Voriconazole-induced periostitis

Case contributed by Chris Newman
Diagnosis almost certain


? Bone changes post prolonged anti-fungal therapy. History of heart-lung transplantation

Patient Data

Age: 55 years
Gender: Female

CASE OF THE MONTH: This case was selected as the Case of the Month for November 2022.

WB bone scan & SPECT/CT

Nuclear medicine

Multifocal areas of moderate to intense osteoblastic activity throughout mainly the appendicular skeleton and pelvis.

  • the osteoblastic activity is localized to nodular and sheet-like periostitis on the cortex of the tibia, fibula and femur in both legs on the SPECT/CT
  • the whole body delayed images demonstrate several other osteoblastic foci including proximal mid ulna bilaterally, mid-shafts of both humeri, bilateral hand proximal phalanges and metacarpals on the left hand

Findings are suggestive of extensive periostitis.

Case Discussion

Voriconazole use has been associated with osteoarticular pain and periostitis. This phenomenon has been described primarily with high dosage or prolonged use of voriconazole therapy in immunocompromised and transplant patient populations 1.

The pathophysiology is thought to relate to the high fluoride content in the drug formulation. The absorbed excess fluoride is incorporated into the bony matrix (hydroxyapatite), forming fluorapatite, which causes a disorganized osteoblastic reaction, resulting in periosteal thickening and pain 1

This patient had persistent pulmonary fungal colonization and was on a prolonged course of antifungal treatment. 

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