Voriconazole-induced periostitis in stem cell transplant patient

Excerpt

A 66-year-old woman with history of chronic kidney disease and T-cell lymphoma in remission after allogeneic hematopoietic stem cell transplantation (HCT) 5 years before, complicated by chronic skin graft-versus host disease off immunosuppression for 3 months before the current presentation. She was admitted with 4-week history of right ankle pain with no prior trauma or penetrating wound. She denied fever, fatigue or weight loss. The patient had invasive pulmonary aspergillosis, treated with voriconazole and kept on 200 mg twice daily as secondary prophylaxis for the last 4 years. Physical examination revealed distal right lower leg tenderness without inflammation. Laboratory studies showed white blood cell count, 5900/μL; creatinine, 1.59 mg/dL; mildly elevated alkaline phosphatase, 144 U/L (normal range 35–104 U/L). Ankle X-ray showed thick and irregular periostitis of distal tibia and fibula without any evidence of local tumor or infection (Fig. 1). Technetium bone scan showed increase cortical tracer uptake. The patient was diagnosed with voriconazole-induced periostitis. After discontinuing voriconazole, the bone pain started subsiding and patient remained free of symptoms on subsequent clinic follow-ups.

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