Periostitis Deformans Research Articles

A rare case of voriconazole-induced vertebral periostitis in a patient with invasive aspergillus spondylodiscitis

The author illustrates the first ever reported case of voriconazole-induced periostitis of vertebral body. A 66-year-old immunocompetent male patient was diagnosed with multilevel invasive aspergillus spondylodiscitis of dorsal spine and was put on long-term voriconazole therapy for the same. Initially, the patient showed a good response to treatment but later on paradoxically the patient started to deteriorate symptomatically as well as radiologically. Differential diagnosis of misdiagnosis or co-in­fection with an another mold, inadequate voriconazole blood levels, voriconazole-induced periostitis were thought. After a detailed radiological and serological investigation, the patient was diagnosed with voriconazole-induced vertebral periostitis. Based on thorough literature review, discontinuation of voriconazole therapy was opted as treatment. Clinically, the patient started improving within four weeks of cessation of therapy and was symptom-free by the end of four months. Hence, to conclude, clinicians and spine surgeons should be aware of the fact that long-term voriconazole treatment of invasive aspergillosis can be complicated by skeletal fluorosis and painful periostitis. Once the symptoms of periostitis develop, investigations such as skeletal imaging and measurement of serum fluoride levels should be performed and if periostitis deformans is confirmed, reducing the dose or ceasing voriconazole should be considered.

Correction to: Voriconazole-induced periostitis deformans: serial imaging in a patient with ANCA vasculitis.

The original version of this paper unfortunately contained mistakes in the affiliations for all authors.

Periostitis deformans secondary to prolonged voriconazole treatment: A case study

We report a case of fluoride toxicity manifesting as periostitis deformans occurring as the result of prolonged treatment with the fluoride-rich antifungal voriconazole. A 39-year-old woman was commenced on voriconazole, 400 mg BD, because of Aspergillus infection causing intracranial abscesses as a post-operative complication of orthotopic liver transplant. Three months later, skeletal imaging performed in the context of bone pain and reduced shoulder and elbow mobility showed features consistent with periostitis deformans, with multiple bilateral exostoses adjacent to the radial and humeral shafts and lateral aspects of the scapulae. Bone scan showed diffuse cortically based uptake involving the appendicular skeleton and multiple ribs. Voriconazole was ceased. To address the association with voriconazole, serum fluoride levels were assayed on samples collected 4 days before and 4, 8 and 12 days after ceasing voriconazole: levels were 16.3, 7.9, 8.5 and 6.8 umol/L, respectively (reference interval 0.3-2.2 umol/L). Corresponding voriconazole levels were 4.1 and

Multiple painless masses: periostitis deformans secondary to fluoride intoxication

The differential diagnosis based on the imaging findings included ossification of subperiosteal hematomas, ectopic calcification in the setting of a connective tissue disorder, and periostitis deformans secondary to fluoride intoxication. Laboratory assays were requested by the patient’s rheumatologist, which were notable for a mildly elevated alkaline phosphatase level (216 U/L, reference range=40–115 U/L) and a markedly elevated serum fluoride level (3.9 mg/L, normal range <0.2 mg/L), confirming the diagnosis of fluoride intoxication. The findings were discussed with the patient, who admitted to chronically “huffing” Freon, or inhaling the chlorofluorocarbon gas from a plastic bag.

Periostitis Secondary to Prolonged Voriconazole Therapy in a Lung Transplant Recipient

This article reports a case of perostitis deformans in a lung transplantation patient taking the fluoride-containing medication voriconazole, a relatively new and potent anti-fungal. The patient had a normal range of motion in all joints and a normal gait. On radiographs at presentation, multifocal areas of periostitis were visualized involving the left-hand first, second, and third proximal phalanx shafts. Similar periostitis was present on the left-hand third, fourth, and fifth middle phalanx shafts. Plain radiographs of the right hand also demonstrated multifocal periostitis of the third and fourth proximal and middle phalanges. Aggressive periostitis at the level of the right fourth proximal and middle phalanges was also present. Given her long-term treatment with voriconazole and a presentation consistent with periostitis deformans, voriconazole was presumed to be the offending agent and was replaced with itraconazole. The patient's symptoms resolved shortly after withdrawal of voriconazole.Voriconazole-associated periostitis has only recently been reported in the literature. Food and Drug Administration-approved in 2002, voriconazole is efficacious in treating serious, invasive fungal infections that are generally seen in immunocompromised patients. Due to the novel nature of voriconazole and the uncommon indications for its long-term use, the periostitis deformans described in this article may be unfamiliar to the orthopedic surgeon. Consequently, a patient presenting with bone pain and periosteal involvement on plain radiographs may provoke a broad, expensive, and ultimately unnecessary diagnostic evaluation. The clinical case and imaging findings presented here can help to promote understanding of this benign condition and its simple cure: voriconazole discontinuation.

Multifocal Nodular Periostitis Associated With Prolonged Voriconazole Therapy in a Lung Transplant Recipient

We report a case of painful, nodular periostitis in a lung transplant recipient on long-term voriconazole therapy. Symptoms, signs, and laboratory abnormalities resolved quickly after drug withdrawal. The presentation more closely resembles periostitis deformans than hypertrophic osteoarthropathy, suggesting that the fluoride moiety of voriconazole may be pathogenic for this condition. Clinicians should be aware of this association.

Medication-induced periostitis in lung transplant patients: periostitis deformans revisited

Medication-induced periostitis in lung transplant patients: periostitis deformans revisited

Medication-induced periostitis in lung transplant patients: periostitis deformans revisited

We report five cases of diffuse periostitis resembling hypertrophic osteoarthropathy and perostitis deformans in lung transplantation patients on chronic voriconazole, a fluoride-containing compound. Although drug-related periostitis has long been known, the association of lung transplant medication with periostitis was only recently introduced in the literature. To our knowledge, imaging findings have not been fully characterized in the radiology literature. Imaging features along with clinical history help to distinguish this benign condition from other disease entities. In this article, we review the current literature and illustrate the variety of imaging characteristics of this entity so that interpreting radiologists can make accurate diagnoses and avoid unnecessary work up.

The fluoric origin of the bone lesion in the Pithecanthropus erectus femur.

AbstractThe femur of a patient autopsied 11 years ago is presented in which an osteophyte comparable to the one of the Pithecanthropus Erectus femur can be observed. Their analogous anatomopathological disposition is due to the fact that both are caused by the ossification of the tendinous insertion of the adductors of the thigh. The orifices they both present correspond to the channel of the perforating arteries which normally pierce them. This type of osteophyte is only present as a result of bone fluorosis. The autopsied patient presents a bone fluorosis of the Periostitis deformans' type, as described by the author in 1952. The femur of the Pithecanthropus was found by Eugene Dubois in some geological strata composed mainly of volcanic ash. In the Pithecanthropus, the fluoric intoxication came from the ingestion of fruits and plants impregnated with the fluorine filled volcanic ash. This volcanic fluorisis, known as Gaddur, is now seen among animals living on the volcanic region of Iceland. For these reasons we assume that the Pithecanthropus erectus suffered a bone fluorosis of the type of the Periostitis deformans, which would be the first disease known in man.

Radiological aspects of a new type of bone fluorosis, periostitis deformans.

In 1952 one of the authors described a new bone disease, which was called periostitis deformans (1, 2), and in 1964 he identified it as a new type of bone fluorosis due to habitual drinking of wine containing fluorine—wine fluorosis (3). Although this disease is rare, 28 cases have been observed in Spain since the time of its original description. Many others have undoubtedly passed unnoticed, since a high proportion of them have been erroneously diagnosed as benign and malignant bone tumors, chronic osteomyelitis, chronic polyarthritis, rheumatoid disease, and tabetic arthropathy or Paget's osteitis deformans. The x-ray examination of bones is sufficient to establish the diagnosis, some special features having a pathognomonic value. The condition is of considerable interest, as in several countries fluorine is customarily added in excessive quantities to wine as a preservative (4, 5). The subsequent intoxication remains unsuspected by both patient and attending physician in the majority of cases, so that frequently the disease is discovered initially by the radiologist. Periostitis Deformans and Fluorosis Changes Our cases of periostitis deformans were carefully studied from clinical, radiological, and pathological points of view, and the findings were compared with those in classical bone fluorosis of drinking water or professional origin and with those in experimental fluorosis. Common Changes in Fluorosis The typical pathological features seen in roentgenograms of all patients with chronic fluorosis may be classified in four wide groups of lesions, as follows: 1. Endosteal changes or fluoric osteitis: (a) condensing osteitis, visualized as sclerotic or osteopetrosis-like bone changes; (b) rarefying osteitis, characterized by porotic and malacic bone aspects; (c) sclero-atrophic osteitis, a mixed form. 2. Periosteal changes due to fluoric periostitis, which appear as osteogenic periosteal proliferations. 3. Pathological changes in tendinous and muscular structures around the bones, which may be considered as osteophytosis invading the soft tissues (invading osteophytosis). 4. Joint changes or fluoric arthrosis. Typical Changes in Periostitis Deformans The following are typical features of periostitis deformans: 1. Endosteal changes due to sclero-atrophic osteitis: A slow initial osteosclerosis appears, which gradually resolves into osteoporosis and bone atrophy. We have termed this process “sclero-atrophic osteitis” (Figs. 1 and 4). 2. Periosteal changes developed through outbreaks of periostitis deformans: Periodically subacute outbreaks are observed of hyperostotic periostitis.