Voriconazole-induced periostitis in a patient with overlap syndromes

BMJ Case Rep. 2014 Mar 5:2014:bcr2013203485. doi: 10.1136/bcr-2013-203485.

Abstract

A 52-year-old woman with overlap syndrome and interstitial pneumonia underwent immunosuppressive therapy and she was suspected to suffer from pulmonary aspergillosis. Oral voriconazole was initiated, and a rapid elevation of alkaline phosphatase (ALP) occurred after 4 weeks. After 2 months, the patient presented diffuse pain in bilateral skeletal regions, and bone scintigraphy revealed bilateral multiple areas of increased radiotracer uptake. We suspected the skeletal involvement as voriconazole-induced periostitis. Actually, the plasma fluoride level was increased. Voriconazole was replaced with itraconazole, and after 3 weeks, the patient stopped complaining of bone pain concomitant with the decrease in ALP. Voriconazole-induced periostitis is a rare condition but had previously been reported in solid organ or patients with bone marrow transplant who received a long-term voriconazole therapy. Our present case is distinctive of previous ones, because it occurred in a patient with connective tissue disease which had its rapid progression.

Publication types

  • Case Reports

MeSH terms

  • Antifungal Agents / adverse effects*
  • Antifungal Agents / therapeutic use
  • Female
  • Humans
  • Immunocompromised Host
  • Immunosuppressive Agents / adverse effects
  • Immunosuppressive Agents / therapeutic use
  • Middle Aged
  • Periostitis / chemically induced*
  • Periostitis / diagnosis
  • Pulmonary Aspergillosis / drug therapy*
  • Pulmonary Aspergillosis / immunology
  • Rheumatic Diseases / complications*
  • Rheumatic Diseases / drug therapy
  • Voriconazole / adverse effects*
  • Voriconazole / therapeutic use

Substances

  • Antifungal Agents
  • Immunosuppressive Agents
  • Voriconazole