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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.
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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
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Li Z, Wu C, Wang C, Deng Z. Spectrum of voriconazole-associated periostitis in clinical characteristics, diagnosis and management. Infection 2022; 50:1217-1224. [PMID: 35288847 DOI: 10.1007/s15010-022-01795-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/25/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Previous knowledge about the relationship between voriconazole exposure and periostitis was mainly based on limited case reports and few retrospective studies. The purpose of this study was to assess the clinical characteristics, diagnosis and management of voriconazole-associated periostitis. METHODS Case reports and case series from 1998 to November 30, 2021 on periostitis induced by voriconazole were collected for retrospective analysis. RESULTS Forty four patients (18 male and 26 female) from 34 studies were included in total. The median age was 58 years (29-74). The majority of patients had undergone organ transplantation (50.0%) or suffered from hematologic malignancy (31.81%). The median onset time of symptoms was 6 months after the start of voriconazole. The most common initial symptom was diffuse skeletal pain (68.28%) which can be severe and even disabling (66.7%). Ribs (37.21%), femurs (32.56%), scapulae (25.58%), humerus (23.26%), and clavicle (23.26%) were the common involved locations. Most cases were accompanied by different degrees of elevated serum alkaline phosphatase and fluoride level, while some presented with elevated bone-specific alkaline phosphatase. The main radiological features included periosteal reaction and multifocal high radiotracer uptake on bone scintigraphy. The formation of new bone was characterized with bilateral, irregular, nodular, as well as high density. The resolution of symptoms was observed with discontinuation of voriconazole in all patients, of whom 18 patients (52.94%) were relieved within a week. Itraconazole, posaconazole or isavuconazole were safe alternatives to voriconazole in voriconazole-induced periostitis. CONCLUSION Voriconazole-induced periostitis is an infrequent complication characterized by bone inflammation involving one or multiple skeletal areas. Bony pain, elevated serum alkaline phosphatase as well as fluoride level are suspicious signs during voriconazole treatment.
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Affiliation(s)
- Zuojun Li
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Cuifang Wu
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Chunjiang Wang
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China
| | - Zhenzhen Deng
- Department of Pharmacy, The Third Xiangya Hospital, Central South University, Changsha, 410013, Hunan, China.
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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.
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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
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Voriconazole-induced periostitis in stem cell transplant patient. Infection 2020; 48:809-810. [PMID: 32430648 DOI: 10.1007/s15010-020-01445-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/11/2020] [Indexed: 01/30/2023]
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Cormican S, Adams N, O'Connell P, McErlean A, de Freitas D. Voriconazole-induced periostitis deformans: serial imaging in a patient with ANCA vasculitis. Skeletal Radiol 2018; 47:191-194. [PMID: 28866833 DOI: 10.1007/s00256-017-2764-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 07/25/2017] [Accepted: 08/17/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVES A 61-year-old with acute granulomatosis and polyangiitis developed Aspergillus fumigatus pneumonia after admission to the intensive care unit with a small bowel perforation. This occurred after immunosuppression (intravenous methylprednisolone, intravenous cyclophosphamide, and plasmapheresis) for his initial presentation with stage 3 acute kidney injury. MATERIALS AND METHODS The mycologist recommended long-term treatment with voriconazole after initial recovery. RESULTS After 7 months of treatment, the patient complained of joint pain and swelling in his hands. Radiographs, computed tomography, and single-photon emission computed tomography appearances were consistent with periostitis. A diagnosis of Voriconazole-induced periostitis deformans was made and the voriconazole was stopped. Plasma fluoride level was 278 μg/L (normal range < 50 μg/L). Discontinuation of voriconazole led to clinical improvement. CONCLUSIONS Periostitis deformans due to fluorosis is a rare complication of voriconazole treatment. The imaging in our case is unusually dramatic. We were able to track the evolution of periosteal reactions over serial imaging.
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Affiliation(s)
- S Cormican
- Nephrology Department, Beaumont Hospital, Royal Oak, MI, USA.
| | - N Adams
- Radiology Department, Beaumont Hospital, Royal Oak, MI, USA
| | - P O'Connell
- Rheumatology Department, Beaumont Hospital, Royal Oak, MI, USA
| | - A McErlean
- Radiology Department, Beaumont Hospital, Royal Oak, MI, USA
| | - D de Freitas
- Nephrology Department, Beaumont Hospital, Royal Oak, MI, USA.
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Tucci JR, Whitford GM, McAlister WH, Novack D, Mumm S, Keaveny TM, Whyte MP. Skeletal Fluorosis Due To Inhalation Abuse of a Difluoroethane-Containing Computer Cleaner. J Bone Miner Res 2017; 32:188-195. [PMID: 27449958 PMCID: PMC5977397 DOI: 10.1002/jbmr.2923] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 07/07/2016] [Accepted: 07/14/2016] [Indexed: 12/13/2022]
Abstract
Skeletal fluorosis (SF) is endemic in many countries and millions of people are affected worldwide, whereas in the United States SF is rare with occasional descriptions of unique cases. We report a 28-year-old American man who was healthy until 2 years earlier when he gradually experienced difficulty walking and an abnormal gait, left hip pain, loss of mobility in his right wrist and forearm, and progressive deformities including enlargement of the digits of both hands. Dual-energy X-ray absorptiometry (DXA) of his lumbar spine, femoral neck, total hip, and the one-third forearm revealed bone mineral density (BMD) Z-scores of +6.2, +4.8, +3.0, and -0.2, respectively. Serum, urine, and bone fluoride levels were all elevated and ultimately explained by chronic sniffing abuse of a computer cleaner containing 1,1-difluoroethane. Our findings reflect SF due to the unusual cause of inhalation abuse of difluoroethane. Because this practice seems widespread, particularly in the young, there may be many more such cases. © 2016 American Society for Bone and Mineral Research.
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Affiliation(s)
- Joseph R. Tucci
- Department of Medicine, Roger Williams Medical Center, Providence, RI, USA 02908; Boston University School of Medicine; Boston, MA, USA, 02118
| | - Gary M. Whitford
- Department of Oral Biology, School of Dental Medicine, George Regents University; Augusta, Georgia, USA, 30912
| | - William H. McAlister
- Department of Pediatric Radiology, Mallinckrodt Institute of Radiology at St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO, USA, 63110
| | - Deborah Novack
- Division of Bone and Mineral Diseases, Department of Internal Medicine, and Department of Pathology, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, MO, USA, 63110
| | - Steven Mumm
- Division of Bone and Mineral Diseases, Department of Internal Medicine, and Department of Pathology, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, MO, USA, 63110
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospital for Children, St. Louis, MO, USA, 63110
| | - Tony M. Keaveny
- Departments of Mechanical Engineering and Bioengineering, University of California; Berkeley, CA, USA, 94720
| | - Michael P. Whyte
- Division of Bone and Mineral Diseases, Department of Internal Medicine, and Department of Pathology, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, MO, USA, 63110
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospital for Children, St. Louis, MO, USA, 63110
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Sircar M, Kotton C, Wojciechowski D, Safa K, Gilligan H, Heher E, Williams W, Thadhani R, Tolkoff-Rubin N. Voriconazole-Induced Periostitis & Enthesopathy in Solid Organ Transplant Patients: Case Reports. ACTA ACUST UNITED AC 2016; 4:8-17. [PMID: 27990445 PMCID: PMC5158005 DOI: 10.4236/jbm.2016.411002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Voriconazole is frequently used to treat fungal infections in solid organ transplant patients. Recently, there have been reports suggesting that prolonged voriconazole therapy may lead to periostitis. Aim Here we present two cases of voriconazole-induced periostitis in solid organ transplant patients. Case Presentation Voriconazole was given to two transplant patients-one with a liver transplant and the second with a heart transplant, to treat their fungal infections. Both developed voriconazole-induced toxicity. While undergoing voriconazole therapy, they had incapacitating bone pain. The liver transplant patient had to be taken off voriconazole, and the heart transplant patient succumbed to non-voriconazole related causes. Conclusions Voriconazole therapy in two solid organ transplant patients resulted in periostitis. We provide potential etiologies underlying voriconazole-induced periostitis, including fluoride toxicity, abnormalities in the pulmonary vascular bed leading to the production of downstream inflammatory mediators, and abnormal pharmacokinetics of hepatic drug metabolism. In addition to monitoring blood voriconazole trough levels, we suggest careful assessment for musculoskeletal pain in patients undergoing voriconazole treatment for two months or more, particularly if their daily dosages of voriconazole exceed 500 mg per day. Appropriate workup should include measurement of alkaline phosphatase, voriconazole trough and fluoride levels as well as a bone scan. Overall, early recognition of voriconazole-induced musculoskeletal toxicity is important for better morbidity outcomes.
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Affiliation(s)
- Monica Sircar
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Camille Kotton
- Division of Infectious Disease, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - David Wojciechowski
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; MGH Transplant Center, Departments of Medicine and Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Kassem Safa
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; MGH Transplant Center, Departments of Medicine and Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Hannah Gilligan
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; MGH Transplant Center, Departments of Medicine and Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Eliot Heher
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; MGH Transplant Center, Departments of Medicine and Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Winfred Williams
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; MGH Transplant Center, Departments of Medicine and Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Ravi Thadhani
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Nina Tolkoff-Rubin
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA; MGH Transplant Center, Departments of Medicine and Surgery, Massachusetts General Hospital, Boston, MA, USA
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Voriconazole-Induced Periostitis Mimicking Chronic Graft-versus-Host Disease after Allogeneic Stem Cell Transplantation. Case Rep Infect Dis 2016; 2016:3242196. [PMID: 27403356 PMCID: PMC4923522 DOI: 10.1155/2016/3242196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 05/24/2016] [Indexed: 01/30/2023] Open
Abstract
Voriconazole is an established first-line agent for treatment of invasive fungal infections in patients undergoing allogeneic stem cell transplantation (ASCT). It is associated with the uncommon complication of periostitis. We report this complication in a 58-year-old female undergoing HSCT. She was treated with corticosteroids with minimal improvement. The symptoms related to periostitis can mimic chronic graft-versus-host disease in patients undergoing HSCT and clinicians should differentiate this from other diagnoses and promptly discontinue therapy.
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Moon WJ, Scheller EL, Suneja A, Livermore JA, Malani AN, Moudgal V, Kerr LE, Ferguson E, Vandenberg DM. Plasma fluoride level as a predictor of voriconazole-induced periostitis in patients with skeletal pain. Clin Infect Dis 2014; 59:1237-45. [PMID: 24992954 DOI: 10.1093/cid/ciu513] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Voriconazole is a triazole antifungal medication used for prophylaxis or to treat invasive fungal infections. Inflammation of the periosteum resulting in skeletal pain, known as periostitis, is a reported side effect of long-term voriconazole therapy. The trifluorinated molecular structure of voriconazole suggests a possible link between excess fluoride and periostitis, as elevated blood fluoride has been reported among patients with periostitis who received voriconazole. METHODS Two hundred sixty-four patients from Michigan were impacted by the multistate outbreak of fungal infections as a result of contaminated methylprednisolone injections. A retrospective study was conducted among 195 patients who received voriconazole therapy at St Joseph Mercy Hospital during this outbreak. Twenty-eight patients who received both bone scan and plasma fluoride measurements for skeletal pain were included in the statistical analyses. Increased tracer uptake on bone scan was considered positive for periostitis. The primary outcome measure was the correlation between plasma fluoride and bone scan results. RESULTS Blood fluoride (P < .001), alkaline phosphatase (P = .020), daily voriconazole dose (P < .001), and cumulative voriconazole dose (P = .027) were significantly elevated in patients who had periostitis compared with those who did not. Discontinuation or dose reduction of voriconazole resulted in improvement of pain in 89% of patients. CONCLUSIONS High plasma fluoride levels coupled with skeletal pain among patients who are on long-term voriconazole therapy is highly suggestive of periostitis. Initial measurement of fluoride may be considered when bone scan is not readily available. Early detection should be sought, as discontinuation of voriconazole is effective at reversing the disease.
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Affiliation(s)
- Woo J Moon
- Department of Internal Medicine, St Joseph Mercy Hospital
| | - Erica L Scheller
- Department of Molecular and Integrative Physiology, University of Michigan
| | - Anupam Suneja
- Department of Internal Medicine, St Joseph Mercy Hospital
| | | | - Anurag N Malani
- Department of Internal Medicine, St Joseph Mercy Hospital Section of Infectious Diseases
| | - Varsha Moudgal
- Department of Internal Medicine, St Joseph Mercy Hospital Section of Infectious Diseases
| | - Lisa E Kerr
- Department of Pharmacy, St Joseph Mercy Hospital, Ann Arbor, Michigan
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