A 49 year old gentleman presented with intermittent bilateral knee swelling for the past 37 years and was eventually diagnosed as primary hypertrophic osteoarthropathy after secondary forms were excluded. This case illustrates that the disease can present during childhood with an insidious onset and progressively become more severe and that is when medical attention is sought. Furthermore, the patient did not voluntarily report his skin changes as he considered the slow progressive changes as normal. We report a case of primary hypertrophic osteoarthropathy, its clinical presentation, imaging findings and therapeutic treatment. It is a rare differential diagnosis for chronic joint pain and swelling.

A 62 year-old gentleman with underlying ANCA vasculitis was admitted to hospital for severe musculoskeletal pain involving both shoulders, hips and hands. There was a history of long term usage of anti-fungal medication-voriconazole for his Aspergillus fumigatus lung infection as treatment and prophylaxis. Clinically the range of movement of both shoulders and hips was restricted with the presence of digital swelling of both hands. His imaging findings noted the presence of periosteal reaction involving shoulders and hips in addition to increased radiotracer uptake on his bone scan. A diagnosis of voriconazole induced periostitis was made and discontinuation of therapy led to rapid clinical improvement.