1
|
Ashmeik W, Schirò S, Joseph GB, Link TM. Associations of cumulative voriconazole dose, treatment duration, and alkaline phosphatase with voriconazole-induced periostitis. Skeletal Radiol 2024:10.1007/s00256-024-04707-2. [PMID: 38760641 DOI: 10.1007/s00256-024-04707-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 05/01/2024] [Accepted: 05/11/2024] [Indexed: 05/19/2024]
Abstract
OBJECTIVE To investigate the associations of cumulative voriconazole dose, treatment duration, and alkaline phosphatase with voriconazole-induced periostitis. MATERIALS AND METHODS One hundred and thirty-one patients with voriconazole use were identified using a clinical informatics tool. Health record data including age, sex, immune status, alkaline phosphatase, voriconazole levels, voriconazole dose, frequency, and treatment duration were collected. Imaging studies during the duration of treatment were reviewed by two radiology trainees and imaging features of voriconazole-induced periostitis were confirmed by a board-certified musculoskeletal radiologist. The length, location in the body, location in the bone, type, and morphology of periostitis lesions were recorded. Incident voriconazole-induced periostitis was defined as new periostitis on imaging after 28 days or more of voriconazole treatment in the absence of an alternative diagnosis. Univariate Firth's logistic regression models were performed using cumulative voriconazole dose, treatment duration, and average ALP as predictors and incident VIP as the outcome. RESULTS There were nine patients with voriconazole-induced periostitis and 122 patients without voriconazole-induced periostitis. The most common lesion location in the body was the ribs (37%) and morphology was solid (44%). A 31.5-g increase in cumulative voriconazole dose was associated with 8% higher odds of incident periostitis. Increased treatment duration (63 days) and higher average alkaline phosphatase (50 IU/L) were associated with 7% higher odds of periostitis and 34% higher odds of periostitis, respectively. CONCLUSION Increased cumulative voriconazole dose, treatment duration, and average alkaline phosphatase were associated with higher odds of voriconazole-induced periostitis.
Collapse
Affiliation(s)
- Walid Ashmeik
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 185 Berry Street, Suite 350, San Francisco, CA, 94107, USA.
| | - Silvia Schirò
- Department of Medicine and Surgery (DiMeC), University of Parma, Parma, Italy
| | - Gabby B Joseph
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 185 Berry Street, Suite 350, San Francisco, CA, 94107, USA
| | - Thomas M Link
- Department of Radiology and Biomedical Imaging, University of California San Francisco, 185 Berry Street, Suite 350, San Francisco, CA, 94107, USA
| |
Collapse
|
2
|
Guarascio AJ, Bhanot N, Min Z. Voriconazole-associated periostitis: Pathophysiology, risk factors, clinical manifestations, diagnosis, and management. World J Transplant 2021; 11:356-371. [PMID: 34631468 PMCID: PMC8465512 DOI: 10.5500/wjt.v11.i9.356] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/19/2021] [Accepted: 08/27/2021] [Indexed: 02/06/2023] Open
Abstract
Voriconazole use has been associated with osteoarticular pain and periostitis, likely due to high fluoride content in the drug formulation. This phenomenon has been described primarily with high dosage or prolonged course of voriconazole therapy in immunocompromised and transplant patient populations. Patients typically present with diffuse bony pains associated with elevated serum alkaline phosphatase and plasma fluoride levels in conjunction with radiographic findings suggestive of periostitis. We provide a comprehensive review of the literature to highlight salient characteristics commonly associated with voriconazole-induced periostitis.
Collapse
Affiliation(s)
- Anthony J Guarascio
- Department of Pharmacy, Duquesne University School of Pharmacy, Pittsburgh, PA 15282, United States
| | - Nitin Bhanot
- Division of Infectious Disease, Medicine Institute, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA 15212, United States
| | - Zaw Min
- Division of Infectious Disease, Medicine Institute, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, PA 15212, United States
| |
Collapse
|
3
|
Fernández Ávila DC, Diehl M, Degrave AM, Buttazzoni M, Pereira T, Aguirre MA, Basquiera AL, Scolnik M. Voriconazole-induced periostitis. Reumatismo 2021; 73:44-47. [PMID: 33874646 DOI: 10.4081/reumatismo.2021.1368] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 01/23/2021] [Indexed: 11/23/2022] Open
Abstract
Voriconazole is a fluorinated drug from the triazole group that is widely used in the prophylaxis and treatment of fungal infections in immunosuppressed patients. Chronic use of this medication can generate, as an adverse effect, a multifocal, asymmetric, diffuse and nodular periosteal reaction, associated with severe and disabling skeletal pain and elevated alkaline phosphatase and serum fluoride. Radiography is the imaging technique of choice for periostitis diagnosis. In general, clinical manifestations and radiographic findings disappear, when the drug is discontinued. We report the clinical case of a 44 year-old woman diagnosed with acute myeloid leukemia, who developed an invasive fungal infection treated with voriconazole after a stem cell transplant. Nine months after starting antifungal treatment, she manifested symptoms and radiological signs compatible with periostitis. Due to clinical suspicion, we decided to suspend voriconazole, with consequent resolution of clinical manifestations and radiological findings.
Collapse
Affiliation(s)
- D C Fernández Ávila
- Rheumatology Section, Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires.
| | - M Diehl
- Metabolic bone disease Section, Endocrinology Department, Hospital Italiano de Buenos Aires, Buenos Aires.
| | - A M Degrave
- Metabolic bone disease Section, Endocrinology Department, Hospital Italiano de Buenos Aires, Buenos Aires.
| | - M Buttazzoni
- Metabolic bone disease Section, Endocrinology Department, Hospital Italiano de Buenos Aires, Buenos Aires.
| | - T Pereira
- Metabolic bone disease Section, Endocrinology Department, Hospital Italiano de Buenos Aires, Buenos Aires.
| | - M A Aguirre
- Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires.
| | - A L Basquiera
- Hematology Section, Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires.
| | - M Scolnik
- Rheumatology Section, Internal Medicine Department, Hospital Italiano de Buenos Aires, Buenos Aires.
| |
Collapse
|
4
|
Khawar T, Hamann CR, Haghshenas A, Blackburn A, Torralba KD. A 31-Year-Old Man With A Fungal Infection, Elevated Alkaline Phosphatase Level, and Polyarthritis. Arthritis Care Res (Hoboken) 2020; 72:601-606. [PMID: 30452124 DOI: 10.1002/acr.23812] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
| | - Carsten R Hamann
- Herlev and Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | | | | | | |
Collapse
|
5
|
Elmore S, Wisse A, Chapin RW, Whelan TP, Silver RM. Voriconazole-associated periostitis presenting as hypertrophic osteoarthropathy following lung transplantation report of two cases and review of the literature. Semin Arthritis Rheum 2019; 49:319-323. [PMID: 31103239 DOI: 10.1016/j.semarthrit.2019.04.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/17/2019] [Accepted: 04/22/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND Hypertrophic osteoarthropathy (HOA) is a syndrome characterized by abnormal proliferation of skin and osseous tissue frequently associated with underlying pulmonary disorders. Cardinal features include digital clubbing, periostitis and significant joint and bone pain. A number of recent reports have emerged of HOA and periostitis occurring in association with the antifungal agent voriconazole. METHODS We present two additional cases of voriconazole-induced HOA and periostitis in lung transplant recipients with a review the medical literature. RESULTS In both cases, symptoms were painful and severe enough to require opioid medication. Rapid improvement occurred within days of voriconazole cessation. A review of existing literature revealed an additional 17 cases of voriconazole-induced HOA and periostitis in lung transplant patients. CONCLUSION We highlight the importance of recognizing the association of voriconazole with painful HOA and periostitis in lung transplant patients receiving antifungal therapy. Management of this painful condition involves cessation of voriconazole therapy, which may necessitate alternative anti-fungal drug therapies as well as adjustment of immunosuppressive drug dosage since voriconazole is a strong drug-inducer.
Collapse
Affiliation(s)
- Stephen Elmore
- Division of Rheumatology and Immunology, Department of Medicine, Medical University of South Carolina, 96 Jonathan Lucas Street, Suite 822, Charleston, SC 29401, USA
| | - Amy Wisse
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC 29401, USA
| | - Russell W Chapin
- Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC 29401, USA
| | - Timothy P Whelan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC 29401, USA
| | - Richard M Silver
- Division of Rheumatology and Immunology, Department of Medicine, Medical University of South Carolina, 96 Jonathan Lucas Street, Suite 822, Charleston, SC 29401, USA.
| |
Collapse
|
6
|
Spectrum of Voriconazole-Induced Periostitis With Review of the Differential Diagnosis. AJR Am J Roentgenol 2018; 212:157-165. [PMID: 30403528 DOI: 10.2214/ajr.18.19991] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Voriconazole is an antifungal medication used primarily for the treatment of Candida and Aspergillus infections. A fairly newly described side effect of long-term voriconazole use is periostitis. The purpose of this article is to describe the main differential consideration-hypertrophic osteoarthropathy-and other differential diagnoses, including venous stasis, thyroid acropachy, and hypervitaminosis A. CONCLUSION With knowledge of imaging appearance, clinical manifestations, and outcomes, radiologists can make an accurate diagnosis of voriconazole-induced periostitis, and clinical teams can initiate appropriate management.
Collapse
|
7
|
Voriconazole-induced periostitis: a new rheumatic disorder. Clin Rheumatol 2016; 36:609-615. [DOI: 10.1007/s10067-016-3341-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 06/22/2016] [Accepted: 06/22/2016] [Indexed: 02/04/2023]
|
8
|
Reber JD, McKenzie GA, Broski SM. Voriconazole-induced periostitis: beyond post-transplant patients. Skeletal Radiol 2016; 45:839-42. [PMID: 26980228 DOI: 10.1007/s00256-016-2365-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 02/24/2016] [Accepted: 02/29/2016] [Indexed: 02/02/2023]
Abstract
Voriconazole-induced periostitis (VIP) is a rare but increasingly encountered entity since Food and Drug Administration (FDA) approval of the second generation antifungal medication in 2002. Literature reports most commonly include transplant recipients on immunosuppressive therapy simultaneously requiring antifungal therapy. Nontransplant patients receiving long-term voriconazole have an equal risk of developing the disease, but may experience a delay in diagnosis due to a lack of familiarity with the process outside of the post-transplant and/or immunosuppressed population. We present a case of VIP in a nontransplant, immunocompetent patient on suppressive antifungal therapy for prior abdominal aortic stent graft fungal infection. Radiologist review of current medications and recognition of periostitis on multiple imaging modalities may hasten the diagnosis and lead to earlier treatment and resolution of symptoms.
Collapse
Affiliation(s)
- Joshua D Reber
- Department of Radiology, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55905, USA.
| | - Gavin A McKenzie
- Department of Radiology, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55905, USA
| | - Stephen M Broski
- Department of Radiology, Mayo Clinic, 200 1st St. SW, Rochester, MN, 55905, USA
| |
Collapse
|