Voriconazole-Induced Periostitis in a Patient after Orthotopic Liver Transplantation

HomeRadiologyVol. 310, No. 3 PreviousNext Reviews and CommentaryFree AccessImages in RadiologyVoriconazole-Induced Periostitis in a Patient after Orthotopic Liver TransplantationPokhraj Prakashchandra Suthar, Sumeet Virmani Pokhraj Prakashchandra Suthar, Sumeet Virmani Author AffiliationsFrom the Department of Diagnostic Radiology and Nuclear Medicine, Rush University Medical Center, 1653 W Congress Pkwy, Chicago, IL 60612.Address correspondence to S.V. (email: [email protected]).Pokhraj Prakashchandra SutharSumeet Virmani Published Online:Mar 26 2024https://doi.org/10.1148/radiol.232902MoreSectionsPDF ToolsAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookXLinked In A 43-year-old female patient presented with symptoms of reduced appetite, fatigue, and body pain. Four months earlier, she had received an orthotopic liver transplantation due to alcoholic cirrhosis. At presentation, she was taking voriconazole. Technetium 99m methylene diphosphonate bone scintigraphy revealed increased periosteal and cortical uptake in bilateral ribs and bones of the extremities (Figure) This finding is pathognomonic for voriconazole-induced periostitis.Images in a 43-year-old female patient with voriconazole-induced periostitis after orthotopic liver transplantation. (A, B) Whole-body technetium 99m methylene diphosphonate bone scintigrams in the (A) anterior and (B) posterior view reveal increased tracer uptake (arrowheads)—primarily around the cortical surface and periosteum in bilateral ribs and bones of the extremities—related to the effects of voriconazole-induced periostitis. (C) Radiograph of the right ankle in the lateral view demonstrates subtle lamellated periosteal reaction, indicative of periostitis, in the right distal fibula (arrowheads). (D) Radiograph of the left wrist in the anteroposterior view demonstrates fluffy periostitis along the inferior margin of the pisiform (left arrowhead) and minimal periostitis at the proximal base of the second metacarpal along the radial aspect (right arrowhead).Download as PowerPointVoriconazole, an antifungal medication commonly used in transplant recipients, is linked to periostitis, which affects 15%–50% of patients (1). Symptoms usually emerge 6 months to 3 years after treatment initiation, but can emerge as early as 6 weeks or as late as 8 years after treatment initiation. The fluorine content of the drug may induce fluorosis-like periostitis. Whole-body bone scintigraphy detects periosteal reactions, which exhibit varied radiotracer uptake (2).Disclosures of conflicts of interest: P.P.S. No relevant relationships. S.V. Honorarium from AbbVie for speaking at an educational symposium and member of the board of governors (unpaid) of the Central Chapter of the Society of Nuclear Medicine and Molecular Imaging.References1. Barajas MR, McCullough KB, Merten JA, et al. Correlation of pain and fluoride concentration in allogeneic hematopoietic stem cell transplant recipients on voriconazole. Biol Blood Marrow Transplant 2016;22(3):579–583. Crossref, Medline, Google Scholar2. Wang TF, Wang T, Altman R, et al. Periostitis secondary to prolonged voriconazole therapy in lung transplant recipients. Am J Transplant 2009;9(12):2845–2850. Crossref, Medline, Google ScholarArticle HistoryReceived: Oct 25 2023Revision requested: Nov 24 2023Revision received: Nov 26 2023Accepted: Dec 18 2023Published online: Mar 26 2024 FiguresReferencesRelatedDetailsRecommended Articles Periosteal Pathologic Conditions: Imaging Findings and PathophysiologyRadioGraphics2022Volume: 43Issue: 2Hypertrophic Osteoarthropathy: Clinical and Imaging FeaturesRadioGraphics2016Volume: 37Issue: 1pp. 157-195Pediatric Ribs at Chest Radiography: Normal Variants and AbnormalitiesRadioGraphics2023Volume: 43Issue: 12Traumatic Rib Injury: Patterns, Imaging Pitfalls, Complications, and TreatmentRadioGraphics2017Volume: 37Issue: 2pp. 628-651Imaging Findings of Metabolic Bone DiseaseRadioGraphics2016Volume: 36Issue: 6pp. 1871-1887See More RSNA Education Exhibits The Dreaded Black Line of Stress FracturesDigital Posters2020Pediatric Ribs: Roadmap to Become A Rib ExpertDigital Posters2022Judging A Bone By Its Cover: A Radiologist's Guide To Periosteal PathologyDigital Posters2021 RSNA Case Collection Caffey Disease RSNA Case Collection2021Toddler Fracture RSNA Case Collection2021Hypertrophic OsteoarthropathyRSNA Case Collection2020 Vol. 310, No. 3 Metrics Altmetric Score PDF download