Fluorosis and periostitis deformans as complications of prolonged voriconazole treatment

Abstract

We describe a case of development of painful periostitis deformans in a 39-year-old woman who was receiving long-term voriconazole treatment for Aspergillus infection as a complication of orthotopic liver transplant. Measurement of fluoride levels strongly supports fluorosis to be the mechanism of the voriconazole-induced periostitis deformans and supports the concept that such measurements might be of use in predicting this complication of long-term voriconazole treatment.

Voriconazole-associated periostitis: Pathophysiology, risk factors, clinical manifestations, diagnosis, and management

“…A total of 89 cases of voriconazole-induced periostitis were reviewed (Table 1 ), including 2 pediatric patients, one 14-year-old lung transplant patient and one 3-mo-old stem cell transplant recipient[ 5 - 53 ]. Cases were published in the format of case reports (limited 1 case in an article, 19 articles)[ 7 , 9 , 10 , 16 , 19 , 22 , 25 , 27 , 30 , 32 , 34 , 37 , 38 , 40 , 42 , 43 , 45 , 47 , 51 ], case series (> 1 case in an article, 9 articles)[ 5 , 8 , 11 , 15 , 18 , 23 , 35 , 39 , 48 ], image section (12 articles)[ 12 , 13 , 17 , 21 , 28 , 31 , 33 , 36 , 46 , 49 , 50 , 53 ], photo quiz (1 article)[ 20 ], conference abstracts (5 articles)[ 6 , 14 , 24 , 26 , 29 ], letter to the editor (2 articles)[ 41 , 44 ], and clinicopathologic conference (1 article)[ 52 ]. One case report was published in both Danish and English, and it was included in our analysis because there was ample amount of information in English[ 51 ].…”

“…The duration of voriconazole therapy was described in 77 cases (30 SOT patients[ 5 , 7 , 8 , 11 - 13 , 16 , 18 , 21 , 26 , 30 , 32 , 35 , 39 , 43 , 44 , 47 , 48 , 50 ], 16 HSCT recipients[ 6 , 10 , 11 , 14 , 15 , 28 , 31 , 35 , 37 , 40 , 41 , 49 , 53 ], 18 immunocompetent hosts[ 23 , 38 , 51 , 52 ], and 13 others[ 19 , 20 , 22 , 23 , 27 , 42 , 45 ]. The voriconazole trough level was mentioned in 38 cases, including 9 SOT patients[ 11 , 26 , 32 , 34 , 44 , 47 ], 2 HSCT recipients[ 10 , 11 ], 17 immunocompetent hosts[ 23 , 51 ], and 10 others[ 20 , 22 , 23 , 42 ].…”

Voriconazole-Induced Periostitis & Enthesopathy in Solid Organ Transplant Patients: Case Reports

“…Patient 1 is the third patient (earlier patients were reported by Becce et al ., 2012 and Rad, 2015) to develop voriconazole-induced periostitis after a liver transplant [2] [15]. It is likely that hepatic metabolism of voriconazole is affected by the interaction with tacrolimus [24].…”

Denouement

“…[1][2][3][4][5][6] Most reported cases are in patients with malignancies or a history of transplant. It has not previously been reported in a patient with CGD.…”