A 40-year-old man was evaluated for diffuse arthralgias during a hospitalization for sepsis. Six months prior, he underwent a simultaneous liver and kidney transplant for alcoholic cirrhosis. He had a complicated postoperative course including Trichosporon asahii fungemia requiring indefinite voriconazole therapy. Examination revealed severe, painful pitting edema of his hands. He was also noted to have diffuse myofascial tenderness throughout his extremities and pain with range of motion. An x-ray of his hands showed areas of irregular mineralization at the radius, ulnar styloid, scattered carpal and metacarpal bones, and the phalanges (arrows). These find-ings were consistent with voriconazole-induced periostitis, a musculoskeletal disorder characterized by calcium hydroxyapatite deposition in the periosteum, diffuse bone pain, and joint swelling. Voriconazole is a trifluorinated molecule, and fluoride excess is the hypothesized pathophysiology underlying this disorder. The patient's pain and swelling improved 2 days after stopping voriconazole and starting posaconazole, a nonfluoridated triazole agent.Differential diagnosis: Drug-induced periostitis, hypertrophic osteoarthropathy, infection-related periosteal apposition, thyroid acropachy. FIGURE. Scattered areas of irregular mineralization at the distal radius, ulnar styloid, scattered carpal bones, bases of the metacarpals, and the diaphyses (arrows).
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