Voriconazole-induced periostitis in two post-transplant patients

Abstract

While drug-related periostitis has been known of for many years, the specific association of diffuse periostitis with voriconazole (most frequently in transplant patients) has only been recently explicitly addressed in the literature. Recognition of the radiologic and clinical manifestations of voriconazole-related periostitis is important for helping to narrow an otherwise broad differential diagnosis. We present two cases that illustrate different radiologic presentations of this painful cause of diffuse periostitis. Case 1 features a 60 year-old woman with a history of orthotopic heart transplant who was hospitalized for "full body pain" with progressively worsening bone tenderness involving the humeri, knees, femurs, hips, and hands. Case 2 describes a 48 year-old man with a history of acute lymphoblastic leukemia status post stem cell transplant who presented with diffuse arthralgias involving bilateral ankles, knees, wrists, and elbows.

Keywords: Periostitis deformans; hypertrophic osteoarthropathy; lung transplant; voriconazole.

Figure 1

60 year-old woman with voriconazole-induced periostitis following heart transplant. (A) Axial noncontrast CT image at presentation demonstrates fluffy, irregular periosteal new bone formation along the posterolateral aspect of the left seventh rib (solid arrow) with coned down image below (C) (GE LightSpeed16 Slice CT Scanner, 120 kVp, slice thickness = 2.5 mm. CTDIvol (mGy) = 1.75, DLP (mGy-cm) = 48.63). (B) Axial noncontrast CT image four months following discontinuation of voriconazole the periostitis has completely resolved, with coned down image below (D) (GE LightSpeed VCT Scanner, 120 kVp = 120, mAs = 39, slice thickness = 2.5 mm. CTDIvol (mGy) = 1.29, DLP (mGy-cm) = 43.30, 30% adaptive statistical iterative reconstruction (ASIR)).

Figure 2

60 year-old woman with voriconazole-induced periostitis following heart transplant. Anteroposterior views of the left humerus (A) and bilateral hips (B, C) demonstrate multifocal, dense, irregular periosteal new bone formation along the medial aspect of the left humeral neck; the medial proximal right femur, inferior to the lesser trochanter; and along the medial and lateral proximal left femur, inferior to the lesser trochanter (solid arrows). The respective coned down images are shown in the second row of the figure (D, E, F).

Figure 3

60 year-old woman with voriconazole-induced periostitis following heart transplant. At presentation, anterior and posterior (A, B) whole body views were obtained 3 hours following the intravenous injection of 19 mCi of Tc-99m MDP (ADAC Vertex Gamma Camera), with coned down views of the thorax from A and B shown in E and F, respectively. There are multiple abnormal scattered foci of uptake, most prominent at the medial left proximal humeral neck and the left sixth and seventh ribs (arrows) but also involving the medial right humeral neck (arrow); the bilateral proximal femoral diaphyses, inferior to the lesser trochanters (dashed arrows); and the proximal tibial diaphyses (dashed arrows). Five months following discontinuation of voriconazole, anterior and posterior whole body views (C and D) were obtained 3 hours following the intravenous injection of 20.1 mCi Tc-99m MDP which demonstrate marked interval resolution of the previously noted abnormal foci of uptake (ADAC Vertex Gamma Camera).

Figure 4

48 year-old man with voriconazole-induced periostitis following stem cell transplant for acute lymphoblastic leukemia. Lateral (A), anteroposterior (B), and oblique (C) views of the elbow demonstrate dense, irregular, bulky periosteal new bone formation about the elbow joint (arrows). Specifically, there is bulky periosteal new bone along the proximal radial and ulnar diaphyses, at the posterior and medial aspects of the olecranon, and along the distal medial humeral metaphysis in the supracondylar region. Coned down images of each view are shown in the lower row of the figure (D/E, F, and G, respectively).

Figure 5

48 year-old man with voriconazole-induced periostitis following stem cell transplant for acute lymphoblastic leukemia. Single anteroposterior (A) radiograph of the right hand and coned down images at right demonstrate irregular, bulky periosteal new bone formation involving the first proximal phalanx medially (B), the fifth metacarpal medially (C) (arrows), the distal radial metadiaphysis laterally (D), and the distal ulnar diaphysis laterally (E). Coned down image of the fifth metacarpal (C) also demonstrates sclerosis and abnormal morphology of the fifth metacarpal head consistent with prior fracture (dashed arrow).