Voriconazole periostitis

Cases of voriconazole-induced periostitis continue to be reported. Voriconazole preparations contain fluoride, and the mechanism of this adverse effect has been linked to the accumulation of fluoride. The EIDOS and DoTS descriptions of this reaction are shown in Figure 2. 

A 65-year-old Caucasian man with a left single lung transplant took voriconazole (200 mg twice daily) for pulmonary aspergillosis after 9 months therapy, a follow-up chest computed tomography showed no infectious disease, hut revealed multifocal periostitis in the axial and appendicular skeleton that was not seen initially [43A]. Bone pain was not assessed because the patient had severe dementia. The authors discuss the case and review published case reports and series on voriconazole-induced periostitis. 

Conclusions The mechanisms by which chronic voriconazole treatment predisposes to periostitis seem to involve highly elevated fluorine levels, although other coinciding factors are most likely affecting as well. Plasma fluorine levels are usually elevated after 6 months of voriconazole administration but improvement of symptoms after voriconazole discontinuation is fast. 

Wermers RA, Cooper K, Razonable RR, Deziel PJ, Whitford GM, Kremers WK, et al. Fluoride excess and periostitis in transplant patients receiving long-term voriconazole therapy. CUn Infect Dis 2011 52(5) 604r-ll. 

Tedja R, El-Sherief A, OlbrychT, Gordons. Multifocal periostitis as a complication of chronic use of voriconazole in a lung transplant recipient. Transpl Infect Dis 2013 15(4) 424r-9. 

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