplant Center, Departments of Medicine and Surgery, Massachusetts General Hospital, Boston, MA, USA
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Voriconazole-induced periostitis: a new rheumatic disorder. Clin Rheumatol 2016; 36:609-615. [DOI: 10.1007/s10067-016-3341-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 06/22/2016] [Accepted: 06/22/2016] [Indexed: 02/04/2023]
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Voriconazole Enhances the Osteogenic Activity of Human Osteoblasts In Vitro through a Fluoride-Independent Mechanism. Antimicrob Agents Chemother 2015; 59:7205-13. [PMID: 26324277 DOI: 10.1128/aac.00872-15] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Accepted: 08/27/2015] [Indexed: 01/30/2023] Open
Abstract
Periostitis, which is characterized by bony pain and diffuse periosteal ossification, has been increasingly reported with prolonged clinical use of voriconazole. While resolution of clinical symptoms following discontinuation of therapy suggests a causative role for voriconazole, the biological mechanisms contributing to voriconazole-induced periostitis are unknown. To elucidate potential mechanisms, we exposed human osteoblasts in vitro to voriconazole or fluconazole at 15 or 200 μg/ml (reflecting systemic or local administration, respectively), under nonosteogenic or osteogenic conditions, for 1, 3, or 7 days and evaluated the effects on cell proliferation (reflected by total cellular DNA) and osteogenic differentiation (reflected by alkaline phosphatase activity, calcium accumulation, and expression of genes involved in osteogenic differentiation). Release of free fluoride, vascular endothelial growth factor (VEGF), and platelet-derived growth factor (PDGF) was also measured in cell supernatants of osteoblasts exposed to triazoles, with an ion-selective electrode (for free fluoride) and enzyme-linked immunosorbent assays (ELISAs) (for VEGF and PDGF). Voriconazole but not fluconazole significantly enhanced the proliferation and differentiation of osteoblasts. In contrast to clinical observations, no increases in free fluoride levels were detected following exposure to either voriconazole or fluconazole; however, significant increases in the expression of VEGF and PDGF by osteoblasts were observed following exposure to voriconazole. Our results demonstrate that voriconazole can induce osteoblast proliferation and enhance osteogenic activity in vitro. Importantly, and in contrast to the previously proposed mechanism of fluoride-stimulated osteogenesis, our findings suggest that voriconazole-induced periostitis may also occur through fluoride-independent mechanisms that enhance the expression of cytokines that can augment osteoblastic activity.
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