Voriconazole-induced periostitis post lung transplantation

Abstract

Voriconazole is a broad-spectrum triazole antifungal used to treat invasive fungal infections. It is commonly used prophylactically in immunocompromized patient cohorts, including transplant recipients. Diffuse periostitis is a very rare complication of chronic voriconazole use. It is associated with diffuse bone pain, elevated serum alkaline phosphatase and fluorine levels. Characteristic imaging findings include periosteal thickening with a dense, nodular, irregular and often bilateral pattern. We describe the case of a 71-year-old female who presented with multifocal bone pain six years following double lung transplantation. Her post transplantation course had been complicated by a life threatening episode of sepsis secondary to Scedosporium apiospermum, a rare invasive fungal infection following which lifelong prophylaxis with oral Voriconazole was commenced. We discuss the characteristic clinical and imaging manifestations of this rare condition.

Keywords: Lung transplantation; Periostitis; Voriconazole.

Fig 1

AP radiograph of the left shoulder: There are foci of juxta cortical mineralisation at the proximal left humerus (white arrow) and inferior left clavicle (white arrowhead) consistent with periostitis. Surgical clips are noted at the hila bilaterally (yellow arrows) in keeping with the history of bilateral lung transplantation.

Fig 2

a and b. Whole-body radionuclide bone scan demonstrates multifocal radiotracer uptake in the ribs and left shoulder.

Fig 3

(a). Axial SPECT scan of the thorax demonstrates juxtacortical ossification at the posterior aspect of the proximal left humerus, associated with prominent tracer uptake (white arrow). (b). Parasagittal SPECT image of the left shoulder demonstrates juxtacortical ossification at the posterior aspect of the proximal left humerus, associated with prominent tracer uptake (white arrow). (c). SPECT image at the left parasagittal level shows juxtacortical ossification with tracer uptake in a left posterior rib (white arrow). (d). Axial SPECT image of the upper thorax demonstrates juxtacortical ossification bilaterally at the clavicles (white arrows) and at the left posterior humoral head and left glenoid with low grade increased tracer activity (arrowheads).