Mimicking Multiple Myeloma: Voriconazole-Induced Hyperfluorosis and Bone Lesions

Abstract

A 70-year-old man was found to have diffuse lytic and sclerotic bone lesions during a work-up to rule out malignancy after sustaining an unprovoked pulmonary embolus (Fig. 1). The patient reported several months of deep "bone pain" and debilitating weakness. Past medical history was significant for a history of disseminated coccidioidomycosis for which he was being treated with voriconazole. An extensive work-up, including biopsy of a bone lesion, bone marrow biopsy, and protein electrophoresis, was unrevealing. Due to an elevated alkaline phosphatase level in the setting of chronic voriconazole use, a fluoride level was checked and found to be markedly elevated at 16 mmol/L (normal 1-4 mmol/L).