Thread by @IUIDfellowship

#idboardreview heart-lung transplant 2yrs ago on tacrolimus, mycophenolate, TMP/SMX, lung nodules on voriconazole, +diffuse body aches, AlkP 2x ULN, Bone scan numerous scattered areas of uptake. Xray periosteal thickening, Calcified excrescences. dx? #medEd #idmedEd #idtwitter

#voriconazole #Periostitis Ref pic ajronline.org/doi/pdf/10.221…

#Voriconazole SE vision changes, rash, nausea, vomiting, abnormal liver function tests, hallucinations
#Periostitis w/ long term voriconazole diffuse body aches, ,inc AlkP patches of periosteal thickening on Xray &+bone scan. Calcified excrescences are sometimes seen.

#voriconazole #periostitis occurs after at least 6 months of therapy, although cases have been reported after 6 weeks of therapy. Serum fluoride levels are characteristically elevated as well as serum alkaline phosphatase

#periostitis resolves gradually after stopping #voriconazole. Only azole to have 3 three fluorines in the molecule; other azoles have 2 fluorines. One hypothesis 3rd fluorine can be released into blood stream during metabolism of the drug & cause fluorosis.

#voriconazole #periostitis Ddx
-hypertrophic osteoarthropathy (often w/malignancies or chronic infections)
-venous stasis w/ periosteal rx
-thyroid acropachy (autoimmune thyroid dz w/ periosteal reactions, clubbing, digital swelling)
-hypervitaminosis A

#voriconazole #periostitis @NEJM nejm.org/doi/full/10.10…